INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 (INEY - 2) PROGRAM-FOR-RESULTS (PforR) ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT (ESSA) REPORT MAY 3RD, 2023 PREPARED BY THE WORLD BANK INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INTRODUCTION (INEY - 2) TABLE OF CONTENTS CONTENTS TABLE OF CONTENTS .......................................................................................................................... I CONTENTS.............................................................................................................................................. I List of Tables ................................................................................................................................................ ii List of Figures ............................................................................................................................................... ii 1. INTRODUCTION .......................................................................................................................... 2 1.1 Background and Objective ............................................................................................................. 2 1.2 Approach to the ESSA ................................................................................................................... 2 2. INEY PHASE 2 PFOR PROGRAM DESCRIPTION .................................................................... 4 2.1 Government Program .................................................................................................................... 4 2.2 PforR Scope .................................................................................................................................. 7 2.3 Program Boundary ......................................................................................................................... 9 3. ENVIRONMENTAL AND SOCIAL IMPACT ASSESSMENT .................................................... 11 3.1 Exclusion of Significant E&S Impacts .......................................................................................... 11 3.2 Environmental and Social Risks and Effects................................................................................ 11 3.2.1 Environmental and Social Benefits ............................................................................. 11 3.2.2 Environmental and Social Risk and Effects ................................................................ 12 3.3 Contextual Risks .......................................................................................................................... 15 3.4 Institutional Capacity and Complexity Risks ................................................................................ 15 3.5 Political and Reputational Risks ................................................................................................... 16 3.6 Overall Environmental and Social Risks Rating ........................................................................... 16 4. ASSESSMENT OF GOI ENVIRONMENTAL AND SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY ................................................................................................................. 17 4.1 Relevant National Policy and Regulatory Framework .................................................................. 17 4.2 Institutional Responsibilities ......................................................................................................... 23 4.2.1 Environment ................................................................................................................ 24 4.2.2 Social .......................................................................................................................... 24 4.3 Experience from INEY Phase 1 and Other World Bank Projects ................................................. 25 4.4 Assessment of E&S Capacity and Management System ............................................................ 25 5. RECOMMENDATIONS OF PROJECT ACTION PLAN ............................................................ 39 5.1 Conclusions ................................................................................................................................. 39 5.2 Project Implementation Support and Recommended PAP .......................................................... 40 ANNEX A STAKEHOLDER ENGAGEMENT AND SITE VISIT SUMMARY ....................................... 43 A.1 INEY 2 Preparation Mission, Jakarta, December, 2022 ...................................................................... 43 A.2 INEY 2 Preparation Mission, Jakarta, Surabaya, Sragen and Manggarai Timur February, 2023 ........ 44 ANNEX B ESSA STAKEHOLDER CONSULTATION ......................................................................... 50 ANNEX C SUMMARY OF INEY 2 DLIS ............................................................................................... 54 ANNEX D E&S RISK AND IMPACTS SCREENING ........................................................................... 57 ANNEX E ALIGNMENT OF INEY 2 PFORR PROGRAM WITH GOI PROGRAM .............................. 59 Environnemental and Social Systems Assessment (ESSA) Page i INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INTRODUCTION (INEY - 2) List of Tables Table 2-1 Overview of the Pillars of the National Strategy for Acceleration of Stunting Reduction based on Perpres 72/2021 ...................................................................................................................... 5 Table 2-2 Summary of INEY 2 DLIs ........................................................................................................ 9 Table 2-3 Proposed Scope of the Program .......................................................................................... 10 Table 4-1 Medical Waste Treatment Facilities Capacity in 12 Priority Provinces ................................. 19 Table 4-2 Key Institutional Stakeholders for the Program .................................................................... 23 Table 4-3 Institutional Roles and Responsibilities for Environmental Performance ............................. 24 Table 4-4 Institutional Roles and Responsibilities for Social Performance .......................................... 24 Table 4-5 E&S Capacity Assessment and Gap Analysis ...................................................................... 26 Table 5-1 Environmental and Social Measures for the Program Action Plan ....................................... 40 List of Figures Figure 2-1 Ilustration of Health System in Indonesia .............................................................................. 7 Figure 4-1 Electronic-Based- Hazardous Waste Recording and Reporting System in Indonesia ........ 18 Figure 4-2 Distribution of medical waste processing facilities and transporters ................................... 19 Environnemental and Social Systems Assessment (ESSA) Page ii INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INTRODUCTION (INEY - 2) 1. INTRODUCTION 1.1 Background and Objective 1. The ESSA process is guided by the key policy elements as established by the Bank Policy Program for Results (PforR) Financing (November 2017) as they applicable to the assessment of the Government of Indonesia (GOI) systems and the relevant ministries/agencies’ capacity to plan and implement effective measures for managing environmental and social risks and impacts. The key policy elements with regards to environmental and social management systems of the Bank Policy are: a. promote environmental and social sustainability in the PforR Program design; avoid, minimize or mitigate adverse impacts, and promote informed decision-making relating to the PforR Program’s environmental and social impacts; b. avoid, minimize or mitigate adverse impacts on natural habitats and physical cultural resources resulting from the PforR Program; c. protect public and worker safety against the potential risks associated with: (i) construction and/or operations of facilities or other operational practices under the PforR Program; (ii) exposure to toxic chemicals, hazardous waste, and other dangerous materials under the PforR Program; and (iii) reconstruction or rehabilitation of infrastructure located in areas prone to natural hazards; d. manage land acquisition and loss of access to natural resources in a way that avoids or minimizes displacement, and assist the affected people in improving, or at the minimum restoring, their livelihoods and living standards; e. give due consideration to the cultural appropriateness of, and equitable access to, PforR Program benefits, giving special attention to the rights and interests of the Indigenous Peoples and to the needs or concerns of vulnerable groups; and f. avoid exacerbating social conflict, especially in fragile states, post-conflict areas, or areas subject to territorial disputes. 2. The objectives of the ESSA are to assess: a. potential environmental and social risks and benefits; b. environmental and social systems that apply to the program; c. implementation experience and capacity; d. whether system and performance are consistent with the key principles of the Bank Policy; and e. steps to be taken to improve the scope of system or capacity. 1.2 Approach to the ESSA 3. The ESSA process focused on the systems to address the following effects identified through screening: a. Environmental considerations: segregation, storage, collection, and treatment of medical waste including pharmaceutical waste (expired/damaged/unused vaccines, vaccine vials, used syringes); access to clean water supply (quality and quantity); community behavior in relation with sanitation and access to sanitation facilities, e.g., toilet and septic tank, domestic solid waste and wastewater treatment; and government and Primary Health Care (PHC)s influence toward behavior and access to sanitation facilities. b. Social considerations: participation by vulnerable groups in village-level decision making; program benefits for remote communities and Indigenous Peoples; gender-related limitation in decision-making power and control over resources at the household level; accessibility on education and health service delivery; inclusiveness or specificity of the context delivery Environmental and Social System Assessment (ESSA) Page 2 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INTRODUCTION (INEY - 2) (i.e. take into account literacy, including health literacy, language, gender, and cultural aspects); service agreement defining right and responsibilities (including labor health and safety aspects) of voluntary staff and cadres for the Program; availability of reliable grievance redress mechanism that reach out entire segment of community, including ones that have no access to internet or digital communication network. 4. The ESSA was developed through a review of relevant information on the environmental and social systems underpinning the program, as well as engagement and field visits to understand the operationalization of those systems, including the infrastructure in place to support and the capacity to implement them. The ESSA process thus far has included: a. Information review of relevant environmental and social management procedures and standards that are applicable to the Program: • Environment: Government Regulation No. 22 of 2021 on Protection and Management of Environment (‘GR 22/2021’); MoEF’s Regulation No. 6 of 2021 on Procedures and Requirements of Hazardous Waste Management ('MoEF Reg. 6/2021’); MoEF’s Regulation No. P.56/Menlhk-Setjen/2015 regarding Procedures and Technical Requirements for Hazardous and Toxic Waste Management from Health Service Facilities (‘MoEF Reg. 56/2015’); Minister of Health (MoH)’s Regulation No. 18 of 2020 regarding Region-Based Medical Waste Management Practice for Public Health Facilities (‘MoH Reg. 18/2020’); MoH’s Regulation No. 3 of 2014 regarding Community- based Total Sanitation (Sanitasi Total Berbasis Masyarakat, or ‘STBM’) (‘MoH 3/2014’); Act No. 17 of 2019 regarding ‘Water Resource’ (‘Act 17/ 2019’); and Minister of Public Work and Housing (MoPWH)’s Regulation No. 37/PRT/M/2015 on ‘Water an d Water Resource Permit to Use’ (‘MoPWH Reg. 37/2015’); MoH’s Regulation No. 27 of 2017 on Guidelines for Prevention and Control of Infection in Health Service Facility (‘MoH 27/2017’); National standards (Standar Nasional Indonesia, or ‘SNI’) for sanitation facility establishment, e.g., SNI 2398:2017 on procedure for septic tank planning, SNI 6774:2008 on procurement of clean water, etc. • Social: Village Laws and guiding regulations (e.g. community participation, use of village funds, access to information). National instruments with provisions for Indigenous Peoples were also reviewed, along with existing grievance mechanism system at national and sub-national (districts) level and applicable regulations on community and workers health and safety. Understanding implementation of previous projects was also used to inform system capacity under the ESSA. b. Field assessments with the following summary: • Environment: o A site visit to Surabaya District in Jawa Timur Province was conducted on 16-17 February 2023 covering visits to village level PHC (Posyandu Prima1) of Kebonsari Village, Jambangan Sub-District, followed with meeting with Jambangan Sub-District Head and Surabaya City Mayor on stunting prevention action, resource, and data management. In the event, communication was made with Environmental Health Division Head of Surabaya City Health Agency regarding medical waste management at Surabaya City, particularly ones that generated from PHCs. o A site visit to Manggarai Timur District in Nusa Tenggara Timur was conducted on 21- 22 February 2023 covering visits to districts and village level Primary Health Care (Puskesmas, Posyandu, and Poskesdes) of Peot Village and Bangka Kantar Village, Borong Sub-District, followed with meeting with Manggarai Timur Regent on existing 1 Posyandu Prima is a pilot program from the MoH, where Puskesmas-supporting Posyandu (or Posyandu Pembantu, or ‘Pustu’) is upgraded by implementing certain service standards (e.g., service time) and digitalization (e.g., registration and medical recording). Posyandu Prima expands its service from originally focusing only for mother and child’s health to wider range of patients such as teenager, adult, and elder patients. MoH is targeting upgrading 300,000 Pustu units to become Posyandu Primas. Environmental and Social System Assessment (ESSA) Page 3 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INEY PHASE 2 PFOR PROGRAM DESCRIPTION (INEY - 2) stunting prevention program, available resources, sanitation programs, coordination between government stakeholders, waste management, sanitation program, etc. Further explanation about Puskesmas, Posyandu, please see Figure 2-1 and footnote 1. • Social: o Same site visit to Manggarai Timur District in Nusa Tenggara Timur was conducted on 21-22 February 2023, with discussion focusing on stunting prevention program, labor agreement of the used health staffs and cadres including rights and responsibilities, trainings, health and safety aspect, public participation (especially for women), coordination between government stakeholders, grievance redress mechanism, etc. In addition, a meeting with religious leader of Manggarai Timur District was made to align stunting prevention program led by the government with the episcopal social program in the area. c. Consultation for the ESSA as follow: In addition to consultations with district, sub-district, and village level government officials, medical staffs, and religious leaders during the field assessments, consultations were conducted between 7 and 24 February 2023 through series of assessments meeting (offline and online) that involves multi-sectoral government authorities of Republic of Indonesia, led by the Secretariat of Vice President (SoVP) as Project Management Unit (PMU) of the Program, and participated by other ministries of agencies as Project Management Unit (PIU) whom include but not limited to, Ministry of Health (MoH), Ministry of Home Affairs (MoHA), Ministry of Finance (MoF), Ministry of Village (MoV), Ministry of Education, Culture, Research and Technology (MoEC), National Development Planning Agency (Badan Perencanaan Pembangunan Nasional, or ‘BAPPENAS’), and National Population and Family Planning Agency (Badan Kependudukan dan Keluarga Berencana Nasional , or ‘BKKBN’). Separately, consultations regarding institutional capacity on environment and social management were conducted with the Program’s independent reviewer on 28 February 2023 and Program’s representative in SoVP on 17 March 2023. Consultation with MoEF (Ministry of Environment and Forestry) Directorate on Hazardous waste who is in charge for medical waste management at national level in cooperation with Bappenas (National Planning Agency) has also been undertaken on 24 March 2024 to gather more information related to the implementation of medical waste management regulations. Program Action Plan and commitment plan validation for the IPF component were also undertaken on 21 and 24 March 2023 with senior staff at SoVP to discuss feasibility of each action plan/recommendation. A stakeholder consultation with wider audience, particularly from Ministries, Agencies, local government, was conducted via an online workshop on 13 April 2023 (Annex B). 2. INEY PHASE 2 PFOR PROGRAM DESCRIPTION 2.1 Government Program 5. The most recent Indonesian Nutrition Status Survey (Survey Status Gizi Indonesia, or SSGI) 2022 and the National Health Survey (Riskesdas) 2018 indicates that 6.2 percent of children are born with low birthweight, and among children under the age of five, 17.1 percent are underweight, 21.6 percent are stunted, 7.7 percent are wasted, 3.5 percent are overweight, and 38.5 percent are anemic. Anemia—which when experienced during pregnancy can contribute to maternal mortality and low birthweight/small-for-gestational age births—is high in Indonesia: 48.9 percent of pregnant women and 32 percent of adolescent women are anemic. Despite the significant improvements in stunting, the rates are still high, while the continued high rates of underweight children and anemic mothers indicates that this prioritized agenda will need sustained efforts in the near future. Environmental and Social System Assessment (ESSA) Page 4 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INEY PHASE 2 PFOR PROGRAM DESCRIPTION (INEY - 2) 6. Indonesia’s Vice President initiated preparation of a National Strategy to Accelerate Stunting Prevention (Stranas Stunting) in August 2017 drawing on World Bank technical advice. The Stranas Stunting adopted a multi-sectoral convergence approach that commits 23 ministries to increase the impact of almost US$4 billion of government spending each year on nutrition-specific and nutrition-sensitive interventions and services. More recently, the President has added stunting reduction as one of 16 National Priority Projects and incorporated the Stranas Stunting targets and multi-sectoral convergence approach in the National Medium-Term Development Plan (RPJMN) for 2020-24. Implementation began in 2018, supported by the Investing in Nutrition and Early Years (INEY) Program, in 100 priority districts, expanded to an additional 60 districts in 2019, and added an additional 100 districts each year in 2020 and 2021, bringing the total to 360 districts in 2021. 7. A Presidential Regulation No. 72 of 2021 (Peraturan Presiden, or Perpres 72/2021) issued in August 2021 updated the Stranas Stunting and elevated its legal status. This newer Perpres enacted into law as Indonesia’s whole-of-government approach to improve nutritional outcomes, reduce stunting, and accelerate human capital development. While adopting and updating many aspects of the Stranas Stunting, the Perpres 72/2021 solidified new implementation arrangements for the stunting reduction program, one important addition being the introduction of a new entity, the National Population and Family Planning Board (BKKBN) as the lead of the implementation team for stunting reduction. Among its other roles, BKKBN is entrusted with developing the national action plan which is known as National Action Plan for the Acceleration of Stunting Reduction (RAN PASTI) for Indonesia. BKKBN has also facilitated the introduction of Stunting Reduction Acceleration Teams at the provincial, district, and village levels. The first year of implementation of the Perpres 72/2021 has been informative for understanding the gaps and opportunities in the activities of the Stunting Reduction Acceleration Teams with previously introduced implementation modalities under the Stranas Stunting, such as the district convergence actions, village convergence scorecard, and work of the human development workers (HDW). With the Perpres 72/2021, Stranas Stunting implementation expanded nationwide in 2022, ahead of the previous plan to expand to all 514 districts by 2024. 8. To implement the programs stipulated in the Perpres 72/2021, Ministry of Health (MOH) have selected twelve (12) priority provinces which have high prevalence and number of stunting cases to accelerate stunting prevention. The 12 priority provinces consist of seven (7) provinces with the highest prevalence of stunting namely East Nusa Tenggara (NTT), West Sulawesi, Aceh, West Nusa Tenggara (NTB), Southeast Sulawesi, West Kalimantan and Central Sulawesi, while the additional five (5) provinces account for the highest number of stunted children under five. 9. The Perpres 72/2021 targets are to be achieved by implementing activities under the five pillars of the National Strategy for Acceleration of Stunting Reduction as follow: Table 2-1 Overview of the Pillars of the National Strategy for Acceleration of Stunting Reduction based on Perpres 72/2021 Pillar Scope and Rationale Pillar 1: Improving Under this pillar, the President and Vice President will hold limited cabinet leadership commitments meetings; convene national Stunting Summits and encourage subnational and visions in leaders to hold local stunting summits to build top-to-bottom leadership; ministries/agencies, and hold ministers, governors, district heads, and mayors to account for provincial governments, meeting service delivery and stunting reduction targets. The annual district/city governments, Stunting Summits will also recognize districts that successfully reduce and village governments; stunting, share and promote innovation, and showcase best practices. Pillar 2: Improving The President and Vice President will lead a sustained public awareness behavior change campaign targeting policymakers, regional governments, community communication and leaders, parents, Prospective brides and grooms, and the general public. community empowerment; The campaign will use a variety of outreach strategies, from mass media to home visits, and will also scale up and strengthen BCC programming. Environmental and Social System Assessment (ESSA) Page 5 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INEY PHASE 2 PFOR PROGRAM DESCRIPTION (INEY - 2) Pillar Scope and Rationale Pillar 3: Improving the Indonesia has a highly decentralized system of government under which convergence of specific most service delivery is the responsibility of sub-national governments. and sensitive interventions Most nutrition-specific and nutrition-sensitive intervention are the in ministries/agencies, responsibility of local governments. National government has the authority provincial governments, to set priorities which local governments should follow, and programs district/city regional which they should implement, but there are limited mechanisms to enforce governments and village compliance with national priorities. The role of districts is even more governments; important since the introduction of the Village Law in 2014. Substantial resources are now channelled from the central government and to the district and on to the village, but the quality of village expenditure is highly dependent on the quality of support and supervision which districts provide to villages. This is particularly important for nutrition interventions, many of which are delivered at the village level. Pillar 4: Improving food This pillar focuses on food policy reforms and investments to enable and nutrition security at improved access to good-quality and affordable nutritious food. It identifies individual, family and the following four areas: food policy reforms, food fortification reforms, community levels food contamination reforms, and food market investment policies. Pillar 5: Strengthening The President and Vice President will use a dashboard to monitor and developing systems, progress and identify, reward, and sanction the performance of line data, information, ministries, provinces, districts, and villages in accelerating stunting research and innovations. prevention. Perpres 72/2021 calls for strengthening national, district, and village data systems on service delivery, intervention targeting, and stunting. These improvements will also allow for faster and more robust learning and feedback loops and will facilitate course corrections during implementation. 10. Additionally, the Perpres 72/2021 also expands target groups for stunting prevention to adolescents as it considers that ensuring the health and nutritional status of both teenage boys and girls is important in preventing stunting. The high number of cases of anemia and other social issues (e.g., early marriage and pregnancy) especially for teenage girls, will have an impact on health outcomes including stunting. Therefore, education and health promotion activities regarding the importance of consuming balanced nutrition, iron tablets, and risks of early marriage/pregnancy need to be carried out on an ongoing basis. Educational/promotional activities not only targeted to teenagers, but also parents, schools, religious leaders, and society in general. 11. Simultaneously, Ministry of Health (MoH) offers complementary opportunities to strengthen the quality and delivery of primary health care (PHC) services that are at the core of accelerating stunting reduction. Indonesia’s 237,000 Posyandus (village level PHC) and 10,300 Puskesmas (sub-district level PHC)2 jointly aim to close gaps in geographic and financial access to quality health care. However, significant gaps are observed along the spatial and socioeconomic spectrum in terms of availability and quality of health care provision, exacerbated by the COVID- 19 pandemic. The health transformation objective is to strengthen the health system's capacity to deliver high-quality, affordable, and accessible PHC services to all Indonesians, particularly those in remote and disadvantaged areas. The illustration of the health system in Indonesia is shown below in Figure 2.1. 2 Posyandu, or integrated village-level service facilities are supported by a health worker and run by (volunteer) community health workers, or kader, that deliver essential health services, particularly related to child and maternal health. Puskesmas are sub-district level community health centers that provide primary care and population health management. Environmental and Social System Assessment (ESSA) Page 6 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INEY PHASE 2 PFOR PROGRAM DESCRIPTION (INEY - 2) Figure 2-1 Illustration of Health System in Indonesia 12. The PHC pillar of health transformation includes a thematic focus on stunting, in addition to PHC service delivery improvement, health promotion, tuberculosis, and immunization. In responding to the health and nutrition issues mentioned above, the Ministry of Health has stipulated eleven specific nutrition interventions. Those 11 essential nutrition specific intervention include screening for anemia for adolescent, Iron-Folic Acid Supplementation (IFAS) consumption for adolescent, antenatal check at least six times, IFAS consumption for pregnant women, complementary food with high animal protein for malnourished pregnant women, exclusive breastfeeding for at least 6 months, complementary foods rich in animal protein for age of 6-23 months, monitoring children under five growth and development through Posyandu activities, proper treatment for wasting and undernourished children under five, improving immunization coverage and expansion, and health and nutrition education/promotion. Through the convergence of these nutrition interventions at the sub-national level, Indonesia aims to strengthen primary health care and combat childhood stunting. The recruitment of approximately 75,000 human development workers has provided frontline support in identifying gaps in services while simultaneously drawing household members to obtain better health and nutrition services at the Posyandu and Puskesmas level. 2.2 PforR Scope 13. The World Bank and the Global Financing Facility (GFF), through the first phase of Investing in Nutrition and Early Years (INEY) Program, have been supporting the implementation of the government’s program since 2018, first under Stranas Stunting and later under the Perpres 72/2021. The INEY Program development objective (PDO) is to increase simultaneous utilization of nutrition interventions by 1,000-day households in priority districts. INEY was designed to complement the existing World Bank portfolio at the time of approval (FY19) and focuses on: (i) addressing the management and system challenges that undermine convergence at each level of intervention delivery (central, district, and village); (ii) plugging critical gaps in the Government’s mix of sector programming; and (iii) strengthening citizen engagement in the frontline delivery and oversight of nutrition interventions. It aims to incentivize ten implementing agencies, hundreds of local governments, and tens of thousands of villages to collaborate to converge a multi-sectoral package of priority nutrition-specific and -sensitive interventions on priority households at the village level. Environmental and Social System Assessment (ESSA) Page 7 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INEY PHASE 2 PFOR PROGRAM DESCRIPTION (INEY - 2) 14. The proposed second phase PforR Program builds on the experience of the INEY’s first phase and comprises an International Bank for Reconstruction and Development (IBRD) PforR loan in the amount of US$600 million combined with an IPF component in the amount of US$24 million financed by GFF (US$14 million) and the Gavi, the Global Vaccine Alliance (US$10 million). The second phase Program is in alignment with the Perpres 72/2021 national program for acceleration of stunting reduction and the primary health care transformation agenda. The design of the second phase is based on recommendations from the midterm review (MTR) of INEY whereby new financing is proposed to achieve the objectives for converged community level service delivery and sustain support to the GOI ambitious targets of achieving 14% stunting by 2024 and continue until 2030. The PforR will cover all program beneficiaries as outlined in Perpres 72/2021. The IBRD financing for INEY 2 will support: (a) Program scale up over four additional years (2023-27); (b) modification of results areas (RAs), DLIs, and targets to emphasize high impact interventions and learn from phase 1 Program implementation; and (c) new DLIs to target high impact, attainable aspects of the stunting reduction program, prioritized in the MTR. With many of the governance, coordination, and management concerns being substantially addressed in INEY’s first phase, bandwidth is available from a Program management perspective to prioritize critical sectoral intervention support under the phase 2 financing, with a particular focus on essential health, nutrition, and immunization services delivered through the health sector3. 15. The PforR will support following four RAs to be implemented in allover Indonesia: RA1 - Strengthening leadership, commitment, and accountability for stunting reduction. Center-of-government oversight and coordination systems are critical to ensure that stunting remains politically salient, resources are managed to ensure program delivery, and there remains a consistent focus on outcomes. The DLIs under this RA sustain and deepen the elements of the whole-of-government approach implemented under INEY: (a) cascading political commitment, backed by accountability mechanisms, at all levels of government to implement Perpres 72/2021 according to respective responsibilities; (b) planning and budgeting systems that link resources to targets and outcomes; and (c) monitoring of implementation progress, evaluation of program performance, and dissemination of annual stunting data to resolve bottlenecks, drive better service delivery, and promote salience and accountability of the stunting reduction agenda across levels. RA2 - Delivery and quality of specific and sensitive interventions. RA2 is designed to incentivize progress and improve the delivery of nutrition-specific and nutrition-sensitive interventions in Perpres 72/2021 that are high-impact and lack of support by existing operations and development partners. DLIs under this RA are designed to address gaps in (i) the implementation of high-quality early-learning program (PAUD) services (OR Implementation of Nutrition Action or Aksi Bergizi) and (ii) the strengthening of nutrition-specific interventions at national level through improvements in evidence & guidelines. RA3 - Service delivery and convergence at district/city level for stunting reduction. Pillar 3 of Perpres 72/2021 focuses on strengthening regional and community level convergence, coordination, and consolidation. In INEY’s first phase, all 514 district/city leaders signed memoranda of understanding to address stunting and implement eight Convergence Actions. Perpres 72/2021 proposes to continue the mobilization and accountability of district leaders by: engaging Regional Development Planning Agency (Bappeda), the local planning agency, to undertake analysis of key drivers of stunting in the local area and convene sector ministries to integrate stunting reduction in district plans, targets and budgets; implementing systems of results-based transfers to encourage continued progress; and to monitor and evaluate district performance. RA4 - Service delivery and convergence at village & household level for stunting reduction. RA 4 delivery supports activities that will converge delivery of priority interventions on 3 The Theory of Change of the PforR is provided in the Program Appraisal Document (PAD) - P180491 Environmental and Social System Assessment (ESSA) Page 8 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INEY PHASE 2 PFOR PROGRAM DESCRIPTION (INEY - 2) all target households in villages. The objectives of RA4 are to: (i) strengthen capacity of village Kader's to implement Perpres 72/2021 activities, including identifying households at risk of stunting and supporting nutrition intervention convergence; (ii) monitor changes in village convergence based on the consolidated beneficiary, Village Convergence Scorecard, and expenditure data; and (iii) strengthen Posyandus as the site of maternal and child health and nutrition service delivery. The RA will aim to incentivize villages to allocate additional budget from the Dana Desa to improve demand and supply for priority nutrition-specific and nutrition-sensitive interventions and increase the quality of and participation in community-based growth promotion and immunization activities. 16. The PforR Program comprises eleven disbursement linked indicators structured around four results areas as follow: Table 2-2 Summary of INEY 2 DLIs4 Responsible Results Area Disbursement-linked Indicators (DLI) Ministries/ Agencies SoVP, Bappenas, DLI 1: Commitment, performance, and accountability of MoV, BKKBN, Strengthening district & provincial leaders to accelerate stunting prevention Kemeno PMK leadership, commit & MoH ment 1 DLI 2: Results-Based and Climate-Responsive Nutrition and accountability MoF & Bappenas Planning and Budgeting Systems for stunting reduction DLI 3: Integrated and climate-responsive monitoring and Bappenas, evaluation (M&E) systems for the acceleration of stunting BKKBN, & MoH reduction Delivery and DLI 4: Delivery of nutrition interventions through the MoEC & MoH quality of specific education sector 2 and sensitive interventi DLI 5: Evidence-Based and Climate-Responsive Nutrition MoH & Bappenas ons Specific Interventions DLI 6: Improving the quality of essential health and nutrition MoH services at Puskesmas Service delivery and convergence DLI 7: Performance-based fiscal transfers incentivize Bappenas, 3 at district/city level districts to improve the coverage of essential health and MoF & MoH for stunting nutrition services reduction DLI 8: Districts achieve good performance in convergence of MoHA, interventions for acceleration of stunting reduction MoF, Bappenas DLI 9: Village kaders are skilled to support their villages to Service delivery deliver, coordinate, and achieve good performance for BKKBN, MoV, and convergence service delivery and convergence acceleration of stunting MoH & MoF 4 at village & reduction household level for stunting reduction DLI 10: Strengthening the provision of quality essential MoH health and nutrition services at the village level 2.3 Program Boundary 17. The program boundary is defined along the following dimensions: i) program focus; ii) focus area; iii) the implementing agency with overall responsibility, and iv) duration; and v) out-of-scope activity. These dimensions are defined as follows: 4 Detailed description on each DLIs for respective RA is provided in Annex C. Environmental and Social System Assessment (ESSA) Page 9 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 INEY PHASE 2 PFOR PROGRAM DESCRIPTION (INEY - 2) i. Program focus: The second phase Program is in alignment with the Perpres 72/2021 national program for acceleration of stunting reduction and the PHC transformation agenda. The PforR will cover all program beneficiaries as outlined in Perpres 72/2021. The PforR will support modification of results areas (RAs), DLIs, and targets to emphasize high impact interventions and learn from phase 1 Program implementation; and new DLIs to target high impact, attainable aspects of the stunting reduction program, prioritized in the mid-term review (MTR). ii. Focus Area: The Program will be applied allover Indonesia. ii. Implementing agency with overall responsibility: The implementation of the national agenda to eliminate stunting (the government program) require a multisectoral approach, by involving SoVP as PMU and other ministries and government agencies as PIU as listed in Error! Reference source not found.. iii. Duration. The IBRD financing for INEY 2 will support Program scale up over four additional years (2023-27). iv. Out-of-scope activity: This Program does not include establishment of large infrastructure that require considerable land acquisition, natural habitats degradation, or landscape change such as construction of puskesmas, clinics, sanitary landfill facility, medical waste treatment facility, clean water filtering or domestic wastewater treatment facility at industrial/municipal-scale. 18. Alignment between GOI program and the PforR Program with is shown below. Table 2-3 Proposed Scope of the Program Item GOI Program Program Supported by the INEY-2 PforR Title National Strategy to Accelerate Stunting Investing in Nutrition and Early Years Prevention (Stranas Stunting), updated Second Phase Program (INEY-2) with provision under Perpres 72/2021 Objective To accelerate reducing stunting To enhance the delivery and convergence prevalence rate to 14 percent by 2024 with of services to accelerate the reduction of further reduction until 2030. stunting in Indonesia. Duration 2018-2030 2023-2027 Geographic Nationwide, with emphasis to 12 priority Nationwide coverage provinces Results • Pillar 1: Improving leadership • RA1 - Strengthening leadership, areas commitments and visions in commitment and accountability for ministries/agencies, provincial stunting reduction. governments, district/city governments, • RA2 - Delivery and quality of specific and village governments and sensitive interventions. • Pillar 2: Improving behavior change • RA3 - Service delivery and communication and community convergence at district/city level for empowerment; stunting reduction. • Pillar 3: Improving the convergence of • RA4 - Service delivery and specific and sensitive interventions in convergence at village & household ministries/agencies, provincial level for stunting reduction. governments, district/city regional governments and village governments; • Pillar 4: Improving food and nutrition security at individual, family and community levels • Pillar 5: Strengthening and developing systems, data, information, research and innovations. Environmental and Social System Assessment (ESSA) Page 10 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ENVIRONMENTAL AND SOCIAL IMPACT (INEY - 2) ASSESSMENT Item GOI Program Program Supported by the INEY-2 PforR Overall US$ 6,593 million US$ 198 million Financing (Annual) 3. ENVIRONMENTAL AND SOCIAL IMPACT ASSESSMENT 3.1 Exclusion of Significant E&S Impacts 19. Under the Bank Policy on Program-for-Results Financing, activities that are judged to have significant adverse impacts that are sensitive, diverse, or unprecedented on the environment and/or affected people are not eligible for the PforR financing and are excluded from the PforR Program. 20. By adopting the exclusion principles of the Bank Guidance5, it was agreed that the INEY-2 PforR will apply the following exclusion criteria • Significant conversion or degradation of critical natural habitats or critical cultural heritage sites; • Air, water, or soil contamination leading to significant adverse impacts on the health or safety of individuals, communities, or ecosystems; • Workplace conditions that expose workers to significant risks to health and personal safety; • Land acquisition and/or resettlement of a scale or nature that will have significant adverse impacts on affected people, or the use of forced evictions; • Large-scale changes in land use or access to land and/or natural resources (eg ecological resettlement); • Adverse E&S impacts covering large geographical areas, including transboundary impacts, or global impacts such as greenhouse gas (GHG) emissions; • Significant cumulative, induced, or indirect impacts; • Activities that involve the use of forced or child labor; • Marginalization of, discrimination against, or conflict within or among, social (including ethnic and racial) groups; and • Activities that would (a) have adverse impacts on land and natural resources subject to traditional ownership or under customary use or occupation; (b) cause relocation of ethnic minority groups from land and natural resources that are subject to traditional ownership or under customary use or occupation; or (c) have significant impacts on ethnic minority cultural heritage. 21. In addition to the abovementioned project characteristic that are excluded from the PforR; considering the potential significant E&S risks of solid waste disposal facilities, medical waste treatment facilities, clean water purification facilities, and other large-scale infrastructure, following activities are excluded from the PforR scope: 1) construction or upgrading of primary health care facilities such as puskesmas, or medical waste treatment facility; 2) construction or upgrading of domestic waste disposal/treatment facilities (e.g., sanitary landfill facility; 3) construction of large-scale clean water purification facility; 4) procurement of domestic waste collecting vehicles; 5) construction of large scale clean water distribution network and associated equipment such as pump house, etc. The list of activities under Government program (Perpres 72) that are aligned with INEY 2 are shown in Annex 5. From this annex the following Environmental and Social Risks and Effects are undertaken. 5 Para.14 of Bank Guidance for Program-for-Results Financing Environmental and Social Systems Assessment (Sep. 18, 2020). Environmental and Social System Assessment (ESSA) Page 11 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ENVIRONMENTAL AND SOCIAL IMPACT (INEY - 2) ASSESSMENT 3.2 Environmental and Social Risks and Effects 3.2.1 Environmental and Social Benefits 22. The Program is anticipated to bring some benefits from the E&S standpoints, described as follow: • Convergence at district/city level, including appointment of a dedicated focal agency handling the Program’s E&S elements whom is authorized to coordinate with other relevant stakeholders in district/city level (such as sub-national health agencies, kaders at village level), would increase the opportunity of PHCs (particularly in the remote areas or without access to medical waste treatment/disposal facilities) to receive guidance and support in a more intensive and clearer manners on how they supposed to manage their own medical wastes so they could comply with the regulatory requirements. The agency may provide directions to those PHCs to handle their medical waste following procedures of the Appendix VI of the Minister of Environment and Forestry’s Regulation No. P.56/Menlhk -Setjen/2015 regarding Procedures and Technical Requirements for Hazardous and Toxic Waste Management from Health Service Facilities (‘MoEF Reg. 56/ 2015’) also monitor and evaluate the actual implementation of this approach. • Strengthened service delivery and convergence at district, village, and household levels could collaboratively improve accessibility of community members, including families with high-risk of stunting, for using appropriate sanitation facility provided in their household surroundings following technical specifications provided in the Minister of Health’s Reg ulation No. 3 of 2014 (‘MoH Reg. 3/2014’) regarding Community-based Total Sanitation (Sanitasi Total Berbasis Masyarakat, or ‘STBM’). This would include easier and more reliable access to individual or communal toilets, black water treatment unit (such as septic tank), and clean water distribution network and filtering apparatus. • Strengthened service delivery and convergence at district, village, and household levels could also improve the way local health agency at district level partnering with PHCs in delivering STBM to the community as well as to monitor the impact and evaluate whether an adjustment of strategy/approach is required instead. To achieve this, the local health agency should be able to provide clear guidance and support continuously to the PHCs along the Program’s lifetime. • The Program could potentially provide an equal service for all community members, including indigenous people and vulnerable community, by also paying attention to cultural acceptability aspect. • The Program could emphasize the aspect of rights of medical and volunteer resources in PHCs for obtaining appropriate trainings and instruments that are essential in order to protect their own health and safety while improving delivery of health services for the community. • The Program could establish a better communication and coordination at district level that is exclusive among stakeholders, involving community members, medical staffs, cadres, government authorities, non-government organization (NGO), etc. • The Program could set up an integrated mechanism to communicate and respond to grievances in accordance with internationally accepted standards. 3.2.2 Environmental and Social Risk and Effects Environmental Risk and Effects 23. The overall potential environmental risk from the PforR components of INEY Phase 2 is considered as Moderate and is related to the implication of the increased numbers of Posyandu, supporting Posyandu strengthening, outreach and monitoring of zero dose immunization children, which generate medical waste from the vaccination (used syringe) and other nutrient interventions activities (expired vitamins, food waste etc.). Below are detailed rationales: Environmental and Social System Assessment (ESSA) Page 12 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ENVIRONMENTAL AND SOCIAL IMPACT (INEY - 2) ASSESSMENT • Implementation of the Program in primary health care centers (such as pre-natal care and examination, birth support, child vaccination, supplementary nutrition supply for toddlers, etc.) are expected to contribute to the increment of medical waste, relative to the facilities’ regular operational activities. In areas where PHCs could potentially generate a considerable amount of medical waste, such as in high-populated city like Surabaya, waste handling transporter and facilities are already accessible. For areas where access to licensed waste transporter and treatment facilities are very limited, a technical procedure in the Appendix VI of MoEF Regulation No. 56/2015 that allows medical waste to be handled safely can be applied. This procedure focuses on isolation and containment of medical waste within low permeability thick-clay (or for sharp objects layered with concrete) underground pit, which minimizes possible pathway for exposure against human and ecological receptors. It is noted however that such regulatory provisions have yet made familiarized to medical staffs and sanitarian at less developed area, leading to cases of prolonged storage of medical waste in inappropriate locations. This Program, on the other hand, should promote appointment of focal government agency that is responsible to ensure rightful implementation of such procedure by all primary heath care centers. • Provisions of sanitation facilities at household scale in remote areas (including clean water pipelines, toilets, and septic tanks, dedicated domestic wastewater channel, nature-based water filtering device, and waste composting equipment) that are promoted by the Program, as part of the convergence actions, have positive effects and limited adverse impact on the environmental landscape. Most of the impacts are from construction activities that can be mitigated by the code of practices from public work agencies or the handbook of Good and Bad Infrastructure for the CDD-type construction works (PNPM, 2008). Establishment of such facilities have the potential to introduce positive effects on some environmental aspects, including pollution prevention and GHG emission reduction, as described below: o the provisions of separated domestic wastewater channels, toilets, and septic tanks are useful to control the release of fecal microorganisms into the natural media.; o the use of nature-based water filtering media reduces the possibility of disposal of chemical waste typically generated post treatment in water cleaning process, e.g., chlorine, hydrogen peroxide, etc.; and o the promotion of composting practice reduces emission from the burning of organic and domestic waste on each household yards in absence of municipal waste collector and nearby landfill facility system. To address the issue with the potential increase of medical waste generation from the Posyandu6, current measures are in place to handle the medical waste aspect as stipulated in the national regulations, and the increment of medical waste is not expected to overwhelm the existing system. However, there are incidents when medical waste is not properly collected, transported, and disposed of as per the regulations from the health care facilities other than Posyandu, such as Puskesmas or district hospital. This has gradually improved since 2017 (See Box 1). Measures will be included in the Program Action Plan to strengthen the awareness of the healthcare workers of the Puskemas/district hospital to transport their waste to the closest facilities available at provincial level. Whereas for health care facilities at a very remote area/lagging regions the socialization on the application of Annex 6 of PermenLH 56/2015 shall be intensified. In addition, an action plan similar to the one under I- 6MOH intends to increase the Posyandu numbers at village and urban wards (kelurahan) level but careful assessment of the activities at Posyandu reveals that Posyandu sessions are conducted on at least a monthly basis that will include growth monitoring, Family Planning, mental health counseling, general MCH care, guidance on the prevention of diarrhea, immunization and curative services. The immunization used will also vary (oral dose most of the time as compared injections). Outside of the Posyandu sessions, kaders are responsible for updating a register with names of pregnant women, postpartum and breastfeeding mothers, infants, and under-5 children); (2) updating the statistics describing Posyandu session utilization; (3) carrying out follow- up visits to houses of absent participants and participants who need further health education; and (4) attending community committee meetings. Source: https://chwcentral.org/indonesias-community-health-workers-kadersl/ Environmental and Social System Assessment (ESSA) Page 13 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ENVIRONMENTAL AND SOCIAL IMPACT (INEY - 2) ASSESSMENT Sphere and Covid PforR will also be developed, such as a regular coordination between MoH and MoEF and the formal appointment of focal point at SoVP to closely monitor this issue during program implementation (especially for remote locations and lagging regions in Indonesia) and to continuously remind TPK cadre and Posyandu staff of proper management of medical waste. Box 1: The Provision of Medical Waste Treatment Facilities Since 2015 Indonesia through the MoEF (Ministry of Environment and Forestry) and Bappenas (National Planning Agency) started a breakthrough program for handling medical waste to respond to a nation-wide media coverage on illegal dumping of medical waste at a riverbank in Cirebon area (detik.com). This was due to a serious violation from the waste service provider and due to lack of facilities provided by the Government in handling medical waste. In 2017 Bappenas funded a project for MoEF to construct a medical waste facility by incinerating system that is properly designed and operated. The project is located at KIMA Industrial Estate in Makassar South Sulawesi. In 2020-2021 when pandemic hit, Bappenas decided to replicate the project by constructing one medical waste treatment facility for each province. Up to now, 2023, there are now 15 facilities across Indonesia that is full dedicated only to treat medical waste. In 2024 Bappenas targeted to construct another 10 facilities. The total target capacity is 26,880 tons/year. The first pilot project in KIMA with the capacity of 100 kg/hour is now started generating revenue and a set of provincial regulation as well as institutional arrangement (UPTD) had been established and this has become a model for other provinces. MoEF routinely monitor the performance of this facility including the environmental parameters. In Java Island itself there are now already 6 private companies who treat the medical waste certified by MoEF. The largest capacity to be built outside Java is 300 kg/hrs. The overall plan is to increase the capacity of treated hazardous waste to 26,880 tonnes per annum. As the key principle to medical waste treatment is ‘proximity concept’; the surrounding provinces in other islands than Java that have no facilities can send their waste to the closest province. This will reduce the cost a lot as compared to send the same to Java Island. Whereas the medical waste handling for a very remote health care facilities (e.g., to reach the village we need to take a 4-hour boat trip) appendix VI of Permen 56/2015 is applied with permit issued by the local Health and Environment Agency. In cooperation with Environmental Health Directorate of Ministry of Health, the above information and available capacity and practice could become one of the program action plans to socialize these to Kaders at Posyandu, Health care workers at Puskemas, and Pustu (Puskesmas Pembantu). Social Risk and Impact 24. The overall social risk of the PforR component of the INEY Phase 2 is rated Moderate, given the scale and complexity of the project, nationwide coverage. The INEY Phase 2 program is expected to contribute to addressing equity issues in nutrition intervention program distribution in the community. However, social risk remained, pertaining to equality in community access to the services and benefits of the program including across vulnerable groups and Indigenous People (if present in the targeted communities), potential challenges in engaging the disadvantages and hard-to-reach communities, cultural sensitivity of the Indigenous People, also the complexity of grievance mechanism that can be applied across provinces and villages. 25. Similar to the INEY Phase 1, the main social risks from the PforR components are related to the ability of individuals, households, and diverse community groups including the Indigenous Peoples and other vulnerable groups such as remote community and poor families, to get benefits from the stunting program and services in an accessible, safe, and inclusive manner. Assessment undertaken during project preparation informed that communities in remote areas and vulnerable groups experience (and more prone to) challenges to access the educational and behavioral change communication, as well as in receiving nutrition specific interventions, particularly health services. It was observed that in the remote or traditional community, cultural barrier in receiving nutrition specific were still presence, while poor families with lesser education and limited access to advance health knowledge were still having low awareness on the urgency of pregnant mother and child nutrition in affecting stunting. 26. Such potential for inequality might create risk of conflict which stems from real or perceived differences in how the benefits of the program are distributed which makes the need for an effective grievance system important. As identified during the INEY Phase 1 implementation, there were challenges in the accessibility of community and stakeholder to a clear grievance mechanism (for receiving, tracking, and handling concerns, issues, challenges, inputs, and lessons learned) in relation to stunting reduction as well as program implementation. Based on Environmental and Social System Assessment (ESSA) Page 14 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ENVIRONMENTAL AND SOCIAL IMPACT (INEY - 2) ASSESSMENT the recent mission for the Phase 2 ESSA preparation, grievance handling practices among regions vary. A range of alternative mechanisms were observed although not all of them are formally recognized as a grievance mechanism. In less developed regions, health issues are communicated from person to person, via cadres or directly to the village government. Concerns/issues and challenges are also communicated during the quarterly multi-sectoral district government workshop meeting on health issue (Lokakarya Mini Lintas Sektor Kesehatan). However, these mechanisms are not formally recognized as channels for grievances handling. As such, concerns/ issues shared through these channels are not captured/reported, properly tracked, and resolved. Meanwhile, in the more developed regions, mobile applications are utilized as a tool to monitor effectiveness of government’s intervention program and to target the right beneficiaries. At national level, the effectiveness of Lapor!, a grievance handling mechanism which was proposed for the INEY Phase 1, varies between region, depending on the level of community access and familiarity with internet system, advanced electronic devices for communication and to social media. While it is considered to be effective in capturing concerns/issues/inputs from wider public/national level stakeholders, the latest INEY Phase 1 ISM identified challenges to properly record, track, report, and resolve grievances due to absence of specific role within the executing agency or staff in-charge for this channel. In addition, limited knowledge of broader community at village level regarding Lapor! was also reported. Alternative mechanisms, such as the use of social media (with the identified presence of TP2S in social media), issues and inputs/suggestions might be raised from public via Instagram, Facebook, LinkedIn, etc.; are also available. There is a need for improvement in managing the grievances received from all the channels to ensure appropriate response/ resolution is implemented. 27. Another risk is related to occupational health and safety (OHS) of workers involved in the operationalization of the program, particularly the community workers in Pustu/Posyandu (i.e., local cadres and volunteered staff). It is understood that generally, these community workers are not familiar with the health and safety standards and practices. Occupational health and safety risks may occur during their travel to sites for program implementation and during the use of health equipment when undertaking medical action (e.g., when assisting medical staffs in birth handling or if any interaction with pregnant women or child with communicable diseases). Limited access of these local cadres and volunteered staff to adequate occupational health and safety training program or facility may exacerbate the potential risks and impacts. 3.3 Contextual Risks 28. The contextual risk of the Program is considered Moderate. The Program will be implemented widely all over regions in Indonesia i, where some cultural sensitivities and ability to open access for distributing Program’s services to remote sites will become essential factors to ensure the Program’s objectives are achieved. 29. IP communities and other vulnerable groups are potentially living in the Program areas which makes these groups considered as potential subject of the Program implementation. Knowledge and skill on cultural-based approach are essential to be wielded by cadres and voluntary personnel in educating and ensuring participations of those groups in the Program. Equality of receiving services from PHCs or for having sanitation infrastructure established around the living area is likely going to be a challenge since many communities live in a geographically remote location from major cities. 30. Additionally, risks regarding enforcement of labor rights have to be considered, where it should promote cadres and volunteer personnel (‘staf sukarela’) to receive fair compensation and benefit for their efforts. Any contractual agreement between local agency with cadres and volunteer personnel should always guarantee protection of their rights, including the right to obtain adequate trainings and access to appropriate equipment while doing the works to ensure the health and safety of those personnel. Environmental and Social System Assessment (ESSA) Page 15 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ENVIRONMENTAL AND SOCIAL IMPACT (INEY - 2) ASSESSMENT 3.4 Institutional Capacity and Complexity Risks 31. Institutional capacity and complexity risk of the Program is considered Moderate. With the issuance of the Perpres 72/2021, adjustment on the INEY Phase 2 implementation arrangement will be made, as the Regulation substantially alters the implementation for the stunting reduction agenda beyond what was envisaged at the original INEY Phase 1 project design. The new regulation mandates BKKBN, as key technical lead of the national stunting prevention program, to be responsible for collecting field data and carrying out analytics, contributing to updated Convergence Action guidelines. The SoVP continues to play a central role, as the Chair of the Steering Committee. Bappenas is assigned to undertake the role of monitoring and evaluation for the program. The Coordinating Ministry for Human Development and Cultural Affairs (Kemenko PMK) is the Deputy Chair on implementation supervision and the MoHA is the Deputy Chair for oversight and monitoring of local governments. It is understood that the INEY Phase 2 will also add the Ministry of Health (MoH) to the implementation arrangements, which would be a valuable addition for the environment risk management, particularly related to medical waste issue. Previously under the INEY Phase 1, institutional support to the MoH at the central level has been deployed through SoVP. However, there is a need for substantial increase in the financing toward MoH objectives, requiring additional, intensified TA resources to support the agenda to be agreed with new leadership. MoH will be the lead agency tracking and conducting performance evaluation of national spending on priority nutrition interventions and priority districts implementation, and the implementation of behavior change communication activities. 32. Based on the Institutional Review, SoVP will resume its role that under the previous INEY-1 and the initial process of INEY-2 is in charge. Specifically on E&S aspects, SoVP currently has limited resource to appoint a dedicated focal point or specialist to ensure facilitation of E&S principles of the Bank, including through arranging a closer coordination between PHCs and relevant agencies in charge on E&S management (e.g., local health or environmental agencies). 3.5 Political and Reputational Risks 33. The overall political and reputational risks for the Program are considered Moderate. The Program is led by multi-sectoral ministries and agencies at both national and regional levels, which emphasizes convergence of various stakeholders at both levels to be able to obtain the best results of the Program. Separately, Indonesian government has determined to conduct a nation-wide presidential and legislative elections on 14 February 2024, followed with regional leader election on 27 November 2024. As consequences, changes in the leadership and organizational structure of relevant ministries and agencies at both national and regional levels are to be expected. In such situation, it is anticipated that the government's priorities would be then to follow the immediate political wills of respective elected leaders. Although it is unlikely that the new government regime is going to terminate or changes significantly the way the Program is implemented, there is a possibility that the coordination scenario between ministries, agencies, and other stakeholders will need to be reconsolidated anticipating changes of bureaucratic officers within the government bodies that are highly likely to happen following the leader election. The new leaders and authorized officers should maintain the same commitments with what the institutions have agreed before the electoral events, and to prioritize the Program along their newly introduced agenda. Additionally, the new-appointed officers at government bodies (if they are) should be provided with sufficient information and knowledge on how the Program is being implemented so far, and what the expected goals and roadmap. 34. Aside of the abovementioned political concern, there is no considerable risk on reputational aspect coming out of the Program. 3.6 Overall Environmental and Social Risks Rating 35. The overall environmental and social risk rating for the Program consolidates the findings from the above assessment, with consideration of: 1) likely E&S effects as Moderate; 2) likely E&S Environmental and Social System Assessment (ESSA) Page 16 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY contextual risks as Moderate; 3) likely institutional capacity and complexity risks as Moderate; and 4) likely political and reputational risks as Moderate. 36. The results show that the Program-supported activities tend to have moderate for both environmental and social impacts which revolves around the cultural appropriateness of the Program particularly for IP, equality to service delivery of the Program particularly for vulnerable groups and community in remote areas, and fulfillment of labor rights for non-staff personnel. The institutional capacity and complexity are Moderate, considering that this Program is implemented by various ministries, agencies, and regional government. SoVP currently may not have an available resource to become a focal specialist to ensure facilitation of E&S principles of the Bank, including through arranging a closer coordination between PHCs and relevant agencies in charge on E&S management (e.g., local health or environmental agencies). Additionally, the election of presidency, legislative, and regional leaders in 2024 is likely going to be followed up with certain changes in organizational structure and position of officers-in charge; causing a necessity for a follow-up coordination between institutions to guarantee prioritization of the Program post-electoral event. 4. ASSESSMENT OF GOI ENVIRONMENTAL AND SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY 37. The review of systems covers the current existing system to manage environmental and social risks associated with the PforR operations in response to the INEY Program. This section covers the review of the relevant policy, legal and regulatory frameworks. A summary of the institutional responsibilities is provided as they relate to environmental and social performance as part of the PforR activity implementation. 4.1 Relevant National Policy and Regulatory Framework Overview 38. There have been quite significant regulatory changes related to stunting since the initial commencement of the INEY Phase 1. Specifically on stunting reduction, the President has added stunting reduction as one of 16 National Priority Projects and incorporated the National Strategy for Acceleration of Stunting Reduction (Stranas Stunting) targets and multi-sectoral convergence approach in the National Medium-Term Development Plan (RPJMN) for 2020- 2024. Following the commencement of RPJMN, a Presidential Regulation (Perpres) No. 72/2021 was issued in August 2021. This new regulation enacted into law Indonesia’s whole- of-government approach to improve nutritional outcomes, reduce stunting, and accelerate human capital development. Meanwhile although there is no one system specifically regulate environmental and social performance, broader E&S regulatory framework has been frequently updated, including through the issuance of the Omnibus Law (UUCK or Job Creation Law). 39. The assessment has focused on the relevant provisions and key instruments that impact on the health and stunting program implementation, including community health service delivery at the household and village level; medical waste management; framework related to Indigenous People and attention to vulnerability; and complaints handling. Medical Waste Management 40. The Government Regulation No. 22 of 2021 on Protection and Management of Environment (‘GR 22/2021’) considers that medical waste, consisted of clinical waste with infectious characteristics, expired pharmaceutical products or chemicals, medical/laboratory equipment contaminated with infectious waste, waste water treatment sludge from hospital and other medical/health facility, is categorized as hazardous waste. The regulation mandated general hazardous waste to be managed under provision of the GR 22/2021 itself with additional details provided in the MoEF’s Regulation No. 6 of 2021 on Procedures and Requirements of Hazardous Waste Management ('MoEF Reg. 6/2021’). Environmental and Social System Assessment (ESSA) Page 17 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY 41. Requirements from the abovementioned regulations are harmonized with the Good International Industry Practice (GIIP), including the provisions on waste identification, reduction, segregation, storage, transport, disposal and occupational health and safety for waste handler – with all activities to managing medical (hazardous) waste, including to store, transport, treat or dispose, require valid permit/license from relevant agencies. 42. The country’s approach in hazardous waste management is built upon the “cradle to grave� principle with a rigid manifest system to track the flow of waste from the generator to the disposal. As per 2020, manifest reporting is conducted through an online reporting application (namely “SIMPEL� or “SIRAJA�) directly by hazardous waste producer, transporter, or treatment facility/company or via barcoded manual manifest for later input into the online reporting system. This is system is established under the MoEF’s Regulation No. P.4./MENLHK/SETJEN/KUM.1/1/2020 on Hazardous Waste Transportation (‘MoEF Reg. 4/2021’) with schematic process provided in Figure 4-1. Figure 4-1 Electronic-Based- Hazardous Waste Recording and Reporting System in Indonesia7 43. Based on the Government Regulation No. 66 of 2014 on Environmental Health (‘GR 66/2014’), waste management is part of the efforts to protect public health, in which waste management in health facilities, including clinics, laboratories and hospitals, must comply with the related Minister Regulations. As per regulatory requirements in Indonesia, medical waste ideally should be managed in accordance to the Minister of Health’s Regulation No. 18 of 2020 regarding Region-Based Medical Waste Management Practice for Public Health Facilities (‘MoH Reg. 18/2020’) which in general mandating medical waste to be disinfected and appropriately segregated, manifest-recorded, stored temporarily at designated and licensed area, transported by licensed transporter, and finally destructed or landfilled in licensed facilities provided by the city/municipality government, or through agreement with certain private companies operating in the region. 44. In remote areas or communities where access to waste management collection and treatment facilities are not available/limited, such requirements are however not completely implementable. Healthcare facilities located in remote areas, and smaller healthcare facilities with limited amount of medical waste generation and budget for medical waste management often face challenges. For health facilities located far from any medical waste treatment facilities, when the amount of medical waste generated have not met the minimum amount for 7 Translated from MoEF’s website, 2020 (https://www.menlhk.go.id/site/single_post/3102/transformasi-digital-klhk-dengan- manifes-elektronik-limbah-b3) Environmental and Social System Assessment (ESSA) Page 18 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY transport, the medical facilities will request extension of temporary storage of medical waste with the local Environmental Agency. 45. The GOI through MoEF and Bappenas have progressively increased numbers of medical waste treatment facilities in Indonesian starting from 2015 to overcome issues caused by uneven presence of licensed medical waste facilities in Indonesia. Currently 15 medical waste facilities have been established, with a projected addition of 10 facilities in 2024. Uneven distribution of licensed hazardous waste transporters, with 97 out of 140 licensed transporters located in Java should be considered as well as an aspect that needs to be improved. Using the ‘proximity principles’ the government is trying to establish one medical waste treat ment facility per province so the cost and the risks from transportation of medical waste will be reduced. Based on the distribution and availability of medical waste processing facilities in Indonesia (Figure 4- 2), it is evident that the waste processing facilities in the country are currently dominated by the use of incinerators. Figure 4-2 Distribution of medical waste processing facilities and transporters 8 46. Based on information collected from the MoEF, medical waste treatment facilities have been established in each of priority provinces with details provided in Error! Reference source not found., however, during the assessment mission, it was noted that not all provinces has such facilities due to the issue of lack of priority for the governors/major , land availability and lack of awareness that this activities are revenue generating activities. Consequently, not all medical waste treatment facilities are available at each province as of now and the health center facilities might need to transport their waste to neighboring provinces which is not always located in reasonable transporting distance to the PHCs in addition to absence of appropriate (licensed) waste transporter service in many locations in remote areas. Indonesia has now 35 provinces. Table 4-1 Medical Waste Treatment Facilities Capacity in 12 Priority Provinces9 Year of Waste Treatment Capacity No. Province Establishment (kg/hour) 1 Sulawesi Selatan 2017 100 2 Aceh 2020 300 8 MoH, 2023 9 MoH, 2023 Environmental and Social System Assessment (ESSA) Page 19 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY Year of Waste Treatment Capacity No. Province Establishment (kg/hour) 3 Sumatera Barat 300 4 NTB 300 5 NTT (Manggarai) 150 6 Kalimantan Selatan 150 7 Bangka Belitung 200 8 Papua Barat 150 2021 9 Sulawesi Barat 150 10 NTT (Sumba) 150 11 Jambi 200 2022 12 Kalimantan Utara 200 47. To meet the regulatory requirements, public health facilities located in remote areas or with minimum access to medical waste treatment/disposal facilities, could be directed and facilitated by district health agency to follow technical procedures regulated in a separate ministerial regulation, i.e., the Appendix VI of Minister of Environment and Forestry’s Regulation No. P.56/Menlhk-Setjen/2015 regarding Procedures and Technical Requirements for Hazardous and Toxic Waste Management from Health Service Facilities (‘MoEF Reg. 56/2015’). This regulation specifies procedure and technical requirement for such public health facilities to prevent or minimize exposure of pathological waste (e.g., body fluids-contaminated materials) and hazardous medical wastes (e.g., sharp objects, like needles or glass vials) generated from their operations by containing them in cemented brick or thick-clay layered dug holes in order to eliminate pathway of exposure to environmental or human receptors around the area. Existing regulations require healthcare facilities at provinces where there are no medical waste treatment facilities to maintain working contract with licensed transporter to transport the medical waste into nearby facilities. These regulations also include measures for environmental and workers’ safety risks. 48. The MoH also makes it mandatory for all hospitals to obtain accreditation every three years. The primary healthcare accreditation, which include medical waste, are required for all Puskesmas and clinics and regulated in MOH Regulations No. 46/2015, and to be reassessed every three years for community health centers and hospitals. All parties involved in medical/hazardous waste management business (storage, transport, treatment, and disposal) will require special permits. The procedure to obtain such permit will follow Government Regulation No. 22/2021. The PforR need to ensure the system to monitor the medical waste generation and proper management of the medical waste are in place. Sanitation Program 49. Framework of sanitation program in Indonesia is regulated in the Community-based Total Sanitation (Sanitasi Total Berbasis Masyarakat, or ‘STBM’) program, formalized under the MoH’s Regulation No. 3 of 2014 (‘MoH 3/2014’). This regulation provides basic sanitatio n principles to be conducted by and for the community, which includes implementation of hygiene behavior supported with procurement and maintenance of sanitation facilities such as (but not limited to) individual or communal toilets, black water treatment unit, such as septic tank; sanitary landfill facility; and clean water distribution network and filtering apparatus. This regulation mandates national and local government to establish specific strategy, technical approach, monitoring and evaluation methodologies for each community. Such strategy and approach should be disseminated to other stakeholders that interact directly with the community to initiate the program, e.g., medical personnel, cadres, volunteer personnel, donors, etc.; with continuous follow-up guidance and supports while they are being executed. However, despite of the relevancy of sanitation aspect to the stunting program, INEY Phase 2 does not directly cover upstream or downstream management of sanitation since it has been carried out by Environmental and Social System Assessment (ESSA) Page 20 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY designated government teams under separate government programs, such as STBM or Pamsimas. Community and worker health and safety 50. Indonesia has a comprehensive legislative framework regarding occupational health and safety (OHS) as well as community health and safety. Although main institutional responsibility of OHS management is under the Ministry of Manpower, however in relation to the Program, particularly the delivery of nutrition-specific and sensitive interventions (healthcare services and early years education providers) at village-level, responsibility of the workers’ health and safety will be under each of the respective agency. These include the health and safety of midwives, nurses, cadres, and staff under Puskesmas and Posyandu (under the MoH), village facilitators (under the MoV/MoHA), also PAUD teachers under the Village Government coordination. 51. Applicable regulatory framework including the Law 1/1970 on Work Safety (Work Safety Law); Government Regulation (GR) 50/2012 on Implementation of Occupational Safety and Health System; and the Ministry of Manpower Regulation 5/2018 on Occupational Health and Safety in a Workplace Environment. In addition, relevant to the Program social risk on the community workers, applicable regulatory framework includes Law No. 36/2009 on Health and Law No. 4/1984 on Infectious Disease. Attention to Indigenous People and Vulnerable Groups 52. To date, there is no statutory law that specifically addresses the matter yet. Bills have been introduced in 2014 and again in 2020 but have not been passed. An exception to this is the statutory recognition of the indigenous people in Papua under Law 21 of 2001 on Special Autonomy for Papua Province (as amended). For the rest of the country, the matter of indigenous people is addressed under various sectoral regulations. The second amendment to the 1945 Indonesian Constitution enshrines state recognition and respect for communities living by the customary law (Adat) and traditional value systems. Subsequent laws, such as the Basic Agrarian Law No. 5/1960 and the Forestry Law No. 41/1999 (with recent revision through Constitutional Court Ruling No.35/2013), also the Government Regulation (GR) No. 23/2021 on Management of Forestry and MoEF Regulation 9/2021 on Social Forestry Management provide recognition to the rights of Adat communities. However, these sectoral laws, including implementing presidential and ministerial regulations are focused on land and natural resources, as such they are not relevant to the ESSA. The recent enactment of the Village Law No.6/2014 also provides opportunities for Adat communities to strengthen their participation, including managing development that addresses their needs and aspirations through support from the village funds. However, guiding regulations with regards to Adat communities are still being developed and further facilitation support is currently being provided to some degree by MoV at the village level that corresponds to the needs of these communities. 53. Indonesian laws use various terms to refer to Indigenous Peoples which are interconnected with the regulation definition of vulnerable groups, including masyarakat suku terasing (isolated tribal communities/remote Indigenous communities), masyarakat tertinggal (lagging communities), masyarakat terpencil (remote communities), masyarakat hukum adat (customary law communities), and more simply masyarakat adat (communities governed by custom). These communities usually dependent on natural resources and have limited access to public facilities. Remote Indigenous Community is defined (Article 1 (2) of PR No. 186/2014), i.e., a group of people who are bound by geographical, economic, and/or socio-cultural unity, and are poor, live in a remote area, and/or are socio-economically vulnerable. They are to be empowered to be independent in meeting their basic needs such as food, clothing, housing, health, education, work, and/or social services (Articles 2 and 1(4) of Ministry of Social Affairs (MoSA) Regulation No. 12/2015). Implementation falls under the authority of MoSA in coordination with MoV, since program implementation at local (district and village) level would very much depend on the local government capacity. Another village regulation relevant to vulnerable groups is the MoV Regulation No. 19/2017 concerning prioritizing the use of village funds to improve the welfare of the village community and the quality of human life, which are Environmental and Social System Assessment (ESSA) Page 21 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY essential for reduction of poverty. However, the legal framework is generally silent on specific differentiated measures to prevent exposing these groups to adverse impacts resulting from a project. Broader attention to project impacts on vulnerable groups is incorporated within the GoI’s environmental impact assessment process as well as in the land acquisit ion for public interest, neither do not directly applicable for the Program. 54. The ESSA approach on Indigenous Peoples and vulnerable groups has been very much informed by the imperatives for social inclusion and Indigenous Peoples’ ability to participate in program interventions in a meaningful and informed way. Therefore, the challenges foreseen with regards to Indigenous Peoples are not related to the legal framework pertaining to the rights of Indigenous Peoples, but more on technical aspects within the Program to ensure that the approach and engagement suits the needs and aspirations of these communities as well as the ability of the Program interventions to reach these communities, who may live in remote areas or still live in a nomadic and sedentary fashion, and therefore are hard to access. This will be further discussed in the section on findings. Grievance Mechanism 55. There is no one system for receiving and addressing inputs, feedback or complaints, a range of existing mechanisms relevant to the Program are described below. • National grievance channel: existing national complaint handling management system for all public services is called Lapor! and is managed under the Ministry of Administrative and Bureaucratic Reform (KemenPAN-RB). Under the INEY Phase 1 the system was agreed to be used by the Program for its grievance handling mechanism. The system has been integrated with most of government institutions, thus was expected to enable complaints resolution effectively. Stunting issue has been added into the Lapor! application menu. Feedback or concerns related to stunting program was expected to be channeled and handled by relevant ministries and institutions. • Local (village and district) level: There is no single formalized channel for complaints handling at the village level. The INEY Phase 1 ESSA identified that the village community empowerment and development agency was the primary institutional unit for handling complaints related to village governance, however dominated by the misuse of village development funds, followed by village boundary disputes and misuse of authority by village officials. The current Program assessment identified potential roles of other agencies through their existing channels including MoV through their Village Facilitators; BKKBN through their Family Facilitators; and District government through the quarterly district government meeting for health sector. Complaints handling does not appear to form part of the responsibilities of any specific role/unit, and there is no specific assignment or involvement in the actual dispute settlements, however with their local presence, capacity and regular coordination with the village stakeholders, their roles can be optimized to oversee and report issues related to Program. • Puskesmas/Posyandu: There is no specific regulation on complaint handling for the delivery of Posyandu services. Should any serious adverse events such as illness post vaccination, common practice is to direct the complaint to Puskesmas staff or through midwives or directly to the District Health Agency. • PAUD: Formal grievance handling at PAUD is not specifically regulated, however the preparation assessment of the Program identified that complaints related to PAUD were usually not related to the services provided for the delivery of holistic, integrated early childhood education and development (ECED), but rather the amount (or different amounts) of fees PAUD teachers/cadres received. Similar issue was identified in the INEY Phase 1 program. Grievances are handled on an ad-hoc basis. Health services delivery at village level Environmental and Social System Assessment (ESSA) Page 22 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY 56. The new Village Law No 6/2014 was issued in January 2014, replacing the previous Law No. 32 of 2004 on Regional Autonomy. The Village Law incorporates a number of key Community Driven Development (CDD) principles and institutions, including participatory village planning, implementation of village-level projects, inter-village collaboration, community facilitation and community oversight. Under the Village Law, village governments are responsible for administering village funds (Dana Desa and Alokasi Dana Desa) and accommodating community needs through democratic processes (hamlet and village deliberations). The Village Law introduces an additional function of Village Councils (BPD, Badan Permusyawaratan Desa) to supervise the performance of Village Heads (Article 55). 4.2 Institutional Responsibilities 57. The key institutions involved in the delivery of the INEY Phase 2 PforR are presented in the table below. Table 4-2 Key Institutional Stakeholders for the Program Results Area Responsible Agencies DLI1: SoVP, Bappenas, BKKBN & MoHA 1 – Strengthening leadership, commitment DLI2: MoF & Bappenas and accountability for stunting reduction DLI3: Bappenas & MoH 2 – Delivery and quality of specific and DLI4: MoEC & MoV sensitive interventions DLI5: MOH, Bappenas DLI6: MOH & MOHA 3 – Service delivery and convergence DLI7: Bappenas, MoF, MOHA & MOH at district/city level for stunting reduction DLI8: MoHA, MOF, Bappenas DLI9: BKKBN, MoV, MOH & MoF 4 – Service delivery and convergence at village & household level for stunting DLI10: BKKBN, MoV, MOH reduction DLI11: MOH, MOHA, MOV 58. For the Village-level delivery of the program, the following institutional arrangement applied: • Village Government is the key stakeholders for addressing social performance are the village government, and the village and household level healthcare and early years education providers. Village governments play a critical role to ensure availability of nutrition-specific and sensitive interventions at Posyandu and PAUD. Under the Village Law, village governments are responsible to administer village funds (Dana Desa and Alokasi Dana Desa) and accommodate community needs through democratic processes (hamlet and village deliberations). The role of village governments in mainstreaming health and education into village development plans (RKPDes) and village development budget plans (APBDes), including in determining budget allocation and/or directing how allocated budget is spent, is critical and may continue to become stronger in the coming years. • Frontline health services are essential for nutrition-specific interventions (supported by the Program) are administered by Puskesmas (public PHCs) and their auxiliary and outreach services, including midwives and nurses. The public primary care system also includes auxiliary Puskesmas (Pustu) for outreach activities in remote regions, village-level delivery posts (Polindes, often the home of the village midwife) and village health posts (Poskesdes). Frontline service delivery at village-level across Indonesia is also undertaken through Posyandu and by village midwives (who are formally part of the health system). Posyandu is a monthly event manned by at least five types of community health workers that cater to the five essential services: registration, weighing and monitoring children’s growth, recording of child growth in health cards, counselling and education; immunization and ante and post-natal care as part of outreach services of Puskesmas. Midwives and Environmental and Social System Assessment (ESSA) Page 23 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY nurses are important frontline service providers due to their placement and/or operations at the village level and therefore, are more accessible compared to doctors who are mainly based in Puskesmas at the sub-district level. Cadres - who work on a voluntary basis - are not part of the formal health system and do not receive monthly salaries (only minimum transport allowance from village governments). • PAUD is main stakeholder for the delivery of holistic, integrated early childhood education and development (ECED) are run by PAUD teachers who either serve on a voluntary basis or recruited by the village government, and in some cases paid from parents’ contribution/voluntarily fund. PAUD services are demand-driven and there could be a lack of incentives for PAUD teachers to outreach to tend to children from diverse community groups. 4.2.1 Environment 59. Under the INEY PforR, the main institutions which are expected to play a role in environmental management performance include MoH, MOHA and MOEF. The table below describes roles and responsibilities of the institutions in managing the potential environmental risks. Table 4-3 Institutional Roles and Responsibilities for Environmental Performance Institutions Roles and Responsibilities for Environmental Performance Secretariat of SoVP (as PMU) to hire/designate a focal point that able to oversee the overall Vice President performance of E&S management of the Program in accordance to regulatory (SoVP) requirements [and the Bank’s PforR standards]. The focal point to coordinate with the Bank’s E&S Safeguards and other relevant ministries or agencies that has direct control to the implementation of relevant environmental requirements, for example, regarding medical waste handling at PHCs. Ministry of MoH through Directorate General of Public Health (Ditjen Kesmas) and Directorate Health (MoH) General of Health Service, in coordination with the MoEF, to coordinate with regional health agencies (Bidang Kesehatan Lingkungan of Dinas Kesehatan) to provide direction and supervision for appropriate medical waste handling at PHCs (e.g., Puskesmas, Posyandu, Poskesdes, etc.). Additionally, to ensure that guidance on strategic, approach, monitoring on any sanitation-related program that is delivered as part of the PHC are received in clear manner by medical staff, voluntary staff or cadres that are involved.. Ministry of MOHA provides supports to Posyandu. Implementation of Posyandu requires inter- Home Affairs sectoral collaboration between MOH and MOHA. (MoHA) Ministry of MoEF has established a Directorate General of Domestic Waste, Waste and Hazardous Environment Waste (‘Ditjen PSLB3) that overseen implementation of regulatory requirements and Forestry particularly on hazardous waste management. MoEF in coordination with MoH, to monitor (MoEF) the implementation of regulation related to medical/pharmaceutical waste management; to issue the permit for medical waste handling companies and storage facilities located in the PHCs; to provide guidance and advise on medical waste management particularly for less developed area where access to the medical waste treatment facilities are very limited. 4.2.2 Social 60. The table below describes roles and responsibilities of the institutions in managing the potential social risks. Environmental and Social System Assessment (ESSA) Page 24 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY Table 4-4 Institutional Roles and Responsibilities for Social Performance Institutions Roles and Responsibilities for Social Performance Secretariat of Vice SoVP (and TP2S) has key role in making sure appropriate management of social risks, including in monitoring the inclusion of Indigenous community and vulnerable President (SoVP) groups in the program, coordinating preparation of an integrated system and socialization of grievance mechanism (including tracking, recording and resolution), and preparation of plan for capacity building of the health and safety of all workers involved in the program, including at village level. Ministry of National Bappenas roles to undertake the role of monitoring and evaluation for the program, Planning (Bappenas) and the MoHA as the Deputy Chair for oversight and monitoring of local and Ministry of Home governments, are essential in oversee the social risk management implementation. Affairs (MoHA) National Population Coordination between relevant institutions/agencies (such as BKKBN with its local and Family Planning team, MoV facilitators, MoH through its local health staffs at Puskesmas/Posyandu, Board (BKKBN), and Ministry of Administrative and Bureaucratic Reform (MenPAN-RB) with its Ministry of Village Lapor! System) is required, to optimize existing media/channel for receiving and (MoV), Ministry of handling concerns, issues, challenges, inputs, and lessons learned, also ensuring Health (MoH) accessible grievance mechanism for all stakeholders and diverse community groups/program beneficiaries. Local government, • Local government/agencies (particularly frontline healthcare services) are key agencies, and stakeholders for addressing social performance particularly in ensuring program community inclusion at local (village) and household level. Village government and village figures/leaders level organisations (including community figures and religious leaders) (including represent communities and advocate their aspirations, including if any Village/Kelurahan concerns/issues related to the program inclusion (under the responsibility of Government, Religious MoV and in coordination with MoSA and/or BKKBN). leaders, PAUD, • Frontline health service providers and early years education providers (such as Puskesmas, midwives, nurses and cadres at Posyandu, also PAUD coordinators and Posyandu, local cadres teachers) are essential in social risk management to ensure program inclusion and volunteered staffs) and outreach to all community groups (including Indigenous People and vulnerable groups) as well to ensure the health and safety of community members/staffs involved in the program implementation (in provisions of nutrition-specific and sensitive interventions), under coordination of MoH. 4.3 Experience from INEY Phase 1 and Other World Bank Projects 61. With regard to capacity of the project executing agency as well as PIU, the previous assessment from the INEY Phase 1 and during the Phase 2 Concept Stage reported that the IPF component support to SoVP has strengthened national leadership in stunting prevention; SoVP has initiated monitoring and convening of its 2 priority provinces. Remaining gaps and challenges were identified related to the management of ES issues, including in grievance mechanism socialization, monitoring, and reporting. Meanwhile, the allocated grants for MoHA which have been able to finance the existing Technical Assistance Pool to oversight and monitoring of local governments were limited to early stage of program. MoV capacity building also continues with the addition of a data coordinator role at the village level to coordinate with other village actors. In the meantime, BKKBN has moved very quickly to respond to the new regulation mandate as key technical lead of the national stunting prevention program, by collecting field data and carrying out analytics, contributing to updated Convergence Action guidelines in coordination with MoV and MoHA. 62. MOH has prior experience in implementing Bank financed projects. MoH is currently implementing three World Bank-funded projects in the health sector: Indonesia – Supporting Primary Health Care Reform Program (ISPHERE), which have operated for four years and largely focuses strengthening a primary health care accreditation system, Indonesia Emergency Response to COVID19 Program which focus on strengthening key aspects of Indonesia’s emergency to the COVID19 outbreak systematically, and Indonesia Strengthening National Tuberculosis Response to improve coverage, quality and efficiency of tuberculosis services in Indonesia. Environmental and Social System Assessment (ESSA) Page 25 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY 4.4 Assessment of E&S Capacity and Management System 63. In this section, existing environmental and social system is assessed in light of the Banks’ six E&S Core Principles for PforR with the identification of remaining gaps that need to be filled to fully meet the Bank’s E&S Core Principles. Environmental and Social System Assessment (ESSA) Page 26 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY Table 4-5 E&S Capacity Assessment and Gap Analysis 64. Core Principle #1: Program E&S management systems are designed to (a) promote E&S sustainability in the Program design; (b) avoid, minimize, or mitigate adverse impacts; and (c) promote informed decision-making related to a Program’s E&S effects. No. Key Attributes related Provision in the System Identified Gap Recommendation of gap-filling to Core Principles measures 1-1 Operate within an The overall Program is mandated under the • There has not been regulatory or legal • Ministry of Health to expedite adequate legal and Perpres 72/2021. Additionally, regulatory and basis for Posyandu Prima (still in pilot establishment of regulatory or legal basis regulatory system to legal frameworks related to E&S risks and project). that defines scope and terms of service, guide E&S impact impacts on the Program are generally taskforce arrangement, equipment and • Medical waste storage in public health assessments, available, e.g., regulation on procedures for other supporting instruments for facility is not always have their required mitigation, handling, distributing, and storing Posyandu Prima. permit available. management, and supplement, vaccines, vitamins are available; • Designated medical waste treatment • Local health agency to ensure technical monitoring at the PforR as well as regulation on how to implement facility is not always available or appropriateness of medical waste storage Program level immunization activities. Moreover, regulation accessible in several provinces and in facility in each PHCs in coordination with on PHCs is quite comprehensive including local environmental agency, and to their accreditation system. Also, a clear remote areas. promote enactment of necessary distinction between national, provincial and • In some regions, some voluntary staff or permitting for the storage facilities once district level jurisdiction for permitting system community workers involved in the technical requirements are met. of medical waste management handling at program are not always exposed to Supervision to be reported and discussed primary care level is available (MoEF training events that include safety with Ministry of Health. Regulation No. 56 of 2015) with regulation on procedures when doing medical support, using medical equipment. • Local health agency to provide guidance permitting system for wastewater effluent for PHCs to ensure an alternative and emission. • There is no clear regulatory framework approach to contain/immobilize medical With regards to social inclusion, including to provide voluntary staff, cadres, or waste as regulated in Appendix VI of MoH attention to Indigenous People and community with trainings to deliver the Reg. 56/2015 is applied in limitation of vulnerable groups, there are a range of task securely, for example regarding access to transport the collected medical provisions in the Indonesia regulations, safety during travelling to remote area or waste at designated treatment facility. including the Village Law No.6/2014, PR No. safety requirement for medical handling. 186/2014, MoSA Regulation No. 12/2015, • Local health agency and PHCs to provide and MoV Regulation No. 19/2017. trainings on safety procedures and to use medical or analytical equipment The Program is mainly implemented through mandated for all staffs including voluntary PHCs and cadres at village level. The staff. existing regulatory instruments (e.g., MoH Reg. 43/19 and MoH Reg. 44/16) define the • Ministries/agencies to develop or include qualifications of each medical and a guideline that focuses on self-safety administrative staffs of the PHCs, which is and security, communication protocol, considered as one of basic safeguard to etc. for voluntary staff, cadres, or ensure health, safety, and security of the community with trainings in delivering the task. Environmental and Social System Assessment (ESSA) Page 27 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gap Recommendation of gap-filling to Core Principles measures staffs and patients in providing the medical services. 1-2 Incorporate recognized Identification of potential E&S risks and Secretariate of Vice President (SoVP), as elements of good Other than what are being mandated in the impacts and measures to mitigate those regulatory requirements, there are no other the Project Management Unit (PMU), practice in E&S topics are embedded in multiple regulatory should assign a dedicated taskforce to assessment and formal mechanism to conduct self- frameworks specifying procedures to screening on residual or recently coming conduct supervision on the overall E&S management, establish, certify, and operate PHCs as the aspect relevant with the implementation of including: up E&S risk and impact; more over to main implementor of the Program as listed identify and evaluate appropriate mitigation the Program. Despite the absence of formal (i) Early screening of below: regulated environmental risk and impact potential impacts. measures that need to be taken. Under the • MoH’s Regulation No. 43 of 2019 MoEF Regulation No. 4 of 2021 on assessment process, the taskforce should regarding Puskesmas; ‘Activity/Business that require cover identification of applicable E&S risk and impact according to Bank’s standards, • MoH’s Regulation No. 44 of 2016 on Environmental Impact Assessment: developing mitigation plan and action, and Puskesmas Management Guidelines; and AMDAL10/UKL-UPL11/SPPL12’ (‘MoEF’s monitor the remained risks and evaluate • MoH’s Regulation No. 34 of 2022 on Reg. 4/2021’), any activities/services further action to be taken. The taskforce Accreditation of Puskesmas, Clinic, conducted by PHCs only required to have should be in close coordination with Laboratory, Blood Transfusion Unit, an SPPL, which is basically a letter of relevant ministries or agencies at national Private Physician Clinic, and Private commitment to manage environmental risk level that will furtherly circulate direction on Dental Clinic. and impact as per regulatory requirement. E&S requirement to be fulfilled to In addition, separate regulations have been No formal risk and impact screening, environmental agency and PHCs at district established and implementable as basic monitoring, and reporting are needed level. It should be noted that the local health framework for identifying as well as mitigating mandated from the SPPL. agency and PHCs at district level are the pre-identified risk and impact relevant with Additionally, there is no other mechanism entities deal directly with the actual E&S risk the Program. Amongst the regulations are: to assess certain E&S risk and impact and impacts and thus has capacity to • MoH’s Regulation No. 42 of 2013 specified in Bank’s acceptable standards provide input on site or cultural-specific regarding ‘Immunization’ that outlines that has not been covered in the regulatory mitigation plan and action in a case-by-case screening of health risk, prioritization of requirements, for instance, regarding basis. patient, prevention of contraindication, cultural appropriateness and equality of etc.; service for Indigenous People and • MoH’s Regulation No. 51 of 2016 vulnerable groups, risk of gender-based regarding ‘Nutritional Supplement Product violation, etc. Standard’ that outlines provision requirement, nutritional content, preparation standards, etc.; 10 AMDAL: Analisis Mengenai Dampak Lingkungan Hidup (Environmental Impact Assessment Document) 11 UKL-UPL: Upaya Pengelolaan Lingkungan Hidup – Upaya Pemantauan Lingkungan Hidup (Environmental Management and Monitoring Effort Document) 12 SPPL: Surat Pernyataaan Pengelolaan Lingkungan Hidup (Environmental Management Statement Letter) Environmental and Social System Assessment (ESSA) Page 28 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gap Recommendation of gap-filling to Core Principles measures • MoH’s Regulation No. 18 of 2020 on ‘Medical Waste Management’ and MoEF’s Regulation No. 56 of 2015 regarding ‘Procedures and Technical Requirements of Hazardous Waste Management of Medical Facilities’ that outlines detailed mechanism to manage medical waste; • MoH’s Regulation No. 3 of 2014 regarding ‘Community-based Total Sanitation’ that includes technical specifications for conducting community- based sanitation program; • Some national standards (Standar Nasional Indonesia, or ‘SNI’) for sanitation facility establishment, e.g., SNI 2398:2017 on procedure for septic tank planning, SNI 6774:2008 on procurement of clean water, etc. With regards to social issues: • Risk of inequality in program delivery is expected to be addressed in the selection and proposal of focus villages and/or priority provinces, which is understood will be based on the stunting prevalence data. • Screening of the potential health and safety risk of the involved community (particularly local workers involved in the program delivery at village level) will be conducted against national standards for OHS and Community Health and Safety. 1-3 (ii) Consideration of This Program will be implemented as a There is no considerable gap on E&S risks No gap-filling measure recommendation strategic, technical, and response of the urgent stunting condition in relative to the overall strategy, technical applicable for this aspect. site alternatives Indonesia which is at 21.6% by 2022. approach, and sites selection that demand (including the “no Strategic and technical approaches have alternative to these aspects to be action� alternative) been pre-determined based on multi-sectoral materialized. Environmental and Social System Assessment (ESSA) Page 29 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gap Recommendation of gap-filling to Core Principles measures ministries and agencies agreement by incorporating some lesson learned from INEY-1 program. The Program will need to be implemented for the entire regions of Indonesia, though it will be initiated for 12 priority areas with highest prevalence rate. As such, there is no E&S risks that currently considered material to trigger alternative to the strategy, technical approach, and site. 1-4 (iii) Explicit assessment The Program is not expected to have There is no considerable gap on E&S risks No gap-filling measure recommendation of potential induced, cumulative or transboundary adverse relative to the potential induced, applicable for this aspect. cumulative, and environmental and social impacts. Though cumulative, and transboundary impacts transboundary impacts. the Program is to be implemented nationwide, the environmental issues are confined individually in each PHCs that separated one another; while the risk of social inequality and health and safety of community workers would be limited to individual village. 1-5 (iv) Identification of Refer to row 1-2 Refer to row 1-2 Refer to row 1-2 measures to mitigate adverse E&S risks and impacts that cannot be otherwise avoided or minimized. 1-6 (v) Clear articulation of The institutional arrangement of the Program At this moment, there is no formal focal ■ SoVP to appoint a taskforce on E&S institutional appointed SoVP as the PMU of the Program point from the government end that has aspect as mentioned in row 1-2 and 1- responsibilities and in collaboration with other ministries and been appointed to be the Bank’s 4. resources to support regional (provincial and district-level) counterpart to ensure appropriate implementation of ■ SoVP directly or through other government, subject to their relevant DLIs. management of identified E&S risk and ministries or agencies should plans. Based on communications with various impact. emphasized the roles and stakeholders during assessment mission, it is From assessment mission, it was noted responsibilities of local agencies at understood that implementation relevant that some misalignments in practical level district level in the overall E&S aspect E&S aspects of this Program would fall under is possible if there is lack of coordination management, for example, Health responsibilities of regional and local (village) between institutions. For example, PHCs Agency and Environmental Agency for government agencies. (with programs derived from Health medical waste management, and Civil Ministry and regional government) may not Environmental and Social System Assessment (ESSA) Page 30 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gap Recommendation of gap-filling to Core Principles measures aware that a Family Counseling Team (Tim Work and Public Housing Agency for Pendamping Keluarga, or ‘TPK’, with provision of sanitary facilities. programs derived from BKKBN) is present thus may not able to work on the Program in synergy. It is also noted that in some regions, PHCs, volunteers, and cadres were expected to take higher responsibilities that supposed to be owned by the regional agencies, e.g., identifying strategy, monitoring, and evaluating for sanitation programs. 1-7 (vi) Responsiveness Perpres 72/2021 encourages all reports in There has not been a single nation-wide ■ SoVP to outline a comprehensive and accountability relation to implementation, monitoring and mechanism that proven to be equally framework for collecting and through stakeholder evaluation of the Program to be channeled accessible throughout all regions in responding to grievance, which include consultation, timely for communication between government Indonesia and reliable in terms of non-electronic/internet communication dissemination of institutions through the integrated portal of demonstrating responsiveness and as most suitable way for people located relevant information, Satu Data Indonesia accountability in addressing grievances. in remote area. It should be able to and responsive (https://data.go.id/home). Existing GRM channel (‘Lapor!’) monitor the incoming grievance Grievance Redressal Satu Data Indonesia was understood able to redirected to Satu Data Indonesia and Mechanisms (GRMs) effectiveness reported to be varied archive recapitulation of public grievances between regions, relative to their internet to evaluate input related to the Program collected through online channels, such as network coverage and communication (for example, with keyword of Lapor! (which is the existing national device availability. “stunting�, “immunization�. “supplement complaint handling management system for nutrition�, etc.) if appropriate response It was noted that the Minilok may not all public services). Online grievance have been provided by the recipient reached all of relevant stakeholders, for channel is also used in the more developed agencies and if the grievance example cadres whom recruited under provinces/districts such as the Public Online addressing process is on track. BKKBN’s program. Aspirational and Grievance Service There has not been an actual ultimate ■ SoVP to invite and mandate (Layanan Aspirasi dan Pengaduan Online participation of all relevant parties to Rakyat). ministry/agency to own the accountability to oversee adequacy of responses over the Program at district level in Minilok On the other hand, in less developed area, the grievance. Since currently grievances event. In addition to that, to direct local dissemination of information and media for are reported through several non- agencies to document any covenying concerns and issues such as from integrated reporting mechanisms (through agreed/directed results for further PHCs staffs vice versa, is being conducted local government online platform, social distribution to non-participating through a more conventional channel such media, messaging apps, and face to face organization or person, if any. as through the quarterly multi-sectoral health meeting/communication), responses and workshop meeting at district level action to address those are conducted by Environmental and Social System Assessment (ESSA) Page 31 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gap Recommendation of gap-filling to Core Principles measures (Lokakarya Mini Lintas Sektor Kesehatan, or respective ministry and agency whom the Minilok). grievance is addressed. Alternative mechanisms, such as the use of social media (with the identified presence of TP2S in social media), issues and inputs/suggestions might be raised from public via Instagram, Facebook, LinkedIn, etc.; are also available. 65. Core Principle #2: Program E&S management systems are designed to avoid, minimize, or mitigate adverse impacts on natural habitats and physical cultural resources resulting from the Program. Program activities that involve the significant conversion or degradation of critical natural habitats or critical physical cultural heritage are not eligible for PforR financing. No. Key Attributes related Provision in the System Identified Gaps Recommendation of gap-filling to Core Principles measures 2-1 Identify, and screen for This Program, by nature, will not introduce major There is no considerable gap on E&S No gap-filling measure adverse effects on landscape change since it will not cover establishment risks relative to the overall strategy, recommendation applicable for potentially important of associated facilities and infrastructure. technical approach, and sites selection this aspect. biodiversity and cultural Establishment of any facilities and infrastructure that that demand alternative to these aspects resource areas and contemporaneously executed along this Progam will be to be materialized. provide adequate funded by source beyond the PforR scheme. The measures to avoid, Program in a way also promotes preservation of minimize, or mitigate natural habitat and physical cultural resources from adverse effects. certain adverse impacts potentially occurring from residential activities, through reduction of the risk of fecal contamination or water-purification chemical contamination on natural water body and soil (Refer to Section 2.3.2). 2-2 Support and promote the protection, conservation, maintenance, and rehabilitation of natural habitats. Not applicable, refer to 2-1 2-3 Avoid significant conversion or degradation of critical natural habitats Not applicable, refer to 2-1 2-4 If avoiding the significant conversion of natural habitats is not technically feasible, employ measures to mitigate or offset the Not applicable, refer to 2-1. adverse impacts. Environmental and Social System Assessment (ESSA) Page 32 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gaps Recommendation of gap-filling to Core Principles measures 2-5 Consider potential adverse effects on physical cultural property and provide adequate measures to avoid, minimize, or mitigate Not applicable, refer to 2-1 such effects. 66. Core Principle #3: Program E&S management systems are designed to protect public and worker safety against the potential risks associated with (a) the construction and/or operation of facilities or other operational practices under the Program; (b) exposure to toxic chemicals, hazardous wastes, and otherwise dangerous materials under the Program; and (c) reconstruction or rehabilitation of infrastructure located in areas prone to natural hazards. Environmental and Social System Assessment (ESSA) Page 33 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gaps Recommendation of gap-filling to Core Principles measures 3-1 Promote adequate This Program is mainly implemented through PHCs and It was understood that for some regions, ■ SoVP’s E&S taskforce community, individual, cadres at village level. The existing regulatory some voluntary staff in PHCs are not through MoH and local health and worker health, instruments (e.g., MoH Reg. 43/19 and MoH Reg. always exposed to training events that agency to identify required safety, and security 44/16) define the qualifications of each medical and include safety procedure when doing trainings that must be through the safe design, administrative staffs of the PHCs, which is considered medical support, or using medical received for any person construction, operation, as one of basic safeguard to ensure health, safety, and equipment. This type of worker was also working in PHCs including and maintenance of security of the staffs and patients in providing the reported not always have adequate the voluntary staffs. The MoH Program activities; or, in medical services. access to get and use personal and local health agency to carrying out activities that The Perpres 72/2021 has not clearly detailed type of protective equipment while doing their verify that voluntary staffs may be dependent on training that the personel on field must have should service, imposing risk on the personnel have equal opportunity to get existing infrastructure, they are assigned to deliver information and stimulation health and safety. the training. incorporate safety measures, inspections, or in the context of stunting reduction. Training on such The current regulatory framework has not ■ SoVP’s E&S taskforce to activities is only mentioned to be designated for early- specified which parties aside of the insert the element of cultural remedial works as learning school (Pendidikan Anak Usia Dini, or PAUD) PAUD teachers that have to receive appropriate. appropriateness in any teachers. The regulation does not specify if the training particular trainings prior being deployed preparatory trainings given to will include how to deliver the materials in a way that it as a part of the taskforce. The regulatory medical staffs, voluntary is culturally- safe/acceptable, how and to whom they framework has not specified staffs, and cadres assigned should communicate with, how to go and return from methodology to deliver the task securely, to any Program’s activities target location, etc.; which is essential to assess ones for example through culturally-acceptable involving engagement with health, safety, and security aspects in doing their tasks. way of communication with the targeted the community. community. 3-2 Promote measures to The existing regulatory instruments (e.g., MoH Reg. It was understood from interviews with MoH and local government address child and forced 43/19 and MoH Reg. 44/16) rule out the responsibilities voluntary staffs of the PHCs during the agency to define clear roles, labor. and qualifications of medical and administrative staffs in assessment mission, that in some responsibilities, and rights of PHCs. It has not regulated rights and responsibilities of regions, a PHC is usually supported by voluntary staffs in doing their task voluntary staffs as worker at the same facilities with the many voluntary staffs. These voluntary in PHCs. The roles, medical staffs. staffs are generally working without responsibilities, and rights should On child labor, some regulatory instruments should formal agreement. The voluntary staffs be formalized in an agreement apply to the Program, i.e., Act No. 19 of 1999 where it submitted a self-made statement letter to that acknowledged by the ratified Convention concerning the Abolition of Forced the local health agency that state that voluntary staffs and local health Labor, 1957 (No. 105); and Act No. 13 of 2003 that they are willing to work without expecting agency. None of the agreement regular compensation and benefit. may allow violation or deviation Environmental and Social System Assessment (ESSA) Page 34 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gaps Recommendation of gap-filling to Core Principles measures mention in Article (69) that child worker (13-15 years Occasionally, payment is received only from regulatory requirements, old) hiring only under the following terms: when it is budgeted. Some of the including rights to obtain ■ written permission from parents or guardians; voluntary staffs have medical educational compensation or benefits background and motivated to work at the (including health and labor ■ work agreement between entrepreneur and parent PHCs only to obtain an insurances) when regulated, and or guardian; acknowledgement letter from the health obligation to follow medical ■ maximum working time of 3 (three) hours; agency after finishing their services. Note professional procedures and ■ carried out during the day and does not interfere that there are generally no obligation or ethics. with school time; binding commitment for the health ■ Occupational Health and Safety; agency to issue such acknowledgement letters. ■ there is a clear working relationship; and In absence of the formal work ■ receive wages in accordance with applicable agreements, these voluntary staff could regulations. not be identified as workers yet exposed to labor risk including health and safety risk. They are not subject to receive labor-related benefits, such as access to adequate equipment, equality to receive appropriate trainings, admission to health and labor insurances, etc. On the other hand, the voluntary staffs are not bound by any formal responsibilities that allow them to work and treat the patient/community in full compliance with professional standards, SOP, and professional ethics. 3-3 Promote the use of Hazardous waste that is considered relevant and In remote regions or area with limited SoVP's E&S taskforce through recognized good practice considerable in this Program is limited to medical waste access to medical waste treatment MoH and local health agency to in the production, that potentially have their quantities increased due to facilities, medical waste is known to be promote implementation provision management, storage, improvement of medical service delivery (including stored in any available and vacant space of Appendix VI of MoEF Reg. transport, and disposal of immunization) brought by the Program throughout the (wardrobe, crate, etc.) within the PHCs 56/15 for remote areas or areas hazardous materials country. Management of medical waste is regulated even though they are not meeting with limited access to waste generated under the under provision in the MoEF Reg. 56/15 and MoH Reg. technical requirements as medical waste treatment facility. Refer to row 1- PforR. 18/20 (Refer to Section 3.1). temporary storage facility. The condition 1. also triggers extensive storing, that could reach up into a year or more, depend to availability of the nearest medical waste destruction or treatment area. Environmental and Social System Assessment (ESSA) Page 35 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related Provision in the System Identified Gaps Recommendation of gap-filling to Core Principles measures 3-4 Provide training for Any PHCs, from level of sub-district area, i.e., Sanitarian assigned in PHCs of remote SoVP's E&S taskforce through workers involved in the Puskesmas, should have a Sanitarian staff work at the area or area with limited access to MoH and local health agency to production, procurement, facility. Sanitarian took responsibilities to day-to-day medical waste treatment facility, may not guide sanitarian in PHCs to storage, transport, use, management of medical waste, domestic waste, be familiar with (or have not always implement provision of Appendix and disposal of chemical, pest control, etc. in the facility boundary. A receiving direction from governing VI of MoEF Reg. 56/15 for remote hazardous chemicals in sanitarian must be a person whom graduated from agency) to implement an alternative areas or areas with limited access accordance with the environmental health course in education and other approach to contain/immobilize the to waste treatment facility. Refer relevant international trainings to get sanitarian certifications, i.e. Sanitarian medical waste as per the Appendix VI of to row 1-1 and 3-3. guidelines and Personnel Registration Certificate (Surat Tanda MoEF’s Reg. 56/15 (Refer to Row 3-3). conventions. Registrasi Tenaga Sanitarian, or ‘STRTS’) and Sanitarian Personnel Work Permit (Surat Izin Kerja Tenaga Sanitarian, or ‘SIKTS’). Complete regulatory framework to ensure competency of a sanitarian is available in the Minister of Health’s Regulation No. 32 of 2013 on ‘Provision of Sanitarian Personnel’ (‘MoH Reg. 32/13’). 3-5 Apply adequate The Program will not include significant structural The aspect is considered not applicable No recommendation is proposed. measures to avoid, development that potentially increase risk of exposure with the Program scope. minimize, or mitigate of community or worker involved to naturally-occurring risks for the community, hazard or the ones triggered by climate events. individual, and worker exposure to natural hazards such as floods, hurricanes, earthquakes, or other severe weather or affected by climate events. Environmental and Social System Assessment (ESSA) Page 36 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY 67. Core Principle #4: Program E&S systems manage land acquisition and loss of access to natural resources in a way that avoids or minimizes displacement and assists affected people in improving, or at the minimum restoring, their livelihoods and living standards. No. Key Attributes related Provision in the System Identified Gaps Recommendation of gap-filling to Core Principles measures 4-1 Avoid or minimize land By nature, this Program will not include any landscape The aspect is considered not applicable No recommendation is proposed. acquisition and related change that requires land acquisition. with the Program scope. adverse impacts. 4-2 Identify and address economic or social impacts caused by land acquisition or loss of access to natural resources, including Not applicable, refer to Row 4-1 those affecting people who may lack full legal rights to resources they use or occupy. 4-3 Provide compensation sufficient to purchase replacement assets of equivalent value and to meet any necessary transitional Not applicable, refer to Row 4-1 expenses, paid before taking land or restricting access. 4-4 Provide supplemental livelihood improvement or restoration measures if taking of land causes loss of income-generating Not applicable, refer to Row 4-1 opportunity (e.g., loss of crop production or employment). 4-5 Restore or replace public infrastructure and community services that may be adversely affected by the Program. Not applicable, refer to Row 4-1 4-6 Include measures for land acquisition and related activities to be planned and implemented with appropriate disclosure of Not applicable, refer to Row 4-1 information, consultation, and informed participation of those affected. 68. Core Principle #5: Program E&S systems give due consideration to the cultural appropriateness of, and equitable access to, Program benefits, giving special attention to the rights and interests of Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities, and to the needs or concerns of vulnerable groups. No. Key Attributes related to Provision in the System Identified Gaps Recommendation of gap-filling Core Principles measures 5-1 Undertake meaningful The program intended for the interventions to be Program implementation at local (district Community level systems exist to consultations if the undertaken in priority area with high stunting and village) level very much depend on enable participation, such as Indigenous Peoples/Sub- prevalence that will potentially benefit Indigenous the local government capacity, while the through BKKBN’s Family Saharan African Peoples, including remoted indigenous communities. practice for engagement with Indigenous Facilitators and Cadres, in Historically Underserved This is aligned with the existing Indonesia regulation community for stunting reduction is coordination with the local Traditional Local which has recognized and respect for communities varied. Puskesmas/Posyandu and the Communities or ethnic or living by the customary law (Adat) and traditional value MoV HDW/Village Facilitators racial groups are systems. potentially affected (positively or negatively), Environmental and Social System Assessment (ESSA) Page 37 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY No. Key Attributes related to Provision in the System Identified Gaps Recommendation of gap-filling Core Principles measures to determine whether In more recent practice, BKKBN has initiated the there is broad community engagement and involvement of indigenous community support for the PforR in leading the stunting reduction program Program activities. implementation at local level (as reported in https://www.bkkbn.go.id/). Although cultural barrier was often identified as one of the key challenges of INEY 1 in achieving the stunting reduction target, and data shown that stunting prevalence is noticeably high among indigenous people and in rural communities reportedly in some regions, there are areas across Indonesia with useful Indigenous knowledge to support the stunting reduction, including in South Sulawesi (as reported in https://www.ekuatorial.com/). 5-2 Ensure that Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities can participate in Not relevant devising opportunities to benefit from exploitation of customary resources and indigenous knowledge, the latter (indigenous knowledge) to include the consent of Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities. 5-3 Give attention to groups The program intended for the interventions to be Vulnerable groups identified based on Community level systems exist to vulnerable to hardship or undertaken in priority area with high stunting literature review and fieldwork. Practice enable participation, such as discrimination, including, prevalence that will potentially benefit vulnerable on inclusive approaches still under through BKKBN’s Family as relevant, the poor, the people, including lagging community and poor assessment. Facilitators and Cadres, in disabled, women and households, and other vulnerable groups. This is coordination with the local children, the elderly, aligned with the existing Indonesia regulation such as Puskesmas/Posyandu and the ethnic minorities, racial through the MoSA Regulation No. 12/2015 and MoV MoV HDW/Village Facilitators groups, or other Regulation No. 19/207 which include provisions to marginalized groups; and improve the welfare of vulnerable groups. if necessary, take special measures to promote equitable access to project benefits. Environmental and Social System Assessment (ESSA) Page 38 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ASSESSMENT OF GOI ENVIRONMENTAL AND (INEY - 2) SOCIAL CAPACITY AND MANAGEMENT SYSTEMS FOR INEY 69. Core Principle #6: Program E&S systems avoid exacerbating social conflict, especially in fragile states, post-conflict areas, or areas subject to territorial disputes. No. Key Attributes related Provision in the System Identified Gaps Recommendation of gap-filling to Core Principles measures 6-1 Consider conflict risks, By nature, priority area of the Program implementation The aspect is considered not applicable No recommendation is proposed. including distributional will be influenced by the stunting prevalence, thus with the Program scope. might be implemented in area with social conflict of equity and cultural post-conflict areas. However, the scope of program sensitivities. implementation is not expected to create significant social issues/risks which may trigger or exacerbate conflict, thus this principle is considered not applicable for the Program. Environmental and Social System Assessment (ESSA) Page 39 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 RECOMMENDATIONS OF PROJECT ACTION PLAN (INEY - 2) 5. RECOMMENDATIONS OF PROJECT ACTION PLAN 5.1 Conclusions 70. The PforR aims to enhance the delivery and convergence of services to accelerate the reduction of stunting in Indonesia. The ESSA noted that regulatory requirements pertaining procedures and requirements to manage identified E&S concern that is relevant to implement the Program have been established in Indonesia. It is noted however that such procedures and requirements have not been able to be implemented equally all across Indonesia, due to various baseline conditions, such as access to medical waste treatment facilities, access to clean water, access to sanitation facility, cultural background, etc. 71. Through E&S screening, the PforR’s overall E&S risk rating is Moderate, with environmental risk rated Moderate and social risk rated Moderate. 72. Following areas have been identified to be improved: a. Person or taskforce dedicated to conduct supervision of overall E&S performance against GOI regulation and Bank Standards and to conduct coordination within and between appointed ministries/agencies have not been appointed or procured. b. Best management practice based on regulatory requirements regarding medical waste management has not been implemented consistently throughout Indonesia due to limited access to treatment facility, while medical or sanitarian units in less developed area have not fully aware of presence of alternative direction to manage medical waste in such condition. c. Coordination between local health agency and PHCs have yet reached a point where the PHCs staffs are able to fully understand the goals and strategy of sanitation improvement program hence they could deliver the program in the most acceptable approach and to monitor the changes appropriately for further evaluation. d. Assessment undertaken during project preparation informed that communities in remote areas and vulnerable groups experience (and more prone to) challenges to access the educational program, as well as in receiving nutrition specific interventions, particularly health services. It was observed that in the remote or traditional community, cultural barrier in receiving nutrition specific were still presence, while poor families with lesser education and limited access to advance health knowledge were still having low awareness on the urgency of pregnant mother and child nutrition in affecting stunting. e. Attention to be provided to voluntary staffs in PHC, and community workers and cadres to receive adequate trainings covering health, safety, and security aspects while conducting their assignments. f. Potential for inequality might create risk of conflict which stems from real or perceived differences in how the benefits of the program are distributed which makes the need for an effective grievance system important. It is understood that multiple channels are used in practice, thus an integrated mechanism/system to manage concerns/issues, challenges and inputs from the affected people/beneficiaries and stakeholders are required. Environmental and Social System Assessment (ESSA) Page 40 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 RECOMMENDATIONS OF PROJECT ACTION PLAN (INEY - 2) 5.2 Project Implementation Support and Recommended PAP13 73. Following actions are included in the Program Action Plan (PAP) to be undertaken during the PforR implementation: Table 5-1 Environmental and Social Measures for the Program Action Plan No. Action Description Responsibility Timing Completion Measurement PAP 1 Project Operation Manual (POM) to be Project Prior to project POM completion has developed/updated in such a way that it will Management Unit effectiveness included (a) procedure of cover provisions of the following items: (PMU) date coordination between (a) technical guidance on environmental and agencies, (b) coordination social management that also facilitates with other relevant quick or regular coordination between projects, (c) evidence of ministries/agencies (e.g., with BKKBN, improvement of existing MoH, MoHA, MoEF, district government, guidelines, (d) training etc.); programs on E&S (b) actions to improve existing system, for management; (e) E&S risks example, addition of information on available medical waste service provider management monitoring (and how to engage them) in the existing and reporting. guidelines owned/developed by the MoH’s Environmental Health Directorate General; (c) training programs relevant to implement environmental and social management; (d) procedure to report environmental and social management (particularly for items determined in this PAP) as part of Project Management Unit (PMU) regular reporting to the Bank. PAP 2 Environmental Specialist and Social Specialist as PMU Whole Provision of contact person Focal Points to be recruited/appointed/assigned implementation or team of the E&S focal to be responsible for overseeing and reporting stage points to the Bank’s E&S the implementation of E&S management, that Safeguards, followed with may include consolidation of relevant parties, continuous coordination development of technical guidelines, along the whole program implementation of mitigation actions, monitoring implementation stage. and evaluation (and remedial action when needed). PAP 3 In coordination with E&S Focal Points (see PAP 2) MoH and district- Whole One national level to establish or improve regular training and level Health implementation workshop on the subject supervision of PHC’s staff and sanitarian by local Agencies stage and a local health agency’s health agencies on implementation of MoH’s report on actual Regulation No. 18 of 2020 (Permenkes 18/2020) implementation of the on medical waste handling or for remote area, provisions on medical 13 It should be noted that during development of this ESSA, discussion to determine final DLIs and each verification protocols are still ongoing. The recommendations and PAPs provided below were made under limitation that DLIs and verification protocols are referring to what have been circulated for discussion up to development of this ESSA version, i.e., before 28 April 2023. Though there is no anticipated fundamental changes on the conclusion of the assessment, any changes to the DLIs and verification protocol beyond that timeframe might triggers some adjustments/updates to the recommendation and PAPs of the ESSA. Note that the project task team has agreed to give opportunity for the E&S risk management and mitigation measures to be mainstreamed into the verification protocols of the program. Environmental and Social System Assessment (ESSA) Page 41 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 RECOMMENDATIONS OF PROJECT ACTION PLAN (INEY - 2) No. Action Description Responsibility Timing Completion Measurement implementation of Appendix VI of the MoEF’s waste management in all Regulation No. 56 of 2015 (Permen LH 56/2015). PHCs, subject to their respective access to the existing waste treatment facilities. PAP 4 Awareness raising, refresher training, MoV, MoHA, Whole eHDW and AKSI BANGDA mainstreaming of E&S management, and access BKKBN, MoH implementation applications are equipped to information on medical waste facilities at stage with information related to district level including in its relation with the procedures on medical regulatory requirements of PermenLH 56/2015 to waste handling, awareness be included in the electronic Human raising and training Development Workers (eHDW) program that is materials, guidelines and known has been applied for 74,000 villages in information of the closest Indonesia through Human Development Cadre medical waste facilities. (Kader Pembangunan Manusia, or ‘KPM’) from Ministry of Village and also through AKSI BANGDA application from Ministry of Home Affairs. PAP 4 to be implemented in collaborative works with E&S Focal Points. PAP 5 On social inclusion (including IP, remote area BKKBN, MoV, In stages, Guideline on social community/village, and other vulnerable groups), district level throughout inclusion has been a guideline for the Program's implementor, government and program prepared or particularly at local (District and Village) level, to village-level implementation added/annexed in existing be developed or added/annexed in existing government higher-level guideline for higher-level guidelines, to ensure consideration the Program and have been of cultural appropriateness of activities, equitable properly informed or access to program benefits, and strategy/special trained to the Program’s attention are provided (e.g., for data collection implementors. and specific approach to response when stunting is identified). Training and socialization of the social inclusion guideline to be conducted aligned with the existing capacity building program for the national stunting program implementer at local level. PAP 6 With regards to community (workers) MoH and district- In stages, OHS best practice or occupational health and safety (OHS), OHS level Health throughout procedure has been suggested best practice or procedure to be Agencies program embedded in the included in an integrated Program’s basic training implementation integrated basic training modules and capacity building plan for frontline module for frontline actors. actors (HDW, TPK, Kader Posyandu, etc.). PAP 7 Mechanism to manage concerns/issues, PMU, MoV, district In stages, Mechanism to manage challenges and inputs from the affected level government throughout concerns/issues/inputs has people/beneficiaries and stakeholders to be and village-level program been included in the POM included in the Program Operational Manual government implementation that covers aspect (POM) that will be developed/updated for the mentioned in the action INEY Phase 2 Program and the training modules. description column. The mechanism should at least covers Additionally, the TOR of management of multiple existing grievance E&S Focal Point has channels and media (at national and local level), included task to coordinate Environmental and Social System Assessment (ESSA) Page 42 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 RECOMMENDATIONS OF PROJECT ACTION PLAN (INEY - 2) No. Action Description Responsibility Timing Completion Measurement guidance on how the E&S Focal Point to have a with relevant system in place to coordinate regarding such Ministries/Agencies in concerns/inputs with relevant ministry and handling the agency as defined in the E&S Focal Point TOR, concerns/issues/inputs. guidance to do socialization of such channel and system, and guidance to monitor and report regularly on the resolution of concerns/issues and challenges. Environmental and Social System Assessment (ESSA) Page 43 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX A STAKEHOLDER ENGAGEMENT AND (INEY - 2) SITE VISIT SUMMARY Annex A Stakeholder Engagement and Site Visit Summary A.1 INEY 2 Preparation Mission, Jakarta, December, 2022 Date Stakeholders consulted Topics discussed 09/12/2023 Secretariat of the Vice President (SoVP), Coordinating Kick Off meeting Ministry for Human Development and Culture (Kemenko PMK), Ministry of National Development Planning/National Development Planning Agency (Bappenas), Ministry of Finance (MoF), Ministry of Home Affairs (MoHA), Ministry of Health (MoH), Ministry of Village, Disadvantaged Areas and Transmigration (MoV), Ministry of Education, Culture, Research and Technology (MoECRT), Ministry of Social Affairs (MoSA), National Population and Family Planning Agency (BKKBN), National Statistics Agency (BPS) 12/12/2023 MoHA– Director General of Regional Development, DLI 7 Discussion: Predictability and Bappenas, MoF –Directorate General of Fiscal Balance results orientation of fiscal transfers that support convergence MoH –Directorate General of Public Health Strengthening Primary Healthcare SoVP Discuss DLI 1 and overall management and progress of INEY implementation (IPF, E&S) 13/12/2023 BKKBN, World Bank, SoVP Preparation of BKKBN to be PIU of INEY Bappenas, MoF – Director General of Budgeting DLI 2 Discussion: Tracking and performance evaluation of national spending on priority nutrition interventions MoH –Directorate of Health Promotion, Director General DLI 6 Discussion: Priority District of Public Health, Ministry of Communication and implementation of locally-adapted Informatics: Directorate of Informatics and IPC activities Communications for Human and Cultural Building Bappenas, BKKBN, MoHA – Director General Village Monitoring and Evaluation Development 14/12/2023 SoVP, Tanoto Foundation, Bill and Melinda Gates IHCA Steering Committee Foundation, KFW, Global Financing Facility DLI 4: Early Childhood Education MoECRT and Development MoSA – Director General of Community Empowerment; DLI 5: Discussion on Sembako Bureau of Planning, Kemenko PMK, TNP2K Program MoV Development of Disadvantaged Regions and DLI 9: Reporting of village Transmigration of Republic of Indonesia, MoF – convergence; and DLI 10: Directorate of Public Budget Transfer, SoVP Convergence in the home MoF – Directorate General Of Budget Financing and Risk Discussion with MOF- DJPPR Management 15/12/2023 SoVP, Kemenko PMK, MoH, MoV, MoHA, BKKBN, Multi-agency workshop to follow up Bappenas, Representative of local government and on village-level coordination frontliners, Tanoto 16/12/2023 SoVP, Kemenko PMK, Bappenas, MoF, MoHA, MoH, Wrap-up Meeting MoV, MoECRT, MoSA, BKKBN, BPS, SoVP Environmental and Social System Assessment (ESSA) Page 44 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX A STAKEHOLDER ENGAGEMENT AND (INEY - 2) SITE VISIT SUMMARY A.2 INEY 2 Preparation Mission, Jakarta, Surabaya, Sragen and Manggarai Timur February, 2023 Date Location Stakeholders consulted Topics discussed 07/02/2023 Hotel WB, MoF, SoVP, MoH, Mission kick-off meeting; objectives: Aryaduta, Bappenas, MoHA, MoV, BKKBN, 1. Introduce team and outline mission objectives Tugu Tani KemenkoPMK, MoEC, DJSN, Jakarta BPJS, KemenPAN-RB, PKK 2. Share a preliminary mapping of the roles Pusat and responsibilities of key INEY2 stakeholders 3. Technical discussions 4. Agreed on the proposed mission schedule Kemenkes WB, MoH (Roren & Imunasi) Meeting to discuss World Bank’s Investing in Office Nutrition Early Years (Phase 2) Program, proposed to be cofinanced with Gavi 08/02/2023 Ruang SoVP Rapat Lt-5 Deep-dive discussions; objectives: Grand 1. Discuss the technical scope of INEY 2 and potential DLIs and targets Kebon Sirih 2. Discussion (Feb 8, 2023): BKKBN BKKBN, SoVP Office 1. Stunting reduction team 09/02/2023 GKS office, MoH –Gizi, MCH, Promkes- level 5 Posyandu 2. Puskesmas service strengthening Hybrid, Kemenko PMK, SoVP 3. Adolescent place tbd Bappenas MoF (DTK), Bappenas (KGM), 3. DLI 2 discussion including expansion to office MoHA (Bangda SUPD III), SoVP sub-national tagging and tracking (Feb 9, 2023) 10/02/2023 Hybrid, MoF (DJA, DJPK), Bappenas Bappenas (KGM), MoHA (Bangda SUPD 4. Garner feedback on roles, office III), SoVP responsibilities and result indicators 5. Identify technical needs and 10/02/2023 Workshop, SoVP, MoH, MCoI, BKKBN, Rep Behavioral Change (BCC) Technical Assistance Phase 1 Hotel Venue of Magelang and Manggarai Findings, Lessons Learned, and Timur District, IDCOMM Recommendations Dissemination Workshop 1. To share findings, lesson learned, model of TA support, and recommendations from implementation of district BCC TA in Kota Magelang and Manggarai Timur 2. To gather feedback from key line ministries (MoH, MoC&I, and BKKBN) in strengthening the TA for phase two (BCC implementation quality assessment) and potentially using the established BCC TA materials for other districts Environmental and Social System Assessment (ESSA) Page 45 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX A STAKEHOLDER ENGAGEMENT AND (INEY - 2) SITE VISIT SUMMARY Date Location Stakeholders consulted Topics discussed 3. To discuss how the results from the BCC TA implementation may be used to restructure DLI6 for INEY 2 11/02/2023 Bangda MoHA (Bangda & Adwil), Deep-dive discussions; objectives: Office BKKBN, MoV, and MoH 1. Discuss the technical scope of INEY 2 SoVP and MOEC and potential DLIs and targets 2. Discussion: village coordination, integration planning process and Kalurahan and Kecamatan role 3. DLI 4 but also discuss parenting education 4. Garner feedback on roles, responsibilities and result indicators 5. Identify technical needs 14/02/2023 SoVP office MoF, SoVP, MoH, Bappenas, IPF Component Discussions: MoHA, MoV, BKKBN Discuss activities, implementation arrangements, financial management, procurement, environmental and social framework, gender, climate change Online KemePAN-RB, SoVP Discuss on policy and strategy of digital utilization to accelerate stunting reduction to support Perpres 72/2021 15/02/2023 MOH, MOHA – Bina Pemdes, Discussion on integrated village health post MOHA – Bina Bangda, MoV, services (Posyandu Prima) BKKBN Bappenas Bappenas, BKKBN, SoVP Discussion on MonEv system office 16/02/2023 Surabaya Mr Regional Secretary 1. Surabaya converted a Pustu to a Posyandu Prima as part of the the MoH's Primary Care Field Visit – Assistant for Governance and Integration (ILP) Posyandu People's Welfare Prima Assistant for Economy and 2. Assess the implementation of the Posyandu Jambangan Development Prima in Surabaya General Administration Assistant Head of the Regional Development Planning Agency, Research and Development Head of the Health Service Head of Social Service Head of the Office of Women's Empowerment and Child Protection as well as Population Control and Family Planning Head of Communication and Information Service Head of the Education Office Head of the Library and Archives Service Head of Government and People's Welfare Section Environmental and Social System Assessment (ESSA) Page 46 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX A STAKEHOLDER ENGAGEMENT AND (INEY - 2) SITE VISIT SUMMARY Date Location Stakeholders consulted Topics discussed Head of Organizational Section Representative of BKKBN East Java Province District of Jambangan Village Head of Kebonsari Village Chief of Jambangan Village Chief Kara Pagesangan village head Head of TP PKK Jambangan District TP PKK in Jambangan District Jambangan Police Chief Jambangan Military Command KUA Jambangan District Head of LPMK Kec. Vase Posyandu Prima cadres 19 people Great Surabaya Cadres 10 People TPK cadres 24 people (4 sub- districts per sub-district 2 teams/ 6 people) Bangda Team (5 people) Group of Guests/Team (15 people) 17/02/2023 Surabaya Chairman of TP PKK Surabaya Discussion with Head of Kelurahan, Cadres, TPK Field Visit – City and Posyand Cadres Mayor's Mr Regional Secretary Office Assistant for Government and People's Welfare Assistant for Economy and Development Assistant General Administration Head of Regional Development Planning Agency, Research and Development Service for Women's Empowerment and Child Protection as well as Population Control and Family Planning Head of Health Service Head of Social Service Head of Food Security and Agriculture Service Head of Communication and Information Service Heads of Culture, Youth and Sports Services and Tourism Head of Water Resources and Highways Service Environmental and Social System Assessment (ESSA) Page 47 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX A STAKEHOLDER ENGAGEMENT AND (INEY - 2) SITE VISIT SUMMARY Date Location Stakeholders consulted Topics discussed Head of Education Office Head of the Department of Transportation Head of Goods/Services Procurement and Development Administration Head of Government and People's Welfare Section Head of the Surabaya City Ministry of Religion Director of PDAM Surya Sembada LGCB ASR Reg 3 Teams 20/02/2023 Sragen Field Bapperida, Department of Health 1. Dialogue with the Regent of Sragen Visit – P2KBP3A Service, PMD Service 2. Visits and dialogues at posyandu Posyandu 3. Posyandu name: 4. Mardi Lestari, Dk Karangmalang, RT. 20 Puro Village 5. Visits and dialogues at the Karangmalang Health Center 21/02/2023 Sragen Field Bapperida, Department of Health Discussion/Dialogue with Village Officials Visit – P2KBP3A Service, PMD Service Posyandu & Puskesmas 22/02/2023 Sragen Field Head of TPPS Kab. Sragen Discussions/dialogues with TPPS, sub-district Visit – (Deputy Regent of Sragen) heads, health centers, Community Empowerment Sambiloto Secretary/Assistant/Head of TA, Stunting Task Force Hall Health Service/P2KBP3A Office PIC : PMD Service PMD Service 23/02/2023 Secretariat's Participants from elements: 1. Monev FGD facilitated by Bappenas Up Room Kades, KPM, TPK, Posyandu 2. Discussion on the implementation of monitoring and evaluation in the field Cadres, TP-PKK (implementers, tools, systems, data integration between OPDs) 3. Constraints on monev implementation 4. Recommendations for improvement 20/02/2023 Manggarai Vice Bupati Welcoming the mission team and introduction of Timur Field Sekda District Secretary the team Visit TPPS Borong District Head of Dinas Offices (Health, Education, DP2KBP3A, PUPR, Religious Affair , DPMD Head Peot Health Center TPK Bappelitbangda Discussion /dialogue with Vice Bupati, Sekda, Department of Health Head of Bapelitbangda, TPPS, head of Dinas DP2KBP3A offices, Camat, Head Health on Stunting DPMD acceleration program in Borong District, Role for TPK each sectoral offices, achievement, challenges Environmental and Social System Assessment (ESSA) Page 48 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX A STAKEHOLDER ENGAGEMENT AND (INEY - 2) SITE VISIT SUMMARY Date Location Stakeholders consulted Topics discussed Tenaga Profesional Pendamping Discussion and dialogue on stunting acceleration Desa and Pendamping Desa program, role and responsibility of different DP2KBP3A sectors, challenges DPMD 21/02/2023 Manggarai Religious leader from Catholoc Dialogue with Romo and visits to Church Timur Field Church Visit Bappelitbangda Visit to Peot Health Center and Posyandu Satar Department of Health Peot Village and discuss with key multisector DP2KBP3A actors in the village on stunting prevention DPMD program TPK Village Head of Satar Peot Head Peot Health Center TP. PKK, Satar Peot Village Posyandu cadres Companion Team Family Satar Peot Village KB field Extension Human Development Cadres Satar Peot Village 22/02/2023 Manggarai World Bank Team and Coordination /Dialogue with Regent East Timur Field Ministries/Agencies Manggarai Visit Bappelitbangda Department of Health DP2KBP3A DPMD Stunting Companion Team World Bank Team and Visit to Peot Health Center Ministries/Agencies Bappelitbangda Department of Health DP2KBP3A DPMD Stunting Companion Team Head Peot health center and staff World Bank Team and Visit to Posyandu Bangka Kantar Village, Ministries/Agencies observed posyandu activities and dialogue on Bappelitbangda ongoing stunting prevention program, Department of Health achievement, challenges, multistakeholders DP2KBP3A coordinations DPMD Stunting Companion Team Head of Bangka Kantar Village Head Peot Health Center TP. PKK of Bangka Kantar Village Posyandu cadres TPK Bangka Kantar village, family Planning Field KB Extension Environmental and Social System Assessment (ESSA) Page 49 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX A STAKEHOLDER ENGAGEMENT AND (INEY - 2) SITE VISIT SUMMARY Date Location Stakeholders consulted Topics discussed Bangka Kantar Village Assistant Bangka Kantar Village Human Development Cadres 24/02/2023 Online Bappenas Rice fortification SoVP office MoF, SoVP, MoH, Bappenas, Mission debrief meeting; objectives: MoHA, MoV, BKKBN, 1. Review mission findings and DLI proposals, including key agreements and KemenkoPMK, MoEC, DJSN, next steps BPJS, KemenPAN-RB, PKK Environmental and Social System Assessment (ESSA) Page 50 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX B ESSA STAKEHOLDER CONSULTATION (INEY - 2) Annex B ESSA Stakeholder Consultation In alignment with the World Bank’s Directive for Program for Result Financing (2020), prior to ESSA finalization, the Bank’s E&S safeguards have conducted a stakeholder consultation, that involved discussion regarding the ESSA that have been developed for the INEY-2 Program, with various invited ministries, agencies, and district-level government representatives in an online meeting forum. The stakeholder consultation event was conducted on Thursday, 13 April 2023 from 13.00 to 16:00 West Indonesian Time (WIB). Parties invited to the meeting were: No. Ministries or Agencies Division 1 Secretariate of Vice President (SoVP) Deputy Assistant of Poverty Eradication 2 National Demography and Family Planning Directorate of Field Line Enforcement Training (Direktur Agency (Badan Kependudukan dan Bina Penggerak Lini Lapangan) Keluarga Berencana Nasional, or ‘BKKBN’) 3 National Development Planning Agency Directorate of Health and Public Nutrition (Badan Perencanaan Pembangunan Nasioanl, or Bappenas) 4 Ministry of State Apparatus Utilization and Deputy Assistant of Public Service Digital Transformation Bureaucratic Reform (Indonesian: of Public Service Deputy Kementerian Pendayagunaan Aparatur Negara dan Reformasi Birokrasi, or KemenPAN-RB) 5 Ministry of Home Affair (MoHA) Directorate of Regional Government Matter Synchronization (Sinkronisasi Urusan Pemerintah Daerah, or SUPD III) Directorate General of Regional Development Lead (Bina Pembangunan Daerah, or ‘Bangda’) 6 Ministry of Village, Development of Directorate of Socio-Cultural Development and Village(s) Disadvantaged Regions (Pengembangan Sosial Budaya dan Lingkungan Desa And Transmigration (Kementerian Desa, dan Perdesaan, or ‘PSBLDP’) Pembangunan Daerah Tertinggal dan Transmigrasi, or ‘Kemendes’) 7 Ministry of Environmental and Forestry Directorate of Hazardous and Non-Hazardous Waste (MoEF) Head of Sub-Division of Enactment and Notification 8 Ministry of Health (MoH) Directorate of Environmental Health Directorate of Health Promotion and Community Enforcement Directorate of Public Health Management 9 Local Government Representatives Health Agency of Surabaya District Health Agency of Manggarai Timur District Environmental Agency of Surabaya District Environmental Agency of Manggarai Timur District Regional Development Planning Agency of Surabaya District Regional Development Planning Agency of Manggarai Timur District Representative of PHC in Surabaya District Representative of PHC in Manggarai Timur District Hazardous Waste Management Task Implementor Unit (Unit Pelaksana Tugas Pengolahan Limbah B3, or UPT LB3) of Environmental Agency of South Sulawesi Environmental and Social System Assessment (ESSA) Page 51 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX B ESSA STAKEHOLDER CONSULTATION (INEY - 2) In the stakeholder consultation meeting, the Bank presented the summary of the ESSA to the participants with the outline in order as follow: • Explanation of the objective of the stakeholder consultation meeting; • Lesson learned from previous nutritional intervention project in Cianjur, West Java; • Preview of medical waste treatment facilities establishment in Indonesia; • News update on medical waste treatment facility establishment in Makassar Industrial Estate (KIMA) in Makassar, South Sulawesi; • Background and objective of the ESSA; • Relevancy of the financial program with Government of Indonesia’s plan; • Description of Result Areas (RAs) and Disbursement-Linked Indicators (DLIs); • Approach of the ESSA; • Presenting applicable exclusion criteria; • Presenting main observation from E&S Aspect (i.e., medical waste management in remote areas, social inclusion for receiving service, grievance mechanism, OHS for community worker); • Describing results of risk analyses of E&S (Moderate); • List of Proposed Action Plan PAP (1-8); and • List of additional recommendations. In addition to the Bank’s explanation of the ESSA summary, a sharing session regarding establishment and operation of medical waste treatment facilities in Makassar, South Sulawesi was conducted by the Head of Hazardous Waste Management Task Implementor Unit (Unit Pelaksana Tugas Pengolahan Limbah B3, or UPT LB3) of Environmental Agency of South Sulawesi Province. During the stakeholder Consultation meeting some feedbacks were received with detailed comments/questions/suggestions and Banks’s responses are documented as follow. No. Questioner Question/Comment/Suggestion Bank’s Answer/Response 1 Mr. Harris • To provide clarification on • The proposed action plan related to Rambey of social inclusion criteria social inclusion is proposed to be Bappenas • What is government level that managed as part of project design (as need to manage medical the program is expected to prioritizing waste? areas with high prevalence of stunting • To check parties named as which is also often identified as area responsible entity for the PAPs. with high poverty number or remote location), also through ensuring a proper mechanism to capture feedbacks, inputs, and concerns is available for the program and accessible for public and stakeholders (through an integrated grievance mechanism). • Medical waste will likely be generated by medical staff that works in Puskesmas (sub-district level) and district level facility. • Will revisit the name of the parties 2 Mr. Ridwan • Request for clarity on whom to Training is proposed conservatively for all Fadjri of BKKBN be the object for training resources involved in the project, even regarding medical waste. Is it though they are not part of medical team for field cadres (village, sub- whom by nature generate medical waste. district) or else? By understanding the way to manage medical waste, it is expected that the non- medical resource could support the overall management by preventing exposure of the medical waste to human receptor or the environment. 4 Mrs/Ms. Monica • The GOI acknowledged that Feedbacks were received and noted of KemenPAN- there are multiple grievance RB reporting channels made by ministries, agencies, or regional Environmental and Social System Assessment (ESSA) Page 52 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX B ESSA STAKEHOLDER CONSULTATION (INEY - 2) government. However, GOI emphasizes the commitment to continue integration of these channels so in the end there will be one accessible channel, i.e., “LAPOR!� application that cover “stunting prevention program�. This program will accommodate anonymity and secrecy principle. It determines limit to respond to collected grievance. Other than that, the grievance mechanism could be done directly by reporting to any government officials in each region. 5 Mr. Chandra • Long discussion has been Bank will communicate further with Mr. Rudyanto – undertaken regarding DLI 6 and Chandra and consider such suggested Takelmas 11. It is suggested to consider if option. Division of MoH the ESSA’s PAPs to not be attached to particular DLIs, noting the difficulty to get an agreement to it. As a guarantee, other feasible options such as assigning dedicated personnel (like 3 personnel) to supervise good E&S management is doable. Discussion with Directorate of Environmental Health and Directorate of Health for Productive and Senior Age are recommended for discussion on DLI 6 and 3, respectively. 6 Mrs./Ms. Maria • To emphasize that the number • The World Bank has not planned to of Health of medical waste treatment return to Manggarai Timur District yet. Agency of facility in NTT province is very It is expected that the PAPs that are Manggarai limited. Currently there is only provided will strengthened the E&S Timur District one incinerator available in management at each region, where Manggarai Timur District supervision will be conducted, without appropriate permit. For independently by government bodies. 29 PHCs there is only 1 public • Benefit to the district is anticipated, at hospital that can facilitate the the minimum by avoidance of impact incineration. from medical waste to the surrounding • Will Bank Team returns to environment and workers at PHC. Manggarai Timur to check improvement from the INEY-2 program? • Will this program bring benefit to the district? • How difficult to get medical waste treatment facility permit? 7 Mr. Thamrin of Responding to Mrs./Ms. Maria from Feedbacks were received and noted Environmental Health Agency of Manggarai Timur Agency of South District: Based on experience, even Sulawesi with support from MoEF on Province. permitting process, it would take a year to secure a permit after the medical facility is operated 7 Mrs./Ms. Irma • Has the ESSA included the • Gender equality is assessed Siahaan of gender equality aspect? proportionally in the ESSA, while SoVP • Has the ESSA considered that behavioral changes as part of the there is a cultural factor that cultural factor are assessed separately prevents stunting reduction and not deeply discussed in the ESSA. program? Such as, open • Agree to change the term SoVP with PMU. Environmental and Social System Assessment (ESSA) Page 53 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX B ESSA STAKEHOLDER CONSULTATION (INEY - 2) defecation culture, food taboo • Agree to have follow up communication culture, etc. with MoHA, MoH and BKKBN for PAP • To consider changes from 5, 6, and 7. appointing SoVP directly in the PAP into put it in general as PMU. • To consider discussion with MoHA on sanitation program in PAP 5. • To consider discussion with MoH and BKKBN on involvement in PAP 6 and 7, particularly to develop guidelines on social aspects, such as social inclusion and OHS. Environmental and Social System Assessment (ESSA) Page 54 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX C SUMMARY OF INEY 2 DLIS (INEY - 2) Annex C Summary of INEY 2 DLIs Summary of INEY 2 DLIs are presented in the following table. Results Area Disbursement-linked Indicators (DLI) Descriptions 1 Strengthening DLI 1: Commitment, performance and 1.1 SOVP organizes an annual stunting summit jointly with BKKBN, Kemenko PMK, leadership, commitment, accountability of district & provincial leaders to Bappenas, MOHA, MOH and MOV to reconfirm subnational commitments and acknowledge and accountability for accelerate stunting prevention and reward good provincial and district performance in the acceleration of stunting reduction stunting reduction DLI 2: Results-Based and Climate-Responsive 2.1 (a) Bappenas approves a national climate and nutrition action plan (CNAP) and Nutrition Planning and Budgeting Systems monitoring framework 2.1 (b) Bappenas monitors and reports on CNAP implementation progress and anchor project(s) in annual reports of the stunting reduction program 2.2 MOF and Bappenas issue annual and semi-annual performance and expenditure reports in accordance with updated guidelines, meeting requirements set forth in the Verification Protocol DLI 3: Integrated and climate-responsive 3.1 MOH has published national and district stunting rates on the MOH website monitoring and evaluation (M&E) systems for the acceleration of stunting reduction 3.2 Bappenas has piloted a new guideline on M&E of the stunting reduction program for national, provincial, district, and village levels; issued the report of the pilot; and disseminated the guidelines 3.3 Bappenas and BKKBN have provided annual and semi-annual reports to the Steering Committee detailing progress of the stunting reduction program, key bottlenecks, and recommendations for program improvement 2 Delivery and quality DLI 4: Delivery of nutrition interventions through 4.1 Districts scale up the implementation of holistic integrated early childhood education and of specific and the education sector development (ECED) in ECED centers, meeting requirements set forth in the Verification sensitive interventions Protocol 4.2 Junior and senior high schools in Priority Districts implement the nutritious action program to improve nutritional status for in-school adolescents DLI 5: Evidence-Based and Climate-Responsive 5.1 MOH updates nutrition-specific interventions to respond to climate change including: Nutrition Specific Interventions (a) issuing technical guidelines for maternal micronutrient supplementation (MMS); (b) issuing technical guidelines for Local complementary food supplementation for infants and young children; Environmental and Social System Assessment (ESSA) Page 55 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX C SUMMARY OF INEY 2 DLIS (INEY - 2) (c) initiating MMS distribution to all Priority Districts 5.2 MOH carries out a national micronutrient survey, meeting requirements set forth in the Verification Protocol 5.3 a) MOH issues updated regulatory action for production of fortified rice kernels in Indonesia; b) Bappenas approves climate-sensitive action plan for scaling up fortified rice 5.4 MoH provides on the job training to midwife, nutritionist, and cadres at the village level on standardization of Growth Monitoring Promotion (GMP) and anthropometric surveillance in Priority Districts 3 Service delivery DLI 6: Improving the quality of essential health 6.1 Number of Puskesmas in priority provinces that meet minimum clinical standards for and convergence and nutrition services at Puskesmas service-readiness for essential maternal, newborn, child, and adolescent health and nutrition at district/city level for services, meeting requirements set forth in the Verification Protocol stunting reduction 6.2 Number of Puskesmas in Priority Districts submitting standardized reports of nutrition specific service delivery on a monthly basis to district and national level 6.3 Percentage of pregnant women in the Priority Districts receiving the sixth antenatal care visit, meeting requirements set forth in the Verification Protocol 6.4 Number of identified underperforming districts with >=10 percentage point increase in coverage for Complete Basic Immunization over the baseline in 2023 6.5 Number of districts with >=5 percentage point increase in coverage for the first dose of diphtheria, pertussis and tetanus vaccine over the baseline in 2023 6.6 Percentage of children receiving DTP1 in priority provinces (Number of districts in identified priority provinces with >=3 percentage point increase in coverage for DTP1 in each year- scalable) DLI 7: Performance-based fiscal transfers 7.1 Number of districts that achieved improved performance against the updated BOK incentivize districts to improve the coverage of Puskesmas guidelines over the baseline year in 2023-24 essential health and nutrition services DLI 8: Districts achieve good performance in 8.1 Number of Priority Districts that include stunting reduction as District Medium-Term convergence of interventions for acceleration of Development Plan indicators stunting reduction 8.2 Directorate of Evaluation and System Information-DGFB MoF and Directorate of Local Government Affairs Synchronization (SUPD III)-DGRD MOHA publish annual report of districts stunting budget tagging and expenditure tracking for stunting reduction program Environmental and Social System Assessment (ESSA) Page 56 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX C SUMMARY OF INEY 2 DLIS (INEY - 2) 8.3 Number of district/city Governments achieving good performance in converging interventions for the Acceleration of Stunting Reduction, meeting requirements set forth in the Verification Protocol 4 Service delivery DLI 9: Village kaders are skilled to support their 9.1 (a) MOH finalizes and issues a training on 25 competencies and standard home visits for and convergence at villages to deliver, coordinate, and achieve good Posyandu Kader (b) Number of Posyandu with 2 Kaders completing the common stunting village & household level performance for service delivery and reduction module and certified at Madya (MCH +school age + adolescent) against the new 25 for stunting reduction convergence acceleration of stunting reduction Posyandu Kader competencies 9.2 Number of villages with Family Assistance Teams trained by BKKBN in the Family Assistance Team training module and common stunting reduction module. 9.3 Number of villages with Human Development Workers (HDW) trained by MOV in the updated HDW training module and the common stunting reduction module, as per verification protocol 9.4 Number of villages achieving good performance in the acceleration of stunting reduction, meeting requirements set forth in the Verification Protocol DLI 10: Strengthening the provision of quality 10.1 Guideline issued on: (a) Number of active Posyandu, meeting requirements set forth in essential health and nutrition services at the the Verification Protocol; (b) Number of active Posyandu (as defined in the verification village level protocol) reporting number of visits and service delivery on a monthly basis to the district health authorities and MOH; 10.2 (a) MOH issues regulation on Pustu as part of the Integration of Primary Health Care Program, including minimum service standard; (b) Number of Pustu established and functioning as per the verification protocol; (c) Number of Pustu reporting number of visits and service delivery on a monthly basis to the district health authorities and MOH Environmental and Social System Assessment (ESSA) Page 57 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX D E&S RISK AND IMPACTS SCREENING (INEY - 2) Annex D E&S Risk and Impacts Screening Result Areas & Environmental Risks Social Risks Proposed PAP Link to DLIs Activities Results Area 1. The activities under RA1 are not expected to have significant The activities under the RA1 are expected to contribute to addressing • POM preparation/updates, to include: (a) mechanism of regular - Strengthening adverse and long-term direct environmental impacts. equity issues, thus the downstream implications of the key program coordination between agencies (e.g., with MoH, MoEF, MOHA, leadership, Potential environmental benefits: Improved and strengthened results to community are expected to be positive, whilst capacity BKKBN, Bappenas, etc.), (b) coordination with other projects (as commitment and governance at district and provincial level could potentially strengthening activities will also benefit national stakeholders relevant, e.g., ISphere PforR, COVID PforR, other health projects accountability for enhance the effectiveness and compliance of environmental (including strengthen multisectoral coordination and through provision in the future, village government capacity building program, etc.), stunting reduction protection laws and regulations. of technical support to sector line agencies in data collection, and (c) E&S risks management monitoring and reporting. diagnosis, synchronized planning, budgeting, monitoring and Regular project reporting to the Bank to include updates on the evaluation through performance assessments of national spending E&S mitigation implementation. on nutrition interventions, and acceleration of learning), and therefore • Environmental Specialist and Social Specialist or Focal Points to the risk has been rated as moderate, given the scale and complexity be recruited/appointed/assigned to oversee implementation, of the project and nationwide coverage. monitoring, and reporting of E&S management. Results Area 2. The activities under RA3 are not expected to have significant Activities under RA2 are expected to contribute to addressing equity On social inclusion (including IP, remote area community/village, and - Delivery and quality adverse and long-term direct environmental impacts. issues in food assistance program and early childhood education, other vulnerable groups), a technical guideline to be prepared in of specific and Potential environmental benefits: Improved and strengthened whilst considering the following assessment, the social risk is rated guiding the Program implementer, particularly at local (District and sensitive interventions governance at sub-national and district level could potentially as moderate, given the scale and complexity of the project, Village) level to ensure consideration of cultural appropriateness of enhance the effectiveness and compliance of environmental nationwide coverage, potential challenges in engaging the activities, equitable access to program benefits, and strategy/special protection laws and regulations. disadvantages and hard-to-reach communities, cultural sensitivity of attention are provided (e.g., for data collection and specific approach the Indigenous People, also and the complexity of grievance to response when stunting is identified). Training and socialization of mechanism that can be applied across regions: the technical guideline to be conducted aligned with the existing • Ability of individuals, households and groups to obtain services in capacity building program for the national stunting program an accessible, safe, and inclusive manner, and are delivered in a implementer at local level. way that takes into consideration local context including literacy, language, and cultural aspects of the beneficiaries. • Potential for inequality resulting to conflict due to perceived differences in how the benefits of the program are distributed among community groups, including the most vulnerable (likely Poorer families, lesser educated mothers, young mothers, older mothers, unmarried mothers, single parent families or child headed households, and parents with HIV status) and Indigenous Peoples (if present in the targeted communities). • Community access to raise complaints and concerns and adequately informed to ensure consent in participating in the program. Results Area 3. The activities under RA2 are assessed as Moderate, The activities under the RA3 are expected to contribute to addressing • Close coordination between Bappeda, MoH, local health DLI8 Service delivery considering potential public health issues related to safe equity issues, thus the downstream implications of the key program agencies, local public work agencies and MOHA on the goals and convergence handling, distribution, storage and disposal of oversupplied results to community are expected to be positive, whilst capacity and strategy of sanitation improvement program, as well as at district/city level for supplement tablets and increased immunization as strengthening activities will also benefit sub-national stakeholders evaluation on approach of delivery, monitoring, and evaluation. stunting reduction implications of promoting health, immunization, and nutrition (including through provision of technical support in prioritization of Evidences that can demonstrate coordination for the goal, in schools and improved management of nutrition-specific district and village plans and budgets to address stunting, the strategy, monitoring and evaluation of the sanitation program to interventions at puskesmas level execution of stunting program, intervention targeting and service be provided as a requirement in the verification protocol of DLI 8 Potential environmental benefits: delivery outcomes), and therefore the risk has been rated as on this aspect. • Improved and strengthened governance at national level moderate, given the scale and complexity of the project, nationwide • For mechanism to manage concerns/issues, challenges and DLI3 could potentially enhance the effectiveness and coverage, potential challenges in engaging the disadvantages and inputs from the affected people/beneficiaries and stakeholders, a compliance of environmental protection laws and hard-to-reach communities, cultural sensitivity of the Indigenous technical guideline to be prepared to cover management of regulations. People, also and the complexity of grievance mechanism that can be multiple existing grievance channels and media (at national and • Incorporation of good environmental safeguards applied across regions. local level) to be optimized, while ensuring the E&S Focal Point practices such as safe handling of medical waste and has a system in place to coordinate with relevant ministry and safe disposal of unused medication through the IPC agency, socialization of such channel and system, monitor and activities report regularly on the resolution of concerns/issues and challenges. Evidence on improvement on coordination between ministries and agencies to address such concerns where the feedback/ concerns from the communities and stakeholders related to the program and how these are being resolved is proposed to be included as requirement in verification protocol of DLI 3 on this aspect. Environmental and Social System Assessment (ESSA) Page 58 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX D E&S RISK AND IMPACTS SCREENING (INEY - 2) Results Area 4. The activities under RA4 are assessed as Moderate, Through the RA4, the INEY program is expected to contribute to • Awareness raising, refresher training and access information to DLI6 Service delivery considering potential public health issues related to handling, addressing equity issues in the nutrition intervention program, while medical waste facilities at provincial level and PermenLH and convergence at distribution, storage and disposal of oversupplied supplement increase quality of and participation in community-based activities 56/2015 are included in the eHDW (electronic Human village & household tablets and immunization from the nutrition-specific and through nutrition counselling. Social risks remained as follow, and is Development Workers) application for 74,000 villages in level for stunting nutrition-sensitive interventions. rated as moderate, given the scale and complexity of the project, Indonesia through KPM (Kader Pembangunan Manusia) from reduction nationwide coverage, potential challenges in engaging the Ministry of Village and also AKSI BANGDA application from disadvantages and hard-to-reach communities, cultural sensitivity of Ministry of Home Affairs. the Indigenous People, also and the complexity of grievance • Regular training and supervision of PHC’s staff and sanitarian by DLI6 mechanism that can be applied across regions: local health agencies on implementation of MoH’s Regulation No. • Ability of individuals, households and groups to obtain services in 18 of 2020 (Permenkes 18/2020) on medical waste handling or an accessible, safe, and inclusive manner, and are delivered in a for remote area, implementation of Appendix VI of the MoEF’s way that takes into consideration local context including literacy, Regulation No. 56 of 2015 (Permen LH 56/2015). One national language, and cultural aspects of the beneficiaries. level workshop on the subject and a local health agencies’ report • Potential for inequality resulting to conflict due to perceived on actual implementation of the provisions on medical waste differences in how the benefits of the program are distributed management in all PHCs, subject to their respective access to among community groups, including the most vulnerable (likely the existing waste treatment facilities is proposed to be Poorer families, lesser educated mothers, young mothers, older conducted/provided as a requirement in the verification protocol mothers, unmarried mothers, single parent families or child for DLI 6 on this aspect. headed households, and parents with HIV status) and • With regards to community (workers) occupational health and DLI9 Indigenous Peoples (if present in the targeted communities). safety (OHS), to prepare OHS training module and capacity • Community access to raise complaints and concerns and building plan (including for PusTu/Posyandu staffs and cadres). adequately informed to ensure consent in participating in the This is proposed to be incorporated in the verification protocol of program. the DLI 9 to ensure Village kaders have skills and support to deliver quality essential health and nutrition services and coordinate service convergence, including capacity related to OHS. • For mechanism to manage concerns/issues, challenges and DLI3 inputs from the affected people/beneficiaries and stakeholders, a technical guideline to be prepared to cover management of multiple existing grievance channels and media (at national and local level) to be optimized, while ensuring the E&S Focal Point has a system in place to coordinate with relevant ministry and agency, socialization of such channel and system, monitor and report regularly on the resolution of concerns/issues and challenges. Evidence on improvement on coordination between ministries and agencies to address such concerns where the feedback/ concerns from the communities and stakeholders related to the program and how these are being resolved is proposed to be included as requirement in verification protocol of DLI 3 on this aspect. Environmental and Social System Assessment (ESSA) Page 59 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX E ALIGNMENT OF INEY 2 PFORR (INEY - 2) PROGRAM WITH GOI PROGRAM Annex E Alignment of INEY 2 PforR Program with GOI program Alignments of the activities under the National Strategy for Acceleration of Stunting Reduction, by Pillar, with the INEY 2 Program are presented in the following table. INEY 2 No Component Notes PforR Pillar 1: Improving leadership commitments and visions in ministries/agencies, provincial governments, district/city governments, and village governments. A. Improve commitment to accelerating stunting reduction 1 Organize annual coordination meetings attended by high-ranking officials at ✓ RA 1 national, provincial and district/city levels. 2 Organize Coordination meetings at district/ city level ✓ RA 3 3 Deliver Stunting Rembuk (boot-camp) events at subdistrict level. ✓ RA 4 District head/mayor policies/regulations in place concerning ✓ RA 3 4 villages’/kelurahans’ jurisdiction over stunting reduction. 5 Ensure availability of village/kelurahan midwives as necessary ✓ RA4 6 Monitor stunting-free villages/kelurahans. ✓ RA 4 Monitor Provincial Regional Governments budget allocations to Acceleration ✓ RA 3 7 of Stunting Reduction. Monitor district/city Regional Governments budget allocations to Acceleration ✓ RA 1, 3 8 of Stunting Reduction. B. Improve capacity of Village Governments. 1 Provide capacity building to villages to handle Stunting Reduction ✓ RA 4 Acceleration Train Family Hope Program (PKH) facilitators trained with health and nutrition X 2 modules 3 Train human development workers (from district/city Regional Governments) ✓ RA 4 Pillar 2: Improvement of behavior change communication and community empowerment A. conduct sustainable change behavior communication and campaigns 1 Implement National Campaigns for stunting prevention X 2 Promote Open Defecation Free (ODF) families. X 3 Promote practicing a Clean and Healthy Lifestyle (PHBS) among families X 4 Deliver full set of basic immunization to under-five children ✓ RA 2, 4 B. Strengthen institutional capacity in behavior change communication for stunting reduction. 1 Ensure that districts/cities have a minimum of 20 basic-level trainers and X education and training in stimulation parenting to manage stunting for Early Childhood Education (ECE) teachers. Train Early Childhood Education (ECE) teachers in villages/kelurahans on X 2 stimulation parenting to manage stunting Develop Holistic-Integrative Early Childhood Education for Early Childhood ✓ RA 2 3 Education (ECE) institutions Ensure compliance with standards for growth and development monitoring ✓ RA 4 4 services at Posyandu Organize under-five Family (BKB) classes on parenting in the First 1000- X 5 days of Life (HPK) in villages/kelurahans Promote Family Capacity Building Sessions (P2K2) using health and nutrition X 6 modules for beneficiary Families (KPM) of the Family Hope Program (PKH) Environmental and Social System Assessment (ESSA) Page 60 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX E ALIGNMENT OF INEY 2 PFORR (INEY - 2) PROGRAM WITH GOI PROGRAM Provide reproductive health and nutrition education for adolescents at X 7 Information and Counseling Centers (PIK) for Adolescents and Adolescent Family Guidance (BKR) C. Strengthen the role of religious organizations in behavior change communication on stunting reduction. 8 Create and implement forums for behavior change communication on stunting reduction across religions. Deliver marriage guidance with material on stunting prevention to brides and ✓ RA 4 9 grooms Pillar 3: Improvement of convergence of Specific Interventions and Sensitive Interventions in ministries/agencies, provincial Regional Governments, district/city Regional Governments and Village Governments. A. Converge planning and budgeting, and carry out activities to improve types, coverage and quality of nutrition interventions at national and subnational levels. 1 Integrate Stunting Reduction Acceleration programs and activities in regional ✓ RA 3 planning and budgeting documents (Regional Long-Term Development Plans, Regional Mid-Term Development Plans, Food and Nutrition Regional Action Plans, Regional Government Work Plan, and Regional Budgets, and Work and Budget Plans) at the level of provinces and districts/cities Implement convergence of Stunting Reduction Acceleration at the ✓ RA 3 2 districts/cities levels Integrate Stunting Reduction Acceleration programs and activities in ✓ RA 4 village/kelurahan planning and budgeting documents (Village Mid-term 3 Development Plans, Village Government Work Plans, and Village Budgets, and Village Work and Budget Plans). Increase village/kelurahan fund allocations to Specific Interventions and ✓ RA 4 4 Sensitive Interventions for Stunting Reduction. Converge the Acceleration of Stunting Reduction at the level of ✓ RA 4 5 villages/kelurahans 6 Implementing Community-Led Total Sanitation (CLTS) in villages/kelurahans X Provide Iron Folic Acid Tablets (TTD) to prospective brides and ✓ RA 2, 3, 4 7 grooms/prospective mothers Provide supplementary nutrient intake to pregnant women with Chronic ✓ RA 2, 3 8 Energy Deficiency (KEK) Ensure pregnant women consume a minimum of 90 Iron Folic Acid Tablets ✓ RA 2, 3 9 (TTD) during pregnancy 10 Promote exclusively breastfeeding for infants under 6 months old ✓ RA 2, 3 11 Provide complementary foods (MP-ASI) to children aged 6-23 months ✓ RA 2, 3 Deliver malnutrition management services to malnourished children under ✓ RA 2, 3 12 five years old (under-five) 13 Provide supplementary nutrient intake to malnourished under-five children ✓ RA 2, 3 Provide food security interventions to support the Acceleration of Stunting X 14 Reduction in districts/cities Provide facilitation as women-friendly and child-friendly regions in the ✓ RA 4 15 Acceleration of Stunting Reduction. B. Converge efforts to prepare for family life 1 Ensure coverage of assistance for families at risk of stunting. ✓ RA 4 Deliver reproductive health counseling and nutrition education for 3 months ✓ RA 4 2 before marriage to prospective Childbearing Age Couples (PUS) receiving 3 Provide anemia status checks (hemoglobin test) to adolescent girls ✓ RA 2, 4 4 Strengthen surveillance data on families at risk of stunting. ✓ RA 4 Environmental and Social System Assessment (ESSA) Page 61 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX E ALIGNMENT OF INEY 2 PFORR (INEY - 2) PROGRAM WITH GOI PROGRAM Promote an Age-Specific Fertility Rate/ASFR (15-19) of at least 18 per 1,000 N 5 in districts/cities 6 Provide postpartum birth control services N 7 Address unmet needs for birth control services N Pillar 4: Improvement of food and nutrition security at the individual, family and community levels. A. Meet needs for food and nutrition at the individual, family and community levels, including needs during a disaster. 1 Provide home garden benefits to improve nutrient intake to families at risk of N stunting 2 Promote increased domestic fish consumption for families at risk of stunting N Provide diverse food assistance in addition to rice and egg (carbohydrate, N animal protein, vegetable protein, vitamins and minerals, and/or 3 Complementary Foods (MP-ASI) to beneficiary Families (KPMs) with pregnant women, breastfeeding mothers and children under two years old (under-two) Provide conditional cash transfers for childbearing Age Couples (PUS) with N 4 status as poor and people with social welfare problems Provide non-cash food assistance to childbearing Age Couples (PUS) with N 5 status as poor and people with social welfare problems receiving Provide Health Security Premium Subsidy (PBI) to poor and financially weak N 6 Childbearing Age Couples (PUS) B. Improve food fortification quality 1 Promote control over fortified food products followed up by business actors. N Pillar 5: Strengthening and development of systems, data, information, research and innovation A. Strengthen integrated Monitoring and Evaluation systems for the Acceleration of Stunting Reduction 1 Promote good performance in converging the Acceleration of Stunting ✓ RA 1, RA 3 Reduction for provincial and district/city Regional Governments Promote good performance in converging the Acceleration of Stunting ✓ RA 4 2 Reduction for Village Governments 3 Ensure the publication of data on stunting at district/city level. ✓ RA 1 Strengthen Monitoring and Evaluation of the implementation of the National ✓ RA 1 4 Strategy for Acceleration of Stunting Reduction. Strengthen Monitoring and Evaluation of the Acceleration of Stunting ✓ RA 1 5 Reduction in provincial Regional Governments. Strengthen Monitoring and Evaluation of the Acceleration of Stunting ✓ RA 1 6 Reduction in district/city Regional Governments. Strengthen monitoring and Evaluation of the Acceleration of Stunting ✓ RA 1 7 Reduction in Village Governments 8 Conduct audits of stunted children under two years old X B. Develop an integrated data and information system 1 Support an integrated regional and village/ kelurahan fund transfer system to ✓ RA 3, 4 support the Acceleration of Stunting Reduction Support an integrated data and information system to support the ✓ RA 1 2 Acceleration of Stunting Reduction. Ensure the availability of data on families at risk of stunting updated on the X 3 Family Information System (SIGA). Ensure the availability of a system for screening and counseling for X 4 prospective Childbearing-Age Couples (PUS) ready for marriage. Monitor nutrition interventions for stunting reduction in districts/cities through ✓ RA 1, 2, 3, 4 5 electronic nutritional surveillance data systems Environmental and Social System Assessment (ESSA) Page 62 INDONESIA – INVESTING IN NUTRITION AND EARLY YEARS - 2 ANNEX E ALIGNMENT OF INEY 2 PFORR (INEY - 2) PROGRAM WITH GOI PROGRAM C. Strengthen research and innovation and promote the use of research and innovation results 1 Provide assistance in the Acceleration of Stunting Reduction through the X Three Pillars of Higher Education (Tri Dharma) to districts/cities D. Develop a knowledge management system 1 Support a platform for knowledge sharing on the Acceleration of Stunting X Reduction Institute a system of awards to regions for the Acceleration of Stunting ✓ RA 1 2 Reduction. Develop an integrated system of financial incentives for regions rated as well- ✓ RA 3 3 performing districts for the Acceleration of Stunting Reduction. Conduct an assessment of government budget for the Acceleration of ✓ RA 1, RA3 4 Stunting Reduction. Environmental and Social System Assessment (ESSA) Page 63