The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) Integrated Safeguards Data Sheet Restructuring Stage Restructuring Stage | Date ISDS Prepared/Updated: 1-May-2019| Report No: ISDSR25124 Regional Vice President: Axel van Trotsenburg Country Director: Yaye Seynabou Sakho Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Daniel Dulitzky Task Team Leader: Eleonora Del Valle Cavagnero The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. . I. BASIC INFORMATION 1. BASIC PROJECT DATA Project ID Project Name P159213 Crecer Sano: Guatemala Nutrition and Health Project Task Team Leader(s) Country Eleonora Del Valle Cavagnero Guatemala Approval Date Environmental Category 24-Mar-2017 Partial Assessment (B) Managing Unit Is this a Repeater project? GHN04 PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 109.00 Total Financing 109.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 100.00 Non-World Bank Group Financing Trust Funds 9.00 Global Financing Facility 9.00 2. PROJECT INFORMATION The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) Current Project Development Objective The Project Development Objective (PDO) is to improve selected practices, services and behaviors known to be key determinants of chronic malnutrition (with an emphasis on the first 1,000 days of life) in the intervention areas. . PROJECT DESCRIPTION The proposed Project will finance three Components to be implemented over five years. Component 1. Providing Inter-sectoral Services to Address Chronic Malnutrition Risk Factors (US$ 81.00 Million – Bank financing) This Component will support provision of quality nutrition and health services to mothers and children; promotion of behavioral change interventions targeted to families and communities; improving access to safe drinking water and sanitation; and enhancing coordination across sectors. It will finance works for health posts, small water supply and sanitation systems, and select community centers, as well as equipment, medical and nonmedical supplies, health promotion activities, technical assistance, studies and training. Component 2. Moving the Focus towards Results (US$ 14.75 million – Bank financing) This Component will introduce results-based financing to: (i) promote the use of health services, including timely prenatal care; (ii) promote behavioral changes, including exclusive breastfeeding during the first six (6) months of life; and (iii) strengthen the Conditional Cash Transfer Program in the intervention areas. Component 3. Supporting Project Management, Monitoring and Evaluation (US$ 4 million – Bank financing) This Component will provide support to the Ministerio de Salud Publica y Asistencia Social (MSPAS), for the carrying out of Project management, coordination and evaluation. It will finance consulting services including consultants to support MSPAS, office equipment, training, and operating costs, and an external entity to evaluate achievement of the Disbursement Linked Indicators. . 1. PROJECT LOCATION AND SALIENT PHYSICAL CHARACTERISTICS RELEVANT TO THE SAFEGUARD ANALYSIS (IF KNOWN) The Project will finance investments and activities in an estimated 138 municipalities in seven prioritized departments. The first phase will include 81 municipalities from Alta Verapaz (17 municipalities), Huehuetenango (32 municipalities), Quiché (21 municipalities), and Chiquimula (11 municipalities). The second phase, estimated to start during year two of implementation, will include: San Marcos (30 municipalities), Totonicapán (8 municipalities), and Sololá (19 municipalities). The PHC package will be offered simultaneously in all of the seven departments. All of the targeted municipalities have Indigenous populations that meet the four criteria of OP/BP 4.10, and four of the seven have the largest percentage of The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) Indigenous populations in the country, i.e., Totonicapán (97.8%), Sololá (96.5%), Alta Verapaz (89.7%), and Quiché (88.6%). The Indigenous populations of the other beneficiary departments are: Huehuetenango 57.5%, San Marcos 30.3%, and Chiquimula 7.10%. The Social Cultural Assessment documented important differences between departments and linguistic families in regards to capacity to communicate in native languages and Spanish, literacy, extreme poverty, fertility rates, and maternal mortality that should be taken into account when designing project interventions. For example, only 56% of Indigenous women are literate in Spanish compared to 77.7% of Indigenous men. Women´s education levels and chronic malnutrition appear to have a strong correlation as 69.3% of illiterate women are chronically malnourished whereas that rate drops to only 20.1% among women with secondary education. In regards to linguistic and literacy tendencies, in Alta Verapaz 51.8% of Q’eqchi’ are monolingual in their native language and literacy rates in Q’eqchi’ are 28.5% whereas only 17.3% of Mam are monolingual (and thus a significant portion also speak Spanish) and literacy rates in this native language fall to 6.9%. These differences are important to take into account when designing communications tools and strategies to ensure the most effective use of linguistic and written materials. It was also found that being Indigenous is not necessarily a determining factor for fertility rates, as both Alta Verapaz and Chiquimula have fertility rates of 3.9 vs. the 3.7 average for rural Guatemala, despite the fact that Alta Verapaz is predominantly Indigenous and Chiquimula has a small Indigenous population. 2. ENVIRONMENTAL AND SOCIAL SAFEGUARDS SPECIALISTS ON THE TEAM Erin Conner, Environmental Specialist Dianna M. Pizarro, Social Specialist Fabiola Maria Lucia Mercado Jaldin, Environmental Specialist SAFEGUARD_TABLE 3. SAFEGUARD POLICIES TRIGGERED Safeguard Policies Triggered Explanation The Project is classified as Category B. The potential environmental impacts associated with the type and size of works are expected to be relatively minor to moderate, and will not involve significant impacts, and the potential negative impacts would be managed appropriately. An Environmental and Social Management Framework (ESMF) was prepared to manage the potential associated Environmental Assessment (OP) (BP 4.01) Yes environmental impacts and risks related to the types of works to be financed under Project Sub- component 1 (works to rehabilitate and build some new health posts (“puestos de salud�) as well as rehabilitate a few community centers; medical equipment; medical and non-medical supplies; technical assistance and training; some equipment for secondary level health facilities that would The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) contribute to build health networks), Sub- component 3 (design and implementation of water supply and sanitation subprojects in rural communities in the prioritized areas), and Component 2 (co-finance the Government strategy through disbursements linked to eligible expenditures and specific results defined in relation to results chain (Disbursement-linked Indicators – DLI). The Project will be highly participatory in nature, building on the successes of the Inclusive Health Model that supports complementarity between traditional and official health systems, intervening at individual, family and community levels. The ESMF includes a grievance redress mechanism to ensure adequate and reiterative information, communication channels and a system to address complaints in a transparent, efficient, and confidential manner. The ESMF also includes screening criteria to identify and avoid any potential cases of land acquisition that would generate involuntary resettlement impacts per OP/BP 4.12. Performance Standards for Private Sector No Activities OP/BP 4.03 The Project does not contemplate rehabilitation or Natural Habitats (OP) (BP 4.04) No new works in areas of natural habitats or that would significantly impact natural habitats. The Project will not finance activities in forests or Forests (OP) (BP 4.36) No that could potentially affect forest resources or their management. The Project will not finance activities involving the use of pesticides nor will it promote and is not Pest Management (OP 4.09) No expected to lead to an increase in the use of pesticides (e.g. for mosquito control). Due to Project scope in water and sanitation projects in rural areas, there might be a possibility Physical Cultural Resources (OP) (BP 4.11) Yes of chance findings that will be managed via the ESMF. The Project will finance activities and investments that benefit, almost in the majority, Indigenous communities that meet the four criteria of OP/BP 4.10. Given this, the Project is considered an Indigenous Peoples (OP) (BP 4.10) Yes Indigenous Peoples project and all requirements of this Policy was complied with through Project preparation and will continue during implementation, guided by the PAD and Project The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) Operations Manual. A sociocultural assessment was carried out to inform project design that included consultation processes at a departmental and national level. Based on the results of the sociocultural assessment and consultation process, specific Project actions and provisions for community level participation and to ensure broad community support in relevant project decisions have been incorporated into the Operations Manual. The Inclusive Health delivery model works directly with communities to diagnose and treat health issues and attend to community concerns and priorities. The entire Project will engage at the community level to increase knowledge and awareness among expected beneficiaries and promote access to services through the COCODES and COMUDES. Project-related grievances will be handled in accordance with the GRM outlined in the ESMF. During Project preparation it was determined that no investments will be supported that could introduce involuntary resettlement impacts per this Policy. The ESMF includes screening criteria to Involuntary Resettlement (OP) (BP 4.12) No avoid the involuntary taking of land and that if usage or acquisition rights are attained for health posts or WSS infrastructure, these are fully voluntary in nature by the individual or community granting or transferring the rights. The Project will neither support the construction or rehabilitation of dams nor will it support other Safety of Dams (OP) (BP 4.37) No investments which rely on services of existing dams. Given the limited amounts of water to be abstracted and the localized nature of the sources, the Task Team has concluded that while the activities financed under project consist of additions or alterations of the ongoing scheme, they: (i) will not adversely change the quality or Projects on International Waterways (OP) Yes quantity of water flows to the other riparian; and (BP 7.50) (ii) will not be adversely affected by the other riparian possible water use. An exception to the riparian notification requirement was granted on November 7, 2016, on the basis that while the activities financed under the Project consists of additions and alterations to The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) an ongoing scheme, they will not affect point i and ii mentioned above. The Project will not finance activities in disputed Projects in Disputed Areas (OP) (BP 7.60) No areas as defined in the policy. KEY_POLICY_TABLE I. KEY SAFEGUARD POLICY ISSUES AND THEIR MANAGEMENT A. SUMMARY OF KEY SAFEGUARD ISSUES 1. Describe any safeguard issues and impacts associated with the Restructured project. Identify and describe any potential large scale, significant and/or irreversible impacts. Environment: Guatemala’s environmental and health legislation and associated regulatory instruments are quite extensive. The government’s capacity to enforce compliance however, is limited. Weak institutional capacity will require project support to strengthen implementation. The potential environmental impacts associated with the type and size of works are anticipated to be relatively minor to moderate, and will not involve significant impacts, and with appropriate standard mitigation measures the potential negative impacts would be managed appropriately. Social: The majority of the Project’s beneficiaries are Indigenous peoples. Given this, and the fact that the Primary Health Care (PHC) Inclusive Health Model to be supported by the Project builds fully on Indigenous health systems and community driven models, for the purpose of OP/BP 4.10, the Project is considered an Indigenous Peoples Project. The Project does not introduce any potential large scale, significant and/or irreversible impacts. Potential social safeguards risks for this Project include the exclusion of Indigenous populations, the delivery of health care systems that are culturally insensitive or undermine traditional beliefs and practices, and/or discrimination or poor treatment of Indigenous populations in health posts or centers supported by the Project. Whereas historically, all of these risks have been present in the delivery of PHC in Guatemala, in the case of this Project, indigenous populations will be among the predominant beneficiaries due to the ethnic make-up of the targeted departments. At the same time, the Government’s new Strategy to combat Chronic Malnutrition and the proposed PHC model for builds on a highly successful intercultural model for health care delivery. This model builds complementarity between traditional Indigenous systems and concepts of health and illness and western “official� systems, strengthening and building complimentary, mutual understanding and referral systems between official and traditional health service providers. In addition, traditional health service providers, such as midwives or "comadronas" and traditional healers and specialists are integrated into the health delivery system, fully recognizing their knowledge, importance and role within their communities and as service providers. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area. Environment: The Project’s anticipated activities are relatively minor and are not expected to have any indirect and/or long term impacts. In fact, the Project’s interventions are expected to improve environmental management both of health posts and rural water supply and sanitation systems through the application of Guatemala’s extensive environmental legislation and regulatory instruments together with other Project supported activities such as capacity building, occupational health and safety training and environmental education. Social: There are no potential indirect or long term impacts due to anticipated future activities in the Project area that would raise safeguards concerns. The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) 3. Describe any potential alternatives (if relevant) considered to help avoid or minimize adverse impacts. Environment: N/A Social: The primary Project alternative considered was the extent to which the Inclusive Health Model could be escalated and adopted within the Government’s primary health care delivery model. The original proposal for Project design was to only include some aspects of the Model due to budgetary limitations and compliment as necessary with the IPPF. After further consideration the Ministry of Public Health and Social Assistance has decided to escalate the full model by reducing costs through eliminating some actors on the extramural teams so that the extramural service will be focused solely on the nursing assistants working integrally within the communities and with the traditional health service providers to ensure the full application of the Model. With this change it was decided that the Project could be considered an Indigenous Peoples Project as it will implement the actions requested and recommended through the Sociocultural Assessment and participatory processes. The specific decision points and key issues for implementation that were requested through the participatory processes with Indigenous leaders and representatives have now been integrated into the Project´s Operations Manual and a separate IPPF or preparation of IPPs is not necessary. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. Environment: The two main government counterparts are the MSPAS and the Ministry of Environment. The first as the implementing agency and main recipient of project funds and the second as an important partner in guaranteeing compliance with environmental legislation. The Government undertook an extensive review of Guatemala’s environmental and health legislation and regulatory instruments as they pertain to the Project. These were found to comply with the requisites of the World Bank’s safeguards policies. Health service providers targeted under the Project will implement the MSPAS guidelines for health care waste management, storage and disposal system to adequately accommodate any additional waste that would occur as a result of the expanded coverage. Where sufficient capacity does not exist, the Project will finance activities as needed to ensure adequate disposal of all health care waste related to the Project. Equally, the Government will ensure that water supply and sanitation systems supported by the Project will be done in accordance with current legislation and Bank policies thus minimizing any potential environmental impact. The MSPAS will have a professional responsible for coordinating the environmental issues. This Project is considered an Indigenous Peoples project as the overwhelming majority of direct beneficiaries are Indigenous. A sociocultural assessment (SA) was carried out to inform Project design that included consultation processes at a departmental and national level. Based on the results of the SA and consultation process, specific Project actions and provisions for community level participation in relevant Project decisions have been incorporated into the Operations Manual. MSPAS will hire a social specialist to supervise implementation of these actions and provisions, elaborate and implement a culturally appropriate communications strategy, and to ensure any concerns or issues that arise during Project implementation at a community level are adequately addressed. The SA included: (i) a stakeholder mapping at both the national and departmental levels for the first four participating departments; (ii) interviews with key stakeholders at a national, departmental and community level, including government actors, NGOs, and Indigenous organizations; (iii) focus groups in 12 municipalities from the four departments prioritized under the first phase, with Indigenous leaders - traditional health care providers, youth and The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) Indigenous women; and (iv) a desk analysis of barriers to access, and both unsuccessful and successful past experiences in reducing chronic malnutrition, infant mortality, maternal mortality, and increasing adoption of family planning methods. The full SA was published on the Bank’s, MSPAS, MIDES,and SESAN’s websites. 5. Identify the key stakeholders and describe the mechanism for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Key stakeholders include beneficiary communities in the seven departments where the Project will be implemented, local and Indigenous community leaders, health personnel working at health posts and centers, extramural nurse assistants, midwives, and other Mayan healers and specialists. These stakeholders participate and are represented in the Community Development Councils and Municipal Development Councils where key project decisions will be made. The MOP requires a revision of the legitimacy of these Councils and, in cases where Indigenous authorities are not adequately represented, additional measures should be taken to ensure their voice in key Project decisions. Given this restructuring, the ESMF has been revised, as part of the implementation phase, to include MSPAS as implementing agency. The revised ESMF was disclosed on the MSPAS’s and on the World Bank's websites on April 26, 2019. DISCLOSURE_TABLE B. DISCLOSURE REQUIREMENTS ENV_TABLE Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank Date of submission for disclosure 25-Apr-2019 26-Apr-2019 For Category ‘A’ projects, date of distributing the Executive Summary of the EA to the Executive Directors “In country� Disclosure Country Date of Disclosure Guatemala 26-Apr-2019 Comments https://www.mspas.gob.gt/images/files/proyectos/crecersano/PROYECTOCRECERSANO.pdf INDIG ENOUS_TA BLE Indigenous Peoples Development Plan/Framework Date of receipt by the Bank Date of submission for disclosure The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) 05-Sep-2016 04-Nov-2016 “In country� Disclosure Country Date of Disclosure Guatemala 27-Oct-2016 Comments COMPLIANCE_TABLE C. COMPLIANCE MONITORING INDICATORS AT THE CORPORATE LEVEL EA_TABLE OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? Yes If yes, then did the Regional Environment Unit or Practice Manager (PM) review Yes and approve the EA report? Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes PCR_TABLE OP/BP 4.11 - Physical Cultural Resources Does the EA include adequate measures related to cultural property? Yes Does the credit/loan incorporate mechanisms to mitigate the potential adverse Yes impacts on cultural property? IP_TABLE OP/BP 4.10 - Indigenous Peoples Has a separate Indigenous Peoples Plan/Planning Framework (as appropriate) Yes been prepared in consultation with affected Indigenous Peoples? If yes, then did the Regional unit responsible for safeguards or Practice Manager Yes review the plan? If the whole project is designed to benefit IP, has the design been reviewed and Yes approved by the Regional Social Development Unit or Practice Manager? PIW_TABLE OP 7.50 - Projects on International Waterways The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213) Have the other riparians been notified of the project? No If the project falls under one of the exceptions to the notification requirement, has this been cleared with the Legal Department, and the memo to the RVP Yes prepared and sent? Has the RVP approved such an exception? Yes PDI_TABLE The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank for Yes disclosure? Have relevant documents been disclosed in-country in a public place in a form and language that are understandable and accessible to project-affected groups Yes and local NGOs? ALL_TABLE All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been Yes prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included in the project Yes cost? Does the Monitoring and Evaluation system of the project include the monitoring Yes of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed with the borrower Yes and the same been adequately reflected in the project legal documents? II. APPROVALS Eleonora Del Valle Cavagnero Task Team Leader(s) Marco Antonio Aguero Approved By Practice Manager/Manager Christel Vermeersch 03-May-2019 . The World Bank RESTRUCTURING ISDS Crecer Sano: Guatemala Nutrition and Health Project (P159213)