Summary Report Guatemala: Leveraging Social Protection Systems for Improved Nutrition (P163524) Contents Introduction .............................................................................................................................................. 2 Context ...................................................................................................................................................... 2 ASA/Grant Results and Implementation of Activities by Component ...................................................... 6 Challenges experienced during the implementation of the grant financed activities ............................. 9 Lessons learned....................................................................................................................................... 10 Team Composition .................................................................................................................................. 11 1 Guatemala: Leveraging Social Protection Systems for Improved Nutrition (P163524) Introduction 1. This ASA was an integral part of an active sectorial policy dialogue in Guatemala. The Grant Development Objective was to support the Conditional Cash Transfer (CCT) Program to effectively contribute to reduce malnutrition and poverty, by providing technical assistance to strengthen the foundational systems of the CCT to more effectively target households, deliver benefits and manage co-responsibility verification as part of an integrated approach to reducing chronic malnutrition. The ASA, also supported by an RSR grant (TF0A4781) carried out activities that strengthened: i) the monitoring and evaluation system of the CCT program and ii) the functionality of the MIS of the CCT Bono Social as a dynamic tool to prioritize, coordinate and harmonize Social Protection interventions across sectors. 2. This was the first RSR grant support for Guatemala that provided a timely opportunity to assist the Government of Guatemala (GoG), and especially the Ministry of Social Development - MIDES (Ministerio de Desarrollo Social) in strengthening coordination and harmonization across the CCT Program, making stronger connections between line ministries and data sources, and incorporating assessment mechanisms to evaluate and improve individual programs’ design and operation to maximize efficiency and impact of the CCT Program. For example, the grant allowed contracting technical assistance, providing high quality advice, and bringing in international experiences. The just- in-time TA on the monitoring system, the impact evaluation design, the development of baseline instruments (manuals for enumerators and anthropometric forms), the design of beneficiaries’ program perception survey, the information system proposal, the targeting of the CCT Program assessment, the multiple TA visits by local and other international experts, as well as the continuous World Bank TA are just some examples of what the ASA/RSR grant made possible. Another significant contribution is that through this activity the Bank was able to maintain a strong technical dialogue with the most important Social Protection stakeholders in Guatemala, during a critical period of political transition. In fact, in June 2018, the Bank team liaised with UNICEF and MIDES to support the development of the MIS-CCT Sistema de Informacion del Bono Social (SIBS). In a final dissemination forum held in Guatemala on February 26, 2018, the GoG expressed its high appreciation of the contributions made through this activity. The Summary Report provides a brief background at the time of the ASA/RSR approval and summarizes the grant activities that were carried out, the impact achieved, and some key lessons learned. Context 3. Guatemala is among the countries with the highest poverty rates in LAC. From 2000 to 2014, the poverty rate (US$4 per day poverty line) increased from 55 to 60 percent. This implies that the number of Guatemalans living below the poverty line increased from 6.8 million to 9.6 million during the same period. This trend is in striking contrast to the overall decline in poverty in both LAC as a whole and most of Central America. 4. The impact of high levels of poverty is evident in the country’s social indicators, such as chronic malnutrition (stunting). Despite the fall in the chronic malnutrition rate from 55 percent in 1995 to 2 46.5 percent in 2014/15, Guatemala’s stunting rates are the highest in LAC and remain extremely high for its level of income. It is only exceeded by countries with significantly lower per capita incomes, such as Bangladesh and Ethiopia. Poor, rural, and indigenous populations are the most affected, with stunting rates of 66 percent, 59 percent, and 61 percent, respectively. Guatemala’s high chronic malnutrition rate affects the quality of its human capital and therefore, its growth and development potential. 5. In 2012, the Government promoted the coordination among social programs through the creation of the Ministry of Social Development (MIDES), the establishment of the new Unified Registry of Beneficiaries (RUUN), and the Social Information systems (SISO). These elements are positive developments in terms of strengthening the institutional framework for an integrated delivery system, particularly for safety nets interventions. However, further improvements in efficiency of social spending to better use the limited public resources to support poor households in line with key national priorities, such as reducing chronic malnutrition, are critical. Two areas stand out: (i) strengthening the conditional cash transfer (CCT) program to leverage its potential to increase synergies within the multisectoral nutrition strategy and (ii) strengthening of the social information system (SISO) and increasing its use by existing programs. 6. In February 2016, the Government established the Commission for the Reduction of Stunting and, in March 2016, officially launched the National Strategy to Reduce Chronic Malnutrition 2016-2020. The national strategy is a multisectoral integrated approach including actions to (i) increase access to and strengthen the quality of primary health and nutrition care services, (ii) support behavioral change at the community level; (iii) improve access to safe drinking water and sanitation; and (iv) improve household income and resources to contribute to enhancing dietary quality. 7. In the context of a multisectoral strategy to address chronic malnutrition, CCTs can play an important role. They can lead to positive changes in service utilization by promoting access to health services and behavior change. They also increase incomes, allowing households to purchase more and higher quality foods, thereby increasing food security, and diet quality, and improving nutrition. To allow households to plan, these transfers must be predictable, timed appropriately, and adequate in size. Guatemala’s CCT targets families with children, promoting regular health visits for children age 0-6 years (and pregnant women) through a health transfer, and school attendance for children ages 6 to 15 through an education transfer. It also has a broad coverage (693,936 active households in 2015), although targeting and frequency-reliability of the transfers remain an issue for the poorest beneficiaries (almost 70% of its beneficiaries are among the poorest 40% of the population). 8. Despite coverage expanding rapidly, budget allocations have not kept in line with the size of the program, resulting in an overextended program providing a limited number of transfers to a large number of people, diluting impact. A better targeting would make possible to prioritize scarce resources and achieve stronger results. In addition, shortages in budget releases throughout fiscal years have led to unpredictability related to timeliness of these transfers, affecting regular program operation and the important link between transfers and promotion of behavior changes. Finally, following the Government’s 2015 decision to discontinue the Expansion of Coverage Program (Programa de Extensión de Cobertura – PEC), which used mobile teams to provide a primary health care package to rural, underserved communities through contracted NGOs, a gap in health services severely affected the supply side and therefore the cycle of verification of co-responsibilities. The WB- GoG project “Crecer Sano� was finally approved in 2019 but with a substantial delay, and the Government is progressively replacing the PEC with its own health facilities and teams to provide a 3 more comprehensive package of services on a more frequent basis. This will imply a need to reformulate the package of services as well as co-responsibilities, including monitoring systems for the CCT. 9. Despite these serious challenges, the program has the potential to support the National Strategy to Reduce Chronic Malnutrition in different ways. If operating efficiently, the CCT would provide poor households with higher incomes, while promoting their increased access to health services and behavior change via regular monitoring of co-responsibilities. Early evaluations of the Guatemalan CCT found evidence of a rise in access to health services: the number of check-ups attended by children participating in the program rose 48% compared to 28% among those not targeted. In fact, as part of its support to the Government’s National Strategy to Reduce Chronic Malnutrition, the World Bank’s Improved Governance of Public Resources and Nutrition DPF (P160667) is supporting increased reliability of the CCT health transfers in the departments prioritized by the Strategy, and the Crecer Sano Health Project (P159213), whose objective is to “improve practices, services and behaviors known to contribute to reducing chronic malnutrition (with an emphasis on the first 1,000 days of life) in the intervention areas� will finance the critical investments needed in the area of primary health infrastructure and human resources, as well as provide financing (via Disbursement Linked Indicators) tied to successful completion of the CCT co-responsibilities cycle for children 0 to 2 years of age. 10. The Unified Registry of Beneficiaries (Registro Unico de Usuarios RUUN) gathers information on beneficiaries of social programs implemented by 15 agencies that form part of the Gabinete Específico de Desarrollo Social, for a total of 67 programs and over 4 million beneficiaries. The National Social Information System (Sistema Nacional de Informacion Social – SNIS/SISO), additionally collects information relative to national social objectives, information and statistics from the RUUN and on other social indicators. It uses business intelligence tools to visualize data and key indicators related to social spending and development goals. Currently, this information is not being used to inform policy and program level decisions. Additional efforts to make intensive and dynamic use of this information to support targeting and coordination, while further strengthening the underlying data and its interaction with different administrative systems, would go a long way to help the sector improve the quality of spending and develop strategies to run a more integrated approach for the different target populations (children, youth, elderly), and different geographic areas (urban/rural). In addition, Guatemala is characterized by the presence of several indigenous groups with an historical lack of access to basic services, given their location in hard-to-reach areas. In order to ensure an appropriate coverage, the SP system and programs shall provide specific efforts to incorporate them as part of the most important safety nets tools. 11. Based on that, the WB approves a Trust Fund – TA on leveraging Social Protection Systems for Improved Nutrition in Guatemala under the Window of the RAPID SOCIAL RESPONSE. The proposal was approved on May 23th, 2017 with a closing date is June 25th, 2019. The RSR provided combined support along with the ASA to the areas specified in the present summary report: mostly the definition of a package of tools for the baseline survey of the CCT and the ambitious new MIS for the Bono Social program. It is envisioned that in a next stage of TA between the Bank and MIDES, activities can be implemented to support more broadly the Social Registry – RUUN. 12. The RSR-funded activities were aligned with the priorities established by the sector to support the multisectoral integrated National Strategy to Reduce Chronic Malnutrition 2016-2020. The proposed activities supported the strengthening of existing national social information systems and their 4 interactions/functionality for improved regular monitoring of interventions, with a focus on the CCT and its coordination with health and nutrition interventions. Resources were channelized through the RSR and the ASA to support this agenda. The availability of data and close monitoring of interventions was a very important element to ensure the implementation of succesful strategies to tackle chronic malnutrition, given their multisectoral nature. In addition, activities to improve overall harmonization and coordination of existing SP interventions were developed to lead to system-wide improvements in efficiency (e.g., by allowing prioritization of scarce resources and reducing duplication). 5 ASA/Grant Results and Implementation of Activities by Component 13. Achievement of grant’s development objectives. In line with the above-mentioned context, the development objective of the activity was to support the CCT Program “Bono Social� to effectively contribute to reduced malnutrition and poverty. Specifically, the ASA/RSR supported the following areas: i. Strengthening the foundational systems of the CCT to more effectively target households, deliver benefits and manage co-responsibility verification as part of an integrated approach to reducing chronic malnutrition. ii. Strengthening the CTT program’s monitoring and evaluation system. iii. Increasing the functionality of the social registry and information systems as a dynamic tool to prioritize, coordinate and harmonize SP interventions across sectors. 14. The impact of the different activities on the development objective is positive. The technical assistance provided in the areas that were identified as the main constraints have been adopted and incorporated in the Government system. The most relevant examples are: (i) the impact evaluation design, (ii) the baseline instruments, (iii) the targeting assessment of the CCT Program to extreme poor population, and (iv) the design of a comprehensive and efficient Information system to roll out the CCT. This new information system is currently under development and will ensure synergies among different stakeholders, such as MIDES, MINEDUC and MSPAS. All these activities have contributed to an improved social protection system, emphasizing the need to create appropriate and timely monitoring and evaluation systems for the CCT to follow up on health and education indicators at the individual level. The ASA also contributed to assess and identify bottlenecks and estimated impacts on stunting reduction, through an analysis of the health and nutrition co-responsibilities of the program. In the following paragraphs, the detailed activities and impacts are described. 15. A summary of main findings and recommendations are compiled in the following documents (see Table 1). First, the proposal to strengthen the core design and implementation of the CCT (activities 2, 3, and 4) is presented in Macroproceso de Corresponsabilidades, Estrategia Operativa de Focalización, and Diseño de Evaluación de Impacto. On the other hand, the work to strengthen the linkages with health and nutrition services (activities 1 and to some extent 5) are delivered through the Assessment of Health Co-responsibilities, presentation of the new MIS for the CCT (SIBS) presentacion SIBS Viceministro Mejia, and GT Nivel de Bono. Activity 1: Assessment of Health Co-responsibilities (US $ 30,000; Delivery: September 2017) The lack of progress in Guatemala in improving chronic malnutrition rates, is in part attributed to the limitation of information and data regarding to the fulfillment of co-responsibilities, particularly the ones on Health and Nutrition. Therefore, the activity supported the elaboration of a report that gathered information of all processes involved, from the field level up to policy-makers at the Health and Social Development Ministries, to evaluate and certificate the fulfillment of health co- responsibilities of the CCT program. The report explains how information related to compliance with health and nutrition co-responsibilities of the Bono Salud sub-program and the Crecer Sano intervention is generated and recorded. It also includes details about the interaction between the Ministry of Health and Ministry of Social Development, which allowed establishing the main bottlenecks in the process and proposing remediation activities for improvements. 6 Table 1: Activities and deliverables: Technical Report Activity 2: Review of flow of funds and recommendations for improvements to guarantee timely payment of benefits (US $ 25,000; Delivery: October 2017) The rapid expansion of the coverage of the CCT Program and budget allocation have not kept in line with the size the program, resulting in an overextended program providing limited number of transfers to a large number of people, and delaying the timeliness of payments. These issues create negative impacts on the efficacy and effectiveness of the CCT Program. Thus, this activity aimed to develop a diagnostic that would allow to identify where and how these bottlenecks could be solved. This diagnostic includes the current causes of delay and incomplete disbursement of funds for the CCT program through technical reports that identify how the flow of funds really works, from the co- responsibility verification process to the actual payments. Timeliness of payments are essential to ensure that the co-responsibilities are contributing to change behaviors, particularly for malnutrition. Table 1: Activities and deliverables: 2.1 Macroproceso Corresponsabilidades and 2.2 Generación de Planillas Activity 3: Review of CCT targeting (US $ 35,000; December 2017) This activity supported a report that provide the following inputs: i) an assessment of the targeting system used to date; and ii) a proposal for rehashing the targeting process of the program in line with the National Strategy to Reduce Chronic Malnutrition and to prioritize households with children under risks of falling into malnutrition and extreme poverty. This document provides a detailed guideline to implement geographic targeting at the municipio level. It also includes some insights about the strategy that the Program could follow to carry out a progressive geographic expansion of the transfers. The review of the targeting processes will allow for reduced exclusion errors, particularly in indigenous areas where stunting rates are particularly high. Table 1: Activities and deliverables: 3. Estrategia Operativa de Focalización Geográfica Mi Bono Seguro Activity 4: Strengthening of Monitoring and Evaluation (US $ 130,000; Delivery May 2018) The evidence about the impact that “MI Bono Seguro� (currently Bono Social) Program has on the actual beneficiaries is very restricted and limited. Based on that, the ASA financed the development of tools (surveys and methodological design) to carry out an impact evaluation of the “Mi Bono Seguro� Program, to assess how the program has influenced the beneficiaries access to health and education services in rural and urban areas. Table 1: Activities and deliverables: Impact evaluation Design and Power Calculation 4.1 Diseño de la Evaluación de Impacto The activity supported a randomized control trial intervention design, including outcome indicators and an agenda to gather information on the field. The Bank worked closely with the MIDES team creating baseline instruments, such as a sample design, power calculation, and digitalization of data. Table 1: Activities and deliverables: 7 4.2 Cálculo de muestra y Cálculo de Poder The grant also supported the development of baseline instruments. Using the best international practices, the Bank and MIDES team created a tool to gather anthropometric children’s measures called “Boleta Antropometrica�. This tool collects information of each children, which would allow to follow up nutrition data at an individual level, allowing a better monitoring of children’s health indicators. This tool includes an Anthropometric Manual that provides a detailed guideline on how enumerators should gather anthropometric measures and use the instruments on the field. Table 1: Activities and deliverables: Baseline Instrument 4.3 Boleta Antropométrica 4.4 Manual de Antropometría Complementary to the baseline instruments, the ASA/Trust Fund designed a perception survey form and its implementation manual to provide a better understanding about the beneficiaries’ profile and their understanding about the program and related issues on access to health and education services. The survey has 11 modules and collects information about socio-economic conditions and program perception from households and individual users. This instrument was also discussed closely with the government authorities and their feedback was incorporated. Table 1: Activities and deliverables Perception Survey 4.5 Cuestionario Línea Base Mi Bono Seguro 4.6 Manual Levantamiento MBS final Activity 5: Support to RUUN/SNIS Strengthening (US $ 50,000; Delivery May 2018) This activity promoted an information system proposal that increases the functionality of the RUUN as a dynamic tool to prioritize, coordinate, and harmonize SP interventions across sectors as well as to inform policy and program level decisions within MIDIS. Based on the lesson learned during the technical assistance, the current system has some difficulties that limits the correct program implementation. Therefore, the proposal tries to improve the implementation and monitoring of the program. It mainly includes the targeting, monitoring flow of beneficiaries (entry-stay-exit), and payment processes. It also incorporates some additional procedures, such as petition, complains, and claims management and assessment of results. Table 1: Activities and deliverables Information System Proposal 5.1 Sistema de Información Mi Bono Seguro This proposal was closely coordinated with the technical team from MIDES and UNICEF. This coordination allowed to have agreements related on how to measure, register and track information 8 at the household level, and propose an agenda to implement the new information system for the Bono (SIBS). The proposal was also disseminated to the Vice-minister of MIDES to follow up the outcomes of this TA, which were well-received by the government. The SP-MIS is expected to be complemented – connected with an HMIS that could trace individual data of children. This is one of the key activities expected in the context of the Crecer Sano operation. Table 1: Activities and deliverables Dissemination of the Information System Proposal to the MIDES’s Vice-minister 5.2 SIBS Viceministro Mejia In addition to the information system proposal, the government required an assessment related to the identification criteria of beneficiaries of the “Bono Social� Program that are under health and education conditionalities. This assessment used two national household surveys (ENCOVI 2006 and ENCOVI 2014) to evaluate the identification criteria and propose new targeting criteria that would allow the expansion of the program to extreme poor population, under a very restricted budget scenario. Table 1: Activities and deliverables Assessment of identification criteria of “Mi Bono� Seguro� Program’s beneficiaries 5.3 Una nueva prueba de medias Guatemala 2014 ENCOVI Febrero 2018 The Bank team did also a cost-effective analysis of “Bono Seguro� Program and compared it to international benchmarking. This analysis confirms that some changes on the Program structure could improve the implementation as well as the impact of the Program in the extreme poor population. Those changes are related to the increase of the amount of the transfers from Q300 to Q500 and the frequency of payments. Table 1: Activities and deliverables International Comparison of Guatemala’s CCT Program 5.4 GT Nivel del Bono enero 2017 Challenges experienced during the implementation of the grant financed activities 16. Politization of the CCT program. There have been political pressures leading to large swings in program parameters as well as pressure from the opposition leading to legislative initiatives designed to undermine implementation of the program. This risk was identified at preparation and given much attention during implementation. Therefore, the Bank used an impartial advisor role, sharing international experiences. At the beginning, the Bank team provided a policy note to MIDES that demonstrated the very limited size of the transfer as compared with other countries reduced potential impacts of the intervention. This was a successful strategy since the information was used to convince policymakers to better target beneficiary households in order to create budget space to 9 provide a greater amount of transfers to each family. The increase in the value of the transfer from Q300 to Q500 was implemented for Fiscal Year 2017 (see Table 1: 5.4 GT Nivel del Bono enero 2017). Unexpected changes of government counterpart: The TA was prepared and closely coordinated with a broad range of stakeholder: the Vice-minister of MIDES and the team responsible for monitoring the verification of Health and Education conditionalities at Health and Education Ministries. As part of these TA activities, the Bank team liaised with UNICEF to promote a strategic and unique sectorial approach to MIDES. However, during implementation of activities, there were some staff changes, especially at the technical level that hindered the normal pace of the program. The Bank team has delivered to the government all the relevant documentation to ensure that a new government team has all information needed to ensure the sustainability/continuity of these efforts (see Table 2: 5.2 SIBS Viceministro Mejia) I. Supervision of grant activities and deliverables 17. The Bank team kept implementation progress documented through annual review meetings. In fact, management provided valuable inputs to address the above-referenced challenges. The Bank team was comprised of national and international staff and consultants with a variety of relevant skills, as listed in Table 2. Key team members were based in Guatemala, ensuring very regular updates to the government and a close collaboration. Progress reports were conducted following a differentiated dissemination strategy by activity. For the work on monitoring and evaluation broad dissemination was done with national stakeholders and media. For the other activities a more limited dissemination was carried out as the work seeks to influence decision making processes between various government stakeholders and within MIDES itself. Lessons learned 18. Particularly important was that this activity was the first support that the SP sector in Guatemala receives that is fully aligned with the Human Capital agenda, particularly on nutrition and health for the youngest. The activities delivered helped strengthening at the same time Guatemala’s social protection system. 19. The grant allowed the Bank to maintain a dialogue in Guatemala in a very complex situation (political crisis and elections) and laid the groundwork for a potential new operation or for improving these linkages within the current portfolio (Crecer Sano). Currently, the grant activities were in line with WB operations supporting complementary social policy reform (through the DPF P160667) and investments in the supply side through Crecer Sano. 20. At a technical level, the team carried out frequent supervision activities including audioconferences, VCs, and field visits, which proved very valuable to ensuring continuous feedback on implementation and immediate action to address bottlenecks. 21. The TA carried out the first assessments of the CCT Program. Using the best international evidence available, the Bank team supported the government to develop an impact evaluation design as well as implementation process assessment. Those activities were significantly valuable, providing the 10 government with evidence-based criteria to better understand the CCT Program and further ways to improve it, especially with regards to the targeting, M&E, and information system areas. 22. The grant was closely supervised and coordinated by the Bank Team, which permitted to carry out all deliverables on time. Moreover, all deliverables were used by the government to adjust the CCT Program increasing the payment from Q300 to Q500 as well as the frequency from 2 to 3 times. 23. The documents that have been produced under the grant, will better inform Guatemala’s nut rition debate and will be useful to other countries aiming to improve their social protection systems and addressing chronic malnutrition. Analytical products can have an important value as well for policymakers, if adequately coordinated with counterparts. Team Composition Table 2: Project Team Name Title, role and areas William David Wiseman Human Development Program Leader - TTL Hugo Brousset Social Protection Specialist - TTL Claudia Rokx Lead Health Specialist with Nutrition Focus Sara Francisca Giannozzi Senior Social Protection Specialist Junko Onishi Senior Social Protection Specialist - Evaluation Priscila Vera Consultant – Social Protection Mirta Sanchez Program Assistant 11 Table 1: Activities and deliverables Area Deliverable Link to the deliverable Strengthening the linkages with 1: Assessment of Health Co-responsibilities 1. Technical Report health and nutrition services Strengthening the core design and 2: Review of flow of funds and recommendations for 2.1 Macroproceso Corresponsabilidades implementation of the CCT improvements to guarantee timely payment of benefits 2.2 Generación de Planillas 3: Review of CCT targeting 3. Estrategia Operativa de Focalización Geográfica Mi Bono Seguro 4: Strengthening of Monitoring and Evaluation: - Impact evaluation Design and Power Calculation 4.1 Diseño de la Evaluación de Impacto 4.2 Cálculo de muestra y Cálculo de Poder - Baseline Instrument 4.3 Boleta Antropométrica 4.4 Manual de Antropometría -Perception Survey 4.5 Cuestionario Línea Base Mi Bono Seguro 4.6 Manual Levantamiento MBS final Strengthening the linkages with 5. Support to RUU/SNIS Strengthening: health and nutrition services -Information System Proposal 5.1 Sistema de Información Mi Bono Seguro -Dissemination of the Information System Proposal to 5.2 SIMBS Viceministro Mejia the MIDES’s Vice-minister -Assessment of identification criteria of “Mi Bono� 5.3 Una nueva prueba de medias Guatemala Seguro� Program’s beneficiaries 2014 ENCOVI Febrero 2018 -International Comparison of Guatemala’s CCT Program 5.4 GT Nivel del Bono enero 2017 12