IPP278 v.1 rev. Cambodia - Second Health Sector Support Project (HSSP2) Indigenous Peoples Planning Framework (IPPF)

Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized IPP278 v.1 rev. Cambodia - Second Health Sector Support Project (HSSP2) Indigenous Peoples Planning Framework (IPPF) The Second Health Sector Support Project is expected to have a positive impact on the lives of people throughout Cambodia by improving their access to, and utilization of, effective and efficient health services. Since HSSP2 will be supporting activities nationwide, it will affect ethnic minorities. Accordingly, the project will be prepared and implemented in a manner consistent with World Bank Operational Policy on Indigenous Peoples (OP 4.10). 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 policy requires that a process of free, prior, and informed consultation be undertaken with the affected indigenous peoples communities, and that such consultations establish that there is broad community support for the project. HSSP2 builds on the earlier HSSP project, for which a social assessment was undertaken and for which an Ethnic Minorities Development Strategy (EDMS) was prepared. Though similar in most respects, HSSP2 extends project coverage to predominantly ethnic minority provinces (Mondolkiri and Ratanakiri) previously covered under the program as part of other donors projects. Also, HSSP was prepared under an earlier Bank policy pertaining to indigenous peoples (OD4.20). To ensure compliance with OP 4.10 for HSSP2 a two step consultation process has been designed. The first step of this consultation process was completed during project preparation and the second step will take place during the first year of project implementation. This Indigenous Peoples Planning Framework (IPPF) has been prepared to guide the consultation process. In short, the IPPF will help to identify health care priorities and constraints in ethnic minority communities, and to ensure that the project designs and targets health care improvements that are culturally appropriate and inclusive in both gender and intergenerational terms. The consultations are designed to be consistent with the newer OP 4.10 requirement that consultations be free, prior and informed, and are the method of assessing whether there is broad community support for the project. The Second Health Sector Support Project HSSP2 is intended to support the Royal Government of Cambodia (RGC) Strategic Health Plan, which aims to improve access to, and utilization of, effective and efficient health services. It will improve the health status of the Cambodia population by (a) strengthening primary health care and essential referral services; (b) strengthening health financing and social protection mechanisms for the poor; and (c) strengthening human resources and institutional capacity on the Ministry of Health. The project, nationwide in coverage, will have four components: 1

Component A: Strengthening Health Service Delivery This component will support the consolidated and integrated delivery of essential health services in health centers (Minimum Package of Activities) and referral hospitals (Comprehensive Package of Activities) through (a) the provision of Service Delivery Grants and (b) investments for the improvement, replacement, and extension of the health service delivery network. Component B: Improving Health Financing This component will finance (a) Health Protection for the poor through Health Equity Fund arrangements; and (b) support the development of health financing policies and institutional reforms. Component C: Strengthening Human Resources Performance contracting described under Component A, improved management of user fee income, and institutional reforms driven by the Council of Administrative Reform, will support improving the incentive package at front line health facilities. This component will focus on (a) strengthening pre- and in-service training, (b) strengthening human resource management in the MOH, and (c) the Merit Based Performance Incentive (MBPI) scheme for health managers and key technical staff participating in the implementation of the HSP2 at central and provincial levels. Component D: Strengthening Health System Stewardship Function This component will support to the MOH shift from a hierarchical administration of health services towards a policy, regulatory and oversight institution. As the implementation of HSP2 moves forward, Program support will be available for (a) developing a priority set of policy packages identified in the HSP2; (b) strengthening the institutional arrangements at all levels of the health system national, provincial, and operating districts, including a leadership and management training program; (c) private sector regulation and partnerships; and (d) supporting governance and stewardship functions of the national programs and centers overseeing the three HSP2 strategic programs. Project Impact on Indigenous Peoples Previous studies, including a social assessment undertaken for preparation of HSSP, have shown that ethnic minorities face particular challenges in accessing health services and tend to be particularly vulnerable to poor health. Many minority groups live in roughterrain - highland and border areas that are hard to reach - and are generally poorer than average. The sheer physical geography of these settings pose special challenges, as well as costs, in terms of accessing, providing and maintaining health care services. Geographic isolation coupled with language and cultural barriers, and generally poorer human development indicators, make reaching these groups a particular challenge. RGC recognizes the Hill Tribes and the Khmer Cham as Cambodian minorities. The Hill Tribes are mainly concentrated in the northeastern provinces, where they comprise the majority of the population in both Ratanakiri (66%) and Mondolkiri (75%) and less than 2

10% in the adjoining provinces of Kratie and Stung Treng. The Cham, who speak Khmer, constitute about half of the ethnic minority groups and are widely distributed throughout the country. The Cambodian definition of ethnic minorities does not include Vietnamese, Chinese and other groups who are considered migrants even though they have lived in Cambodia for generations. With a wider definition of ethnic groups also including Cham, Lao, Vietnamese and Chinese, the proportion of ethnic minorities is approximately 6%. Many of the Vietnamese are fishermen living along the rivers and on the Tonle Sap Lake, while artisans and traders are found in all large towns. The hill tribes in Mondolkiri and Ratanakiri are among the poorest groups in the country. 1 Literacy rates in these provinces are less than one third of the national average. Women are even less likely to be literate and speak Khmer. This creates extra barriers for women, who have a high need for reproductive health, birth-spacing and child health services. Furthermore, infant and child mortality are particularly high in the easternmost region of the country. The percentage of infants reported smaller than average is 26.6% in Mondolkiri and Ratanakiri compared to 14.5% for the nation as a whole. 2 In general, health indicators for ethnic minorities are low compared to the rest of the country, although it is difficult to develop an accurate understanding of health status as Cambodia does not collect disaggregated data by ethnicity. Statistics on ethnic groups are scare and mainly based on estimates. 3 Key constraints identified by ethnic minorities in accessing health care include: 4 Poor physical access to health services: Only a third of Cambodians live within 10 km or a two-hour walk of a public health centre. The situation is worse in the remote northeast areas, home to many ethnic minorities, where the population is relatively small but dispersed over a large area. Many minority groups live in remote highland areas with rough-terrain highland which makes both access and provision of health services challenging. Costs are unaffordable: High out of-pocket expenses are for many Cambodians unaffordable and impoverishing. Given that poverty rates tend to be high among ethnic minorities, costs are particularly unaffordable for these groups. As health costs can be large and unforeseen expenses, many families find they do not have enough money to pay for the care they need. 5 Health workers absent from facilities and poor quality services: Absent health workers, limited opening hours and generally poor quality services make health facilities a less desirable option, offering low-value for money and wastes scare household resources. 1 For more information see, Report on the Health Status of Ethnic Minorities in Cambodia. Helen Pickering. DFID Health Systems Resource Centre. 2002. The report was commissioned as input to the design of HSSP1. 2 In-Depth Analysis Report on the 2005 Demographic Health Survey for Cambodia. Kingdom of Cambodia. December 2007. 3 Reproductive Health of Ethnic Groups in the Greater Mekong Sub-region. UNFPA. 2008. 4 Health Sector Support Project. Ethnic Minorities Development Strategy. World Bank. 2002. 5 Study on Ethnic Minorities and Access to Health Care in Kratie Province, Cambodia. Partners for Development. 2002. 3

Health workers are not from local communities: In cases when health workers are not from the local communities, language can become an issue as different ethnic groups speak different languages and thus have a hard time communicating. Also, cultural difference may reduce trust in the health workers and the health workers may have a weak understanding of the communities cultural norms and practices, and vice versa. Lack of participation in health development: Limited indigenous community participation in designing and making decisions about health care, may result in the health care offered not fully reflecting the communities needs, and limit the communities ownership of the health services being offered. In addition, consultations with indigenous peoples communities in Ratanakiri, Mondulkiri and Kratie provinces as part of HSSP2 project preparation identified the following: Maternal and child health are key areas of need. Communicable diseases such as HIV, TB and malaria are areas of concern, and there is a general sense that not enough information is available about these diseases or their prevention. Non-communicable diseases and injuries are also important areas of concern, with a particular emphasis on injuries sustained by men working in mining or commercial logging activities. HSSP2 aims to ensure improved and equitable access to essential health care and preventative services. The Project is national in coverage and the target beneficiaries are mothers, children, and the poor, but the Project is envisioned to improve access to health care for all Cambodians. Given the Project s focus on maternal health, women of reproductive age in particular are expected to benefit from the Project. By extending the health network, the Project is also envisioned to have a positive impact on ethnic minorities who tend to live in remote areas with limited access to services. Project financing will be used to support the development of the health sector in areas that are home to ethnic minorities, including Mondolkiri, Ratanakiri, Stung Treng and Kratie as well as other areas in the country. When non-ethnic minorities live in the same area with ethnic minority, the project should attempt to avoid creating unnecessary inequities between poor and marginal social groups. The table below gives a preliminary picture of how the Project will address key constraints identified in earlier consultations with ethnic minorities. The approach, however, will likely differ in different locations reflecting the particular needs and challenges facing the different ethnic groups (as determined, in part, through the participatory stock-taking exercise to be undertaken in the first year of implementation). Constraints Identified by Ethnic minorities Physical access. Remedial Measures Proposed by Stakeholders Introduction of health posts and/or Project Plans in Mondolkiri, Ratanakiri, Stung Treng and Kratie and other areas where large populations of ethnic minorities live Health posts, and flexibility for health service providers to design appropriate outreach services, this is likely to 4

Costs are unaffordable. Lack of participation in health development. Health workers absent from facilities. Health workers are not from local communities. Poor quality services. Language and cultural barriers mobile services. Ensuring that the poor are not charged. Indigenous community participation in designing and making decisions about primary health care. Strategy to retain health workers in highland areas. Recruiting personnel from local communities. Health workers trained to offer MPA. Strategy to provide culturally appropriate information and services include mobile services (such as motorbike and boat). Access can also be improved by creating a communication network via radio between the Health Center and remote villages in the catchment area. Options under consideration include health service providers will be obliged to either provide completely free services, or introduce equity funds to exempt the poor. The project plans to scale-up equity funds to cover increased proportion of the poor population. Research will form the basis for participatory local health planning and monitoring. In some areas, research on health seeking behavior and local perspectives has already been undertaken (such as Mondolikiri Stung Treng and Rattanakkiri) and the project should utilize this information in project design. In other cases new research may have to be conducted. Health service providers are obligated to foster and support community participation in planning and monitoring service delivery. Frameworks for community participation are already in various stages of operations and the Project should incorporate lessons from this work into Project design. MoH will introduce management and quality improvements, financial incentives for good performance. Project will support nurse and midwife training of indigenous people. Development of a primary nurse and midwife training course tailored to the needs local communities. Targeted recruitment from local communities. Training in specific modules of (Minimum Package of Activities) based on needs assessment. Develop behavior change communication strategies and outreach materials that take into account the specific needs of ethnic minorities. Consider using local translators in health facilities and during outreach activities. Similar to HSSP, two approaches will be taken to address social development issues: targeted assistance and mainstreaming. The project will target primary stakeholders by: (i) strengthening health services in particularly poor and disadvantaged geographical areas to increase access affordability and quality; (ii) introducing social protection measures to safeguard the most vulnerable from the cost of health care; and (iii) supporting national health programs that most benefit the poor and disadvantaged. With regards to mainstreaming, the principles of client-centeredness, pro-poor, social inclusion, gender equality, and stakeholder participation will be mainstreaming through the Project s support to sector reform and institutional development. 5

The project will build particularly on earlier program activities in Mondolkiri and Ratanakiri (which were more intensive than in Kratie and Stung Treng). The project s institutional development activities will strengthen capacity for lesson learning across the sector, and this will be particularly relevant for replicating good practices vis-à-vis ethnic minorities. Social Assessment under HSSP2 A social assessment was conducted for HSSP, informing preparation of the Ethnic Minority Development Strategy. The social assessment has been updated for HSSP2, to reflect modifications to program objectives and procedures, as well as changes in the Cambodian regulatory framework and World Bank policies. The updated social assessment takes into account consultations with Ministry of Health officials, Development Partners and NGOs (such as Medicam); recent analytical work on equity, gender issues and ethnic minorities; evaluations and monitoring of HSSP; and analytical work commissioned for HSSP, including a study analyzing the health situation of ethnic minorities in Cambodia, and a more targeted study of health seeking behaviors and constraints accessing health services of ethnic minority groups in selected areas. Both these studies included consultations with and visits to ethnic minority communities. In addition, consultations with selected indigenous people s communities were undertaken during project preparation. These consultations were free, prior and informed, and demonstrated that broad community support exists for the project. Framework for ensuring free, prior and informed consultation with the affected Indigenous Peoples communities For HSSP2 a two-step consultation process has been designed to ensure compliance with OP 4.10: Step 1: Consultations during project preparation with Indigenous Groups in Cambodia, to ascertain through free, prior and informed consultations that there is broad support for the proposed project among the affected Indigenous Groups; and to identify their views broadly. Step 2: Consultations during the first year of project implementation with Indigenous Groups as part of a participatory stock-taking exercise on the suggested design of HSSP2, in order to obtain information on the particular needs and challenges facing the affected Indigenous Groups, and flag any potential areas where additional support and/or different kind of support may be required. In HSSP2, consultant services will be obtained to conduct consultations. Under terms of reference acceptable to RGC and the Bank, the consultants will establish consultation procedures to be followed, ensuring that consultations are to be conducted in a place, time and manner accessible to minority communities, that all minority groupings are included in the consultation process, and that environment for consultations is conducive to open and frank discussion, without outside intervention or intimidation. The consultation process should establish that affected minority communities: broadly support project objectives; 6

are aware of project benefits, and believe them to be culturally appropriate; have had sufficient opportunity to identify their preferences and constraints, as relate to health care; and have sufficient opportunity to have their preferences and constraints considered as a result of the broader stock-taking exercise. Consultations with Indigenous Peoples during project preparation: For the first step of the consultative process, consultations ascertained that there is broad community support for the proposed Second Health Sector Support Program. Free, prior and informed consultations were undertaken with indigenous peoples communities in Ratanakiri, Mondulkiri and Kratie. Consultations took place in eight different villages within the three target provinces, with consultations were conducted through focus group discussions (FGDs) with a small sample of indigenous peoples; the Bunong in Mondulkiri; Jarai, Tampoeun and Kreung in Ratanakiri; and the Muslim Cham in Kratie. FGDs were conducted in single sex groups (to encourage free and open discussion) of no more than 12 participants per group. In total there were 156 respondents (77 men and 79 women). Respondents were selected through a combination of random and purposive sampling to gain a wider range of perspectives. All groups included at least one community member who was either a member of the Village Health Support Group (VHSG) or a village health volunteer. Group discussion was an appropriate method as it stimulated the sharing and debate of ideas and views regarding the proposed project. The broad objectives and specific health-related goals of the HSSP2 were explained to respondents, and all participants expressed general support for the project. A summary of the consultation is attached. Institutional Arrangements for IPPF The project s institutional development activities will strengthen capacity for lesson learning across the sector, and this will be particularly relevant for replicating good practices vis-à-vis ethnic minorities. Integrated into the institutional development and capacity building activities of the project are measures to enhance attention to, and the inclusion of ethnic minority concerns. The mainstreaming of safeguards across the sector is necessary to support the targeted interventions in the four northeastern provinces, but also to capture and respond to the interests of vulnerable ethnic minorities living in other parts of the country. Pathways for mainstreaming are: (a) (b) (c) (d) (e) Strengthening the social assessment capacity of the MOH; Improving delivery of appropriate targeted information and behavior change communication; Local ethnic minority participation in designing and monitoring health development plans; Monitoring, evaluation and the annual sector review process; and Human resource development. 7

Language differences are a significant barrier to health care access for ethnic minorities. Lack of information and educational materials in the languages of ethnic minorities is a major constraint to health education and promotion. The project will through its support for key national programs 6 ensure that behavior change communication (BCC) strategies and materials take into account the specific needs of ethnic minorities and communication approaches and materials are developed that are appropriate for the needs of target minority groups. This will require increased understanding of the health beliefs that influence ethnic minorities in order to design appropriate materials. NGOs are already using a range of BCC approaches and materials in their work with ethnic minorities, and this is an important resource that needs to be better used by MOH. Where appropriate, consideration will need to be given by MOH and Provincial Health Departments to sanctioning the use of local translators in health facilities and during outreach activities. Participation of ethnic minority communities will be encouraged through the development of more participatory planning and monitoring processes at local, district, provincial and the national level. The project will support the MOH s efforts to strengthen the planning process to be more responsive and participatory. This will include strengthening the participation of a diverse range of the community, including ethnic minorities, and undertaking an analysis of the health situation and needs of the catchment population at the local level. NGO participatory planning experience is valuable and provides examples of workable methodologies in Cambodia that could be adapted and scaled up. The presence of NGOs in particularly disadvantaged areas working with difficult to reach social groups, such as ethnic minorities is also a resource for local health managers. MOH is committed to increasing the participation of all sections of society in monitoring services as a means of enhancing public accountability. The project will support this objective by undertaking research to inform the design of participation mechanisms, developing mechanisms in consultation with target social groups, and monitoring the effectiveness of different forms of consumer participation. In all of this work, attention will be given to ethnic minority groups and communities. In the four northeastern provinces, participatory approaches are likely to take different forms than in the rest of the country where ethnic minority populations are less concentrated. To raise the profile of ethnic minorities in planning and monitoring processes throughout the country, the planning and monitoring frameworks will include specific questions on ethnic minorities, training to implement the revised methods will include attention to the health of ethnic groups and methods to promote their inclusion, and guidelines for establishing consumer participation will include representatives of ethnic minorities where they are present in the local population. 6 National Programs include: Maternal and Child Health Program, including reproductive health, immunization, child health and newborn care, and nutrition; Communicable Disease Program, including HIV/AIDS, tuberculosis, and malaria; and Non-communicable Diseases Prevention Program. 8

Monitoring and reporting arrangements The project will assist the Ministry of Health reform sector wide monitoring and evaluation to include civil society participation in the process, and to address social variables such as ethnicity and gender. As part of project mid-term review and final evaluation, social issues (including social safeguard issues such as indigenous peoples and resettlement) should be reflected. Annual reviews of sector performance should aim to disaggregate achievements in accessibility, public and client satisfaction, and health utilization by ethnicity, as well as by gender, as this would significantly increase knowledge on the health and access to health care of ethnic minorities. The Project will support capacity building within the MOH to better gather, analyze and use data disaggregated by sex and ethnicity. Disclosure arrangements The borrowers makes the social assessment report and draft IPPF available to the affected Indigenous People s communities in an appropriate form, manner, and language. Before project appraisal, the borrower sends the social assessment and draft IPPF to the World Bank for review. Once the World Bank accepts the documents as providing an adequate basis for project appraisal, the World Bank makes them available to the public in accordance with the World Bank Policy on Disclosure of Information, and the borrowers makes them available to the affected Indigenous People s communities in the same manner as the earlier draft documents. 9