Page 1 CHINA: Rural Health Project Indigenous Peoples Planning Framework (IPPF) The Rural Health Project is expected to have a positive impact on the lives of people in the eight provinces and 40 counties involved, and, by extension, other areas of rural China. The Project will have an impact on ethnic minority groups that are present in some although not all counties that are part of the project. Ethnic minority groups are covered by the World Bank Operational Policy on Indigenous Peoples (OP 4.10) and, consequently, the project was prepared and will be implemented in a manner consistent with this policy. This policy is intended to ensure that indigenous people are afforded opportunities to participate in, and benefit from, the project in culturally appropriate ways. The policy requires that a process of free, prior, and informed consultation be undertaken with the affected peoples’ communities, and that such consultations establish that there is broad community support for the project. I. Project Description The main project objective is increased and more equitable access to quality health services, improved financial protection, and better management of public health threats in pilot provinces and counties, with lessons to support reforms in non-project areas. The primary activity of the project is to support innovations that can contribute to furthering the government’s on-going health reform agenda. In selected provinces and counties, the project will pilot and then evaluate innovations in health reform that can contribute to the project’s overall goals. Toward this end, the project will test innovations under the following two components. COMPONENT ONE: Health Reform Innovations Supported via Block Grants. As part of this component, counties will pilot innovations in three reform areas. Reform Areas One: Improving Rural Health Financing This component will pilot ways to strengthen and make more effective on-going government programs to provide financial protection for rural households against the escalating costs of health care. Reform Area Two: Improving Quality, Efficiency and Cost Control in Service Delivery The component will support innovations that can: (i) lead to effective control of health care costs; (ii) improve the technical quality of care; (iii) increase internal efficiency in service delivery; and (iv) result in an increased focus on prevention and health promotion. IPP289 Page 2 2 Reform Area Three: Strengthening the Financing and Organization of Core Public Health Functions Through piloting different approaches to the strengthening of public health system financing and organization, this component aims to improve the quality, efficiency and equity of core public health services as well as preparedness for new public health challenges in rural China. COMPONENT TWO: Project Coordination, Policy Development and Lesson Learning This component will aim to guide project implementation and identify replicable models for rural health reform II. Consultations Held Consultations were held as part of project preparation on the content and methodology of the Social Assessment exercise to be carried out by all counties wanting to join the project, including discussion of the involvement of ethnic minorities in the project. The agreements that emerged from these consultations are set forth below. III. Process of Approving County Proposals Counties and provinces who wish to participate in the project are required to submit proposals that are reviewed by the Ministry of Health, the World Bank, and DFID. Only after these proposals are found to be acceptable by these parties are counties permitted to begin project activities and receive project funds. An initial six counties are being appraised for admission to the project upon project effectiveness. Additional counties will be brought in later in a phased manner. An integral part of a county’s proposal is a Social Assessment (SA) based on a set of SA Guidelines—see Annex 1. Each county proposal needs to demonstrate that a SA has been undertaken during the preparation stage before its proposal can be accepted. The key issues to be addressed in each county proposal based on the SA include: · What are core issues of disadvantage or inequality in health status and access to health care in the county? · How might proposed pilot interventions or activities address these? · What indicators will measure progress or achievement of the objectives of improving equity? How will these be monitored? The SA process and key findings, direct consultations with members of relevant population groups, and proceedings of a stakeholder workshop, must be documented in an annex to each county proposal, which should include: · a description of the relevant population groups and their health characteristics, as well as key stakeholders and their interests; Page 3 3 · a discussion of key differences in health status and barriers to access to health services for different population groups, based on characteristics such as ethnicity, gender, age, disability, location and economic status; · an assessment of the extent to which the most vulnerable sectors of the population are currently reached by, or face barriers in access to, existing forms of provision and mechanisms for financial coverage; and · a discussion of the implications of the findings for proposed project activities, implementation and monitoring. Addressing Ethnic Minority Issues in County Proposals While the empirical evidence is limited, the studies available suggest that ethnic minorities in rural China face significant barriers to access to health services due to their location (often in remote, mountainous areas) and lifestyle (many are pastoralists). In general, existing surveys provide evidence of differences in the burden of disease among ethnic minorities. Linguistic barriers are particularly an issue for the elderly and women. The SA for a given county will provide an indication of the numbers of ethnic minorities, if any, in the county and a brief description of their situation. If a county’s SA process indicates that ethnic minorities are likely to be affected by project activities, it will, as part of project preparation, undertake a process of consultation with ethnic minority communities in an appropriate place, time and manner. All affected ethnic minority groups will be included in the consultation process, which will be conducive to open and frank discussion without outside intervention or intimidation. The consultation process should establish that the affected ethnic minorities: · broadly support the project objectives · are aware of the project benefits and find them to be culturally appropriate · understand how they will participate during project implementation · have had sufficient opportunity to identify their preference and constraints, as they relate to health care provision supported by the project even if supported indirectly. The findings from the consultations should be incorporated in county proposals, which should include all the applicable elements of an Indigenous Peoples Plan as specified in the World Bank Operational Policy 4.10. The county proposal, or the elements of the proposal applicable to ethnic communities, should be disclosed locally in an appropriate form and language(s). Furthermore, the project management units at the central and provincial level will contribute to this overall process by highlighting for the all project counties good practices in terms of indigenous minorities’ participation in the project. They should also suggest potential areas where additional support or different kinds of support may be required. Page 4 4 Institutional Arrangements for the IPPF The project has a central focus on learning lessons important for accelerating the health reform process in China. As such, it will support counties in the testing of innovations as well as their careful evaluation to generate lessons that are applicable more broadly to other counties and provinces across China. The primary attention of project implementers will therefore be on formulating and testing policy interventions not primarily implementation of clinical and other direct health interventions as in the case in most “traditional” health projects. Given this orientation, the project will nonetheless attempt to address concerns of ethnic minorities related to project activities in the following ways: · the development of health payment and reimbursement mechanisms that can more easily be used by ethnic minorities in remote areas; · in the area of public health reform support provision of health promotion materials and services in appropriate languages or through cultural activities; · in the area of public health reform encourage a focus on chronic illnesses which disproportionately affect ethnic minorities; · encourage an overall project focus on reaching those ethnic minorities located in more remote areas of the county; · to the extent possible support in the course of implementing innovations community participation and feedback mechanisms which ensure the participation of ethnic minorities. Monitoring and Reporting Arrangements The project places particular importance on the process of learning lessons through routine monitoring data as well as careful evaluation of specific innovations that are tested. Toward that end, routine data systems have been developed to capture changes that occur in the course of the project. In addition a substantial survey effort will be undertaken (as part of a larger national health survey) to provide baseline, mid-term and end of project data to assess project impacts. Given the project’s explicit focus on gender and equity, these measurement efforts will be particularly concerned with determining whether there are differential outcomes among project beneficiaries. These efforts will include attention to ethnicity. Disclosure Arrangements Before appraisal of a county proposal, the borrower will send the SA and draft county proposal (or a stand alone IPP) to the World Bank for review. Once the World Bank accepts the documents as providing an adequate basis for appraisal, the World Bank makes them available to the public in accordance with the World Bank Policy on Page 5 5 Disclosure on Information and the borrower makes them available to the affected ethnic minority communities. Page 6 6 Annex 1 Rural Health Project: Social Assessment Guidelines Introduction to Social Assessment Each county-level proposal must include a discussion of the social context and key social issues relevant to the project. A social assessment ensures that the project takes account of the needs and interests of different groups or institutions who might affect or be affected by the project. This might include: 9 people or groups who may be affected directly (whether positively or negatively) by the project 9 people who should benefit but who are at risk of being excluded 9 people or institutions that may affect the outcomes of the project (e.g. through their support or opposition). Each county proposal needs to demonstrate that a social assessment has been undertaken during the preparation stage. The following note and checklist is designed to assist the counties in undertaking this assessment in order to ensure that a) relevant information is included in the proposals, and b) the project activities and monitoring mechanisms take this information into account. Social Assessment for the Rural Health Project The core goals of the new health program include improving equitable access to quality health services , including public health, for the rural population. The social assessment is therefore concerned with the issues of 9 whether all people are able to benefit from the proposed interventions in an equitable way; and 9 whether the health needs of different groups – particularly the poor or vulnerable - are being considered and addressed. Key questions to address in a social assessment are therefore: 9 What are core issues of disadvantage or inequality in health status and access to health care in your county? 9 How do proposed pilot interventions or activities aim to address these? 9 How will activities be monitored to ensure the goals of equity are achieved? Page 7 7 What information should the project proposal include? Addressing the above questions requires that the proposals provide the following types of information (discussed in more detail in the following pages): 1. Context or background information: · Background information on the economic, social and cultural context of the county including income; poverty rates; the health system, and the opportunities and constraints for achieving more equitable access to quality health care. · Identification of population groups with different health needs or status, differential access to health care; or who may need special consideration in project design (for example, by ethnicity, income, gender, age, illness or disability, location etc.). The proposal should consider: · who are the particular groups of concern for the project? · how would the project affect them? what could the project do to help them ? · what does this mean for design and implementation of the project? 2. Stakeholder Analysis · A discussion of key stakeholders, that is: people likely to be affected by or influence the project) and their interests. The assessment should address: their interests; how they are likely to be affected by, or affect, the project; and how they have been consulted during project design. Findings should be based on consultations, interviews, focus group discussions or stakeholder workshops with identified groups. (See notes on stakeholder analysis below.) 3. Implications for project design and implementation · A discussion of how the proposed pilot activities will address the equity and access objectives of the project and the needs of the groups identified. This should include: how the needs of the poorest or most vulnerable will be addressed through the project; and how these groups will participate in the process of project implementation and monitoring. · A discussion of how the impacts will be monitored and evaluated, including indicators for monitoring the social impacts of the project; what kind of information is already being collected or needs to be collected? Page 8 8 1. Context: County background information Much of the information relevant to the social assessment is already required in the template for the overall project proposal. (See County Template for further detail). This can be provided in the main body of the text or in appendices as appropriate. Source of information : Already available information collected through government information systems or surveys. a) General – economic and social context For example: 9 Income – level and variation in household incomes 9 population: main demographic groups – e.g. by gender, age 9 ethnicity – main groups, share of population 9 poverty rates (share of population that is poor by some measure (eg dibao recipients; pinkun hu; MA recipients etc). 9 literacy or education levels 9 geographic variables – eg distance to township or county; mountainous; etc. b) Health indicators 9 indicators relevant to the health system: facilities, provision, financing mechanisms etc. 9 health status: including for example information about local health issues, disability, chronic illness, poverty / ill health.. cms participation… c) Population Groups 9 Identification of population groups with different health needs or status, differential access to health care, or who may need special consideration in project design (e.g. by sex, age, ethnicity, etc.) For example: some of the following groups might be of particular concern: 9 Households in extreme poverty (wubao, tekun households) 9 Poor, marginal or near poor: households in lower income quintiles / deciles 9 Households / communities located in more remote locations / villages / households 9 Women (especially of reproductive age) 9 Children and the elderly 9 Farmers without land / who have lost their land 9 Migrant population – out-migration and in-migration (to county) 9 Ethnic minority groups with barriers to access for language, cultural or other reasons 9 People with limited education or literacy who are unable to access written information Page 9 9 9 Households / individuals who have become poor through ill-health 9 Household with individuals with chronic health problems or disabilities 9 Those outside NCMS (reasons for not joining; health issues) 9 Those in NCMS but unable to afford co-payments or access appropriate services etc. Page 10 10 2. Stakeholder analysis Stakeholders are all those affected by the intervention (positively or negatively) or who can affect (positively or negatively) the outcome of a proposed intervention. Different groups have different interests in the project intervention, its implementation process and outcomes. These need to be identified. Understanding the key stakeholders is an important part of the risk analysis of a project. In the context of the social assessment , it is important to understand how the interests of different stakeholders can influence whether the project achieves its goals of equitable access to health services for all. For example: · some stakeholders in the health system may prefer to improve quality of high-tech services which are only available and affordable to a few, rather than expand basic public health and preventive services to the poorest or more remote population groups; · women’s health problems may not receive priority attention if most health workers and officials are men; · individuals with limited education and low levels of literacy in Chinese may have limited access to written materials (e.g. about public health information); this may be particular the case for the elderly and ethnic minority groups. The project proposal should include: · a stakeholder analysis (possibly using the format of the table below) · a discussion of the process of consulting with different stakeholders (eg meetings, focus group discussions, stakeholder workshops, etc.) · the implications of the analysis for the project design and implementation. NOTE: Ethnic minority populations For counties (provinces) with ethnic minority populations it is particularly important to provide information on · the situation of ethnic groups in the county · how they have been consulted during project design · their interests in the project · their access to project benefits and how they will participate during project implementation · how their participation and the impact of the project on them will be monitored. Page 11 11 In the case of the rural health project, the stakeholders may include, for example: Stakeholder Interests How affected? Implications for the project Government: · Provincial · County · Township (+ / - ) (direct / indirect) etc. The health system: Relevant government agencies and departments Other government agencies: Civil Affairs, Social insurance, poverty, Women’s Federation… Facilities / service providers – County hospitals, THCs, MCH, CDC etc. Doctors / health workers (county, township, village) Drug suppliers Service users – the rural population Women Ethnic minority populations The elderly ; the disabled; chronic ill Different population groups - Income Location Other disadvantaged groups Other ? Page 12 12 3. Implications for the project proposal and implementation The main purpose of the social assessment is to ensure that the project is designed to meet the needs of the poor, marginalised or vulnerable groups, and that these groups benefit from project activities. The proposal should include a discussion of: The impact of proposed activities on different population groups: · how the proposed activities will address the core objectives of equity and access to quality health services given the identification and analysis of relevant population groups. Participation and Governance: · how will different stakeholders, service users or intended beneficiaries, especially vulnerable groups, be consulted or participate in project implementation? In particular, how will women and ethnic minorities (where appropriate) participate or be consulted? For example, the proposal should include information about: · what mechanisms exist to inform different groups about project activities, find out their opinions, and understand their preferences or concerns? · what mechanisms can be developed for community engagement in different aspects of the project, including design, implementation and monitoring (e.g mechanisms of community based monitoring and supervision)? · what mechanisms need to be put in place to receive feedback about the project (e.g. changes in service provision)? Monitoring and evaluation In line with the results framework (or log frame), indicators and milestones, the proposals should include indicators for monitoring the impacts of the project on the different groups identified in the social assessment. · How will the county monitor and evaluate progress on access and equity? · What indicators can be identified to assess progress? · What kind of information is already being collected or needs to be collected; how? Page 13 13 Tools for Social Assessment A social assessment should involve collecting the above information and consulting with key stakeholders. A short section in the proposals should document the process undertaken by the counties. That is, it should describe who was consulted, when and how? Activities undertaken as part of the social assessment should include the following: · Clarify the necessary information/data needed (described above), identify the relevant information/data sources; collection and analysis of existing data on county situation · Identify the main groups or stakeholders relevant to the project (using the stakeholder analysis described above) · conduct focus group discussions with key groups (eg rural women and men, ethnic minorities, people in remote villages) · Undertake interviews, consultations and discussions with different groups (village / township health workers, different government agency officials, etc) · Stakeholder workshops – bringing together a range of stakeholders to cross-check the findings of other consultations and discussions, and get feedback and input into project design; 1. Village level activities Interviews and focus group discussions at the village level are essential to understand the situation and health care needs of the rural population, and different groups (for example, by age, gender, income (poor/poorest), ethnic groups and location). Activities may include: Women and men ’s focus group discussion: Groups consist of villagers who represent different age, education background, settlement (especially those from remote hamlets), household economic status (especially those from the poor/poorest households) etc.. Interviewing men and women separately allows women to feel more comfortable and confident to speak. Focus group or individual interviews with particular groups: Groups/individuals may include ethnic minority population (essential in counties with significant minority populations), households that have fallen into poverty through ill-health ( yinbinzhipin), households facing catastrophic expenditures, households with members who have chronic disease or disabilities; households without land, and migrant workers (in- or out- migrants). Information obtained during such discussions should include: Page 14 14 · basic information about individuals / group participants: (age, sex, nationality, education background, family situation; employment · information about health status, access and utilisation of health care, and membership of NCMS Discussions should aim to understand: · what are the key health problems for different groups? · what are the differences or main barriers to access to medical services for different groups? and · the major concerns and priority needs of participants which can inform the project design. Groups should consist of 7-12 villagers; it is better not to have local officials or village cadres present during the focus group discussion. Usually, a male field worker is required for moderating the male group interview, a female is required to moderate the female group interview, and ideally a minority field worker is required for moderating the minority group interviews. Village key informant interviews: This should include interviews with the village doctor / health worker and village cadres (including Women’s Representative). Each county may have significant variation in social, economic and cultural conditions across villages. Therefore a number of villages should be selected with different social, economic and cultural characteristics. For example: in one county selected villages could include: one poor remote village, at least one minority village if applicable, one middle- income village and one richer village; or one in mountains, one with flat land; etc. 2. Stakeholder analysis: Identification and interviews with stakeholders (see discussion above) 3. Stakeholder workshop The stakeholder workshop should take place after all the main stakeholders have been identified and, where necessary, separately consulted. It is important that all the main stakeholders, including villagers representing different socio-economic groups , should attend the stakeholder workshop so that they can share the concerns of different groups and learn from each other. It is also very important for the facilitator to use participatory techniques to moderate this workshop and to give opportunities to all groups, especially village participants, to voice their concerns and provide comments. The stakeholder workshop will a) allow different groups to present their main concerns and suggestions; b) present the main findings from the social assessment activities c) receive feedback, comments and suggestions from all participants which can inform proposal development and project implementation. Page 15 15 Example Some suggested activities and topics for interviews or discussion are summarised below (based on example of Social Assessment undertaken by Social Assessment Consultants in Qianjiang District and Meixian). Main stakeholders Main content / questions Bureau of Health: - responsible for project design - main diseases and health problems of the county, especially those relevant to poor / disadvantaged groups; - what are the main issues of inequality (of access, quality of services) in the county - main constraints and difficulties faced in improving quality of services accessible to all population groups Key informants of the NCMS - How the NCMS addresses issues of equity and accessibility for disadvantaged groups such as the poor/poorest, women, children, the aged, and minorities. - Who does not join / drops out? Why? - numbers / reasons of those joining NCMS but unable to use / pay for services Key informants of other government offices (e.g. Finance, Civil Affairs, Poverty Alleviation, Women’s Federation… etc.). 1. Bureau of Finance : - whether budget/financial support to health care sector addresses needs of disadvantaged groups. - who are the beneficiaries of the government medical assistance funds 2. Bureau of Civil Affairs: - how to define the target groups and how to target the defined groups; contents and approach of MA. - how to coordinate MA and NCMS 3. Poverty alleviation office - population and distribution of the poor; main causes of poverty; other socio-economic features of the poor (such as remote geographic location/poor transportation, nationality/minority, gender, education background); - relationship between poverty and ill-health - government strategy and main measures/efforts to alleviate poverty and any measures/efforts relating to medical aide and/or health care. 4. Women’s Federation - key health issues of concern to women; County Health facilities: Hospital, CDC, MCH Questions to health providers: - difficulties of access for different groups (poor, disadvantaged) - specific problems in delivering services to particular groups, or those who cannot afford services or have other access problems - particular health problems (local diseases etc.) Page 16 16 Township visits : THC, government, (including in minority / poor areas) - Township situation: population, area, and economic situation - township health / THC conditions, services (see above – county); accessibility for villagers - main health problems and main diseases of different groups, cost of treatment; problems of access and equity Village social assessment – visit, interviews, focus group discussions (see above) - General village conditions, relevant to health, eg: population, income, ethnicity, causes of poverty; causes of ill-health, water and sanitation, etc. - Specific health problems and access to treatment / facilities or services; cost; NCMS, medical aid for poor households, etc. - Problems facing particular groups (eg women, the elderly, disabled etc. – through focus group or individual discussions) Stakeholder workshop : Meeting with range of different stakeholders for discussion - different groups present their main concerns and suggestions about health problems, access to services, quality etc. - present the main findings from the social assessment activities - receive feedback, comments and suggestions from all participants which can inform proposal development and project implementation. Workshop activity: (depending on time) Use stakeholder analysis table to start short discussion (in groups) about: · who are the particular group(s) of concern in x county; · how would the project (specific proposed activity) affect them? · how can the group(s) participate in project implementation? · how will the impact of the project on this group be monitored (what baseline information is needed; what indicators can be used, etc.)? Materials : Flipcharts / pens for each group (min. 6).