The World Bank Honduras Improving Access and Governance in Health (P176532) Project Information Document (PID) Concept Stage | Date Prepared/Updated: 28-Jun-2021 | Report No: PIDC32129 Jun 28, 2021 Page 1 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) BASIC INFORMATION A. Basic Project Data OPS TABLE Country Project ID Parent Project ID (if any) Project Name Honduras P176532 Honduras Improving Access and Governance in Health (P176532) Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) LATIN AMERICA AND Sep 03, 2021 Oct 28, 2021 Health, Nutrition & CARIBBEAN Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Republic of Honduras Ministry of Health (Secretaria de Salud Honduras) Proposed Development Objective(s) To improve the delivery of primary health care services in selected geographical areas and strengthen public health systems for emergency preparedness. PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 Total Project Cost 55.00 Total Financing 55.00 of which IBRD/IDA 40.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 40.00 IDA Credit 40.00 Non-World Bank Group Financing Trust Funds 15.00 Jun 28, 2021 Page 2 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) Global Financing Facility 15.00 Environmental and Social Risk Classification Concept Review Decision Moderate Track II-The review did authorize the preparation to continue B. Introduction and Context Country Context 1. With a population of 9.9 million and a Gross Domestic Product (GDP) per capita of US$2,340 in 2020, Honduras is among the poorest countries in the Latin America and the Caribbean (LAC) region. In 2019, 49 percent of the population lived on less than US$5.50 per day. Despite some progress achieved through several policy reforms and programs undertaken since 2015, the country’s economic and social development continues to suffer from governance, fiscal, infrastructure, high emigration, and low-skilled labor force challenges, as well as a high vulnerability to external shocks. Human capital outcomes in Honduras are low with significant inequalities1, several of which are driven by uneven access to basic services, poor social protection and high crime rates, although the number of homicides per 100,000 people has decreased from 84 to 41 in 2017. Honduras is also exposed to climate-induced natural hazards, such as the tropical cyclones that hit the country hard in November 2020.2 2. Honduras is among the countries in LAC hardest hit by the direct and secondary impacts of the COVID-19 pandemic. In mid-2020, nearly 68 percent of households reported income losses, and more than one third of households reported food insecurity due to lack of resources.3 The COVID-19 pandemic, combined with the severe effects of Tropical Cyclones Eta and Iota, have exacerbated existing economic and social challenges, threatening the health and welfare of the population. The cyclones affected roughly 40 percent of the population (3.9 million people), with more than 437,000 persons evacuated and 96,000 relocated to temporary shelters.4 Real GDP contracted by 9 percent in 2020 (year on year), with 55.4 percent of the population living under the US$5.50 per day poverty line (an increase of more than 700,000 people), due to a sharp fall in trade, investment and consumption amid the global recession, extended lockdown, and damages caused by the cyclones. The country’s GDP is not expected to reach its pre- pandemic level until 2023 once domestic economic activity and investments are expected to be reactivated. Sectoral and Institutional Context 3. Honduras has made progress in maternal and child health in the last two decades, but inequities and declining coverage of essential health and nutrition services in the face of the COVID-19 pandemic pose a serious threat to 1 World Bank, 2019. Honduras: Insights from Disaggregating the Human Capital Index. https://pubdocs.worldbank.org/en/507141572967503310/ses-HND.pdf?cid=GGH_e_hcpexternal_en_ext 2 Tropical Cyclones Eta and Iota caused a significant damage in November 2020 and had catastrophic impacts on local populations, critical infrastructure, crops, private assets and the economy. 3 World Bank Group, 2020. COVID-19 High Frequency Monitoring Dashboard. Available from: https://www.worldbank.org/en/data/interactive/2020/11/11/covid-19-high-frequency-monitoring-dashboard 4 The social and economic costs of the cyclones are estimated to approach US$1.8 billion (7.2 percent of 2019 GDP). Jun 28, 2021 Page 3 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) maintaining this progress. Maternal mortality decreased from 108 deaths per 100,000 live births in 1997 to 78.1 deaths per 100,000 live births in 2018,5 while child mortality fell from 37 to 17 deaths per 1,000 births between 2000 and 2019.6 The nutritional status of children has also improved, with the prevalence of stunting falling from 30 percent to 23 percent between 2005-06 and 2011-12, but Honduras still has the second highest prevalence of stunting in the Latin America Region,7 in addition to a growing double burden of malnutrition. Although the coverage of many primary health care services is relatively high, the quality of care received is low.8 Moreover, coverage and quality of services are highly influenced by income and education level, urbanicity, and geographical region, with access and quality being remarkably lower among the lowest income quintiles, those with no or little education, and rural populations. Lastly, based on the World Health Organization’s pulse survey of Honduras, primary care services assessed have experienced severe disruptions of 50 percent or greater,9 contributing to large declines in vaccine coverage as well as use of other essential preventive health and nutrition services. The Global Financing Facility (GFF) estimates that the consequences of disruptions to maternal and child health services during the COVID-19 pandemic could lead to a 37 percent increase in child mortality and an 80 percent increase in maternal mortality,10 threatening the progress achieved in recent years. 4. Honduras is challenged by high rates of adolescent fertility, which are the second highest in the region, contributing to an increased risk of mortality among female youth (10-24 years old).11 Despite declines in overall fertility, childbearing begins too early with 22 percent of women having begun child bearing before the age of 18.12 There are strong and marked inequities in adolescent pregnancy and use of family planning services based on geographic location (province, urban/rural), and education levels. Adolescents aged 15-19 years living in rural areas are 30 percent more likely to have been pregnant or be mothers as compared to those in urban areas (29.3 percent versus 19.2 percent in urban versus rural areas). These differences are even starker when comparing education levels, where up to 42 percent of girls aged 15-19 with little or no education have begun childbearing, as compared to 12 percent of girls who have completed secondary education and 1 percent of girls who have continued to complete tertiary education.13 The high levels of adolescent pregnancy hold important, immediate implications not only for the adolescent’s health and survival, but also for the health of their newborns,14 with longer-term social and economic consequences on their educational attainment and subsequently, lifetime earnings.15 Girls who get one year of education beyond the average boost their eventual wages by 10-20 percent; given the important economic contributions of women globally, efforts to reduce adolescent pregnancy are viewed as critical on the pathway to improving human capital outcomes and more broadly, reducing the intergenerational transmission of poverty.16 5 PAHO, 2019. Core Indicators: Health Trends in the Americas. 6 Estimates by UNICEF, WHO, World Bank, UN-DESA Population Division, 2020. Levels and trends in child mortality. 7 UNICEF. The State of the World’s Children 2019 Statistical Tables: Nutrition. Available here: https://data.unicef.org/resourc es/dataset/sowc-2019- statistical-tables/# 8 SEP, INE, SESAL, ICF International, 2012. Honduras National Demographic and Health Survey (DHS). 9 The five services assessed include: (i) health promotion and prevention services; (ii) routine scheduled visits; (iii) visits for undifferentiated symptoms; (iv) referrals to specialty care; (v) prescription renewals for chronic medications. World Health Organization, 2021. Tracking continuity of essential health services during the COVID-19 pandemic. 10 Global Financing Facility, 2020. Country brief on Maintaining Essential Health Services During the COVID-19 Pandemic. 11 PAHO, 2017. Adolescent and Youth Health: Country Profile for Honduras. 12 SEP, INE, SESAL, ICF International, 2012. Honduras National Demographic and Health Survey (DHS). 13 SEP, INE, SESAL, ICF International, 2012. Honduras National Demographic and Health Survey (DHS). 14 World Health Organization, 2020. Adolescent Pregnancy Fact Sheet, available from: https://www.who.int/news-room/fact- sheets/detail/adolescent-pregnancy. 15 Levine et al., 2008. Girls Count: A Global Investment & Action Agenda. Center for Global Development, Washington DC. Available from: https://www.cgdev.org/sites/default/files/15154_file_GC_2009_Final_web_0.pdf 16 Idem. Jun 28, 2021 Page 4 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) 5. Honduras’ capacity to respond to health emergencies is low, but investments in pandemic preparedness and response are increasing. With an assessed core capacity of 34 percent under the International Health Regulations, Honduras’ capacity to detect, assess, notify, and respond to public health risks and emergencies is well below both global and regional averages (61 percent and 65 percent, respectively).17 Among other consequences, weak and limited capacity at both central and subnational levels has translated into a chronic inability to control epidemics, including the severe ongoing dengue epidemic that has affected at least 127,000 people and caused 277 deaths since January 2019. Among other diseases, surveillance of dengue cases and deaths has been severely disrupted since the beginning of the COVID-19 emergency, as the national surveillance and response system has become overburdened, and the actual impact of dengue in recent months is widely understood to be higher than the reported data to date. Several partners continue to support Honduras’ national COVID-19 response through investments in the national laboratory system, communication campaigns, medical and lab supplies, and other areas of the pandemic response. However, the country continues to face severe difficulties in preventing and managing community transmission, while ensuring the continuity of routine health services. Relationship to CPF 6. The proposed project is well aligned with the three pillars of the World Bank Group (WBG)’s Country Partnership Framework (CPF) FY16-20 (Report number 98367), including the recent adjustments made in the context of the COVID-19 crisis. Specifically, the Project objectives are aligned with Pillar I “Fostering Inclusion� and Pillar III “Reducing Vulnerabilities� of the CPF, which includes enhancing resilience to natural hazards as one of its objectives. The Project will directly contribute to the first pillar objective of the CPF by strengthening essential health services. The proposed Project’s focus on strengthening public health preparedness supports the third pillar by boosting preparedness to emergencies. The overall WBG’s program for Honduras as outlined in the CPF remains valid, but small adjustments have been introduced in response to the pandemic. These adjustments are fully aligned with the four pillars of the WBG COVID-19 Crisis Response Approach Paper namely: (i) Saving Lives; (ii) Protecting Poor and Vulnerable People; (iii) Ensuring Sustainable Business Growth and Job Creation; and (iv) Strengthening Policies, Institutions and Investments for Rebuilding Better. The Project supports two of the four COVID-19 Crisis Response adjustment pillars, namely (i) Saving Lives and (ii) Protecting Poor and Vulnerable People. C. Proposed Development Objective(s) 7. To improve the delivery of primary health care services in selected geographical areas and strengthen public health systems for emergency preparedness. Key Results (From PCN) 8. The following key results would be pursued through the proposed Project: a) Increase in children fully vaccinated (Percentage of children aged 15-23 months in project intervention areas) b) Increase in births attended by skilled health staff (Percentage of total births in project intervention areas) c) Improved reporting and response to dengue cases (Percentage of total dengue cases in project intervention areas). 17 World Health Organization, 2017. International Health Regulations State Party Self-Assessment Annual Report, Honduras. Jun 28, 2021 Page 5 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) D. Concept Description 9. The proposed project has four components as follows: Component 1 – Strengthen essential adolescent, maternal, and child health services 10. Taking into consideration the impacts of COVID-19, this component will aim to strengthen the supply and demand for adolescent, maternal and child essential health services through activities focused on : (i) improving quality of health services delivered; (ii) increasing the utilization of health services; and (iii) reverting losses and increasing coverage of primary health care services. Activities will be geographically targeted to prioritize regions with the highest burden and inequity in adolescent, maternal, and health indicators; specific regions will be selected during project preparation in collaboration with SESAL (Secretaria de Salud / Ministry of Health) and key partners. 11. Subcomponent 1.1 – Improve the delivery and utilization of quality adolescent, maternal, and child health services. Under this subcomponent, the Project will finance activities to support the government’s efforts to continue the delivery of quality essential health and nutrition services for adolescents, women and children amidst the COVID-19 pandemic, given the substantial disruptions to these services. Evidence-based demand-creation activities that use Social and Behavior Change Communication (SBCC) and community mobilization will also be supported to increase utilization of services while also addressing fear and misinformation that contributes to low service utilization. 12. Subcomponent 1.2 – Cross-sectoral collaboration to enhance the provision and utilization of adolescent, maternal, and child health services through alternative delivery platforms . This subcomponent aims to enhance collaboration with sectors to increase the uptake of essential health services for targeted populations, particularly adolescents and young children. Proposed activities will be further refined during project preparation based on additional assessments and discussions with SESAL, the Ministry of Education (Secretaría de Educación, SE), and the Ministry of Development and Social Inclusion (Secretaría de Desarrollo Social, SEDIS). Component 2 – Strengthen public health preparedness and response capacity 13. This component will strengthen the preparedness and response capacity of the country to face health emergencies, including pandemics and infectious disease outbreaks, such as dengue, malaria, and COVID-19. Activities under this component will be informed by the ongoing Advisory Services and Analytics task, Public Health Preparedness Assessment in Central America (P175552), which will identify priority actions for the surveillance system under the following domains of public health: governance, financing, information systems, zoonotic diseases, human resources, immunization, laboratory systems, risk communication and health systems resilience. Proposed activities would include: (i) strengthening sub-national laboratories and field surveillance teams capacity through equipment and technical assistance; (ii) strengthening surveillance information systems through the development of innovative information management solutions in national and regional surveillance hubs; (iii) strengthening intra- and inter- institutional capacity at the national and regional levels to implement the National Pandemic, Epidemic and Health Emergency Response Plan, including health emergency operations centers; (iv) training for technical staff in field epidemiology and laboratory, and other related fields; and (v) equipment, supplies, development of communication activities to prevent and respond to infectious disease outbreaks. Component 3 – Support project management and strengthen SESAL’s stewardship of the health sector 14. This component will finance activities to strengthen the capacity of the central SESAL units and regional health authorities in the coordination, implementation management and supervision of the Project (including fiduciary Jun 28, 2021 Page 6 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) aspects and monitoring and evaluation, environmental and social aspects and reporting of project activities and results), and the carrying out of project audits. In addition, this component seeks to address stewardship and systemic deficiencies in the health sector that affect the efficiency with which critical health systems functions are implemented by SESAL at the central and subnational levels. Specifically, activities that will be considered during project preparation include: (i) improving control mechanisms and strategic management of critical health commodities; (ii) strengthening Human Resources management systems through, among other interventions, the piloting of performance-based system to reduce absenteeism and incentivize deployment in underserved areas, at selected frontline service delivery units and Regional Health Directorates; (iii) strengthening SESAL information systems and their interoperability, including investments to implement digital systems for vaccination which are currently paper-based, as well as support and capacity building to improve the quality of health data in order to enable evidence-based decision-making; (iv) activities to enhance governance in the health sector, including citizen engagement mechanisms and enhanced donor coordination and alignment, addressing challenges identified by the Special Commission for the Transformation of the National Health System (integrated by government, civil society and private sector actors). Component 4 – Contingency and Emergency Response Capacity (CERC) 15. This component will provide funding following an eligible emergency. The component will include conditions for the use of the funds and will only be triggered when certain actions, as agreed by the government and the Bank, are met. Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Summary of Screening of Environmental and Social Risks and Impacts . 16. The environmental and social risk rating of the Project is Moderate. The proposed activities to be carried out are aimed at strengthening the primary health care system, improving the quality of health services, increasing capacities and expanding coverage for children, adolescents and women in reproductive age. From an environmental perspective, the proposed project will not finance major civil works or other activities that could affect the quality of the air, bodies of water, soils, vegetation or its associated fauna, in a relevant way, directly or indirectly. The operation of health care centers, provision of medical services and provision of vector control awareness campaigns (such as prevention of zika and chikungunya) have environmental and occupational health risks derived from increased generation of medical care waste which may have biological risk characteristics. These risks will be in situ and managed through the application and enforcement of existing specific Occupational Health and Safety (OHS) protocols for medical waste management and final disposal, and specific control measures, such as use of personal protective equipment (PPE) and training for the application of said protocols. In addition, the Project might finance replacement of electronic equipment and acquisition of new equipment which will require specific mitigation measures to help manage e-waste and adoption of energy efficient equipment. 17. The Project is expected to have overall positive social impacts by strengthening and supporting vital health services, communication to beneficiary and social mobilization and institutional capacity strengthening. Identified social Jun 28, 2021 Page 7 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) risks for this project include: (i) discrimination and difficulties in access to services and vaccination programs by marginalized and vulnerable social groups, which are disproportionately represented by Afro-Hondurans and Indigenous Peoples, migrants, the elderly, LGBTI people and persons with disabilities; (ii) patient-centric risks for those receiving medical attention, including Gender-Based Violence (GBV) or Sexual Exploitation and Abuse (SEA) of patients or health staff; (iii) limited reach of the Project’s communication strategies to inform the population of the Project’s benefits if these are not adequately tailored or culturally adapted; and (iv) insufficient measures to prevent misinformation which may contribute to propagate false expectations or generate mistrust about the benefits of health campaigns or programs. Difficult access to health in rural and remote areas of the country can also pose a challenge for service and vaccination delivery, particularly for single mothers with children with need of vaccination. 18. To address these risks and establish the corresponding mitigation strategies SESAL will draft prior to project appraisal a series of Environmental & Social instruments: an Environmental and Social Management Framework (ESMF) which will reflect the specific applicable legislation and the required measures for the efficient management of risks and impacts in accordance with Environmental and Social Standards (ESS)1 and the mitigation hierarchy and in a manner appropriate to the scale and nature of activities; a draft Stakeholder Engagement Plan (SEP) which should be disclosed in SESAL's portal, including the design of a project-wide Grievance Redress Mechanism (GRM); Labor Management Procedures (LMP) with a description of a worker-specific GRM; and an Indigenous Peoples Planning Framework. The timeframes for finalization, capacity building requirements, staffing needs and monitoring tools will be described in the Projects Environmental and Social Commitment Plan. The Concept Environmental and Social Review Summary (ESRS) was approved and disclosed by the Bank on June 28, 2021. . CONTACT POINT World Bank Nicolas Antoine Robert Collin Dit De Montesson, Roberto F. Iunes Senior Economist Borrower/Client/Recipient Republic of Honduras Luis Fernando Mata Echeverri Minister of Finance lmata@sefin.gob.hn Implementing Agencies Jun 28, 2021 Page 8 of 9 The World Bank Honduras Improving Access and Governance in Health (P176532) Ministry of Health (Secretaria de Salud Honduras) Alba Consuelo Flores Minister albaflores@salud.gob.hn FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Task Team Leader(s): Nicolas Antoine Robert Collin Dit De Montesson, Roberto F. Iunes Approved By APPROVALTBL Practice Manager/Manager: Country Director: Oyebimpe Olufunmilayo Adepoju 28-Jun-2021 Jun 28, 2021 Page 9 of 9