SFG3933 HEALTH SYSTEM PERFORMANCE STRENGTHENING PROJECT (HSPSP) (P160948) MINISTERIO DA SAÚDE MINSA INDIGENOUS PEOPLES POLICY FRAMEWORK Updated version, December 2017 TABLE OF CONTENTS 1. Introduction ......................................................................................................................1 2. Indigenous Population in Angola.....................................................................................1 3. The San Population in Angola .........................................................................................3 4. Previous Development Programs supporting San populations ........................................3 5. The Health System Performance Strengthening Project (HSPSP) ..................................4 6. Potential Impacts ............................................................................................................11 7. Social Assessment ..........................................................................................................12 8. Consultation ...................................................................................................................13 9. Institutional Arrangements.............................................................................................13 10. Disclosure ....................................................................................................................17 11. Organizations Working with San in Angola ................................................................17 12. Estimated Budget .........................................................................................................17 ACRONYMS CSO Civil Society Organization GOA Government of Angola HSPSP Health System Performance Strengthening Project IP Indigenous People IPP Indigenous People Plan IPPF Indigenous People Policy Framework MCH Maternal and Child Health MHSS Municipal Health Services Strengthening Project MINSA Ministry of Health NGO Non Government Organization PBF Performance Based Financing EXECUTIVE SUMMARY This updated version of the Indigenous People Policy Framework (IPPF) was prepared by the Angola Ministry of Health (Ministerio da Saúde – MINSA) for the Health System Performance Strengthening Project (HSPSP) (P160948). The total amount of the HSPSP is of US$100 million. The project has four main components; namely: (i) Component 1 – Improving the Quality of Health Services Delivery in Target Provinces (US$65.0 million), which also includes a new sub-component focused on Performance Based Financing (PBF); (ii) Strengthening System-wide Enabling Factors that Support Delivery of Quality Health Services which also includes focused support to strengthening the pharmaceutical supply chain management system; (iii) Supporting the Capacity to Respond and Prevent Public Health Emergencies; and (iv) Project Management and Monitoring and Evaluation. The project would be implemented across the period from 2018 to 2022. The project development objective is to increase the utilization and the quality of health care services in target provinces and municipalities. The activities developed under the HSPSP would potentially impact indigenous peoples’s rights, lands, livelihoods and culture. A rapid social assessment was undertaken which confirmed there are San indigenous peoples in two of the provinces in which the project will be implemented: Moxico and Cuando Cubango. As the exact locations of the investments will not be identified until implementation, this IPPF will has been prepared to provide guidance including screening criteria, information regarding culturally appropriate participation/consultation and adaptations to ensure that indigenous peoples will benefit from the improvements in health care services and delivery. Regarding the consultation process, it is worth highlighting that in order to ensure that indigenous people are aware of the opportunity to benefit from the project, MINSA reached out to key National Government Organizations (NGOs) that work specifically with San populations to inform them about project opportunities. The IPPF was developed based on inputs and discussions with the NGOs ACADIR and Mbakita who focus on working with San populations in the province of Cuando Cubango. In addition, the IPPF benefits from the direct NGO consultations conducted as part of the rapid social assessment to assess the impact the project could have on indigenous populations. Moreover, the IPPF reflects the experience and insights shared throughout the implementation of the current World Bank-financed health project, Municipal Health Services Strengthening Project (MHSS), and through the preparation missions of the HSPSP which captures the experience of working with the municipal, provincial, and central Government; civil society including NGOs, Consultation Councils; and direct beneficiaries. Annex 1 provides a list of the NGOs consulted. The institutional arrangements for the IPPF will comprise three main building blocks namely: (i) screening; (ii) preparation of an Indigenous Peoples Plan (IPP); and (iii) implementation and monitoring. During the screening, MINSA will work with 1 organizations currently working with San populations to identify where San communities now reside. The IPP will be developed by MINSA and would lay the foundations to ensure that indigenous peoples will receive appropriate support and that mitigation measures for potential limited negative impacts. For the implementation and monitoring phase, MINSA will contract a NGO with previous experience working with Indigenous People to better plan and implement activities benefitting this target group. 2 1. Introduction An Indigenous People Policy Framework was not developed for the Municipal Health Services Strengthening Project (MHSS), which was approved by the Board of Directors on June 8, 2010 and became effective on March 2, 2012. The IPPF was not required for the MHSS Project as it did not trigger Indigenous Peoples (OP/BP 4.10). Indigenous Peoples (OP/BP 4.10) This Indigenous People Policy Framework (IPPF) was developed in December 2017 to reflect the increased geographic scope of the HSPSP to the Cuando Cubango province where San indigenous people reside and the awareness of San population in the Moxico province which was part of the MHSS original geographic scope. The IPPF was developed by MINSA based on the inputs from the rapid social assessment, the consultations, and the experience obtained through the implementation of the MHSS, during which several consultations were organized with local communities and municipal and provincial Governments in the province of Moxico. MINSA consulted and gathered information from provincial authorities from Moxico and Cuando Cubango, where indigenous peoples are currently located. The main sections of the IPPF include: (a) background section; (b) component description and expected impacts; (ii) summary of social assessment; (iii) description of implementation arrangements for a better integration of IP in the Project; and (iv) update of Project locations. 2. Indigenous Peoples in Angola1 Angola is ethnically diverse with 41 different language groups. Peoples of Angola who would be considered indigenous in the context of World Bank OP 4.10 (and also under international law, including the United Nations and African Commission on Human and Peoples’ Rights), include the San peoples found in the provinces of Kuando Kubango (also spelled Cuando Cubango), Cunene, Huila and Moxico, as well as possibly in Huambo and Bie. In terms of the four criteria outlined in OP 4.10: a. Self-identification as members of a distinct indigenous cultural group and recognition of this identity by others: The San have a strong group identity based upon language, culture, livelihood practices, land and in some cases, appearance. They are generally considered to be a minority group based on population in the areas where they live and they have also been subject to social and cultural discrimination. They are not generally considered to be members of neighbouring ethnic groups (low acculturation). b. Collective attachment to geographically distinct habitats or ancestral territories in the project area and to the natural resources in these habitats and territories: The 1 Information extracted from: “The San (Bushmen) of Angola 2007 – A Status Report” by Rulan Heunis. 2007. ImageAfrica.net. 1 San are the earliest known inhabitants of southern Africa, predating colonial and Bantu migrations. Many San groups, including the !Kung and Khwe in Angola, have inhabited the same lands for thousands of years, and have a close relationship with the land and its natural resources. c. Customary cultural, economic, social, or political institutions that are separate from those of the dominant society and culture: The San have little, if any, political representation in Angola, and traditionally had more egalitarian leadership structures rather than chiefdoms or kinship based hierarchies common in other Angolan ethnic groups. The culture and traditional livelihoods of San communities are markedly different to other Angolan groups, and lack the pastoralist or agrarian heritage common to most Angolan groups. d. An indigenous language, often different from the official language of the country or region: All San languages in southern Africa fall within three language families grouped as Khoesan (or Khoisan) languages, which are unique to San and Khoi peoples. The common feature of these languages is the use of click consonants, where up to five different clicks are used. Other groups in Angola, either Khoesan descendent or related to the Ovahimba, would also be considered indigenous under OP 4.10, such as Kuvale, Ovazemba, Kwisi and Kwepe. However, these groups are not known to reside in Kuando Kubango. Angola, in common with many African states, does not recognise a concept of indigenous peoples as broadly applied in international law. There are no specific references to indigenous peoples or minorities in the Constitution, nor in other domestic law and policies. The San appear to be often named as a “vulnerable group”, alongside groups such as disabled people and the extremely poor. The Angolan Constitution does not mention groups such as the San specifically. It does obligate the state to promote and guarantee the measures needed to ensure the universal right to medical and health care, including developing and ensuring an operational health service throughout national territory. The Government of Angola does implement programmes that specifically address San communities, both through national line ministries and provincial government. For example, the Government Act establishing the Ministry of Assistance and Social Reintegration (MINARS - Ministério da Assistência e Reinserção Social) gives a mandate for MINARS to “develop policies and promote social assistance for the most vulnerable groups in Angolan society and 2 establish strategies for policy implementation”2. From reports and media coverage of MINARS activities this appears to include support to and integration of San communities into the mainstream economy. The Ministry of Health and Ministry of Education have also carried out programmes with specific components for the benefit of San communities. However, few reports are publicly available on the work of the Government of Angola with indigenous communities. The Government of Angola is signatory to ILO107, the Indigenous and Tribal Populations Convention of 1957, which it ratified in 1976, though no reporting has been received since 2010.3 Angola is signatory to several international treaties of relevance to the rights of indigenous peoples, including ICERD (International Convention on the Elimination of All Forms of Racial Discrimination), CEDAW-OP (Convention on the Elimination of All Forms of Discrimination against Women including the optional protocol on reporting), CRC (Convention on the Rights of the Child), ICCPR (International Covenant on Civil and Political Rights) and CESCR (Committee on Economic, Social and Cultural Rights). Angola also voted in favour of the United Nations Declaration on the Rights of Indigenous Peoples in 2007, which though non- binding does confer a commitment to develop national policies that embrace the aims of the declaration. Concluding observations by the Committee on Economic, Social and Cultural Rights (CESCR) in 2016 raised issues of the lack of recognition of indigenous peoples, discrimination, limited service provision, lack of consent procedures regarding economic activities on territories and lack of data on indigenous peoples in Angola. The Human Rights Council (UPR) report of 2014 contained comments regarding discrimination against San children and rights regarding reported evictions of indigenous peoples. 3. The San in Angola The San of Angola number between 9,000 and 20,000, potentially the third largest San population in southern Africa after Botswana and Namibia (approximately 60,000 and 40,000 San respectively), though estimates vary and few extensive data collections have taken place. Estimates from anthropologists have historically been lower than this figure, but more recent work by NGOs and Government show a higher national population of San than previously thought (also see the final section of this report). The San are referred to as “khoisan”, “koisan”, “vassequele” and “kamussequele” among other terms, are found mainly in the southern provinces of Huila, Cunene, Moxico and Kuando Kubango. 2 http://www.saflii.org/ao/legis/num_act/eodmdaers580.pdf 3 https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:13100:0::NO:13100:P13100_COMMENT_ID:3295921: NO 3 Each of the different San groups speak their own language or dialect, have distinct customs, traditions and histories. San groups in Angola include the Khwe and Mpungu !Kung (also referred to as !Xun or Mpungu !Xun), who are also related to groups in northern areas of Namibia and Botswana. In this report, the term “San” is used as it was selected by San political representatives at regional meetings (1998 and 2003), attended by San from Botswana, Namibia, South Africa and Angola, as the preferred term for broad reference to the many distinct San groups. In general, the various groups identify themselves with their respective group names rather than the external general terms such as San, Khoisan or Bushmen, denoting the overarching group San groups map of former hunter-gatherers. Some of the Approximately oflost have their language San distribution completely, (WIMSA 2008) and speak the languages of the neighbouring groups. While in the past the San were hunter-gatherers, most in southern Africa now practice a combination of subsistence agriculture, informal manual work and receive food aid, though a number of significant traditional livelihood practices remain, including gathering of bush foods and in some cases hunting and craft production. From NGO reports, research studies and news articles, Angola’s San appear to share similar socioeconomic challenges, marginalisation and deprivation found among the San in neighbouring countries, together with experience over 25 years of civil and cross-border conflict since 1966. Many San fled across the border to Namibia during the conflict in Angola, joining or been co-opted into service with the South African Defence Force (SADF) during the border war in Namibia’s independence struggle, which included a range of Angolan forces (principally FNLA/UNITA alongside the SADF and FAPLA/MPLA alongside Namibia’s PLAN) and their allies. Hence a significant number of !Kung from Angola and their descendants are now living in eastern Namibia and the Northern Cape region of South Africa. 4 The San in Angola have noteworthy media attention on a national level, with the national broadcaster TPA airing short segments on the San approximately monthly, and with some coverage in national newspapers. A TPA broadcast journalist wrote a short book on the San in Kuando Kubango in late 2015. Many of the articles and news stories contain elements of anthropological information but focus on current issues, especially extreme poverty experienced by San communities. It is clear from these Map of ethnic groups in Angola circa 1970, a recognised distinct media segments that the San are treated as Perry-Castañeda Angolan Library Map group Collection, and, given the University of Texas number of stories specifically on the San, one that merits particular attention. The San in Kuando Kubango Kuando Kubango is a large province in southern Angola, bordered by Bié and Moxico Provinces to the north and west, in the east by the Republic of Zambia and to the south by the Republic of Namibia. Of particular interest, across the province’s southern border with Namibia both Khwe and !Kung groups are found in considerable numbers, but with a majority of Khwe. There is lack of easily accessible data on the San in Kuando Kubango, and Angola in general, in comparison to neighbouring SADC countries with San populations. However, numerous reports exist from colonial periods (for example Bleek, 1928 and Schapera, 1930) up to the present day, that give an adequate if not detailed picture of San in the province. Taken together, these reports evidence a long-standing occupation of Kuando Kubango by San groups, as well as use of local natural resources, indicating collective attachment of San to areas of the province. In neighbouring areas of Namibia, San are estimated to have inhabited the area for at least 10,000 years. While the San vary greatly in appearance across the southern African region, they however tend to remain an easily identifiable minority by neighbouring populations, with whom they often have an unequal relationship. This is due to factors including: physical appearance, language, customs and livelihoods, and is also the case in southern Angola. Reports by government, NGOs and communities themselves indicate varying degrees of marginalisation, in particular detailing discriminatory labour and social relations with neighbouring groups, poverty, poor education access and attainment and comparatively low of health outcomes. Land expropriation by the 5 state and private entities has also been reported by San groups in Kuando Kubango (Savate, Mucundi and border areas), and food insecurity has been widely reported in previous years, including a limited number of mortalities in Kuando Kubango’s San communities in 2014. The Government of Angola has taken a range of measures to specifically address inequality between the San and other communities, within Kuando Kubango and other provinces. This includes programmes by the Ministry of Health, Ministry of Education and in particular the Ministry of Assistance and Social Reintegration (the latter having mandate to address “vulnerable communities” and carrying out for specific programmes with San communities). Support includes the provision of food aid, equipment and training for agriculture, schools, clinics and in some cases housing. The provincial government has also been active in promoting these activities implementation a range of support. While a large range of activities take place, the lack of comprehensive reporting for government projects reduces the ability to assess impacts. Four Angolan registered NGOs have current or specific areas of work with San communities in Kuando Kubango. These are:  ACADIR (Associãcao de Conservacão do Ambiente e Desenvolvimento Integrado Rural): A Menongue-based NGO working with San communities on issues of education, advocacy and human rights.  MBAKITA (Missão de Beneficência Agro-pecuária do Kubango, Inclusão, Tecnologia e Ambiente): Also based in Menongue, MBAKITA works principally with agricultural training, livelihoods and human rights issues with San communities. Has previously implemented project components on access to health services for San communities.  OCADEC (Organizacao Crista de Apoio ao Desenvolvimento Comunitario): A Lubango based NGO principally serving San in Huila Province, but having implemented education, human rights and advocacy activities in Kuando Kubango in previous years. Has previously implemented project components on access to HIV/AIDS services for San communities.  ACC (Associação Construindo Comunidades), has carried out work with San in southern Angola on political participation. ACADIR and MBAKITA in particular have a range of reports on their work with San communities. Both NGOs experience difficulties due to the low availability of civil society funding for their activities. Key donors appear to be small to medium programmatic grants from international donors (e.g. Open Society Foundation, Terre des Hommes and grants from Luanda based foreign embassies) and government-linked grants. It should be noted that a number of reports mention missionary organisations that have carried out work with San communities in southern Angola. This includes health outreach, however information on the scope and type of support is not available. 6 Representatives or groups of the San communities in Kuando Kubango have also taken part in various activities and conferences, including with other San from the region with whom they share overarching identity. This includes conferences and meetings in Angola, Namibia and South Africa, to discuss development priorities with officials from the Government of Angola, and with international donors including the Open Society Institute of Southern Africa (OSISA) and Terre des Hommes (TdH). It has been noted in these meetings that the national and international political representation of Angolan San is weak, and no single institution exists to ensure adequate representation or advocacy. Map of a sample of San settlements visited in 2003 (WIMSA) In terms of population and distribution, many San can be found in the areas of Menongue, Cuito Cuanavale (two of the three proposed project municipalities), Cuangar, Nankova, Calai, Dirico and Rivungo. San settlements are also reporting at Waiombua, Jamba Cueio, Bundo Kassela, Mukundi, Ntopa, and Vovo Mambanda. A map above, though dated, illustrates some the main areas where San are found. Population estimates of San in Kuando Kubango, as previous stated, vary to a large extent. However, estimates in the last 10 years tend to be significantly higher than earlier estimates, as illustrated below. This may be explained by a combination of low initial estimates by various experts, increased self-identification as San, improvements in access to some regions previously not regularly visited and an increasing birth and/or infant survival rate in San communities (some newspaper reports significant proportion of the San population being children). 2006 - OCADEC and ACADIR Limited census based on San project beneficiaries Individuals Households Kavanga 57 14 7 Kuinka 47 10 Bairro Novo 66 15 Menongue Ntopa 61 13 Kanhonga 35 9 Kuando Mukundi 65 14 Kubango Savate 32 17 Bº Centro Kambwandi 1 Kuangar and 2 21 11 Tandawe 116 27 Katuitui 82 10 Kuangar sede 78 15 Total 660 155 2008 - MINARS County Area Amount 1 Menongue Wuaiombua 415 People 2 Caiundo Caiundo 515 People 3 Savati Savati 218 People 4 Catuiti Catuiti 680 People 5 Cuangar Cuangar 1521 People Total 3,349 People 2016 – MINARS Total number of San community members registered in Kuando Kubango: 8092. This number consisted of 985 (12%) adult men, 1,311 adult women (16%), 2,303 boys (28%) and 3,493 girls (43%). Notably, this indicates more than two thirds of the population is children4 (71%), and approximately 60% female. 4. Previous Development Programs supporting San populations It wasn’t until 2003 that a San population was discovered to be living in the province of Huila. At that time, they were living in an emergency situation with severe food insecurity. The province of Huila, and civil society organizations (CSOs), assisted the San by providing food, clothes, and medicines. Several government ministries and local government bodies have programs that involve San and other indigenous communities, although the overall support provided to and recognition of indigenous peoples by the Government of Angola is thus inconsistent and limited. En early 2014, the Ministry of Social Welfare (MINARS), supported by OCADEC with funding from the 4 Note that no age bracket was given in this data, however in relevant national laws in Angola children are defined as under 18 years. 8 Embassy of France, supplied oxen, ploughing equipment, seed and food relief to 150 San families in Huila Province, as part of a two-year project that commenced in 2013. During 2007-2008, the government, with the assistance of OCADEC and FAO, facilitated registration of ancestral land for one San community. Unfortunately, no other community has been able to successfully register ancestral land. The process of land registration has been changed as well as the responsible agencies. Several CSOs provide some support to Angola’s San, including three Angolan NGOs (MBAKITA, ACADIR and OCADEC) that work both with the state and in cooperation with international organisations, including the Open Society Initiative for Southern Africa (OSISA), Terre des Hommes (TdH) and, previously, Trocaire. None of them work exclusively with indigenous peoples but do include community projects with the San within wider programmes, mainly in the fields of agriculture, livelihood, health, education and community-based natural resource management. In 2014 MBAKITA, working in the provinces of Cuando Cubango, Bie, Huambo, Huila and Cunene, was implementing community programmes on human rights, food security, preventive health care and education, information and communication. ACADIR, an NGO working on natural resource management, environmental and community issues, has supported registration and identity issues, access to clean water, food security, health and education. OCADEC has a number of programmes focused on San education and representation. 5. The Health System Performance Strengthening Project (HSPSP) Objective and Guiding Principles The HSPSP development objective is to increase the utilization and the quality of health care services in target provinces and municipalities. The project will support efforts that directly address the delivery and quality of health services in its intervention provinces and municipalities, as well as those “indirect” elements related to the strengthening of the national health system that are enabling factors or conditions for the provision of health services of higher quality. Based on the experience accrued from MHSS, the project intervention areas were defined according to two basic criteria: ability to improve access and quality of basic health care services, and alignment with the government’s priority health sector reform agenda. The proposed project would maintain the service delivery coverage under the MHSS, which focused on six provinces and 18 municipalities5 and would add an additional province and four municipalities within the newly selected province. The challenge areas to be addressed through the project include: - the rural/urban disparities, reflecting a lack of access and quality of health services that is more pronounced at the local level; 5 Bengo, Luanda, Lunda Norte, Malanje, Moxico, Uige – e 18 municípios - Dande/Caxito, Ambriz, Icolo Bengo, Lucapa, Cambulo, Cuango, Chitato, Malanje, Cacusso, Calandula, Caculame, Moxico, Luena, Cmanongue, Uige, Maquela de Zombo, Negaje, Sanza Pombo 9 - the weakened national health system with a limited coordination role played by MINSA in management and financing decisions; and - the vulnerability to public health outbreaks that spread rapidly from populated urban centers to the more remote rural areas. Given these key constraints, the project would focus on two main interventions: (a) supporting the delivery of quality primary health services in the target provinces, under which a Performance-Based Financing (PBF) scheme would be piloted as part of the delivery of health services; and (b) supporting activities related to the strengthening of the national health system that create the enabling conditions for the delivery of quality health services. In addition, the project would have a third component to provide flexibility to address potential public health outbreaks and a fourth component for the project management and monitoring and evaluation functions. The HSPSP components reflect a high degree of continuity with the activities and methodologies supported under MHSS, with most of its efforts directed to improving and extending the coverage of existing basic health infrastructure and capacity strengthening activities to remote or underserved municipalities. Project Components The HSPSP contain four components: Component 1 – Improving the Quality of Health Services Delivery in Target Provinces (US$65.0 million). This component would support activities at the provincial and municipal level to improve the quality of the health care services in the target provinces and municipalities with the development of a PBF pilot in two selected provinces (US$10.0 million). Subcomponent 1.1. Improving the Quality of Maternal and Child Health Services at the Provincial and Municipal Level. This subcomponent will focus on improving the quality of maternal and child health services delivered at the provincial and municipal level. The target provinces and municipalities were selected to maintain the coverage under the MHSS project. The selection criteria and number of health facilities is described above in the “Project Beneficiaries” section. This subcomponent will continue to finance the delivery of health services currently supported under the MHSS project which includes: (i) inputs such as equipment, supplies, and mobile health team visits, and (ii) capacity building for provincial and municipal health workers to better manage, supervise, and provide quality control of maternal and child health services provided at different levels of health care, based on norms and guidelines. To complement service delivery, this subcomponent will also support key actions to strengthen local governance of the health system by: (i) incentivizing managers to maintain and implement health system maps (mapas sanitários) in the targeted provinces and municipalities, (ii) developing an enabling environment for the implementation of hospital waste management system in additional target provinces of the project, duplicating the national plans for management of environmental and hospital waste for the Province of Luanda, and (iii) review of existing citizen engagement mechanisms such as the Results Based Financing (RBF) community based survey tool to define an approach that 10 helps clients provide feedback which in turn can be used to improve services. Subcomponent 1.2. Piloting Performance-Based Financing (US$20.0 million). The HSPSP will pilot a supply-side RBF approach referred to as Performance Based Financing (PBF). The PBF pilot will support health service delivery through a performance focus adjusted for the municipal context. Angola has not had any previous experience implementing PBF approaches. An assessment due to commence in December will inform the PBF design in areas to include, but not limited to, the identification of the beneficiary population, the services (interventions) to be incentivized, the data sources for monitoring and verification of results, and funding flows, while keeping an eye to the benefits of PBF for overall health system strengthening. As part of project preparation, the task team will review the basic package of health services supported by the Angola MOH, select key interventions to be incentivized in line with the maternal and child health focus, and cost the intervention using existing costing information and further Bank analysis. In parallel, the Bank team will work with the Social Protection project and the Ministério da Administração do Território (MAT) to use existing social registries and the inputs for those being developed to support the identification and registration of the beneficiary population. The PBF scheme in Angola will introduce contracting mechanisms using the existing flow of funds structure in place in the country (where the MoF directly transfers financial resources to the MOH, the province, the provincial hospitals, and the municipal administration). The contracting scheme will focus on the MoF transfer to the municipality and will assess the possibility of setting aside a percentage of the transfer, and introducing a top-off through the project, to be used for the payment for performance at different levels of the health system. This percentage could be paid based upon the achievement of targets in the interventions selected to be incentivized. The MOH will work with the MoF to: (i) develop and manage the contracts that are to be entered into by the provinces/municipalities documenting the targets to be achieved across the selected intervention areas; (ii) define the reporting periodicity and sources of information for assessing the achievement of the targets; (iii) review the results reported and confirm the achievement or not; and (iv) provide MoF with the validated results against which payment can be made. As per discussion with the MOH, the PBF scheme will be piloted in four municipalities, from two different provinces, that will be determined based upon the inputs to be received from the design assessment. Health facilities in these target provinces will be provided with essential equipment to ensure there is a common baseline level of primary health care services with a basic functional set-up. The PBF pilot will be implemented in a phased manner.  Year 1 (2017) will be dedicated to preparatory activities such as the PBF manual, training on PBF techniques, hiring consultants, preparing PBF contracts, Information Technology (IT) processes, contracting with the potential verification bodies, and engaging NGOs/CSOs to incorporate regular beneficiary feedback as part of the scheme.  Year 2 (2018) will see the start of PBF activities. Component 2 – Strengthening System-wide Enabling Factors that Support Delivery of Quality Health Services (US$25.0 million). This component aims to support institutional 11 strengthening across the national health system towards improving the quality and coordination of health care services delivered at the municipal, provincial, and national levels. The component will therefore contribute to reducing health system inefficiencies -- a critical effort given the country’s limited availability of resources. Activities in Component 2 will support the strengthening of data collection and use for improved evidence-based decision-making, the implementation of normative instruments and regulations for the health sector, and the updating and development of national policies and plans for human resources for health. Component 2 will also support the broader reform agenda of the MOH to address system bottlenecks to improve health outcomes. The component will assist the sector for improved coordination and stewardship of the sector for effective and quality frontline service delivery. Accordingly, Component 2 will provide support the national MOH to: (i) improve the procurement and distribution (supply chain) of medicines; (ii) build capacity in the production and management of a health workforce to increase the availability of providers at the local levels; (iii) strengthen national capacity to detect and respond to public health outbreaks to include strengthening of laboratory services; (iv) support the development of reliable data and health intelligence, from the national School of Public Health, national surveys (DHS and SDI surveys), and strengthening of monitoring and evaluation capacity; (v) improve pharmacosurveillance and regulation of the pharmaceutical sector; and (vi) support improvements to the flow of funds that finance the health system, shifting from an input-based to a results-based approach. In particular, this subcomponent will support strengthening of governance structures in the MOH in the area of procurement (including strategic procurement as part of Public Financial Management). Component 3 – Supporting the Capacity to Respond and Prevent Public Health Emergencies (US$0). The component will provide surge funding to finance response efforts directed at preventing an outbreak from becoming a deadly and costly pandemic. The component will only be triggered in the case of a public health emergency and when certain actions, as agreed by the Government and Bank teams, are met. These actions can include the following: (i) the country declares a national public health emergency; and (ii) presents a sound and actionable country-level response plan. This component provides a platform for country- level discussions on the importance and need for country-level readiness to respond to disease outbreaks. Once triggered, the component will be guided by Operational Policy OP10.00, Paragraph 12, which enables rapid reallocation of funds between project components following an emergency. Together with the operational, fiduciary, procurement, disbursement and financial management arrangements that underpin its implementation, the component provides a conduit for additional emergency funds into the project. Component 4 – Project Management and Monitoring and Evaluation (US$10M). This component supports project implementation by the MOH, including project management, fiduciary tasks and Monitoring and Evaluation (M&E). The figure below presents the project’s theory of change for the two main components of the project as all technical activities will be implemented under these two components. Figure 1. HSPSP Theory of Change 12 6. Potential Impacts HSPSP will focus the implementation at the municipal level. As part of the municipal-level health needs assessments “mapas sanitarios”, San community will be identified to determine the health service access and availability to them at present. If, as part of the municipal-level needs, it is determined that health services need to be strengthened in specific municipalities, which include the San community as part of their catchment population, such investments will be made. In the case of IP, the Project will also promote a proactive approach and work with municipalities on potential activities that could directly benefit IP living in the Project implementation areas. Special arrangements will be integrated into the HSPSP Operational Manual for MINSA to engage with and assist such Indigenous Populations through culturally appropriate methods and experienced organizations. It is presumed that all HSPSP-financed activities which can reach indigenous populations will have positive benefits by addressing priority needs as identified by the municipal-level health needs assessments. The HSPSP will be implemented in at least 2 provinces where San populations can be found – Moxico and Cuando Cubango. MINSA will explore the feasibility of contracting a NGO with previous experience working with Indigenous People to better plan and implement activities benefitting this target group. Social issues and social development outcomes are central to the HSPSP Development Objective and activities. Improving the quality and access to health services through all investments is expected to generate significant positive social impacts in a number of communities across Angola, including the San. The HSPSP expected benefits and impacts include improved access 13 to services for the indigenous populations (IPs), particularly the San population, in the following areas: (i) increased utilization of key health services by IPs in the area of reproductive, maternal, and child health, (ii) improved ability to assess the quality of health services being delivered to IPs targeting pregnant women through focused quality indicators, and (iii) improved efficiency of the health system specifically in terms of availability of essential medicines for IPs. The HSPSP will identify citizen engagement channels appropriate to the IPs cultural and contextual setting to ensure IPs can have a voice through municipal councils and other civic platforms to provide feedback on how to improve service delivery. 7. Social Assessment Once a San community is clearly identified as part of the catchment population under a municipal health facility, HSPSP will conduct a focused social assessment with the active participation of the local population. The social assessment includes the following elements, as needed and relevant:  A review, on a scale appropriate to the project, of the legal and institutional framework applicable to Indigenous Peoples.  Gathering of baseline information on the demographic, social, cultural, and political characteristics of the affected Indigenous Peoples’ communities, the land and territories that they have traditionally owned or customarily used or occupied, and the natural resources on which they depend.  Taking the review and baseline information into account, the identification of key project stakeholders and the elaboration of a culturally appropriate process for consulting with the Indigenous People at each stage of project preparation and implementation.  An assessment, based on free, prior, and informed consultation, with the affected Indigenous Peoples’ communities, of the potential adverse and positive effects of the project. Critical to the determination of potential adverse impacts is an analysis of the relative vulnerability of, and risks to, the affected Indigenous Peoples’ communities given their distinct circumstances and close ties to land and natural resources, as well as their lack of access to opportunities relative to other social groups in the communities, regions, or national societies in which they live.  The identification and evaluation, based on free, prior, and informed consultation with the affected Indigenous Peoples’ communities, of measures necessary to avoid adverse effects, or if such measures are not feasible, the identification of measures to minimize, mitigate, or compensate for such effects, and to ensure that the Indigenous Peoples receive culturally appropriate benefits under the project. HSPSP will, on the basis of the above described Social Assessment and the free, prior and informed consultation, provide a permanent channel through which the affected Indigenous Peoples Communities can provide their feedback on their experience in accessing quality health services and areas for continued improvement. This feedback would need to be reflected in minutes or acts from meetings organized by the municipal and comuna councils. 14 8. Consultation In order to ensure the San are aware of the opportunity to access health services through the Project, HSPSP would request that organizations working with San establish an open communication channel with the HSPSP team to share information and feedback from the San community on their experience accessing health services and continued areas for improvement. These organizations would help the San community in preparing and sharing their feedback to present to HSPSP. The best way to disseminate information to San communities is through direct community interactions. Therefore, MINSA staff involved with the HSPSP at the provincial and municipal level would work directly with organizations working with San, as well as meeting with San communities to inform them of opportunities through the HSPSP. As part of the HSPSP preparation process, MINSA and the World Bank have undertaken consultations with government agencies and non-governmental organizations in order to secure community support for the implementation of the new activities that will be carried out in the project. Thus, MINSA staff working in the field will ensure that San people are involved in the various activities of the project and they will not be negatively affected by the project activities. The IPPF was developed based on inputs and discussions with municipal, provincial, central Government and civil society including NGOs, Consultation Councils and HSPSP beneficiaries and non-beneficiaries that happened during the implementation missions of the MHSS, the preparation mission of the HSPSP, and the direct NGO consultations conducted as part of the rapid social assessment. 9. Institutional Arrangements Screening Due to the massive movements in population due to the civil war, it is difficult to determine where specific San communities are currently located. HSPSP will work with organizations currently working with and reconnecting with San populations to identify where San communities now reside. To this end, once San communities are identified, a consultation will be organized to share the objective of the HSPSP, the services available to the San community supported through the HSPSP, and provide the San community with a chance to provide feedback on how to improve the health service delivery network to be responsive to San community needs. Capacity building will be provided to provincial and municipal Governments hosting San communities on specific approaches and interventions adapted to the livelihoods and culture of San populations. The capacity building will be provided by the Social Safeguards Specialists from the World Bank and by institutions with demonstrated capacity working with Indigenous Populations. Indigenous Peoples Plan 15 On the basis of the results of the Social Assessment (See Section 6 above) and in consultation with affected indigenous peoples, the HSPSP will prepare an IPP that sets out the measures through which it will ensure that: - Indigenous People affected by the Project receive culturally appropriate health services; and - When potentially adverse effects on Indigenous Peoples are identified, those effects are avoided, minimized or mitigated. The HSPSP will be implemented in two provinces where there is evidence that San Populations can be found: Moxico and Cuando Cubango. Implementation and Monitoring The framework for ensuring free, prior, and informed consultation with the affected Indigenous Peoples’ communities at each stage of project preparation and implementation will be included in the Project Operational Manual that will have a specific section with regards to engaging with San communities to ensure that all interactions are culturally appropriate. HSPSP will explore the feasibility of contracting a NGO with previous experience working with Indigenous People to better plan and implement activities benefitting this target group. The NGO would work with the San communities to identify their priorities and needs, ensuring they are included especially given that they are among the poorest communities in Angola. The HSPSP will generate quarterly reports detailing the progress of the activities targeting San populations will be provided as a specific chapter of the Project Progress Report. Activities will be implemented with intensive participation and constant consultation of and feedback by beneficiary households. A grievance and redress system will be put in place as well as a regular monitoring of the operation including follow up of special cases (case management). San communities and individuals who believe they are being adversely affected by the project may submit complaints to existing project-level Grievance Redress Mechanisms or the WB’s Grievance Redress Service (GRS). The GRS will ensure that complaints received are promptly reviewed in order to address project-related concerns. 10. Disclosure The Indigenous Peoples Policy Framework (IPPF) will be shared with all organizations working with San in Angola and will be translated into Portuguese. The IPPF will also be shared with municipalities hosting San populations. The HSPSP social safeguards specialist will share the IPPF with the San communities and discuss opportunities that could be available through the HSPSP. The IPPF will be disclosed via the World Bank Infoshop and via the MINSA website. In addition, it will also be advertised in a national newspaper in Angola. Copies of the IPPF can be obtained at the MINSA central and provincial offices and at the municipal level, in the municipalities participating in the Project. 16 11. Organizations Working with San in Angola  The Irish Catholic Agency for World Development, TROCAIRE  MBAKITA  ACADIR  Open Society Initiative for Southern Africa (OSISA)  Windhoek-based Working Group of Indigenous Minorities in Southern Africa (WIMSA)  Terre des Hommes  Organização Cristã de Apoio ao Desenvolvimento Comunitário (OCADEC)  Ministry of Social Welfare (MINARS)  Catholic Church 12. Estimated budget Activity Cost (US$) Contracting of NGO and Operational Costs 250,000.00 MINSA consultation and operational costs 150,000.00 Preparation of IPP 100,000.00 Total 500,000.00 17 Annex 1. Organizations participating in Consultations ACADIR (2017) MBAKITA (2017) Angola Ministry of Health – Dra. Isilda Neves, Directora Nacional de Serviços Públicos Angola Cuando Cubango Provincial Government – Director of Health Services Angola Cuando Cubango Municipal Health Center – Cuito Cuanavale 18