Page 1 INTEGRATED SAFEGUARDS DATA SHEET CONCEPT STAGE Report No.: AC1918 Date ISDS Prepared/Updated: 12/01/2008 I. BASIC INFORMATION A. Basic Project Data Country: Peru Project ID: P095563 Project Name: PE- (APL2) Health Reform Program Task Team Leader: Fernando Lavadenz Estimated Appraisal Date: January 19, 2009 Estimated Board Date: March 24, 2009 Managing Unit: LCSHH Lending Instrument: Adaptable Program Loan Sector: Health (80%);Non-compulsory health finance (20%) Theme: Health system performance (P) IBRD Amount (US$m.): 15.00 IDA Amount (US$m.): 0.00 GEF Amount (US$m.): 0.00 PCF Amount (US$m.): 0.00 Other financing amounts by source: Borrower 132.40 Inter-American Development Bank 15.00 Financing Gap 0.00 147.40 B. Project Objectives [from section 2 of PCN] Framed within the long-term objectives of the Health Reform Program, the project objectives are to: (i) improve family health care practices for women (during pregnancy, delivery and breast- feeding) and children under three years old in the nine poorest provinces. (ii) strengthen health service network capacities to solve obstetric, neonatal and infant emergencies, and provide comprehensive health services to women (during pregnancy, delivery and breast-feeding) and children under age three in the nine poorest provinces (iii) support MINSA’s governance functions of regulation, quality, efficiency and equity for improving the new health delivery model of maternal and child health care in a decentralized environment. Page 2 C. Project Description [from section 3 of PCN] This proposed second phase APL would have four components and total project costs of US$162.4 million. This project has been jointly prepared with the IADB. The GoP has requested that the Bank and IADB finance up to US$15 million each, with the remainder to be covered by other fiscal resources. The project will be implemented in the same departments as under the APL I (i.e. Amazonas, Huánuco, Huancavelica, Ayacucho, ApurĂ­mac, Cusco and Puno) plus two additional regions: Cajamarca and Ucayali. These departments were prioritized because IMR and MMR still remain well above the national average, and thus need further project intervention. Disbursement for this project will be based on standard mechanisms for investment projects as requested by the GoP and the categories under which funding will cover components were prepared by the borrower. Component 1. Improving health practices at the household level for women and children under age three in rural areas of the nine targeted Departments (US$6.0 million). This component will finance three lines of actions: Subcomponent 1.1. The design, implementation, and monitoring of a Behavioral Change Communication and Education Program (BCCEP). The BCCEP aims to promote healthy practices at the household level, including increase demand for health services, with a focus on mothers during pre- and post-natal periods and children under three, taking into consideration the cultural context of rural and indigenous populations. To achieve this objective, the activities to be financed include: (i) studies to identify current practices, beliefs and attitudes, including the use of health services; (ii) 9 tailored BCCEP strategies (by region); (iii) development, validation, and production of culturally sensitive printed and audio-visual materials (radio spots, soap operas, videos, etc.); (iv) basic training and dissemination equipment (PCs, data display devices, TVs, DVD); (v) training of MINSA, DIRESAs staff, as well as staff, networks, micro-networks, and community agents for the local implementation of the BCCEP; (vi) a training program for local authorities, community leaders, social and civil society organization; (v) learning workshops and study tours; (vi) technical assistance to health staff and community members on the implementation of the BCCEP; (vi) monitoring and evaluation of the BCCEP; (viii) evidence-based studies for health promotion in maternal and neonatal health care. In addition, a competitive fund of approximately US$1 million (to be financed under the IADB loan), would be established to finance local initiatives to improve healthy communities. Subcomponent 1.2. The provision of national identity cards to unregistered pregnant women. This sub-component aims to support the GoP in enrolling eligible women and their children for SIS benefits. The lack of national identification documents is a serious obstacle to accessing social programs: the problem is especially serious in indigenous rural areas. In the country, almost 10% of adult population is undocumented, and women who lack a Documento Nacional de Identidad (DNI) may lose access to health insurance (SIS), as well as to other social protection and development opportunities. Therefore, the Project will support the provision of DNI to unregistered pregnant women. Page 3 Specifically, the project would finance: (i) the design and implementation of a campaign promoting identity rights. This campaign would facilitate the work to be carried out by civil servants in charge of the delivering of the DNI; (ii) the design, production and dissemination of materials promoting identity rights for all nine Departments; (iii) training of health staff and local authorities on the promotion of identity rights; and (iv) minor rehabilitation investments to facilitate the installation of RENIEC or local government registrars in local health facilities which have birthing services. Component 2. Increasing the capacity to provide better maternal and child health services for the poor (US $142.3 million). This component would strengthen the health delivery model through improving the capacity of health service networks to attend obstetric and neonatal emergencies, to improve the integration between pre-natal and post-natal care, and health care for children under three. The component would support: Subcomponent 2.1. Improvement in the quality of services in health facilities. This would include: (i) minor constructions, rehabilitation, and equipment investments for the networks in the Departments supported by the Project, related to the improvement of the 8 essential obstetric care functions, and one neonatal service ; (ii) technical assistance and training for health personnel; (iii) inclusion of an intercultural focus in service provision; and (iv) a fund to support innovative proposals to finance local initiatives for health services provision (to be financed by the IADB).. Subcomponent 2.2. Raising the efficiency and effectiveness of networks. The main purpose of this subcomponent is to improve the new health delivery model to be implemented under the project. The table below explains the differences between the old and new health model for mother and child care. This would include: (i) strengthening management systems at the network level; (ii) improving the referral and counter-referral system, (iii) supporting the implementation of health care chains for maternal and neonatal service referrals and clinical agreements between providers, (iv) clinical governance studies, and (v) regulation of the health networks and maternal health care chains. Component 3. Strengthening government capacities to offer more equitable and efficient health system in a decentralized environment (US$5.2 million). This component would work towards the strengthening of MINSA, and the decentralization of the health system through: Subcomponent 3.1. Regulatory framework in support of service quality. The PARSALUD results-based model entails innovations that require regulatory reforms in order to ensure that they are incorporated into the institution and are sustainable. Technical assistance will be provided in order to support the integrated health model and the development of support systems. These include the development of the regulatory framework and implementation plan for: (i) the accreditation and certification system, currently proposed by the law but not regulated, (ii) infrastructure maintenance systems, (iii) a reference laboratory system, (iv) hemotherapy (v) hospital financing, (vi) pharmaceutical purchasing and logistics system, and (vii) a health communication and promotion system. Page 4 Subcomponent 3.2. Strengthening of SIS. The Project would support SIS to develop the public insurance system. This would entail technical assistance for: (i) the development of the regulatory framework, improvement of the SIS information system, aimed at better monitoring enrollment, coverage and access in the Departments initially included in the project, (ii) quality assurance mechanisms, and technical assistance for the implementation of the SISFOH targeting system to ensure adequate targeting of health insurance financing in urban areas. Subcomponent 3.3. Systems development to enhance the monitoring capacity of MINSA. This set of activities would support the improved implementation of existing systems, namely SIS (see above), SISMED, and SIGA, all of which can produce monitoring data and thus introduce greater accountability into the system. This is particularly important for the MINSA decentralization process, whereby the sector is moving towards a greater regulatory role and the Departments will be taking on greater responsibility for implementation. Subcomponent 3.4. Support to decentralization. The Project would support the continued implementation of Management Agreements (MA) now in place, as instruments for supervision and accountability between the central regulatory level and the Departments, which are responsible for service provision. To this end, the project would provide direct technical assistance and training to MINSA and regional staff in order to implement the MAs. In addition, the Project will support the design of an incentive/penalty system that will ensure that the MAs are effective instruments. Component 4. Project Coordination (US$ 8.9 million) This component would finance activities related to the administration of the project, such as: (i) The financing of external concurrent auditors, (ii) monitoring and evaluation activities, and (iii) project management and procurement team within MINSA. The unit in charge of this project would be the PARSALUD unit which would operate as a PCU under an operations manual agreed with the Bank. D. Project location (if known) The project will be implemented in the same regions as under the APL I (i.e. Amazonas, Huánuco, Huancavelica, Ayacucho, ApurĂ­mac, Cusco and Puno, the poorest Departments of the country) plus two additional regions: Cajamarca and Ucayali. These last two areas were prioritized because despite some advances in the reduction of the IMR and MMR, these indicators still remain well above the national average. The population in these areas is primarily indigenous, rural, and disperses, and speaks native languages, with the exception of Cajamarca, where most of the population speaks Spanish. E. Borrower’s Institutional Capacity for Safeguard Policies [from PCN] The borrower's institutions are fully prepared to apply the safeguard policies. The PARSALUD I ICR reported that during APL I various supervision teams regularly monitored the compliance with the environmental regulations and appropriate procedures for handling and managing medical waste at the participating health facilities, finding no relevant issues. In addition, Page 5 PARSALUD I addressed key issues linked to Indigenous peoples through a number of activities related to the cultural adaptation of maternal and child health services, including the provision of the delivery in vertical position in indigenous areas, as well as training of health professionals in local culture and language. The ICR further reported that the project complied with OP 4.01 (environmental assessment) and OP. 4.10 (indigenous peoples). PARSALUD II will build upon lesson learned on PARSALUD I. In addition, due to Peru’s large indigenous composition, and political will of inclusion reinforced in previous years, the country and the health sector have accumulated extensive experience working on Indigenous populations’ cultural adequacy. In this regard, the project has prepared a state of the art Communication and Health Promotion Strategy that addresses cultural differences, with strong emphasis on indigenous behaviors, beliefs, and practices of maternal and child health care. F. Environmental and Social Safeguards Specialists Ms Isabel Tomadin (LCSHH) Mr Alonso Zarzar Casis (LCSSO) II. SAFEGUARD POLICIES THAT MIGHT APPLY Safeguard Policies Triggered Yes No TBD Environmental Assessment (OP/BP 4.01) X An environmental assessment (EA) concluded that wastes are expected to be generated from minor construction works and rehabilitation of health facilities that the project will intervene, as well as additional health care waste (HCW) generated from the increased demand of health services. The EA addresses issues and required environmental management and mitigation measures associated with the project, with an emphasis on Component 2. It identifies lines of action for every objective, and identifies anticipated impacts associated with each type of activity, by type, duration, geographical area, and magnitude. The EA also analyzes and recommends appropriate technologies for the disposal of HCW that comply with national medical waste regulations. The EA further provides approximate costs for wastewater and hazardous solid waste treatment by type of health establishment. The EA proposes a Solid and Liquid Waste Management System which (i) establishes basic procedures in each of the management stages for HCW produced in health facilities and to proposes best practices for implementation; (ii) defines monitoring and evaluation processes for the management of HCW produced in the intervened health facilities; and (iii) estimates the costs and capacity building strategies for the implementation of the Solid and Liquid Waste Management System, including intercultural and regional adaptations (mountains, jungle, rural or urban). The EA covered the Project as a whole, not only to the part financed by the Bank, as this is a requirement of Peru’s legislation. Natural Habitats (OP/BP 4.04) X This OP is not triggered because the project does not include interventions in protected natural areas or areas vulnerable to disasters. Page 6 Safeguard Policies Triggered Yes No TBD Forests (OP/BP 4.36) X Pest Management (OP 4.09) X This OP is not triggered because the project does not foresee any fumigation regarding tropical and vector control diseases. All interventions are related to the maternal and child health care. Physical Cultural Resources (OP/BP 4.11) X This OP is not triggered because the project does not include interventions in areas with archeological heritage, architectural history or national monuments. Indigenous Peoples (OP/BP 4.10) X On the basis of a Social Assessment through consultations carried out with indigenous communities in two occasions in the Andean areas (Tambo in Ayacucho and Sicuani in Cusco) and in the Amazons areas (Pucallpa in Ucayali and Nieve in the Department of Amazonas), an Indigenous Peoples Plan (IPP) was developed in June 2006, and discussed with the population. This Plan includes (i) findings from the social assessment, (ii) description of the free, prior and informed consultation process, (iii) an action plan of actions that ensure that indigenous peoples receive culturally-sensitive and appropriate health services, (iv) procedures for the resolution of grievances arising from project implementation, and (v) monitoring and evaluation mechanisms for the implementation of the action plan. A detailed budget will be defined during the appraisal mission. Involuntary Resettlement (OP/BP 4.12) X Safety of Dams (OP/BP 4.37) X Projects on International Waterways (OP/BP 7.50) X Projects in Disputed Areas (OP/BP 7.60) X Environmental Category: B - Partial Assessment III. SAFEGUARD PREPARATION PLAN A. Target date for the Quality Enhancement Review (QER), at which time the PAD-stage ISDS would be prepared: 01/26/2006 B. For simple projects that will not require a QER, the target date for preparing the PAD-stage ISDS: N/A C. Time frame for launching and completing the safeguard-related studies that may be needed. The specific studies and their timing 1 should be specified in the PAD-stage ISDS. Both, Environmental and Social Assessments have been conducted. The EA includes a management and mitigation plan. Based on the social assessment an IPP including social communication and health promotion strategy was developed. 1 Reminder: The Bank's Disclosure Policy requires that safeguard-related documents be disclosed before appraisal (i) at the InfoShop and (ii) in-country, at publicly accessible locations and in a form and language that are accessible to potentially affected persons. Page 7 IV. APPROVALS Signed and submitted by: Task Team Leader: Mr Fernando Lavadenz 11/24/2008 Approved by: Regional Safeguards Coordinator: Mr Reidar Kvam 11/25/2008 Comments: Sector Manager: Mr Keith E. Hansen 11/25/2008 Comments: