Page 1 1 LAO PEOPLE'S DEMOCRATIC REPUBLIC PEACE INDEPENDENCE DEMOCRACY UNITY PROSPERITY The Lao PDR Ministry of Health – The World Bank Community Nutrition Project (CNP) Ethnic Group Development Framework (Revised) July 20, 2010 IPP454 Page 2 2 Introduction 1. The Community Nutrition Project (CNP) in the Lao People’s Democratic Republic, is expected to have a positive impact on the lives of people throughout the Project intervention areas. As the Project will be targeting the remote and rural areas were many ethnic groups are concentrated, it is expected to affect ethnic groups. This Ethnic Group Development Framework (EGDF) 1 provides a strategy and a programmatic approach to enhance the inclusion of different ethnic groups in the Community Nutrition Project, in accordance with World Bank Operational Policy 4.10 on Indigenous Peoples. The policy is intended to ensure that indigenous people are afforded opportunities to participate in, and benefit from, the Project in culturally appropriate ways. The Project has been designed in a manner fully consistent with Operational Policy 4.10, and is expected to positively impact upon ethnic groups in the area, this framework emphasizes the manner in which the core activities will be carried out in compliance with the Operational Policies, rather than describing separate activities. 2. To ensure compliance with OP4.10, a multi-step consultation process has been designed. The first step of this consultation process was completed during project preparation, and building on Social Impact Assessment (SIA) which had earlier been carried out in association with the World Bank-funded Health Services Improvement Project (HSIP), an ongoing health project which was designed to cover the same provinces as the Community Nutrition Project. Additionally, funds have been procured to conduct a series of qualitative studies at regular intervals throughout CNP implementation. While each of the studies is expected to have a different focus, 2 each will provide an opportunity to assess whether the adaptable design which has been selected for CNP implementation is succeeding in responding to the needs of the various ethnic groups in the project area and it is expected that each of studies described will be underpinned by an analysis of the degree to which full and informed inclusion of all the representative ethnic groups has been achieved in the Project’s implementation. The Community Nutrition Project Programs and Subprojects 3. By most standards, the Lao People’s Democratic Republic (Lao PDR) is one of the poorest and least developed countries in East Asia. Poverty, especially rural poverty is found primarily among upland ethnic minorities. Health constitutes a key social sector for the socioeconomic development of the country. The proposed project has been designed as a program of investments, rural community education, institutional capacity building needed to improve access to health care and to contribute towards reduction of 1 Sometimes called the Indigenous People’s Planning Framework or IPPF 2 Preliminary plans are to include studies on Child Caring and Feeding Practices; Health information sources and health seeking behavior; Adequacy of CBN implementation; Success of accountability mechanisms in CCT implementation; and Effects of CCTs on HC workload and staff morale Page 3 3 rural poverty. A strong emphasis on the involvement and participation of villagers living in the targeted Project districts is an integral feature of the proposed project. Programs and Subprojects 4. The CNP is designed to have positive impacts for local villagers, especially non- Lao speaking ethnic groups. Specifically, the Project will pilot a conditional cash transfer (CCT) scheme and a community-based health and nutrition program. Additionally, the CNP will provide capacity building to health staff through in-service training and improved supervision and will increase the availability of maternal and child health care supplies in remote rural villages with the assistance of Community Based Distributors (CBDs). Together, these activities are expected to increase the uptake of key maternal and child health (MCH) services, and stimulate behavior change to improve nutrition and broader MCH outcomes. Villagers will also benefit from improved access to health services and from more affordable health-care as a result of the CCT. The health and nutrition component of the proposed project has been explicitly designed to address local barriers to appropriate nutrition and feeding practices, which often stem from traditional beliefs rather than access to food. Feeding practices surrounding births are often highly localized, not only to specific ethnic groups, but even to specific communities. By purposively adopting an adaptable approach, the project is expected to represent the needs and wishes of local ethnic groups, while the process through which the community itself identifies issues of concern will prevent alienation or perceptions of judgment by the group facilitator. 5. CNP will help finance the costs associated with seeking healthcare services around maternal and child health. This is expected to be especially important in a context of high and volatile food prices, when the opportunity costs of abandoning the crops in order to seek antenatal or infant health services are especially high. The global food price crisis is likely to impact adversely on the quantity and quality of food consumed by many households in Lao PDR. Moreover, with rising food prices and other macro shocks putting growing pressures on households, the utilization of key health services may fall even further, undermining efforts to expand coverage of cost-effective interventions to address malnutrition. In this way, rising food prices are likely to have a lasting impacts on physical and cognitive development, learning outcomes, health and productivity, and, ultimately, household welfare. 6. The CNP is not expected to cause negative social impacts. However, there may be issues associated with providing equitable access to project benefits. Participation in project activities will require some commitment of time which could be challenging, especially in upland villages or villages where cultivation activities require long periods away from the village. And since the project will assist villagers with access to health services, there is a risk that some villagers may benefit more than others depending on the location of fields. 7. CCTs are expected to help reduce the financial barriers to accessing care, while the Community Nutrition Program component of CNP will include a focus on isolated Page 4 4 villages in which non-Lao ethnic groups typically live. Community-based distributors are expected to extend this reach even further, and will operate only in communities considered too remote to be able reliably depend on the routine outreach for access to health services. Compliance with OP 4.10, Indigenous Peoples 8. CNP is being designed to meet all requirements of World Bank OP 4.10, on Indigenous Peoples. The objective of this policy is to ensure that groups meeting the definition of “indigenous peoples” can receive culturally appropriate benefits from the project, and that any adverse socioeconomic or cultural impacts imposed by the project are identified, minimized and otherwise mitigated. 9. OP 4.10 requires that such groups are engaged in a process of “free, prior and informed consultation” during the project design phase. The Bank will only support projects involving such groups if such a consultation process demonstrates a pattern of broad community support for project objectives and activities. 10. As already described, CNP is not expected to result in any adverse socioeconomic or cultural impacts. Regarding ethnic minority communities, planning measures have emphasized ensuring equitable access to project benefits. Most CNP implementation processes will be tied directly to the ongoing HSIP, including implementation processes relating to OP 4.10 (e.g., project monitoring and grievance procedures, described below). During the course of project design, a social assessment was conducted, providing the modality for “free, prior and informed consultations.” This process led to a clear expression of support for the project, and a widespread desire for access to project benefits. As detailed implementation arrangements and the identification of specific participating communities will be decided only during the project implementation phase, this EGDF has been prepared. Key findings from the HSIP Social Impact Assessment 11. In general, health indicators for non-Lao ethnic groups are low compared to the rest of the country, although most information is currently based on intermittent survey data and qualitative work as the Lao health information system does not collect data disaggregated by ethnicity. In general, non-Lao ethnic groups typically face significant health-care-related disadvantages: they live in remote areas not readily accessible to the formal health system, they often are poorer, have a lower literacy rate in Lao language, and generally lack access to roads, schools, markets and other services 12. To obtain a first-hand glimpse of the health service situation, a SIA was carried out for the HSIP (insert date….). The SIA consisted of brief field studies in one district in each of the project provinces. Districts were selected so as to include very poor, poor, and non-poor districts (as defined by the NPEP) for a more comprehensive sample. Within each district the research teams met with DHC committees to select at least one representative souksala and two villages within the HC catchment area. The two villages in each case consisted of one old and one new village, and care was taken to include as Page 5 5 many ethnic minority groups as possible. The aim of the SIA field studies was to assess the systems for delivery of services from the perspectives of the various agencies and institutions in the project area, in particular the district, the health center ( souksala ) and the village. Semi-structured interviews were held with health officials, village health volunteers (VHVs) and villagers. 13. The findings of the SIA are essentially that while the Health Systems Improvement Project had no particular negative impacts, positive impacts would depend upon the degree to which an increased effort to include ethnic group participation in the health care system could be successful. To accomplish this, additional focus and financing would have to be directed at programs aimed at the ethnic minorities in the form of (1) language and culture, and (2) the integration of traditional and conventional medical systems. Key findings from Local Consultation for the CNP 14. In addition to the SIA for the HSIP, local consultations have also been carried out on the Community Nutrition Project specifically. In keeping with the principle of free prior and informed consent, consultations were held with six ethnically distinct villages in a sample of two provinces from the project area, during Feb. 27 th and March 5, 2009. Selection of districts and village was purposive in order to select villages which represent distinct minorities; which represent considerable portions of the minority population; and which have poverty incidence rates of 60 percent and higher. 15. Within a series of focus group discussions, women shared their views and experiences with respect to childbirth, pre- and postnatal care, the local clinic and hospital and contact with the government health care system. The CNP project, as described in the project document, was disclosed by the consultation team with special emphasis on the CCTs. The women, facilitated by the consultation team, discussed aspects related to the CCTs. 16. All communications were free, prior and informed and without interference. The language of consultations in Khamkeut was primarily Lao, with some skilled interpretations for Hmong women. In Savannakhet, a team member was able to speak directly to women in their own languages, though most of the women were able to speak Lao. 17. Both the local consultations and the SIA documented high levels of support for the proposed CNP, as well as a wide variety of cultural practices, especially with regard to method of delivery, alimentary interdictions, duration of the roasting period, and so on. With respect to nutrition, the consultations highlighted the variations in understandings of nutrition across the communities. Like maternal and child caring practices, the findings emphasized the need for flexibility in the CNP’s nutrition messaging to ensure local relevancy. Page 6 6 Ethnic Group Development Framework 18. The Project is anticipated to have a positive impact on ethnic groups living in the target districts. In most cases, the upland ethnic groups in the project areas are culturally, socially and economically distinct from the lowland groups, and they are vulnerable to becoming disadvantaged in the development process. As a number of implementation details are expected to be finalized during the first phase of project implementation, the government is required to prepare this Ethnic Group Development Framework (EGDF) rather than a more detailed Ethnic Group Development Plan. The purpose of this EGDF is to document the procedures through which the CNP aims to ensure that vulnerable ethnic groups do not suffer adverse impacts of the Project and that they receive benefits in a manner that is culturally appropriate to their particular circumstances as required by the Bank’s safeguards policy on Indigenous Peoples (OP 4.10). The Framework describes measures and institutional arrangements that address the particular needs and circumstances of ethnic groups that are vulnerable to the development process as defined below. 19. Finally, the Framework prescribes a process during project implementation that provides for: · collection of more site specific information on ethnic groups through participatory methods; · the informed participation of all members of ethnic groups covered by this Framework; · procedures for participatory monitoring and evaluation of project activities and their benefits and impacts on ethnic groups; and · complaint mechanisms. Institutional and Implementation Arrangements 20. The project will be coordinated by the Department of Hygiene and Prevention (DHP) in the MOH. The DHP will be responsible for ensuring the CNP is implemented in accordance with this EGDF. 21. Selection of health centers to be included in the project will be partially done by random selection, and partially based on the provincial needs and preferences. 3 Eligibility requirements include that the health centers be located in a poor or poor priority area, where non-Lao ethnic groups tend to be concentrated. Through this geographic targeting, the CNP expects to focus its efforts on including a high proportion of non-Lao. 22. In the case of the community based nutrition program (CBN) component, management will be conducted by the Lao Women’s Union and an NGO will be contracted to develop the detailed design. Given the ethnic diversity of the project area, 3 In order to allow for robust evaluation, 20 health centers will be randomly selected for inclusion. An additional 20 health centers will be selected based on their similarity to the first group, and excluded from participation in the project to act as controls. Provinces will be asked to select an additional 30 health centers for participation from the remaining pool of eligible health centers. Page 7 7 the design and implementation arrangements will have to be sufficiently adaptable to ensure that they are appropriate to diverse contexts. With this objective in mind, the TORs for the NGO will require the contracted party to explicitly identify the differing needs and challenges in the selected communities, and to develop an approach that can be tailored to meet these diverse needs. The NGO will be asked to address these issues in the training material developed under the project. By definition, the groups will follow a participatory model which responds to the needs identified by participants. 23. The Maternal and Child Health Center will be responsible for coordinating the implementation of staff capacity building and the Community-Based Distribution of MNCH supplies. Under capacity building, the CNP intends to introduce supportive supervision in the project-supported health centers. A key strength of supportive supervision is its ability to pick up on a diverse range of service provision challenges in its deviation from a simple collection of statistics, as is commonly done during supervision visits. Supervisors will work with health center staff to identify and address barriers to utilization of services, including a number on the non-financial barriers highlighted by preliminary consultations conducted for the CNP. At the same time, community based distribution has been explicitly designed to address the access barriers faced by very remote communities. Like the CBNs above, the CBD program will rely upon individuals from within the communities being targeted; during the selection process an emphasis will be placed on strong communication skills. 24. It is expected that the CNP will be driven by the needs of the local populations, and the project components have been selected and designed with the intention of maintaining high level of responsiveness. To a large extent, the success of this design in responding to the needs of the non-Lao ethnic groups will depend on the degree to which the CNP successfully targets regions with a concentration on non-Lao, and the degree to which these communities are willing and able to affirm their rights to drive the CNP’s development. Participatory monitoring mechanisms offer one mechanism to enhance accountability. The project will support this goal through the complaint monitoring and conflict resolution mechanisms outlined below. In addition, linked with CNP implementation, the World Bank will undertake qualitative research aimed at informing the Government and other stakeholders on the implementation of the Project. This research will be conducted in consultation with target social groups, and will monitor the satisfaction of project stakeholders with the CNP. In all of this work, attention will be given to non-Lao ethnic groups. Complaint monitoring and conflict resolution mechanisms 25. Complaint mechanisms will be patterned after traditional institutions for conflict resolution. These exist in varying degrees and may differ considerably among the ethnic groups in the project areas. The NGO that is contracted to support design, implementation, and monitoring will also develop project-specific monitoring and accountability mechanisms. 26. Complaints, and/or conflicts may arise with respect to the project as a whole, and health system development activities, in particular. Certain issues, such as the Page 8 8 compliance with national laws, regulations, policies and mandates are to be addressed through legal and regulatory provisions in consultation with traditional institutions. 27. Regarding the project’s implementation procedures, and social safeguards (including ethnic minority issues), complaints will be handled as follows: · As a first stage, affected or concerned persons will present, verbally or in writing, their complaints to provincial project staff or advisors, who will have to provide a documented response to the claimants within fifteen days. Reports on each complaint and subsequent measures taken must be given to the DHP as attachment to regular/monthly reports. · If the claimants are not satisfied with the decision, the case may be submitted to the Department of Hygiene and Prevention in Vientiane, as well as to local authorities (e.g. the Provincial Assembly or the Lao Front). Specified authorities should record receipt of complaints and reply to the claimants within fifteen days. 28. Claimants will be exempted from any administrative or legal charges associated with pursuing complaints. The national project management team must record reports on each complaint and subsequent measures taken. Monitoring and Evaluation 29. The Project will have a monitoring and evaluation system. This will involve participatory approaches through field-based supervision and qualitative studies that will be implemented during project implementation. 30. The Project will commission external evaluations — one at mid-term and one at the end of the Project. These evaluations will include a section on the effectiveness of the ethnic group development strategy. External monitoring of ethnic issues will also be undertaken during the periodic Supervision Missions of the Project. The Lao Front, Institute for Cultural Research or other relevant organizations may also be involved in supervision and M&E activities. Feedback from the regular monitoring and mid-term evaluation will be used to improve the program. A timeline for these consultations is provided at the end of this document. Disclosure Arrangements 31. The borrower makes the EGDF available to the affected communities in an appropriate form, manner, and language. Page 9 9 C I R P C P P R C P A I O C B H N G C B D MNCH  T O C CBN  CBD T H C CCT CBD CCT CBD MNCH  T L C B H N G C F CBN T P Q S MNCH T S S T D H F CBN CBN T Page 10 10 Tentative Consultation Framework for Community Nutrition Project S T C 1 C C P M C F P 2 A H I H ANC  D 3 S (reviewed two times during   4 CCT F E 5 CCT I (Reviewed twice) Month Study # Comments Month 1 Beginning of Project Activities. Expected : September 2010. All dates calculated based on this assumption. Month 2 Month 3 Month 4 1 Child/Mother Caring Practices Month 5 2 ( January 2011) Health Seeking Behavior Month 6 3/4 CBN & CCT (village level) Evaluation Month 7 Month 8 Month 9 Month 10 Month 11 July 2011 Month 12 5 CCT (HC level) Evaluation Month 13 Month 14 Month 15 Month 16 Month 17 January 2012 Month 18 3 CBN Evaluation Month 19 5 CCT (HC level) Evaluation Month 20 Month 21 1 Child/Mother Caring Practices Month 22 Anticipated End of Implementation (June 29, 2012) Month 23 July 2012 Month 24 Month 25 Anticipated Closing (September 30, 2012)