Page 1 INTEGRATED SAFEGUARDS DATASHEET APPRAISAL STAGE I. Basic Information Date prepared/updated: 12/10/2008 Report No.: AC2321 1. Basic Project Data Country: Peru Project ID: P095563 Project Name: PE- (APL2) Health Reform Program Task Team Leader: Fernando Lavadenz Estimated Appraisal Date: December 9, 2008 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 Environmental Category: B - Partial Assessment Simplified Processing Simple [] Repeater [] Is this project processed under OP 8.50 (Emergency Recovery) or OP 8.00 (Rapid Response to Crises and Emergencies) Yes [ ] No [X] 2. Project Objectives 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; (ii i) 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. 3. Project Description 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 Page 2 to be covered by other fiscal resources. The project will be implemented in the same Regions as under the APL I (Amazonas, Huánuco, Huancavelica, Ayacucho, ApurĂ­mac, Cusco and Puno) plus two additional Regions: Cajamarca and Ucayali. These Regions were prioritized because IMR and MMR still remain well above the national average in each, and thus need further 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 Regions (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. 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. 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 subcomponent includes minor constructions, rehabilitation, and equipment investments for the networks in the regions supported by the Project; technical assistance and training for health personnel; and the inclusion of an intercultural focus in service provision 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. Component 3. Strengthening government capacities to offer more equitable and efficient health system in a decentralized environment (US$5.2 million). This component would work towards the strengthening of MINSA, and the decentralization of the health system through: Subcomponent 3.1. Regulatory framework in support of service quality. This subcomponent includes technical assistance to support the integrated health model and the development of support systems. Page 3 Subcomponent 3.2 Strengthening of SIS. The Project would support SIS develop the public insurance system. Subcomponent 3.3.Systems development to enhance the monitoring capacity of MINSA. This set of activities would support the improved implementation of existing systems, namely SIS, SISMED and SIGA all of which can produce monitoring data and thus introduce greater accountability into the system. Subcomponent 3.4 Support to decentralization. The Project would support the continued implementation of Management Agreements (MA) now in place, as instruments for supervision and accountability between the central regulatory level and the Regions, which are responsible for service provision. Component 4. Project Coordination and Monitoring (US$ 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. 4. Project Location and salient physical characteristics relevant to the safeguard analysis The Project will work to serve the rural population in eight selected regions of the coun try: Amazonas, Huánuco, Huancavelica, Ayacucho, ApurĂ­mac, Cusco, Puno, Cajamarca and Ucayali. These areas were chosen using health and poverty indicators, including high maternal, neonatal and child mortality. The population in these areas is primarily indigenous and speaks a native language (except for Cajamarca where the population speaks Spanish). 5. Environmental and Social Safeguards Specialists Mr Jean-Roger Mercier (IPN) Ms Isabel Tomadin (LCSHH) Ms Rocio Schmunis (LCSHH) 6. Safeguard Policies Triggered Yes No Environmental Assessment (OP/BP 4.01) X Natural Habitats (OP/BP 4.04) X Forests (OP/BP 4.36) X Pest Management (OP 4.09) X Physical Cultural Resources (OP/BP 4.11) X Indigenous Peoples (OP/BP 4.10) X 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 Page 4 II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: The Project triggers the Environmental and Indigenous Peoples Safeguard Policies. With respect to the Environmental Safeguards, the Project is rated as B. Social-Indigenous peoples As part of the project preparation process, consultations with future beneficiaries of PARSALUD II and the current beneficiaries of PARSALUD I were carried out in four indigenous areas of the country: Ayacucho and Cusco in the Andean region and Ucayali and Amazonas in the Amazon region, in March 2006. Consultations included representatives of 33 Quechua communities and 52 communities belonging to the following ethnic groups: Shipibo- Conibo, Asháninkas, Piros (yine), Cacataibos, Aguaruna, and Huambisa. The consultation process included an assessment of health issues for these groups, access to health services and concerns with respect to cultural appropriateness. The objective was to collect information regarding problems that the mothers face during their pregnancy and delivery in the health facilities, as well as issues with breastfeeding. The participants also shared their opinions about what should be done to improve the service. Three main problems were identified during the consultation: (a). Lack of friendly service to clients: Poor disposition and negative attitude of health personnel, which is interpreted by the Andean women as discriminatory and exclusionary. Women reported mistreatment, yelling, lack of use of their own language, and lack of consideration for their cultural practices. (b). Lack of education and information: MINSA does not educate women on the advantages of skilled professional attended deliveries. In addition, women also perceive a lack of information and education about advantages of breastfeeding and benefits of SIS. (c). Accessibility of services: health facilities are located far away and there are no “casas maternas” or “casas de espera” (facilities specifically designed to house women during the last weeks of their pregnancy who live far from the health facility); poor or no community organization to help the patients find health centers; and lack of resources to cover expenditures not paid by the SIS. Lack of access to health facilities is especially difficult in the Amazon region. Recommendations proposed during consultations include the following: (i) cultural appropriateness strategies; (ii) strategies to strengthen the institutional capacities of the sector, taking into account the attention of dispersed indigenous populations; (iii) cross- cutting education and communication approaches. Based on the consultation process and proposed recommendations, an Indigenous Peoples Plan was developed. This Plan includes (i) findings from the social assessment, (ii) a description of the free, prior and informed consultation process, (iii) an plan of Page 5 actions to 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 implementation of the action plan. Environment The second objective of APL II comprises infrastructure activities that entail minor construction, rehabilitation and provision of new equipment for the health facilities. It does not include major building construction but represents the adaptations that most common buildings need to become functional in the health obstetric and neonatal health network. In this sense, no environmental impact is expected from construction of new health facilities. On the other hand, the possible environmental impact in liquid and solid wastes in the health facilities network, due to the anticipated increase in the use of health services will result in increased health care waste (HCW) production. However, since waste management is expected to comply with current legislation, and appropriate current practice in the health system, the impacts will be low (i.e. no higher than those allowed by law). The EA conducted during project preparation includes a diagnostic of solid and liquid wastes that would be generated by project interventions. To reduce, prevent and mitigate risks, the EA includes measures that will be taken into account in the specific design of all minor constructions and rehabilitation of facilities, as well as agreed self-evaluation by hospitals with a methodology that has been successfully implemented in other countries. The EA proposes constant monitoring to mitigate potential environmental risks. This monitoring will ensure compliance with the standards and requirements established by law, as well as assure the use of the guidelines and technical procedures adopted by the health facilities. Following the EA, specific manuals for waste management were developed to be shared with each health facility. As a part of this project, there will be a component of technical assistance that will work directly with MINSA to institutionalize these manuals. The EA proposes a Solid and Liquid Waste Management System which (i) establishes basic procedures in each of the management stages for solid and liquid waste produced in health facilities and proposes best practices for implementation; (ii) defines monitoring and evaluation processes for the management of solid and liquid waste produced in the 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 (Andean/Amazon regions, rural/urban areas). In addition, the Project will work with MOH to promote the application of the Environmental-Friendly Hospitals Accreditation Program, through which health facilities Page 6 are self-accredited if they comply with minimal environmental-friendly practices, including proper management of healthcare waste (HCW), efficient energy use, etc. No large scale, significant, or irreversible environmental or social impacts are expected. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: No long term negative impacts are foreseen arising from the Project. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. Even when there is not a specific adverse impact, to minimize the risks highlighted related to indigenous groups: PARSALUD will primarily intervene in areas whose populations are more than 70% indigenous. In these areas there are widespread practices of traditional medicine that would require special efforts of cultural adaptation by health facilities and providers. A National IPP has been approved by the Bank. It makes reference to a National Health Promotion strategic plan for social communication in health (NHPP). This NHPP was already presented and approved by the Bank. The plan addresses the health services cultural adaptation to practices, beliefs and attitudes to the health of indigenous populations. The IPP for each region where the project operates will adapt both the National IPP, and the NHPP to the specific regional situations. Management Agreements to be signed between the central government and the regions will include the regional IPP. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. 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, 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. For example, during the APL I a number of interventions were tested and, when successful, were standardized by the sectorâ ”in particular, the vertical birthing practice (used by all Indigenous women) now has a health protocol. In addition the Ministry developed a Program for “Healthy Districts and Communities” which clearly requires that interventions take into consideration local culture and language. The SIS also gives priority to Amazon and Andean populations, where the Project will be working. Finally, the Ministry is revising its ELITE program (itinerant health teams that visit highly dispersed populations), to make it more effective and responsive to local demands and needs. In addition, due to Peru’s large indigenous composition, and the political movement toward inclusion in previous years, the country and the health sector have accumulated extensive experience working on cultural appropriateness. In this regard, the project has prepared a state of the art Communication and Health Promotion Strategy that addresses Page 7 cultural differences, with strong emphasis on indigenous behaviors, beliefs, and practices of maternal and child health care. The PARSALUD I ICR further reported that the project complied with OP 4.01 (environmental assessment) and OP 4.10 (indigenous peoples). PARSALUD II will build upon lessons learned on PARSALUD I. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. MINSA's specific area, PARSALUD II coordination Unit, as well as the 9 health offices of the Departments selected, will be in charge of project implementation regarding indigenous peoples plan. The IPP has been publicly disclosed in both, printed and electronic format. The Project area covers 15 Indigenous peoples groups in 639 communities in the Amazon Basin, and Quechua and Aimara populations in about 4000 communities in the Andean Region. After the four consultation workshops that were carried out in Ayacucho and Cuzco in the Andean Region and in Ucayali, and in Amazonas in the Amazon Basin, stakeholders raised critical issues and demands with respect to the provision of health services. These demands were discussed with the Project preparation team in the MINSA, and are reflected in the Indigenous Peoples Plan. B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 03/03/2006 Date of "in-country" disclosure 02/01/2006 Date of submission to InfoShop 12/09/2008 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Resettlement Action Plan/Framework/Policy Process: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Indigenous Peoples Plan/Planning Framework: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 04/21/2006 Date of "in-country" disclosure 05/22/2006 Date of submission to InfoShop 11/24/2008 Pest Management Plan: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Page 8 Date of submission to InfoShop * If the project triggers the Pest Management and/or Physical Cultural Resources, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? No If yes, then did the Regional Environment Unit or Sector Manager (SM) review and approve the EA report? N/A Are the cost and the accountabilities for the EMP incorporated in the credit/loan? N/A OP/BP 4.10 - Indigenous Peoples Has a separate Indigenous Peoples Plan/Planning Framework (as appropriate) been prepared in consultation with affected Indigenous Peoples? Yes If yes, then did the Regional unit responsible for safeguards or Sector Manager review the plan? Yes If the whole project is designed to benefit IP, has the design been reviewed and approved by the Regional Social Development Unit or Sector Manager? N/A The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank's Infoshop? Yes Have relevant documents been disclosed in-country in a public place in a form and language that are understandable and accessible to project-affected groups and local NGOs? Yes All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of measures related to safeguard policies? Yes Have costs related to safeguard policy measures been included in the project cost? Yes Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures related to safeguard policies? Yes Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? Yes Page 9 D. Approvals Signed and submitted by: Name Date Task Team Leader: Mr Fernando Lavadenz 12/08/2008 Environmental Specialist: Ms Isabel Tomadin 11/01/2008 Social Development Specialist Ms Rocio Schmunis 12/08/2008 Additional Environmental and/or Social Development Specialist(s): Approved by: Regional Safeguards Coordinator: Mr Reidar Kvam 12/01/2008 Comments: Sector Manager: Mr Keith E. Hansen 12/01/2008 Comments: