Document of The World Bank

FOR OFFICIAL USE ONLY Public Disclosure Authorized Report No: 34315-GT

PROJECT APPRAISAL DOCUMENT

ON A Public Disclosure Authorized PROPOSED LOAN

IN THE AMOUNT OF US$49.0 MILLION

TO THE

REPUBLIC OF GUATEMALA

FOR A

MATERNAL-INFANT HEALTH AND NUTRITION PROJECT Public Disclosure Authorized December 15,2005

Human Development Sector Management Unit Central America Country Management Unit Latin America and the Caribbean Region

This document has a restricted distribution and may be used by recipients only in the Public Disclosure Authorized performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS

(Exchange Rate Effective 11/28/05)

Currency Unit = Guatemalan Quetzales (GTQ) US$l.OO = 7.63 GTQ FISCAL YEAR January 1 - December 31

ABBREVIATIONS AND ACRONYMS

AINM-C Community Integrated Care for Children and Women (Atencio'n Integral a la Nifiez y Mujer - Comunitario) ARI Acute Respiratory Infection CAIMIs Maternal and Infant Integral Health Care Centers (Centros de Atencidn Integral Materno Znfan ti 1) CAS Country Assistance Strategy CETC Communication, Education and Training at Community level Strategy DHS Demographic Health Surveys DPL Development Policy Loan FG Focus Groups GDP Gross Domestic Product GNI Gross Net Income GNP Gross National Product GOG Government of Guatemala GSR Government Social Policy (Guate Solidaria Rural) HCW Health Care Waste HIV/AIDS Human Immune-Deficiency Virus/AIDS IBRD International Bank for Reconstruction and Development IDA International DeveloDment Association IDB Inter-American Development Bank INE National Institute of Statistics (Znstituto Nacional de Estadisticas) LAC Latin American and the Caribbean Region M&E Monitoring and Evaluation MAGA Ministry of Agriculture (Ministerio de Agricultura, Ganaderia y Alimentacidn) MDGs MillenniumDevelopment Goals MSPAS Ministry of Public Health and Social Welfare (Ministerio de Salud Phblica y Asistencia Social) NGOs Non-Governmental Organizations PCU Proiect Coordination Unit PEC Program for the Extension of Coverage PHRD Japan Policy and Human Resources Development Fund POAs Annual Operational Plan (Plan Operativo Anual) SEGEPLAN Secretariat of Programming and Planning (Secretaria de Planijicacidn y Programacidn de la Presidencia) SESAN Secretariat of Food and Nutritional Security (Secretaria de Seguridad Alimentaria y Nutricional i 1 STAS I Directorate of Internal Health Svstem fDireccidn Sistema Integral de Atencidn en Salud) I -sIL Specific Investment Loan SOE Statement of Expenditures SOSEP Social Work Secretariat of the President’s Wife (Secretaria Obra Social Esposa del Presidente) STIs Sexually Transmitted Infections TBAs Traditional Birth Attendants UCPYP Project and Program Coordination Unit (Unidad Coordinadora de Programas y Proyectos) UPS1 Primary Level Service Provision Unit (Unidad de Provisidn de Sewicio de Primer Nivel) UPS2 Secondary Level Service Provision Unit (Unidad de Provisidn de Sewicio de Segundo Nivel)

Vice President: Pamela Cox Country Director: Jane Armitage Sector Director: Evangeline Javier Sector Manager: Keith Hansen Sector Leader: Laura Rawlings rTask Team Leaders: Marcelo Bortman FOR OFFICIAL USE ONLY This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization.

GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

CONTENTS Page No. A . STRATEGIC CONTEXT AND RATIONALE ...... 1 1. Country and sector issues ...... 1 2 . Rationale for Bank involvement ...... 3 3 . Higher level objectives to which the project contributes ...... 4 B. PROJECT DESCRIPTION...... 5 1. Lending instrument ...... 5 2 . Project development objective and key indicators ...... 6 3 . Project components ...... 6 4 . Lessons learned and reflected in the project design ...... 10 5 . Project Alternatives considered and reasons for rejection...... 14 C. IMPLEMENTATION ...... 16 1. Partnership arrangements ...... 16 2 . Institutional and implementation arrangements ...... 16 3 . Monitoring and evaluation of outcomes/results ...... 17 4 . Sustainability ...... 19 5 . Critical risks and possible controversial aspects ...... 19 .. 6 . Loan condltlons and covenants ...... 20 D. APPRAISAL SUMMARY ...... 21 1. Economic and financial analyses ...... 21 2 . Technical ...... 23 3 . Fiduciary ...... 24 4 . Social ...... 24 5 . Environment ...... 24 6 . Safeguard policies ...... 25 7 . Policy Exceptions and Readiness ...... 25 Annex 1: Country and Sector or Program Background ...... 26 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies ...... 37 Annex 3: Results Framework and Monitoring ...... 40 Annex 4: Detailed Project Description ...... 43 Annex 5: Project Costs ...... 58 Annex 6: Implementation Arrangements ...... 61 Annex 7: Financial Management and Disbursement Arrangements ...... 66 Annex 8: Procurement Arrangements ...... 70 Annex 9: Economic and Financial Analysis ...... 75 Annex 10: Safeguard Policy Issues: Environmental and Social Assesments ...... 82 Annex 11: Project Preparation and Supervision ...... 98 Annex 12: Documents in the Project File ...... 99 Annex 13: Statement of Loans and Credits ...... 101 Annex 14: Country at a Glance ...... 102 Annex 15: Map IBRD 33413 ...... 104 GUATEMALA

GUATEMALA MATERNAL- INFANT HEALTH AND NUTRITION

PROJECT APPRAISAL DOCUMENT

LATIN AMERICA AND CARIBBEAN

LCSHH

Date: December 14,2005 Team Leader: Carlos Marcel0 Bortman Country Director: Jane Armitage Sectors: Health (75%);0ther social services Sector ManagerDirector: Keith E. Hansen (25%) Themes: Child health (P);Nutrition and food security (P);Other human development (S) Project ID: PO77756 Environmental screening category: Partial Assessment

For LoandCredits/O thers : Total Bank financing (US$m.): 49.00

DEVELOPMENT Total: 44.40 4.60 49.00 I Borrower: Republic of Guatemala

Responsible Agency: Ministry of Public Health and Social Welfare - Guatemala Ing. Marco Tulio Sosa Ramirez Minister 6a. Ave. 3-45, Zona 11, Escuela de Enfermeria, 3er Nivel, Ciudad de Guatemala, Guatemala.

Phone: 502-2440-0516 Fax: 502-2475-1 125 Email: despachoministerial @mspas.gob.gt innual 17.72 11.08 11.02 5.56 3.62 0.00 0.00 0.00 0.00 3umulative 17.72 28.80 39.82 45.38 49.00 0.00 0.00 0.00 0.00

Ref. PAD A.3 No Does the project require any exceptions from Bank policies? Ref. PAD 0.7 [ ]Yes [XINO Have these been approved by Bank management? [ ]Yes [XINO Is approval for any policy exception sought from the Board? [ ]Yes [XINO Does the project include any critical risks rated “substantial” or “high”? [X]Yes[ ]No Ref. PAD C.5 Does the project meet the Regional criteria for readiness for implementation? [XIYes [ ]No Ref. PAD 0.7 Project development objective Ref. PAD B.2, Technical Annex 3 The proposed Project aims to: (a) improve maternal and infant health in the project’s 40 areas of intervention; and (b) reduce chronic malnutrition among children younger than 2 years of age in the rural areas of the 70 municipalities targeted by the project. Project description [one-sentence summary of each component] Ref. PAD B.3.a, Technical Annex 4 The proposed Project (IBRD US$49 million) has four components and will be implemented over a five-year period. The project will be complemented with US$13.3 million provided by the Government of Guatemala to support the operations of the CAIMIs during the project life. -Component 1. Strengthening of the Maternal and Infant Health Network (US$22.8 million). This component would support the development of a Maternal and Infant Health Referral Network, promote the demand for maternal and infant health care, and contribute to increase the proportion of safe institutional deliveries, the referral of obstetric emergencies directly from the community, and access to a referral system for children with acute respiratory and digestive diseases. This component is divided into three sub-components: (i)Maternal and Infant Health Promotion from the community; (ii)Strengthening capacity of the secondary Health level; and (iii)Strengthening the referral system. -Component 2. Nutrition - Implementation of the AINM-C and “Creciendo Bien” Strategy (US$21.9 million). This component aims to address the problem of child malnutrition in the selected 70 municipalities by expanding coverage of community-based growth promotion and basic health services. In addition, this component will expand community-based capacity-strengthening of mothers and families in the most vulnerable and indigenous communities. In a country like Guatemala, where half of the children are chronically malnourished and where acute malnutrition is relatively low, concerted actions are needed in the areas of health, access to basic services, education, and specific nutritional interventions. Moreover, in order to tackle the issue of malnutrition seriously in a country where, on average, 70 percent of indigenous children are malnourished, one needs to ensure that special attention is given to indigenous communities. A successful approach to preventing malnutrition therefore needs to focus on the most vulnerable population and consider two issues: i)ensure that demand for services is generated; ii)make sure that those targeted can best respond to intervention. This component consists of three sub- components: (1) Strengthening the basic AINM-C package of services; (2) Extending the Creciendo Bien Program in the most vulnerable communities; (3) Supervision of nutrition activities. -Component 3. Communication, Monitoring, Evaluation and Continuous Auditing Systems ($2.4 million). This component seeks to: (i)provide support to poor families to learn about nutrition and health programs, encourage poor and indigenous population to utilize health and nutrition services, promote pattern behavior, disseminate population’s right to utilize services, and encourage social audit; (ii)design and implement a comprehensive monitoring and evaluation system for the nutrition and health interventions; and (iii)measure Project’s impact on targeted population welfare. In accomplishing these objectives, the component comprises three sub-components: A Communication Strategy, a Monitoring and Evaluation System, and the Impact Evaluation of the Project. -Component 4. Institutional Strengthening ($1.7 million). The Project, through this component, will support the institutional capacity of the Ministry of Health to implement and administer basic health and nutrition services. In particular, the project will support the UCPYP and the SIAS consultant services to provide technical assistance and equipment, for an approximate amount of $1.4 million. Apart from that, the Project will support the recently created SESAN to consolidate its institutional structure. Equally, the Project will provide the Secretariat with consultant services, equipment, and workshops and training, for approximate ($0.3 million). Which safeguard policies are triggered, if any? Ref. PAD D.6, Technical Annex IO The Project triggers two Safeguard policies: (i) Environmental: the more relevant environmental issue resulting from the implementation of Component 1 is the increase in the production of Health Care Waste. The government has a regulatory framework pertaining to the disposal of Hospital Solid Waste, which the environmental assessment prepared for this project found adequate, provided that MSPAS improves its control capacity (Le., meeting the staffing needs of the office in charge of monitoring. This regulatory framework, reducing personnel rotation, and ensuring the availability of equipment for supervision. (ii) Indigenous people: The Project’s targeted population is mainly indigenous. The Project prepared an Indigenous Peoples Plan, whose main recommendations are included in the PAD, and its specific activities were included in the Manual of Operations discussed and approved during negotiations.

Significant, non-standard conditions, if any, for: Ref. PAD C.7 Board presentation: Board presentation is scheduled for January 19, 2006.

Loadcredit effectiveness: Estimated date: June 15, 2006.

Covenants applicable to project implementation: NIA.

A. STRATEGIC CONTEXT AND RATIONALE

1. Country and sector issues

Guatemala needs to invest in the development of the human capital of its poor population to achieve sustained economic growth and reduce chronic poverty.’ Despite important progress in the social sectors over the last decade, Guatemala’s human development indicators still lag well behind other countries’ in the region. This gap is particularly problematic in certain areas where expected progress has not been sustained in the last few years. Maternal and infant mortality rates and particularly chronic malnutrition are among the highest in the world, and much higher than expected given Guatemala’s per capita income (Figure 1). Fifty-six percent of the malnourished children of Central America live in Guatemala. Together with poor schooling, these problems constitute severe constraints for human capital accumulation and the achievement of key Millennium Development Goals (MDGs) in the country.2 Chronic malnutrition and the poor health status of young children cause irreversible losses of human capital formation, affecting current and future generations and underminingeconomic growth.

Figure 1. Prevalence of Child Malnutrition and Maternal Mortalitv in Guatemala and LAC

50

45 5 40 3.. 0 35 -f 30 & 25 8 20 ,$ 15 f

10 E 5t

0 GU N1 HO ES CR PA MX LAC LAC Countrks

Sources: WDI; Guatemala, ENSMI 2002; CIEN

Improving the nutritional and health status of infants, young children, and pregnant mothers constitutes the starting point to overcoming one of the major obstacles in the chain of human capital accumulation and to breaking the intergenerational transmission of poverty. Government efforts to increase human capital should focus on tackling chronic malnutrition and promoting maternal and infant care among the most underserved families. Rural residents and indigenous communities, where poverty incidence is over 75 percent, are particularly vulnerable. Most of the improvements in health indicators in recent years have disproportionately benefited the non-indigenous population. Between 1987 and 2002, the rate of decline in the infant mortality rate among the non-indigenous has been four times faster than among the indigenous. Similarly, the rate of decline in the prevalence of chronic malnutrition among the indigenous has been half that among the non-indigenous. Investing in the human capital of poor young children has among the highest economic and social returns of any type of investment: not only will child mortality be reduced ~ignificantly,~but also school achievement and future productivity will largely depend on improvements in the nutritional and health status of infants and pre-schoolers. Thus, an integral strategy to improve and sustain human capital in Guatemala should (i)pay special attention to rural and indigenous children younger than 24 months and pregnant women; (ii)focus its efforts on providing an adequate package of health and nutrition services emphasizing preventive measures even before birth; and

1 Guatemala. Country Economic Memorandum (2004). 2 Guatemala. Poverty Assessment (2004). 3 It is estimated that malnourished children have between a two-fold higher risk of death (mildly underweight) to an eight-fold higher risk of death (severely underweight) compared with healthy children (The Bellagio Group, 2003). 1 (iii)introduce interventions and incentives to promote demand for these services and encourage rural and indigenous families to take advantage of them, especially those living in remote areas.

Despite a difficult history and a complex country context, the Peace Agreements signed in 1996 after a 36-year civil war created a unique development opportunity for Guatemala, and the objectives established in the Peace Plan continue to guide the development of the country. With a multi-ethnic population of more than 12 million and a per-capita GDP of about $1,760, Guatemala is the largest economy in Central America. Yet, Guatemala faces a challenging legacy of high poverty and inequality, poor social indicators, and deep social and political divisions. These disparities are only slowly being overcome, as the country continues to consolidate democracy and address issues of equityhnclusion, growth and the establishment of credible public institutions. A significant step was the end of the internal armed conflict in 1996 and the corresponding Peace Agreements, which defined a clear and unified vision of Guatemala’s mid-term development. The current administration, in office since early 2004, acknowledges the importance of the Peace Agreements and social reforms.

Ineauality levels in Guatemala are among the highest in Latin America, and as a result, a large share of the population faces high rates of ~ulnerability.~Guatemala’s high poverty and relatively poor social indicators can be traced back in large part to a highly unequal distribution of income, and access to social services and opportunities. Guatemala’s Gini coefficient of 0.57 is the second highest in Latin America (after Brazil) and one of the highest in the world. Guatemala also lags behind in the evolution of the epidemiological transition. Guatemala’s demographic and epidemiological transition is still characterized by high fertility rates, a low proportion of adults within the population, high infant and maternal morbidity and mortality, high and extreme prevalence of chronic malnutrition, and heavy incidence of infectious diseases-in particular diarrhea and respiratory infections (Gragnolati and Marini, 2002).

For the last 15 years, Guatemala has shown some improvement in basic health indicators. However, the results of a recent worldwide analysis that predicted actual life expectancy and infant mortality based on GDP found that among the Central American countries, only Guatemala has poorer actual health outcomes than those predicted by the model (Todd & Hicks, 2003). With half of preschool children chronically malnourished, Guatemala has-by far-the highest prevalence of chronic malnutrition (stunting) in the region and only a handful of other countries in the world exceed its rates. Moreover, with a rate of 153 maternal mortalities per 100,000 births in 2004,5 Guatemala was 35 points above the median rate of countries in the third quintile for income (118 per 100,000) The high mortality rate showcases the serious structural limitations of the obstetric network, and maternal mortality constitutes a key priority for the sector. Child mortality and malnutrition can be linked initially to poor pre-natal conditions in Guatemala. One in five pregnant women has no pre-natal care at all and only 50 percent have their first pre-natal care visit during the first trimester of pregnancy. The rate of attended births grew to 42 percent in 2002 from 34 percent in 1995, but Guatemala still needs to improve obstetrics services. Currently, the proportion of births with no specialized attention or lack of transportation in case of emergency is very high. About four in 10 pregnant women receive qualified services. Low birth weights (currently affecting 12 percent of newborns), deliveries under unsafe conditions, malnutrition, infectious digestive diseases (diarrhea) and respiratory infections cause these deaths and there is a need for a more structured and better quality primary mother-child network (World Bank, 2004). Finally, exclusive breast feeding is in decline, according to the maternal and infant health survey of 2002. These issues combined, all preventable, constitute a major cause in the perpetuation of chronic malnutrition and high infant mortality rates. Government Strategies The Government has prioritized strengthening the Program for Extension of Coverage (PEC), which guarantees the universal provision of an improved basic package of health services in the 111

4 According to estimations made by the Poverty Assessment, in 2000 about 64 percent of Guatemala’s population had a 0.5 or higher probability of falling under the poverty line. 5 Measured using the RAMOS’ method. 2 municipalities, as defined in Government Social Policy (Guate Solidaria Rural - GSR). This strategy is targeted to the poorest municipalities in two phases. The first phase, currently under implementation as a pilot, targets the poorest 41 municipalities, while the second phase is focused on the following 70 municipalities. This project will support implementation of the second phase. Consolidating and scaling-up the PEC requires addressing two weaknesses of the program. On the one hand, the current Ministry of Public Health and Social Welfare's (MSPAS) mother and child referral network is inadequate and unable to respond to the needs of the population and the demand for services generated by the PEC. On the other hand, the current package of services provided through the PEC is insufficient to address chronic malnutrition effectively. The proposed project would strengthen and scale- up the PEC program by addressing these weaknesses. In addition, strengthening the PEC will involve measures to ensure sufficient public funds to finance an enhanced package of services, target the program to the rural areas of the most vulnerable municipalities, and put in place practices to guarantee an appropriate approach to address the needs of the indigenous populations. Accordingly, as part of Guate Solidaria Rural's emphasis on improving the impact of the PEC, the Government (GOG) has decided to complement the package with two interventions: (i)in all municipalities and jurisdictions in which the PEC is providing services, the basic health package will be modified to include or strengthen the Integrated Attention to Children and Women at the community level (Atencidn Integral a la Nin'ez y Mujer - Cornunitario, AWM-C) strategy to prevent chronic malnutrition through a community-based program; and (ii)in the most vulnerable communities of the 111 municipalities (about 30-40 percent), the GOG will be implementing the Creciendu Bien strategy that complements other social interventions, particularly health and nutrition programs through training and capacity development at the individual, household and community levels (see Table 1). Table 1: Characteristics and distribution of the PEC, AINM-C and Creciendo Bien to be financed bv the Proiect" AINM-C Program to Strategy to prevent chronic malnutrition Strategy to complement health provide basic through a community-based program: and nutrition programs health services in 1. Training of community health workers including: rural areas through (monitoras). contracting NGOs 2. Monthly Growth Promotion Sessions. 1. Individual training and 3. Home visits to sick or not adequately counseling to women at growing children. reproductive age. 4. Referral of children. 2. Household level education on 5. Monthly meetings for coordination of good health practices and activities. economic growth. 6. Strengthening community 3. Community level participation. communication activities Before the Project :n the Project area: 11 municipalities io% of villages (lugares poblados) (phase 1 GSR) I11 municipalities n the 41 municipalities covered by 'ECIAINM-C Project support 4lready covered by '0 municipalities 10% of lugares poblados in the 70 through Component he Government nunicipalities covered by PEC- 4INM-C MSPAS)

2. Rationale for Bank involvement

The Bank's recent work on Guatemala has focused on: (1) extensive analytical work, identifying the determinants of poverty and inequality and suggesting near-term priorities; (2) several investment operations, often coupled with technical assistance in the human development sectors, which have supported improvements in service delivery and provided valuable inputs to understanding the context for Guatemala's development; (3) an intensive policy dialogue with the new government, including a new Country Assistance Strategy (CAS, ZOOS), which identifies alternatives for collaboration in the social areas, and in particular in the health and nutrition sector; and (4) a series of Development Policy Loans

3 (DPLs) to support Vamos Guatemala plan and advance further in addressing Guatemala’s key challenges in restoring broad-based growth using an instrument that allows flexibility in specific actions and instruments, especially in view of the current fiscal constraints.

The current CAS supports the Vamos Guatemala plan6 and explicitly includes Bank assistance in the nutrition and health sectors. This project would be part of an integral Bank strategy to support current government efforts through research and operations tackling extreme poverty and fostering sustained growth. The social sector strategy supports the Government social policy-Guate Soliduria-to address the main obstacles delaying human capital formation in the country: chronic malnutrition, maternal and infant health, and insufficient schooling, accompanied by high inequality in access to social services. In doing so, this operation will be coupled with the current Bank support to the basic education sector. The strategy is complemented by a DPL series to promote growth, enhance capacity for public spending in priority sectors, and improve transparency and public sector management.

The World Bank has never been involved in a health or nutrition investment project (HNP) in Guatemala, and preliminary results of the Health and Nutrition PHRD grant under execution have revealed worrisome shortcomings of the health system that need to be followed up on and addressed as soon as possible. The proposed project is needed to take advantages of the momentum and focus of the present administration on this key area, and will contribute to the efficiency and impact of the several other MSPAS initiatives, including the system of purchasing of services from NGOs. The proposed operation also seeks to consolidate a successful and cost-effective government strategy to tackle prevalent malnutrition sustainably (the AINM-C7). The Bank is currently supporting a similar model in other countries and lessons learned so far will permit this project to truly add value to the government’s efforts to address chronic malnutrition effectively, one of the most worrisome red flags in human development in Guatemala.

Bank support through the proposed project will also complement other ongoing operations mostly financed by the Inter-American Development Bank (IDB). While the IDB supports the Government’s expansion of the PEC and strengthening of the Tertiary Hospitals level, improving the quality, efficiency and effectiveness of the maternal and infant health care system requires specifically strengthening maternal and infant health care centers at the secondary levels and ensuring strong coordination capacity to ensure that all lev& are functioning in an integrated matter. In the case of preventing chronic malnutrition, the IDB is also supporting implementation of a pilot program (Creciendo Bien) based on the proven strategy of community growth promotion programs. The pilot is expected to end in 2006. There is a need to define and scale up a single sustainable strategy to tackle chronic malnutrition in the medium- term based on current initiatives. The strategy needs to be part of the basic health and nutrition package offered by the PEC and should integrate current interventions. In both cases, the proposed project would fill the above mentioned gaps.

3. Higher level objectives to which the project contributes

The Guatemalan Government, with the support of multilateral and bilateral agencies, has committed to provide a policy framework and implement a national program to improve maternal and infant health and achieve the MDGs. In 2004, the MSPAS set forth its long term vision (to the year 2015) in “Lineamientos

6 The new administration’s national development plan, Vamos Guatemala is based on reaching the targets established in the1996 Peace Agreements. The plan emphasizes an integrated approach to economic growth while reducing poverty and inequality. The plan is based on tackling poverty, enhancing security and improving public sector management, and social spending effectiveness. As an integral part of Vamos Guatemala, Guate Solidaria Rural is the poverty reduction strategy, which considers human development as an integral component of sustained poverty reduction and economic growth. Key interventions in nutrition and health, together with a special action plan in the poorest municipalities, complement efforts in education and rural development to improve access to basic services and increase the pace of human capital accumulation. 7 The AINM-C, Atenci6n Integral a la Nifiez y a la Mujer en la Comunidad, is a largely preventive health and nutrition strategy integratedas part of the extension of health coverage (PEC). See Annex 4 for details. 4 Bdsicos y Politicas de Salud.” This document identifies eight policies and strategies, and 17 priorities for the period 2004-2008 (Table 2).

2. Satisfying the health needs of the Guatemalan population through delivery of health care services with quality, warmth, equity, and with an inter-cultural and gender focus throughout the different levels; 3. Strengthening the de-concentration and decentralizationprocess for competencies, responsib es, resources, and decision- making power to health administrative areas and hospitals; 4. Timely procurement and provision of inputs required for the development of actions in promotion, prevention, and health recovery; 5. Modernizing the financial-administrative management and planning systems of the MSPAS, as a core element of support for health services provision; 6. Strengthening the development and administration of health human resources; 7. Promoting actions in support of a healthy environment to improve the population’s quality of life; and 8. Protecting the population against risks inherent to the consumption and exposure of foodstuffs, drugs, and other substances detrimental to health. Health priorities Primary Secondary 1. Maternal and neonatal mortality. 1 1. Accidents and \.iolence 2. Acute respiratory illnesses-ARIS 12. Chronic and degenerative diseases (cancer. diabetes 3. Water and food borne diseases and hypertension) 4. Malnutrition 13. Disasters 5. Vector transmitted diseases 11. Addictions (alcoholism, smoking, drug addiction) 6. Immune and preventable diseases 15. lleningitis 7. Rabies 16. Intoxication due to pesticides 8. HIV/AIDS/STIS 17. llental health 9. Tuberculosis 10. Oral health

Within these primary priorities, the Government is making a special effort on the first four through the strengthening and expansion of the PEC, the development of a mother-child reference network, and the creation of the “Front against Hunger” for inter-sectoral coordination.

The proposed project will support these first four priorities that will contribute to reduce infant mortality from 50 per 1,000 to 35 per 1,000 and maternal mortality from 153 per 100,000 births to 110 per 100,000 births, and reduce chronic malnutrition prevalence from 60-70 percent to 40 percent in children under 2 years in the area of intervention. This effort is also consistent with achieving MDG 1,4 and 5.

B. PROJECT DESCRIPTION

1. Lending instrument

The proposed instrument is a five-year Specific Investment Loan (SIL) to support incremental activities on maternal-infant health and nutrition, targeted to the poor, rural and indigenous people. The incremental Bank funds would extend the coverage and improve the quality of already existing Government programs. Although the improvement of maternal-infant health and nutrition requires a long-term commitment, the SIL instrument was chosen considering the satisfactory record of Guatemala on supporting similar programs to implement health projects (i.e., PEC-Health Coverage Extension Program), and bearing in mind that this Project would be the first Health Nutrition and Population project financed by the World Bank in Guatemala. This SIL would: (i)build a relationship with the MSPAS, (ii) build capacity in the MSPAS, and (iii)keep open the possibility of moving towards alternative instruments, (e.g. a Sector Wide Approach (SWAP) or a programmatic loan) according to the evolution over the next few years.

8 Basic Health Policies and Guidelines 2004-2008. Strategic Planning Unit. 2004 5 2. Project development objective and key indicators

Building on the experience of the PEC, the proposed Project aims to: (a) improve maternal and infant health in the project’s 40 areas of intervention; and (b) reduce chronic malnutrition among children younger than 2 years of age in the rural areas of the 70 municipalities targeted by the project.

Specifically, the main outcomes of the project would be: (i)to reduce the indigenoushon indigenous infant mortality ratio and maternal mortality ratio by 10 percent in five years (5% in the third year) in the project’s area; (ii)to reduce the prevalence of chronic malnutrition in children under 2 by 15 percentage points in five years in the areas of intervention; and (iii)to increase the number of institutional deliveries by 15 percent in the areas of intervention.

As intermediate objectives, the proposed project would foster the demand for health and nutrition services as a complement to improving the quality and provision of basic health and nutrition services (supply side). The proposed project would support the introduction of inter-culturally accepted practices within Maternal and Infant Integral Health Care Centers ( “Centros de Atencidn Zntegrul Materno Znfuntil” / CAIMIs) to promote safe institutional deliveries, involving traditional birth attendants as key participants to increase the demand for reproductive health services. At the same time, the proposed project would strengthen community-based programs to provide basic health and nutrition services. These programs, which have proven to be very effective in reaching the extremely poor population-in the case of Guatemala through the PEC program (MSPAS) and recently through Creciendo Bien of SOSEP-are based on contracting NGOs to reach small communities and regularly provide basic health and nutrition services. The project would support improvements in the PEC model through introducing the AINM-C strategy, in coordination with the Creciendo Bien program. By the end of the Project, the Government should have a single integrated program for the implementation of the three strategies: PEC, AN-Cand Creciendo Bien

3. Project components

The proposed US$49.09 million project has four components and will be implemented over a five-year period. The project will be complemented with US$13.3 million provided by the Government of Guatemala to support the operations of the CAIMIs during the project life.

Component 1. Strengthening of the Maternal and Infant Health Network (US$22.8 million). This component would support the development of a Maternal and Infant Health Referral Network, promote the demand for maternal and infant health care, and contribute to increase the proportion of safe institutional deliveries, the referral of obstetric emergencies directly from the community, and access to a referral system for children with acute respiratory and digestive diseases. This component is divided into four subcomponents:

1.1 Maternal and Infant Health Promotion from the community. This subcomponent would focus on the community perception of the maternal and infant health problems, thereby promoting the demand for health services. A community based approach would contribute to enhance the inclusion of the excluded indigenous and rural population in health service provision, and ensure critical behavioral change and demand for health services. Specifically, this subcomponent would: i)support community organization by promoting involvement and participation in decision-making processes on maternal and infant health issues, including promotion to provide culturally accepted interventions; ii)develop a strategy to increase men’s and local leaders’ participation in maternal and infant health promotion; iii) design a communication and training strategy on responsible motherhood and fatherhood; iv) engage community

Including Front End Fee of US$122,500 6 groups and traditional birth attendants to identify obstetric emergencies better and to refer them in a timely manner to the CAIMIs.

1.2 Strenfiheninn cauacitv of the secondarv health level. This subcomponent would develop a higher level of resolution of maternal and infant health services, to support and provide responses to the health problems identified by the PEC. Specifically this subcomponent would: i)finance the upgrading of 40 health units to CAIMIs (Maternal and Infant Health Care Centers), distributed in key strategic points of the Maternal and Infant Health Care Referral Network; ii)strengthen the demand for reproductive health services by disseminating messages on safe motherhood, including the timely referral of obstetric emergencies and promoting the participation of traditional birth attendants as integrated human resources in the CAIMIs; iii)train a network team of skilled personnel and professional obstetrics; iv) determine the maternal and infant health indicator baseline for each new CAIMI; and v) finance contracting out of laboratory services when this option is superior to developing the MSPAS’s services.

1.3 Strengthening the referral system. This subcomponent would focus on the articulation of the PEC and CAIMIs and the CAIMIs and the hospitals. Specifically this subcomponent would: i) finance radio communications and ambulances to support the referrals from the PEC’s units and directly from the communities for obstetric emergencies; ii)support a clear definition of treatment protocols, identification of facility standards and norms for each level of care that establishes criteria for when to refer patients; iii) support five regional blood banks for the regular provision of blood units to the CAIMIs; iv) support of laboratory services; v) incremental human resources on a declining basis during the first two years of each CAIMI, which will be incrementaly absorbed by the MSPAS budget; vi) design and implement appropriate institutional arrangements; vii) design and implement appropriate provider contractual mechanisms; and viii) design and implement appropriate payment systems.

1.4 Creation of Maternal Homes ( “Hoaures Muternos”). This subcomponent would support municipalities to create Maternal Homes ( “Hogures Muternos ”). These Maternal Homes would facilitate access to safe deliveries to those women living in isolated areas. Specifically this subcomponent would support non-medical equipment - e.g. furnitures, home appliances - for Maternal Homes; each of these Maternal Homes would be linked to a CAIMI. The MSPAS will establish agreements with the municipalities to ensure operation and sustainability of Maternal Homes. The operational manual would include a standard model for this agreement.

It is estimated that CAIMIs would provide maternal and infant secondary health to 1.26 million inhabitants in 2,329 small communities, an average of 31,400 inhabitants per CAIMIs. The location of the CAIMIS will be defined with the support of SEGEPLAN and other social actors to ensure strategic provision of services. The location definition criteria will include alignment with broader social strategy, socio-economic vulnerability, and current coverage of health care services.

Overall, this component would support: (i)civil works, medical and non-medical equipment, training, technical assistance, radio communication equipment, ambulances, grants for the development of maternal homes and promotion of community involvement during the entire project; and (ii)laboratory services and incremental human resources on a declining basis during the first two years of each CAIMI. The human resources would be contracted using the same selection process used by the MSPAS. The salaries and benefits of these personnel would be also equivalent to the MSPAS personnel to facilitate the later transference to the MSPAS. The component will not finance drugs and medical supplies, which will be covered by the Government of Guatemala (GoG).

Component 2. Nutrition - Implementation of the AINM-C and “Creciendu Bien” Strategy (US$21.9 million). This component aims to address the problem of child malnutrition in the selected 70 municipalities by expanding coverage of community-based growth promotion and basic health services. In addition, this component will expand community-based capacity-strengthening of mothers and families in the most vulnerable and indigenous communities. In a country like Guatemala, where half of the 7 children are chronically malnourished and where acute malnutrition is relatively low, concerted actions are needed in the areas of health, access to basic services, education, and specific nutritional interventions. Moreover, in order to tackle the issue of malnutrition seriously in a country where, on average, 70 percent of indigenous children are malnourished, one needs to ensure that special attention is given to indigenous communities. A successful approach to preventing malnutrition therefore needs to focus on the most vulnerable population and consider two issues: i)ensure that demand for services is generated; ii)make sure that those targeted can best respond to intervention.”

This component consists of three sub-components: (1) Strengthening the MSPAS’ basic AINM-C package of services including preventive activities (growth monitoring, neo-natal care, early stimulation), basic curative activities (management of prevalent childhood diseases and referral of severely malnourished children), and appropriate individual counseling to mothers including community volunteers; (2) Extending the SOSEP’s Creciendo Bien activities aimed at strengthening women’s, families’ and communities’ capacity in the most vulnerable and indigenous communities of the 70 municipalities, increasing demand for basic social services through informing families living in the targeted areas about their rights related to these services and encouraging them to utilize them; (3) Ensuring appropriate supervision of nutrition activities. Therefore, this component is expected to have a significant impact, not only in terms of the extension of nutrition services to the poorest municipalities, but also because it is expected to produce positive spillover effects through increased demand for social services in very vulnerable areas.

2.1 Strendhenine. the basic AINM-C package of services. The Project would support the MSPAS’ efforts to improve the basic health and nutrition service package provided through the PEC. The project would provide financing and technical assistance to strengthen and consolidate the AINM-C program to engage both families and communities to monitor and maintain the adequate growth of children younger than age two and pregnant and lactating women, and treat and refer children younger than five who are ill.Child health and nutrition activities previously provided under the Creciendo Bien strategy would be consolidated under the PEC through the AINM-C strategy. Services under this project would be provided by the NGOs contracted by the MSPAS for the PEC. The NGOs would provide services for the AINM-C through well trained community workers (monitoras), normally mothers volunteering for the program working in coordination with the health vigilantes of the PEC and the traditional “comadronas” and supervised by local and regional health staff.” The community would be systematically engaged by carrying out its own analysis of why the children are having problems and the actions it needs to undertake as a community to improve the situation.

2.2 Extending the Creciendo Bien Program in the most vulnerable communities. This subcomponent would improve dissemination about social services available to families living in the poorest communities, encourage families to utilize these services, and strengthen the capacity of the most vulnerable populations to implement the AINM-C program successfully. In the most vulnerable and indigenous communities, the project will finance self-esteem and training activities coordinated by the Creciendo Bien program, a two-year long strategy designed to develop the capacity of women and families to generate demand for utilization of health and nutrition services and facilities. The program promotes community self management and community participation and builds on inter-institutional coordination. The subcomponent would provide field officers (“te‘cnicos de campo”) to implement the Creciendo Bien activities. The field officer would coordinate the activities with the monitoras to ensure adequate follow up of relevant AINM-C activities, especially of the growth monitoring element. This

10 It has been shown that large differentials in chronic malnutrition by ethnicity may reflect social exclusion or other forms of differential access to services, or the existence of traditional practices that may interfere with adequate growth of children. ” The AINM-C strategy is currently implemented by community health workers “vigilantes” of the PEC strategy, whose activities are often limited to making sure that mothers and children participate in the health and growth monitoring sessions as they are part of the PEC team and therefore are busy with many other tasks. In addition, the fact that the community health workers are often men which can be unsuitable for individual counseling to mothers, particularly on topics like breastfeeding and birth. 8 close follow-up will support the creation of demand for services and a better understanding and acceptance of the activities offered by the AINM-C strategy. The project would finance the expansion of the Creciendo Bien program, through NGO’s implementing the PEC and AINMC-C, in 30 percent of the most vulnerable communities in the 70 municipalities covered by PEC, with a particular emphasis on the indigenous communities.

(2.3) Supervision of nutrition activities. The objective of this subcomponent is to provide support and technical assistance to the Ministry of Public Health and Social Welfare to consolidate an institutional structure that can guarantee proper monitoring of the provision of basic health and nutrition services. The current supervision system is designed to follow up on the quality of service provided and monitor families’ pattern behaviors regarding child care and nutrition. The project would strengthen the MSPAS to supervise the implementation of AINM-C and Creciendo Bien activities as they are incorporated into the PEC. SOSEP will provide a supervisor who would coordinate his activities with the MSPAS supervisor at the departmental level. In addition, the community health council will systematically (at least twice a year) meet with the NGO team and a representative from the regional health teams to discuss the provision of health and nutrition services in the past period and alternatives to improve services in the future to meet the needs of the population and address the main causes of malnutrition as they emerge during the AINM-C and Creciendo Bien activities.12

Component 3. Communication, Monitoring, Evaluation and Continuous Auditing Systems (US$2.4 million). This component seeks to: (i)provide support to poor families to learn about nutrition and health programs, encourage the poor and indigenous population to utilize health and nutrition services, promote changing in pattern of behavior, disseminate the population’s right to utilize services, and encourage social auditing; (ii)design and implement a comprehensive monitoring and evaluation system (M&E) for the nutrition and health interventions; and (iii)measure the Project’s impact on targeted population welfare. This component has three sub-components: a Communication Strategy, a Monitoring and Evaluation System, and the Impact Evaluation of the Project.

3.1 Communication Stratem (US$l.O million). The general objective of the communication strategy to be executed by SESAN is to influence and promote ownership and sustainability of malnutrition preventive activities at the community level, through the design and implementation of a communication plan using adequate means and communication channels taking into account cultural, ethnic, and gender particularities in targeted areas. In addition, the plan is intended to encourage poor families to utilize health and nutrition services and promote more pro-active work with communities among health staff. It is expected that the strategy will reach at least 80 percent of mothers participating in the AINM-C strategy and from these, at least 60 percent will put into practice at least one of the activities suggested through the communication plan. Finally, the project would support, through community leaders, the dissemination of those SESAN’s nutrition strategies that are consistent with the objectives defined under component 2.

To achieve this result, the strategy includes the following activities: (i)mass dissemination of key messages through diverse communication means previously agreed between SESAN and the MSPAS, with particular emphasis on the role of the volunteer mother and individual counseling; (ii)mass dissemination of key messages to promote health and nutrition services and encourage poor families to utilize them; and (iii)workshops and training at health district levels. This sub-component involves investments in mass media (community radio, TV), press, educational material, and training and workshops.

3.2 Monitoring and Evaluation (US$0.6 million). This sub-component would support several activities to help develop a results-based M&E system, in line with the Government’s efforts to move towards a national integrated results-based M&E system for its social policy. This system would be aimed at: (a) l2These activities are different from the activities of auditoria social. 9 monitoring the effectiveness of program delivery; (b) monitoring and evaluating processes to assess the efficiency and effectiveness of the program’s implementation; and (c) monitoring outcomes and assessing the program’s impacts.

The M&E system would include the development of a management information system to track the project’s progress during implementation. In this process, the project will consider as well the information system in development for the PEC. The key activities that would be monitored to gauge the progress towards meeting these goals include: (a) an inventory of existing inter-governmental partnerships for M&E, sources, frequency and flow information; (b) terms of reference for baseline surveys prepared, then designed and piloted; (c) within a year from the start of the project, an adequate information system will be developed and operational.

The sub-component would finance: (a) hiring of national and international consultants to assist with the design and oversight of the M&E system; and (b) workshops with national and international consultants to discuss and disseminate the overall design of the M&E system with the program management team and policy makers alike.

3.3 Impact Evaluation (US$0.8 million). This sub-component would coordinate a rigorous mid-term and final evaluations to measure the impact of the project in reducing chronic malnutrition in the targeted areas. In terms of impact evaluation methodologies, it will be critical to survey a “control” group of similar non-participants, to generate comparison data of those “with” and “without” the program. Before implementation, the choice of the control group will be defined, and a baseline survey will be conducted. A careful and rigorous evaluation with similar methodology will assess the effect of the Creciendo Bien sub-component, in a sub-sample of the targeted communities before scaling up, aiming at assessing the program cost-effectiveness. This sub-component will be implemented through contracting out to specialized firm under international bidding under the category of consultant services.

Component 4. Institutional Strengthening (US$1.7 million). This component would support the institutional capacity of the Ministry of Health to implement and administer basic health and nutrition services. In particular, the project will support the UCPYP (Unidad Coordinudoru de Programas y Proyectos), and the SIAS consultant services by providing technical assistance and equipment, for an approximate cost of US$1.4 million. The Project would also support the recently created SESAN to improve its institutional capacity to administer the information management system of the SESAN. The Project would finance consultant services, equipment, and workshops and training (approximately US$0.3 million).

4. Lessons learned and reflected in the project design

Broad lessons have been learned in the organization and management of effective maternal and child referral systems and AINM-C programs and projects that have been financed to date. The following lessons were relevant to the design of the proposed project:

General

Focusing on Communitv-Based-Approach The Community-Based-Approach is seen as an important strategy to enhance the inclusion of the alienated indigenous population in health service provision, and ensure critical behavioral change and demand for health services. Specifically, the inclusion of participatory and demand driven programs aim to: (i)improve rural indigenous population demand and access to health care services; (ii)enhance rural indigenous population participation in decision-making processes; (iii)provide culturally accepted

10 interventions; and (iv) create conditions for social integration of the rural indigenous population and enhance social capital.

It is important to include the rural indigenous population in decision-making processes, and not see them just as possible recipients of services. There is also a need to recognize the rural indigenous population as positive agents of change in their community. It is important that programs build on the strengths and assets of the rural indigenous population to promote sustainable health status.

For the above reasons, the project includes strategies in Components 1 and 2 to ensure community engagement, and local leaders’ involvement. In Component 1, this goal is to be achieved by coordinating and strengthening partnerships between traditional birth attendants and skilled formal providers. The traditional birth attendants “comudronus ” are central figures in community service provision during pregnancy, and repositories of accepted knowledge and trust. In Component 2, the strategy of community and local leaders’ involvement is achieved through interventions aiming to empower women and increase self esteem, and their subsequent role as “madres monitoras,” as well as the work targeting fathers, and households.

Focusing; on Culturally Accepted Interventions Both Components 1 and 2 aims to generate behavioral change targeted to address the current low demand for health services and poor habits and practices around nutrition. In order to achieve behavioral change, the project team learned the strategic importance of supporting culturally accepted interventions. This awareness led to carrying out a social and indigenous population assessment, in order to have interventions properly addressing the cultural and social values of the rural indigenous communities. Examples of the main themes addressed are socio-economic factors that could present obstacles to the implementation of the project in the rural indigenous areas, the main hygiene and care practices associated with pregnancy, delivery, and infant care, and the role of women and men in health care household decision making processes.

Component 1

The main causes of maternal mortality are severe bleeding, infection, unsafe abortion, eclampsia, and obstructed labor. While every woman is at risk for experiencing sudden and unexpected complications during pregnancy, childbirth and following delivery, adequate antenatal, obstetric and post-natal care can reduce the risk of death considerably. In Guatemala however, one in five pregnant women has no pre- natal care at all and only 50 percent has the first pre-natal care during the first trimester. Despite the growth in attended births to 42 percent in 2002 from 34 percent in 1995, Guatemala still needs to improve obstetrics services. Currently, the proportion of births with no specialized attention or lack of transportation in case of emergency is very high. About four in 10 pregnant women receive qualified services.

Most deaths of young children are caused by preventable diseases. About one in four deaths in Guatemala are caused by infectious diseases, and less than five percent result from cancer diseases. Also, acute respiratory diseases play a major role in the high morbidity and mortality rates in Guatemala. This group of diseases not only has an extremely high impact on young children (it is the first cause of death among this population group), but also it is the first cause of death among 15-49 year old women. Diarrhea also plays a key role in mortality and morbidity rates as a result of the lack of safe drinking water and adequate sanitation services. About 22 percent of young children suffered from diarrhea in 2002. The impact of this disease is particularly high on chronic malnutrition.

Strengthening Secondary Level of Care In Guatemala the following factors prevent women and children from needed life-saving healthcare services: (i) lack of referral and counter referral systems due to the low availability of health services at the secondary level of care, which would ideally link the primary and tertiary levels and allow for proper 11 care to be provided; (ii)distance from and accessibility to secondary level health facilities; (iii)cost (mainly indirect costs associated with transportation, drugs and supplies); (iv) cultural factors and women’s lack of decision-making power within the family; and (v) low rates of skilled attended birth.

To improve maternal and child mortality the following steps need to be strengthened: identification, transportation, provision of services, and referral. Therefore, the project supports the strengthening of the following mechanisms and structures in the health sector in Guatemala:

Antenatal control by strengthening partnerships between traditional birth attendants and skilled formal providers; building linkages with other reproductive health, and nutrition interventions. Safe institutional deliveries and access to primary care for acute respiratory and digestive diseases among children. This strategy includes the strengthening of the secondary level with the CAIMIs, including the provision of operating rooms in some of the CAIMIs to allow for the performance of a c-section. Trained and skilled personnel - Shortage of skilled providers to provide emergency obstetric care is common in rural and indigenous areas. Therefore, there is a need to build capacity of personnel that can provide prenatal control, safe delivery, and emergency obstetric care, and recognize high risk pregnancies and complicated deliveries and refer them for care at the appropriate time. Access to blood bank - as hemorrhagic events are among the most common causes of maternal morbidity and mortality, the provision of blood is necessary to ensure availability of emergency obstetric care services.

Addressing the Role of Infrastructure Coverage of health facilities, especially in rural areas, remains a big barrier. Indigenous women in rural areas often have to walk a long time to the nearest health facility. Poor road infrastructure and lack of public transportation make access difficult especially when there are complications. As a result indigenous women tend to seek health care from less trained providers who are more accessible. The project team learned and included mechanisms to address this issue in the project.

This component will finance the upgrade of CAIMIs distributed in key strategic points of the Maternal and Infant Health Care Network (on average two per department). These CAIMIs will be developed in already existing health centers, and investment will aim to increase its capacities to provide culturally appropriate and supervised health services to increase safe births assisted rates, and access to oral rehydration and acute respiratory therapy services for children under 5 years. Each of these centers would be linked to a Maternal Home (“Hogares Muternos”) to facilitate access to safe deliveries for those women living in isolated areas.

Training as a Wav to Build Teams The project supports the strategy of a systematic and constant process of capacity building of skilled personnel, which will help build teams. The PEC teams will be participating in training at the CAIMIs on a regular basis, and CAIMIs teams will travel to the referral hospitals on a regular basis. This strategy not only assures that these teams will have up-to-date appropriate skills, but it also increases the level of efficiency by giving the teams an opportunity to network, get to know each other and become more efficient as they climb the learning curve of knowing how to work with each other.

Component 2

Behavioral change essential for sustainability Ifthe Project succeeds in changing families’ knowledge, improving awareness of the value of investing in children’s human capital and strengthening family health and nutritional practices, then most of its benefits will be sustained. Changing family practices in areas like exclusive breastfeeding, complementary feeding, cooking practices, and child care, as well as recognizing the importance of full immunization and regular child growth monitoring are all central goals of the Project. In particular, the Project incorporates activities to support changes in knowledge, attitudes, and practices among poor 12 families through: (i)individual counseling and group training through the AINM-C strategy included in the essential health services packagehutrition services; and (ii)additional training activities and education sessions in the most vulnerable areas as part of the Creciendo Bien Program and through inter-sectoral coordination.

Community based health and nutrition programs are good substitute for monetary incentives Through community-based programs in health and nutrition, the project creates a permanent demand for these services without the need for any incentive, such as conditional cash transfers, which, without a clear exit policy, may risk creating aid dependency and limit the ability of the program to address the needs of a wider group of poor households.

Food distribution is not effective Preventing chronic malnutrition through food distribution and curative activities has not proven effective and may be counterproductive in the long-term. Food distribution and in-kind transfers have little impact on preventing chronic malnutrition since these efforts are targeted to children older than 2 years of age when the damage of malnutrition is already irreversible. Moreover, continued food distribution raises concern about the dependency mentality that it may generate as well as the fact that often food distribution programs supply imported and expensive food that the poor would not be able to afford if they had to buy it. Finally, it is often hard to turn off a food distribution program, once it has started. The Project's approach is therefore preventive, based on growth monitoring and training, to promote long-term changes in family and community behaviors in nutrition and health.

Community nutrition volunteers (rnonitores) should receive periodic retraining One of the key lessons learned from other community volunteer-based programs that have been able to maintain high coverage and participation rates is the importance of retraining or refresher training. Also, it has demonstrated that this practice not only improves their knowledge and capacity, but also constitutes an incentive to maintain these key actors in the program.

Monitores should not be paid but receive some type of (non-monetary) incentives Previous experiences showed the success of using unpaid nutrition volunteers. However, the lack of any forms of incentives or recognition may erode the motivation of the volunteer. For this reason, the monitorus will receive non-monetary incentives and will be formally recognized by the local health team. In addition, the time they devote to nutrition activities will be kept to a minimum.

Monitoring. adequate monthly weight gain instead of nutritional status The shift to adequate monthly weight gain reorients the attention to the children with a current, and not past problem and on prevention rather than treatment. Through this method, a dynamic and visible measure for progress, a child starts to be malnourished when he is not gaining the expected weight, independently of where the point is on the growth chart. In practice, the mother is told the weight that the child should be in a month, based on a table of expected weight gain inter~a1s.l~Growth monitoring for an individual child is therefore based on her own pattern. Malnutrition is not a state or a static situation anymore (a point in the growth chart). Moreover, this method has the advantage of being meaningful to all program participants, from the family to the project management team. For the family, the goal is that a child grows each month; for monitores and the community, the goal is the growth of the children of the community.'4

l3The Minimum Expected weight gain table was created by using two studies by Martell et al. at the Latin American Perinatology Center in Uruguay that looked at the growth of 112 children 0-23 months of age (Martell et al, 1981). l4In order to make the monitoring of community growth more visible, the MSPAS uses a bar chart that was first developed in Indonesia and then adapted in Honduras. The bar chart includes five columns which indicate respectively: i)under-2 children in the community; ii)under-2 children who are weighed; iii)under-2 children who have gained adequate weight; iv) under-2 children who have failed to gain weight; and v) under-2 children who have 13 Children younger than 2 years old are a priority, especially during the first six months It is well documented that malnutrition is more harmful to the child during the first months of life and that its effects in early childhood are not reversed later in life.15 Correction of growth faltering is therefore easier and most critical during the first two years of life: it is then that household practices and timely referral can save lives. Moreover, by focusing only on children under 2, the number of children for which the monitorus are responsible remains low and therefore manageable.

Indigenous children are not short by default Although there are obvious differences between adults of different ethnicities, children of different ethnicities have the potential to achieve similar levels of growth in the first few years of their life. Many comparative empirical studies have demonstrated that socioeconomic factors are of greater importance than race and ethnicity in determining children’s height. Data from IndiaI6 and Guatemala” suggest that ethnic differences in growth potential are minor prior to puberty and that it is during this stage that the major differentiation between ethnic groups takes place. Clear differences surface during adolescence for both sexes; Guatemalan and Indian children who were near the fiftieth percentile of the reference growth charts prior to puberty, ended up near the twenty-fifth percentile by the end of adolescence.

Tackling risk factors Many problems causing poor child growth go beyond the power and capabilities of a family to correct. Poor quality water, lack of sewage and garbage disposal, poor outreach of health centers, which have been shown to be important determinants of malnutrition in Guatemala,” can be tackled by effective community action. For this reason it is essential that communities meet regularly, at least twice a year, in order to make decisions in the best interest of the health of their children. Adequate weight gain indicators offer the community a structured tool to analyze its problems.

Need for periodic evaluations There is need for periodic, design-based evaluations to understand how the program is being implemented (its processes) and its outcomes/impacts. An evaluation that investigates both process and outcome is essential to understanding how and how well the program functions and constitutes an effective feedback mechanism to improve its performance. The proposed project has allocated resources to undertake a rigorous impact evaluation. Process evaluations are relevant as they are able to explain differences in implementation and their effect on mothers’ knowledge, attitudes and practices regarding child nutrition and child-rearing practices. Combined with data on children’s health status, these evaluations can explain how significant the difference in implementation was in terms of impact on child health status.

5. Project Alternatives considered and reasons for rejection

Lending instruments - Sector Investment Loan (SIL) vs. Adaptable Program Loan (APL) vs. Learning and Innovation Loan (LIL). The decision to use a SIL reflects the focus on building the institutional capacity structure for future programs. As this is the first HNP investment the Bank is supporting in Guatemala, the strategic choice of a SIL instead of a programmatic APL approach is supported by the following rational: (i)to build a relationship with the MSPAS, (ii)to build capacity in the MSPAS, (iii)to keep open the possibility of moving towards alternative instruments (e.g. a SWAP or a programmatic loan) according to the evolution over the next few years. A LIL was not considered because of its small size and limited potential impact.

failed to gain weight more than one month in a row (the repeaters). The goal is that the first three bars have the same level. With results visible on the growth charts, monitoras and vigilantes can concentrate on children not gaining weight. 15 Martorell, 1990 and Martorell, 1994. 16 Rao and Sastry (1977). 17 Johnston, Borden, and MacVean (1973). 18 Marini and Gragnolati, 2002. 14 Institutional-based approach vs. creating a separate PCU. The team decided in favor of institutional implementation of the project rather than creating a separate implementing agency in order to strengthen the institutional competencies of the participating government agencies. The institutional approach involves all levels of implementation, including a community-based approach that includes NGOs as nutrition services providers and providers of training and capacity building to participating communities.

Coordinating unit of the AINM-C component: SOSEP vs. MSPAS. In the technical design of the AINM-C component, one option considered was to have the SOSEP act as the principal AINM-C coordinator. The Creciendo Bien program is a two-year strategy that, in addition to growth promotion activities, supports training and capacity development at the individual, household and community level. The program will end in two years and therefore through Creciendo Bien, the SOSEP could not guarantee long term follow up and supervision to nutrition services. The MSPAS supports the AINM-C strategy as part of the PEC program, a modality of service delivery aimed at reaching the poorest and most remote populations. The project supports the option of consolidating the AINM-C administration and coordination under direct responsibility of the MSPAS. This way it not only guarantees long-term sustainability and supervision but also guarantees its coherence and synergies with the basic health system.

The health and nutrition sector in Guatemala presents a scenario where gaps and needs could be found almost everywhere. Most donors and agencies (except for the World Bank) have provided, and are providing support, and close coordination from the MSPAS is needed to avoid overlaps and inclusive contradicted interventions. The goal of supporting the extension of the PEC to some of the remaining areas (2 million people) still not covered by the program includes an HIV/AIDS prevention component and an environmental health component, and studies in connection to these potential components were executed through the financial support of a PHRD grant. But after considering that other projects are supporting the extension of the PEC and Guatemala has received funds from the HIV/AIDS Global Fund, these components were rejected. In addition instead of considering a separate component for environmental health, the hand washing promotion and prevention of indoor air pollution interventions would be included through the Creciendo Bien Program.

The proposed project would build on the existing programs, providing services to the population covered by the PEC, but also to those that still need access to the PEC, a maternal and infant referral system that would provide a more comprehensive primary care and access to the secondary level. With support from the already-existing PEC, this Project would implement the AINM-C model to reduce malnutrition in the 70 poorest municipalities without AINM-C. In addition, the Project would implement the Creciendo Bien Program in highly vulnerable groups (30 percent of the population in those 70 municipalities).

During project preparation, different scenarios were assessed regarding the extension of malnutrition preventive interventions. Particularly, it was a trade off between the initial amount of the loan (about US$35.0 million) and the need to guarantee universal coverage of AINM-C in the areas covered by the PEC and Creciendo Bien in the most vulnerable communities within the 111 municipalities targeted by SEGEPLAN. Under the threshold of the initial loan amount, neither AINM-C would reach the target 70 municipalities nor would Creciendo Bien be implemented at all beyond its pilot phase in the first 41 municipalities. Considering that these two interventions have a long-term impact on chronic malnutrition, self esteem, and access to basic health and nutrition services, it was agreed that the best scenario would be increasing government fiscal efforts to reach these goals. Therefore, the Government and the Bank agreed to increase the amount of the loan to US$49 million.

15 C. IMPLEMENTATION

1. Partnership arrangements

This project will complement other ongoing health sector operations financed by the Inter-American Development Bank (IDB). To date, the IDB has been the main international development agency in the health sector in Guatemala, and it supports the expansion and strengthening of the tertiary level of care (e.g. hospital care). To complement the IDB strategy, this project will focus on the secondary level of care in order to successfully address infant and maternal mortality. This approach includes strengthening the referral network and care centers at the secondary level, providing the linkages between primary and tertiary levels so all three levels can function in an integrated matter. In the case of chronic malnutrition (Component 2), the IDB is supporting the Creciendo Bien program as a pilot in the 41 most vulnerable communities. The proposed project recognizes the success of the Creciendo Bien program and has integrated an expanded nutrition model (AINM-C plus Creciendo Bien interventions) to the PEC package offered to the most vulnerable communities in the next 70 municipalities. The integration of the Creciendo Bien to the project is a result of a series of successful consultations with the IDB.

Therefore, this project is complementing the Government’s successful IDB-financed strategy, and does not need formal partnership agreements.

2. Institutional and implementation arrangements

The MSPAS would be the implementing agency and would have overall responsibility for all Project components. The MSPAS has demonstrated that it has the administrative and organizational capacity to implement interventions to provide basic health services throughout the country. Specifically, the MSPAS has shown flexibility and innovation to go beyond institutional and traditional structures to provide basic health services and has been one of the pioneers in Latin America in introducing innovative and costleffective alternatives to reach very poor and remote areas through the PEC. Lower than expected progress in health and nutrition indicators, especially since the early 2000s, cannot be attributed to the PEC model itself but to external factors which undermine its effectiveness, including: i) insufficient public spending, ii) deficient targeting, iii) incomplete package of services, and iv) lack of proactive approach to involve indigenous communities. The Government has acknowledged these weaknesses and the proposed Project involves measures to support the MSPAS in addressing them.

Therefore, implementing and sustaining basic health and nutrition interventions as included in this project may be challenging for the Ministry. The Project would support the MSPAS to enhance its capacity to scale up, administer, and supervise basic health and nutrition interventions (including Creciendo Bien activities), involving the above mentioned aspects; Le., enhancing the basic package of services, focusing the intervention in targeted areas, increasing public spending in health and nutrition, and adopting inter- cultural methodologies to reach indigenous communities. The MSPAS would implement the Project in close collaboration with the Social Work Secretariat of the President’s Wife of Social Works of the Social Works President’s Wife (SOSEP), and Food and Nutrition Security (SESAN).

The Project would not create any new agencies or units, but would utilize the existing institutional structures and implementation arrangements established within the MSPAS, adequately supported by technical specialists and equipment as needed. Accordingly, the Project would not create a project coordination unit separated from the ongoing administrative organization within the MSPAS. On the contrary, technical aspects and financial, administrative, and procurement matters would be executed by the respective departments or units at the central and sub-national levels (including its “areas de salud”) of the MSPAS. In doing so, the Project includes the above mentioned actions to support monitoring and evaluation and to strengthen current institutional capacity and administrative structures as well as support government to improve coordination mechanisms to consolidate a single nutrition strategy throughout the country.

16 The recently created Project and Program Coordination Unit ( “Unidad Coordinadora de Programas y

Proyectos ”- UCPYP) within the MSPAS is responsible for the administrative, financial, and procurement aspects of all programs implemented by the ministry and financed with external funds, including this project. Accordingly, this Unit would operate on the basis of the inputs prepared by, and in coordination with the existing technical units within the ministry. In the case of this project, the UCPYP would interact with the units with the technical units of SIAS, and with the unit responsible for Monitoring and Evaluation within the ministry. Accordingly, technical units would prepare the annual operating plans (POAs), define and enforce technical norms and regulations, develop terms of reference as needed, supervise progress, and in general would be the primary responsible for project implementation. On the basis of such inputs, and in close coordination with the technical units, the UCPYP would have all responsibilities for the project.

Special attention would be given to improve coordination among central agencies involved in implementing or working in nutrition programs. In the recent past, coordination among at least three of them-the MSPAS, the SESAN, and SOSEP (Social Work Secretariat of the President’s Wife)-has been weak. Therefore, the Project will emphasize improving institutional and implementation arrangements. (See Annex 6).

Financial Management Arrangements: Project administration will be undertaken by MSPAS under its established institutional structure. Accordingly, MSPAS’s unit for coordination of projects and programs financed with external funds (UCPYP), in coordination with MSPAS’ s General Management and MINFIN’s National Treasury, will be directly in charge of financial management (FM) tasks. These will basically include: (i)budget formulation and monitoring; (ii)cash flow management (including processing loan withdrawal applications); (iii)maintenance of accounting records; (iv) preparation of interim and year-end financial reports; (v) administration of underlying information systems; and (vi) arranging for execution of external audits.

The fact that MSPAS has ongoing experience managing projects financed by donors and the IDB, for which it has administrative structures and systems in place, puts it in a good position to take over the cited FM functions. However, the Bank’s FM capacity Assessment (FMA) has identified project-specific actions to be executed within a timeframe to meet the Banks’ minimum fiduciary requirements. Annex 7 describes in detail the FM arrangements and the FM action plan.

3. Monitoring and evaluation of outcomedresults

This project will support the development and implementation of a monitoring and evaluation (M&E) system for health and nutrition programs which will: (i)be integrated within the broader social M&E System being developed by SEGEPLAN; (ii)monitor and evaluate basic nutrition and health services supported by this project; (iii)provide the structure and build capacity for an on-going and broader scope health and nutrition M&E system; and (iv) evaluate the impact of the program on nutrition indicators.

At the moment there is no integrated M&E system in place in Guatemala and the institutional arrangements, including the mandate and responsibilities of each actor, are in the process of being clarified. Currently, SEGEPLAN is leading a national effort to develop and implement an integrated M&E system for all social programs in the country, with the support of all other public agencies. At the same time, Congress recently created SESAN, whose main responsibility is to set up an integrated M&E system for nutrition and food security. As part of this effort, several government institutions and agencies will be involved such as National Institute of Statistics (INE), MSPAS, SESAN, SOSEP, Ministry of Agriculture (MAGA), and SEGEPLAN.

17 The M&E system for health and nutrition for this project will be developed through the collaboration of each implementing agency and will permit the collection and analysis of outcomes and results indicators. The system will generate reports that will be consolidated and analyzed in the MSPAS in coordination with SESAN and SEGEPLAN.

There will be four main tasks: monitoring, implementation assessment, impact evaluation and social auditing.

Monitoring SEGEPLAN: will oversee the process of developing and implementing the M&E for this project, integrated and harmonized within the M&E system for social programs that is being implemented. The Government of Guatemala is moving towards a national integrated results-based monitoring and evaluation system for its social policy. This is part of the broader on-going efforts of the Government to move to a results-focused high performing public sector that delivers effective programs and quality services to the population. For this purpose, SEGEPLAN would create a unit with the specific role of strengthening the country's capacity in: (i)collecting national and provincial social indicators data, (ii) developing social diagnostics and analytical tools for ex-ante program assessments, and (iii)improving real-time program output monitoring and ex-post outcome evaluations.

MSPAS: will be responsible for the implementation of the M&E system for this project. The MSPAS will also ensure that the project's M&E system is integrated and harmonized within the system of health and nutrition monitoring of the government. In particular it will oversee: (i)baseline collection at the beginning of the operation of a CAIMI in the project area; (ii)follow up surveys after two years and at the end of the project; (iii)continuous recording and reporting of operational indicators throughout the year; (iv) a baseline survey in the community where the AINM-C and Creciendo Bien programs will be implemented will be carried out and follow up surveys after two years and at the end of the project; and (v) regular reports from volunteer mothers on the activities being undertaken.

SESAN: will integrate the M&E information resulting from the nutritional component of the project with all other sources of information available. It will also analyze data and prepare reports to MSPAS and other relevant agencies to respond to the strategic needs of combating malnutrition in Guatemala.

Implementation assessment At the end of the first year, an assessment will be conducted on the implementation status of the project. The evaluation will be performed by a specialized firm with the information on the provision and utilization of the services for both components provided by the MSPAS. The findings of the assessment will be used to address shortcomings in the implementation in a timely way.

Impact evaluation At the end of the project, a rigorous impact evaluation of the program on chronic malnutrition will be undertaken. The strategy for evaluation and the baseline survey will have to be defined before the implementation of the program. The impact evaluation will assess changes in indicators of malnutrition that can be attributed to the project. Its aim is to provide feedback to help improve the effectiveness of the future programs and the appropriateness of scaling up. The evaluation will be implemented through contracting out to a specialized firm under international bidding under the category of consultant services.

Social Auditing Social auditing mechanisms will be incorporated for the basic package of health services. The beneficiary communities will be involved in the supervision of the delivery of health and nutrition services in two ways. First, social audit will take place monthly in every jurisdiction, on the date of the visit of the health team to the community centers. Secondly, the social audit will happen once a year when the social audit commission meets with members of the organized civil ~ociety.'~ l9 This mechanism are different from the community meetings of the AINM-C 18 4. Sustainability

Sustainability

The key sustainability issues related to this project are the continuous operation of the CAIMIs, the “Hogares Muternos”, and the operation and supervision of the complete AINM-C and Creciendo Bien models after the project is completed. The proposed Project would finance the CATMIs’ incremental human resources on a declining basis while other recurrent expenditures would be financed from the beginning by the MSPAS. Specifically, the government through MSPAS will finance all operational and maintenance expenditures related to the CAIMIs, and the incremental costs of human resources of such centers after two years of operation. Therefore, it is expected that beginning in the third year of the proposed project, the government through MSPAS will start taking responsibility for the additional personnel hired by the CAIMIs.

Activities included in the AINM-C will be an integral part of the basic health package offered through the PEC. The current administration is in the process of updating the per capita cost of the package raising it from US$5 per year in 2004 to about US$10 or US$1120, including the AINM-C. Currently, the per capita cost is increasing to US$8 and the MSPAS has made the budgetary arrangements to reach the above mentioned target by 2008. Creciendo Bien is a two-year intervention fully financed by the Project which does not imply recurrent costs.

As explained in more detail in Annex 5 and 9, recurrent costs generated by the Project are estimated at about US$7.43 million per year after the project ends, including both the CAIMIs (operation and maintenance and incremental human resources) and the AINM-C services provided through the PEC (training, supervision of rnadres monitoras, and non-medical supplies). This amount is equivalent to about 3.7 percent of the annual MSPAS budget.

5. Critical risks and possible controversial aspects

Risk Mitigation L~~~ofpol,tical and In Guatemala, re-election of administrations is very unlikely. Changes in administrations social sustainabilitynormally mean changes in policies and people. Also, prior to election years, political through changes in tensions in Congress increase and cause delays in necessary approvals that may slow implementation of projects. Associating a program exclusively with any administration may Administrations decrease its political and social sustainability. High The project will mitigate this risk with a three-pronged strategy. First, the projea is supporting the incorporation of the proposed nutrition and infant-maternal interventions within the PEC package. The PEC package has a high level of societal ownership, and ”survived” three administrations. Second, an impact evaluation will be conducted for the nutrition component, and the results are expected to demonstrate evidence leading to higher social and political commitment. Third, the implementation of the project will be accelerated within the mandate of the current administration to achieve high operational levels when expected political changes will come.

Delayed Start of The start of implementation is at risk for delays due to: (i)the need to consolidate the new Implementation unit for external coordination within the MSPAS, hire staff and trained them; and (ii) multiple institutional players that need to be coordinated (e.g. MSPAS, SESAN, SOSEP). Moderate Resources will be allocated and Technical Assistance (TA) will be provided to support the capacity building stage of the cooperation unit. Terms of Reference (TORS) for TA will be

~

2o It is very likely that the per capita cost of the package is going to be higher due to the recently approved “Programa de Reduccio’n de la Desnutricidn Crdnica” of the MSPAS and SESAN that includes food distribution and that is estimated to cost up to US$4 per beneficiaire 19 Risk JNIitigation lapreed before negotiations. To decrease the risk of coordination issues, institutional I arrangements and responsibilities will be in place before negotiations.

Under utilization of In Guatemala, significant segments of society have traditionally been excluded from socio- CAIMIs and of economic opportunities and access to information. This dynamic is particularly relevant for on generating enough nutrition interventions the indigenous population. The project’s successes will depend demand for and ownership of health and nutrition services among the most vulnerable Substantial communities. Therefore, the inclusion of culturally sensitive interventions is essential. The MSPAS has worked to identify and is in the process of changing practices that have been rejected by the indigenous communities, while simultaneously identifying culturally appropriate hospital practices. The CAIMIs will incorporate culturally accepted and non- harmful practices into their maternal and infant care services. The strategic choice of integrating the Creciendo Bien model will help ensure community-based ownership and demand, and generate behavioral changes in the CAIMIs located in the poorest 112 municipalities. The project’s M&E component is part of a broader effort to establish a national results-based Delayed M&E due to M&E system for social programs in Guatemala. The decision to include the proposed dependence on the project as part of this national effort brings substantial benefits, but also increases additional development of risks of delays. broader M&E To mitigate the risk of including the project in this effort, the following actions have been framework planned: (i)the project will work very closely with SEGEPLAN to ensure that the M&E Moderate component is aligned with overall broader efforts; (ii)the project is part of a broader World Bank effort to support the development of a national M&E System; (iii)a M&E capacity building workshop will be delivered; and (iv) in the event of excessive delays in the development of the broader M&E, a stand alone M&E system will be developed.

Food distribution Food distribution programs, planned to start soon, may distract and/or distort beneficiaries’ programs interest from AINM-C activities. This risk may be exacerbated as a result of the impact of hurricane Stan in term of food availability in San Marcos and other remote areas Substantial The project will promote early coordination with SESAN to make sure that food will not be distributed through community nutrition centers and during the same days of the growth promotion activities. This will help ensure that AINM-C beneficiaries will participate in growth promotion activities because they are truly interested in them and not because of the expectation of receiving food.

Lack of financial The risk of lack of financial sustainability is correlated with the level of socio-political sustainability sustainability; thus this risk depends on the risk identified above. As mentioned in the sustainability section (C.4), medium-term success of the interventions depends on the GoG Moderate picking up recurrent and operational costs for the CAIMIs and continuing to support the expansion of the PEC. The GoG contribution is expected to be provided throughout implementation of the project.

Municipalities not The Project will involve community and local leaders in training and workshops to help interested on build the community’s and municipal authorities’ commitments. The Creciendo Bien model supporting AINM-C has a strong emphasis on the community-based approach, to generate strong ownership and demand. and “Hogares Matemos” Low

~ Overall Project Risk Substantial

6. Loan conditions and covenants. NIA.

20 D. APPRAISAL SUMMARY

1. Economic and financial analyses

I.There are strong economic arguments for public financing nutrition intervention in Guatemala. First, public investment in nutrition is iustified on equity grounds: since malnutrition is particularly concentrated among the poorest and most vulnerable segments of the population (preschool children, pregnant and lactating women), investments targeted to the most malnourished are addressing the well- being and health status of the poorest. By reorienting resources towards more preventive care and towards the most vulnerable people the project aims at improving equity. Benefit incidence analysis has revealed that currently the MSPAS expenditure is regressive and the poor, indigenous and rural populations receive less than a proportionate share of resources, exacerbating the health inequities (Table 3).

Q1 Q2 Q3 Q4 Q5 Share of Per Capita Consumption 3% 6% 9% 18% 63% Share of Net Health Subsidy 11% 14% 17% 30% 28%

Second, public investment in nutrition is iustified on the need to address market failure deriving from imperfect information. The malnourished often are not aware of the consequences of their condition on health status and future productivity, do not have complete knowledge of the choices available to them and are less able to articulate the demand for services. This is even more of an issue in Guatemala, where the large indigenous population (40 percent of the total population) often has limited access to health systems because of geographical, economic and linguistic barriers. Indigenous children are twice as malnourished as non-indigenous children, and indigenous women are about one and a half times as likely to be severely stunted as non-indigenous women.

Finally, investments in nutrition have very high payoffs, particularly in countries like Guatemala where half of the children are malnourished. An extensive body of literature has dealt with the implications of child malnutrition on human performance and child health and survival. In particular, there is substantial evidence that malnutrition has potentially irreversible consequences on growth attainment, morbidity, mortality, educational achievement, productivity and adult chronic diseases. Addressing malnutrition and making use of the effective interventions that exist and have been implemented in a few countries would translate into mortality rates that are far lower than current levels.

11. Choice of intervention: cost-effectiveness and feasibility. Once established that funding nutrition is a sound investment for Guatemala, project interventions were based on their respective cost-effectiveness, as known from international literature, and their implementation feasibility in the country. The project includes a 5-year multi-sectoral support to the AINM-C, a project that promotes an inter-sectoral approach to improving nutritional status through growth promotion, micronutrients and strengthening individual capacity. It has been documented in the literature that interventions such as the AINM-C and in general nutrition education and micronutrient supplementation programs are among the most cost effective ways of preventing malnutrition (Table 4)*l.

21 Fiedler, 2003; Alderman, Behrman and Hoddinott, 2004; Mc Guire, 1996, World Development Report, 1993 21 Table 4. Estimated Returns from Nutrition Investments

Cost per Returns to Cost per Life Saved Program Discounted Dollar Healthy ($1 (in wages) Life Year Gained ($) Undernutrition Interventions Food Supplements 18,337 1.4 234 Nutrition Education 797 32.3 10.2 Integrated PHC-N 9,966 2.6 127 Food Subsidies 42,552 0.9 375 School Feeding -- 2.8 534 Iron Deficiency Supplementation of pregnant women only 800 24.7 12.8 Fortification 2,000 84.1 4.4 Iodine Deficiency Supplementation 1,250 13.8 18.9 (repro-aged women only) Supplementation 4,650 6.0 37.0 (all people under 60) Fortification 1,000 28 7.5 Vitamin A Deficiency Supplementation (under five only) 130 50 4.0 Fortification 400 16 12.3 Source: Mc Guire, 1996.

Programs like the AINM-C would imply major savings in terms of lower utilization of health facilities, generated mainly by i) diminished morbidity and ii) substitution effects from mothers going to the community centers rather than the health clinic for monthly growth monitoring of the child. In Honduras, a country with similar socio-economic conditions but a lower rate of chronic malnutrition (29%), the AIN-C project is expected to generate cost savings of about 1.5 million per year or US$2.3 per capita because of the lower utilization of health facilities and as a result of mothers and caretakers of children substituting the AIN-C monitorus care for the MSPAS preventive and curative health provision. Using similar calculations and the same parameters for Guatemala would lead to estimated cost savings of US$2.5 million for the 70 municipalities in areas of project intervention.

Additionally, in order to respond to safe deliveries, the primary cause of maternal mortality in the country, and to address the two major causes of mortality, diarrhea and acute respiratory infections, the project is also strengthening the maternal and child referral network, which has been so far unable to respond to the needs of the PEC. Exempting pregnant women from having to pay for emergency obstetric care when referred by a trained provider addresses the market failure of the insurance market. In Guatemala health insurance coverage is unavailable to approximately 90% of the population**. The network is expected to have a significant impact on the reduction of maternal mortality, low birth weight and treatment of children with diarrhea and respiratory infections.

In conclusion, the above arguments not only suggest that there are strong economic reasons for the government to invest in maternal and infant health in Guatemala but also make the investment in the CAIMIs and the AINM-C an attractive economic option.

22 Gragnolati and Marini, 2002. 22 2. Technical

Technical aspects of this project are limited to civil work for the facilities to be set up at the CAIMIs and the implementation of the full AINM-C and Creciendo Bien models. The CAIMIs’ designs are not expected to pose any major technical difficulties since they will follow well known technologies and standards.

International experience shows that effective interventions directed at preventing malnutrition and lack of early stimulation in young children are the most powerful mechanisms to prevent risks that may cause irreversible damage and affect future productivity. Tackling malnutrition directly reduces child mortality and improves the likelihood of better lifetime earnings. The strategy followed by the MSPAS builds on community-based growth promotion programs, also known as AIN-C, or Atencidn Integral a la Nifiez Cornunitaria, which have proven to be very effective in reducing malnutrition in other countries within and outside Central America.23 The programs have demonstrated very positive impacts on mothers’ knowledge, attitudes, and behavioral practices related to child nutrition, child rearing, and family demand for health care, as well as on child nutritional status.24

In Central America, the AIN-C model was first developed in Honduras, with the support of USAID/BASICS. First launched in 1996 and building on international experience, the AIN-C further refined growth promotion practices by introducing innovations such as the concept of adequate weight gain, a well-developed set of tools for aid workers, and a structured job-based training program for community volunteers. The innovative strategy of the AIN-C focused on preventing mild and moderate malnutrition to ensure a greater impact on child survival, rather than concentrating solely on the treatment of severe malnutrition among children. In general, AIN-C’ s growth promotion activities begin with monitoring a child’s growth to establish whether it is adequate or not. Growth monitoring is accompanied by individual counseling for mothers regarding maternal care, including the value of exclusive breastfeeding, appropriate complementary feeding, the management of basic disease, and the importance and linkages to basic health services. In some countries, programs also provide micronutrient supplementation.

In Guatemala, in reaction to the nutrition crises that emerged in a few communities in 2001, the MSPAS adopted the AIN-C nutrition interventions and adapted them to the Guatemalan reality by strengthening the maternal health component and initiating the AINM-C, Atencidn Integral a la NiRez y a la Mujer en la Comunidad, which is implemented as part of the PEC program. Growth promotion activities and individual counseling to mothers in particular started only in mid 2004, after the development of new communication and counseling materials. In the meantime, SOSEP, after limited progress in the area of malnutrition reduction and following international best practices, decided to launch a new malnutrition reduction program, the Creciendo Bien, which adds a strong component of capacity building at the individual, household and community levels to the traditional growth promotion activities and builds on inter-sectoral collaboration. The proposed project builds on the existing experiences and aims to coordinate the community growth promotion activities under the AINM-C of the MSPAS while strengthening the capacity building activities of Creciendo Bien in the most vulnerable and indigenous communities, where in order to fight malnutrition, programs must also address problems of social exclusion or other forms of differential access to services, and/or the existence of traditional practices that may interfere with adequate growth of children.

23 These programs built on the positive experiences of large-scale programs such as the Iringa Project in Tanzania, the Indonesia Behavioral Change Program and the Tamil Nadu Project in India, that continue to serve as best practice examples of how nutritional issues can be addressed effectively. 24 World Bank (2005). 23 3. Fiduciary

Financial Management. As MSPAS has ongoing experience managing externally-financed projects, it has in place a basic administrative structure, which puts it in a good position to take over the financial management functions of the proposed project (currently, MSPAS is managing a project financed by the IDB, albeit with the help of UNDP). However, the FM capacity assessment (FMA) has identified project- specific actions in order to strengthen the financial management (FM) capacity of UCPYP and enable it to carry out the financial activities of the proposed project effectively.

Therefore, assuming that MSPAS carries out the proposed action plan presented in this assessment, it would have in place adequate financial management arrangements that meet the Bank’s minimum fiduciary requirements to manage the specific financial activities of the proposed project. Annex 7 describes in detail the FM arrangements and the FM action plan.

Procurement. Procurement for the proposed project would be carried out in accordance with the World Bank’s “Guidelines: Procurement Under IBRD Loans and IDA Credits” dated May 2004; and “Guidelines: Selection and Employment of Consultants by World Bank Borrowers” dated May 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Loan/Credit, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity (see Annex 8 for further detail).

4. Social

The social assessment took place in September 2005, and consisted of (a) a bibliographical review of information concerning general, demographic, and socioeconomic indicators, and on existing projects, emphasizing information about indigenous peoples; and (b) a participatory evaluation with a sample of the target population to understand their perceptions, experiences, expectations, attitudes, capacity and willingness to participate in programs similar to those proposed in the Project. This evaluation was undertaken by a local team, supported by the Ministry of Public Health and Social Welfare (MSPAS), with technical assistance from the World Bank (WB). The information obtained from focus groups (FG) of the project’s target population (women and community) and health service providers (midwives, institutions, entities, and NGOs) was used to understand: (a) the practices and cultural values that women develop during the different stages of pregnancy, childbirth and postpartum, (b) health practices at home and infant nutrition, and (c) factors that are obstacles andor facilitate access to health services for the maternal and infant population. Additional information was obtained from in-depth interviews with the women who participated in the FGs. The findings of this Social Assessment are explained in detail in Annex 10, as well as the Indigenous Peoples Plan which was prepared by the Government.

5. Environment

The most relevant environmental issue resulting from the implementation of this project is the increase in the production of Health Care Waste (HCW). The regulatory framework pertaining to the Disposal of Hospital Solid Waste is adequate, but the environmental assessment carried out during project preparation reveals that in order to comply with the regulations, there is a need to improve the MSPAS’ control capacity, which includes meeting the staffing needs in the office responsible for monitoring this regulatory framework, avoiding personnel rotation and ensuring the availability of equipment for supervision. Nursing and cleaning personnel in health care units also require training to apply solid waste management regulations, which is particularly needed in rural areas where supplies necessary to comply with regulations are even more limited.

24 The MSPAS designed a Hospital Solid Waste Disposal Plan for the CAIMIs that includes the recommendations made during the environmental assessment.

6. Safeguard policies

Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [XI [I Natural Habitats (OP/BP 4.04) [I [XI Pest Management (OP 4.09) [I [XI Cultural Property (OPN 11.03, being revised as OP 4.11) 11 [XI Involuntary Resettlement (OP/BP 4.12) [I [XI Indigenous Peoples (OD 4.20, being revised as OP 4.10) [XI [I Forests (OP/BP 4.36) [I [XI Safety of Dams (OP/BP 4.37) [I [XI Projects in Disputed Areas (OP/BP/GP 7.60)25 [I [XI Projects on International Waterways (OP/BP/GP 7.50) [I [XI

7. Policy Exceptions and Readiness

The project meets regional implementation readiness criteria.

A final Project Implementation Plan is ready.

25 By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas. 25 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 1: Country and Sector or Program Background

Country and Sector Background

Guatemala needs to invest in the human capital of its poor population to achieve sustained economic growth and reduce chronic poverty26.Despite important progress in the social sectors over the last decade, Guatemala’s human development indicators still lags well behind other countries’ in the region. This gap is particularly problematic in certain areas where expected progress has not been sustained in the last few years. Maternal and infant mortality rates and particularly chronic malnutrition are among the highest in the world, and much higher than expected, given Guatemala’s per capita income. They constitute, along with poor schooling, severe constraints for human capital accumulation and the achievement of key MDGs in the country2’. Chronic malnutrition and poor health status of young children may cause irreversible losses of human capital formation and economic growth, affecting current and future generations and economic growth in the long-term. In all cases, these indicators are significantly worse than expected given the per capita income of Guatemala.

Improving health status and nutrition conditions of infants, young children, and pregnant mothers constitutes the starting point to overcome one of the major obstacles in the chain of human capital accumulation and to break the intergenerational transmission of poverty. Government’s efforts to increase human capital should focus on tackling chronic malnutrition and promote maternal and infant care among the most underserved families. Rural residents and indigenous communities, where poverty incidence is over 75 percent, are particularly vulnerable. Investing in the human capital of poor young children has the highest economic and social returns: Not only child mortality will be reduced significantly28, but also school achievement and future productivity will largely depend on improvements in the nutritional and health status of infants and pre-scholars. Thus, an integral strategy to improve and sustain human capital in Guatemala should (i)pay special attention to rural and indigenous children younger than 24 months and pregnant women; (ii)focus its efforts on providing an adequate package of health and nutrition services emphasizing on preventive measures even before birth; and (iii)introduce interventions and incentives to promote demand for these services and encourage rural and indigenous families to take advance of them, specially those living in remote areas.

Countrv Context

Despite a difficult past and a complex country context, the Peace Agreements created a unique development opportunity for Guatemala, and the agreed objectives should continue to guide the development of the country. With a multi-ethnic population of more than 12 million and a per-capita GDP of about $1,760, Guatemala is the largest economy in Central America. The country’s difficult colonial past and a debilitating 36-year civil war left a legacy of high poverty and inequality, poor social indicators and deep social and political divisions. These are only slowly being overcome, as the country continues to consolidate democracy and address issues of equityhnclusion, growth and the establishment of credible public institutions. A major significant step was the end of the internal armed conflict in 1996 and the correspondent agreements, which defined a clear and unified vision of Guatemala’s mid-term development. The current administration, in office since early the 2004 acknowledges, the importance of the Peace Agreements and therefore, among its top priorities is to regain the dynamism of the social

26 Guatemala. Country Economic Memorandum (2004). 27 Guatemala. Poverty Assessment (2004) 28 It is estimated that a malnourished children have between two-fold higher risk of death (mildly underweight) to 8-fold higher risk of death (severely underweight) compared with healthy children (The Bellagio Group, 2003). 26 reforms started in the post-conflict years and to maintain the sustainability of the progress in the social indicators in the whole country.

The incidence of poverty in Guatemala has diminished, and since the Peace Agreements the provision of basic services has improved. Mainly due to a relatively high economic growth, the incidence of poverty in Guatemala during the 1990’s declined from 65 percent in 1989 to 54 percent in 2002. At the same time, since the Peace Agreements, the government achieved considerable progress in the provision of basic services - including health - expanding significantly the coverage of education and health especially in rural and poor areas of the country. These achievements resulted in additional 800,000 new children reaching school between 1996 and 2001, and the expansion of primary health coverage has reached more than 3 million beneficiaries through the implementation and scaling up of the PEC. This progress was the result of various factors, of which it is worth highlighting the definition of clear policy objectives supported by national consensus, and to which the government was able to align its functioning to provide adequate support. As an effort to achieve these policy objectives, the government also increased the spending target to the social sectors, and incorporated new models of provision of basic services based on decentralization, community participation, and contracting out with NGOs.

TABLE1.1. LATINAND CENTRAL AMERICA - MAIN SOCIAL INDICATORS

GUd NI HO ES CR PA MX LAC Poverty (% of pop) a 56 50 53 48 22 37 20 GDP Growth (1 990-2002) a 4.1 3.3f 3.2 4.6 5.2 5.0 3.5 3.7 Income per Capita (US$2002) 1,760 710 930 2,110 4,070 4,020 5,920 3,280g” GIN1 Coefficientg 56.0 54.1 53.0 51.8 44.6 54.4 52.7 51.5 Public Expenditure in Education (% GDP) a 2.6 5.0 4.0 3.3 4.4 5.6 4.42 3.3 Public Expenditure in Health (% GDP) a 2.1 8.5 3.9 2.6 5.2 5.3 2.5 3.3 Years of Schooling (25-65 y.0.) 4.0 4.6 4.8 5.1 6.1 8.9 7.2 6.1 School Enrollment, pre-schoola 44 27 21 44 87 68 76 58.2 School Enrollment, primarya 88 80 88 81 91 92 103 97 School Enrollment, secondarya 26 36 35 39 49 51 60 64 Illiteracy rates (adults) a 30 33 24 20 4 8 8.3 10.5 Infant Mortality (per 1,000 live births) a 43 36 31 33 9 20 24 28 Maternal Mortality (per 100,000 live births) a 153 150 110 120 29 100 55 65 Chronic Malnutrition (% of --pop 3-59 mo) 49 20 33 23 6 14 1aa 19a Life Expectancya 65.5 68.7 66.1 70.1 77.6 75.0 73.6 70.7 SourcesaWDI;‘Guatemala, ENSMI 2002, Nicaragua, DHS 2001, El Salvador, FESAL 1998, Honduras, CDC 2001, Panamb, ENV, 1997; dCIEN; ‘Loening, 2003; gDe Ferranti, et. al., 2003; ‘EHPM, 2002,’average of 15 LAC countries.

Despite some progress in the past decade, Guatemala’s social indicators are much below the average in the region and poverty may have increased recently - Guatemala’s social indicators are still among the worst in Latin America, often falling below the indicators observed in countries with substantially lower per-capita incomes. For example, despite significant improvements in primary enrollments over the last decade, the average schooling of the adult population (14 years and older) in 2001 was only 4.3 years, compared to 4.4 years by low income countries, whose GNI per capita averages US$420. Guatemala’s health outcomes are also poor: life expectancy at birth is 65 years compared with 69 years on average exhibited by lower middle income countries (whose GNI per capita averages US$1,400); infant and maternal mortality rates are higher while the pace of improvement slower than that of much poorer Latin American countries such as Bolivia, Honduras and Nicaragua (Table 1.1). Perhaps most alarmingly, malnutrition rates among Guatemalan children are abysmal-- based on the height-for-age measure it is estimated that nearly half of the children under five years are stunted, with four-fifths of the malnourished children coming from poor households. In addition, recent events in the region, particularly the coffee crisis, may have increased poverty incidence and worsened social indicators in the last few years.

27 Inequality levels in Guatemala are among the highest in Latin America, and as a result, a large share of the population presents high rates of ~ulnerability~~.Guatemala’s high poverty and relatively poor social indicators can be traced back in large part to a highly unequal distribution of income, and access to social services, and opportunities. Guatemala’s Gini coefficient of 0.57 is the second highest in Latin America (after Brazil). The fault line separating the rich and poor runs largely along ethnic lines and the places of residence excluding most indigenous and the rural population from the benefits resulting from economic growth and structural social policies. TABLE1.2. SOCIAL INDICATORS BY ETHNIC GROUPS For example, the incidence of poverty among the indigenous populations is 35 Non- Avg. Ind‘ Ind. percentage points above the non- Poverty (% of pop) 76 51 56 indigenous, while extreme poverty is Years in School (25-65 y.0.) 1.9 5.3 three times higher among indigenous Literacy rates (adults) 50 79 68 communities. Along the urban-rural School Enrollment, primary (%) 75 84 79 divide the incidence of poverty is almost School Enrollment, secondary (%) 14 32 25 three times greater in rural than in urban Chronic Malnutrion (% of pop 3-59 mo) 70 36 49 areas, and four times in the case of Infant Mortality (per 1,000 live births) 49 40 44 extreme poverty. Maternal Mortality (per 100000 live births) 21 1 70 126 Attended Birth 19 54 34 In general, the same pattern is observed Pop with Health Insurance 5 18 13 among most social indicators. The Pregnant Woman with no Pre-Natal Care 26 17 21 average years of schooling of the adult I11 People with no Medical Appt 46 36 40 indigenous population (25-65) is only 1.9 Month Income per Capita 54.6 138.2 100 years, while the rest of the population Sources: ENCOVI 2000 (adapted from Shapiro, J. (2004) “Indigenous Poverty averages 5.4 years, also reflected in very in Guatemala, except schooling and completion rates, adapted from CIEN, 2003 significantgaps inschool enrollment. explain below, similar inequities are found in health and nutrition indicators. Even more worrisome, improvement of these and other social indicators has been much slower among indigenous families, compared with non-indigenous communities. On average, poverty incidence among indigenous communities fell 14 percentage points between 1990 and 2002, compared with 25 percentage points among non indigenous population (Table 1.2).

Health Sector issues

Guatemala also lags behind in the evolution of the epidemiological transition. Guatemala’s demographic and epidemiological transition is still characterized by high fertility rates, low proportion of adult population, high infant and maternal morbidity and mortality, high and extreme prevalence of chronic malnutrition, and heavy incidence of infectious diseases-in particular diarrhea and respiratory infections (Table 1.3).

29 According to estimations made by the Poverty Assessment, in 2000 about 64 percent of the Guatemala’s population has a probability of 0.5 or higher to fall under the poverty line. 28 TABLE1.3 . BASIC HEALTHINDICATORS TRENDS 1980-2001

Indicator 1987 1990 1995 1998/9 2000 2002 Gross birth rate x 1.000 37 36 35 Fertility rate* 5,6 5,1 5 .O 4,4 Life expectancy - 60 63 64 65 65 Infant mortality rate x 1.OOO* 73 51 45 39 Under five mortality rate 82 64 59 Maternal mortality rate x 100.000 # 153 Percentage of children 13-24 m. w/complete immunizations * 24,7 42,6 593 62,5 Percentage of children 3-59 m. wkhronic malnutrition* 57,9 49,7 46,4 49,3 Proportion of institutional birth deliveries* 34,3 40,4 42,l Proportion of children 0-2 m. w/exclusive breastfeeding* 55 Sources: * ENSMI, # estimated by Ramos method, ** Estimated using ENSMI 95 data.

The health situation in Guatemala is below that which could be expected given its per capita income level. Even more important, Guatemala is somewhat stagnated in improving crucial indicators and in general the country still has a lower health status than expected given its GDP per capita (Figure 1.1).

FIGURE1.1. CORRELATIONS BETWEEN GNI PER CAPITA (PPP) AND HEALTHINDICATORS

Life ExDectancv at Birth and GNI Der caDita Infant Mortalitv Rate and GNI Der caDita I

a130 Y co w110 + 5 90 co 70 E c, 50 E 39 30 8c Y 10 2.9 450I I15ooO lodo0 l5dOO 2odoo 25doo 3odoo 35& 450 5ooO lodo0 15633 2oooO 25633 3odo0 35odo 3880 3880 GNI per capita 2000 (PPP) GNI per capita 2000 (PPP)

Source: WDI, 2004. 155 countries GNI per capita under US$35000.

For the last fifteen years, Guatemala has shown some improvement in basic health indicators. However, the results of a recent worldwide analysis that predicted actual life expectancy and infant mortality based on GDP found that among the Central American republics, only Guatemala has poorer (actual) health outcomes than those predicted by the model (Todd & Hicks, 2003). Specifically,

29 0 With a life expectancy of 65 years and its current GDP per capita, Guatemala falls well below countries such as Ecuador, El Salvador, and Honduras which have lower of similar income level but higher life expectancy at birth.

0 Infant mortality has decreased from 73 deaths per 1,000 live births in 1987 to 39 per 1,000 in 2002. However, the actual rate is high when compared with that of poorer countries in the Region, such as Honduras and Nicaragua, both with a rate of 34 per 1,000; or when compared with the rest of the countries in the world in the third quintile for income who have a median rate of 33.5 per 1,000.

0 Furthermore, Guatemala has also -by far- the highest prevalence of chronic malnutrition (stunting) in the region and only a handful of other countries in the world exceed its rates.

0 With a rate of 153 maternal mortalities per 100,000 births in 200430, Guatemala was 35 points above the median rate of countries in the third quintile for income (1 18 per 100,000) The high mortality rate showcases the serious structural limitations of the obstetric network, and maternal mortality constitutes a key priority for the sector.

Child mortality and malnutrition can be traced even before birth. One in five pregnant women has no pre- natal care at all and only 50 percent has the first pre-natal care during the first trimester. Even though attended births grew to 42 percent in 2002 from 34 percent in 1995, Guatemala still needs to improve obstetrics services. Currently, the proportion of births with no specialized attention or lack of transportation in case of emergency is very high. About four in ten pregnant women receive qualified services. The low birth weights (currently at 12 percent), deliveries under unsafe conditions, malnutrition, infectious digestive diseases (diarrhea) and respiratory infections generate these deaths and require a more structured and better quality primary mother-child network. Finally, exclusive breast feeding is in decline, according to the maternal and infant health survey of 2002. These issues combined, all preventable, constitute a major cause in the perpetuation of chronic malnutrition and high infant mortality rates.

Most of deaths of young children are caused by preventable diseases. About one in four deaths in Guatemala is caused by infectious diseases, and less than five percent result from cancer diseases. However, lack of adequate and accurate information is a major barrier to clearly define the responsibility in each category. Also, acute respiratory diseases play a major role in the high morbidity and mortality rates in Guatemala. This group of diseases not only has an extremely high impact on young children (it is the first cause of death among this group of population), but also it is the first cause of death among 15-49 year old women. Diarrhea also plays a key role on mortality and morbidity rates as a result of the lack of safe drinking water and adequate sanitation services. About 22 percent of young children suffered diarrhea in 2002. The impact of this disease is particularly high on chronic malnutrition.

In assessing Guatemala’s health indicators it is imperative to also take into account the marked inequities that are masked by national averages. In nutrition and most other health indicators-just as in the distribution of income and wealth-Guatemala has the distinction of being among the most inequitable societies, and the inequalities are worsening. The situation that characterizes the low income population, the indigenous population and the rural sector are significantly more deficient than national averages (Table 4) and these inequities have grown:

0 Most of the improvements in health indicators in recent years have disproportionately benefited the non-indigenous. Between 1987 and 2002, the rate of decline in the infant mortality rate among the non-indigenous has been four times faster than among the indigenous. Similarly, the rate of decline in the prevalence of chronic malnutrition among the indigenous has been half that among the non- indigenous (Figure 1.2). 0 The uneven pace of gains in the fight against malnutrition have left not only the non-indigenous, but also-independent of ethnicity-the poor, increasingly behind the national indicators (Figure 1.2).

30 Measured using the RAMOS’ method. 30 0 Regional disparities are equally wide. While infant mortality in the metropolitan region is half the national average, in the south-east region it is 50 percent higher. Likewise, infant mortality triples when the mothers have a low educational level compared with those with secondary education.

TABLE1.4. ETHNIC GROUPS AND RURAL/URBAN DISTRIBUTION OF HEALTH INDICATORS

Infant mortality in Prevalence of Births delivered by Chronic Fertility Maternal the 10 years prior to contraceptive medical or nursing malnutrition Rate the Survey methods staff under 5 Urban 3.4 35 56.7 65.6 36.5 Rural 5.2 48 34.7 29.5 55.5 Indigenous 6.1 49 21 1 23.8 19.1 69.5 Non indigenous 3.7 40 70 52.8 57 35.7

~~ Source : ENSMI 2002

Fertility rates are higher among the rural and indigenous population, whereas their access to services and the prevalence of contraceptive methods among them is lower. The proportion of births delivered by medical or nursing staff at the national level is 41.4 percent, compared with urban areas is 65.6 percent; while in rural areas is only 29.5 percent. This difference is even higher among the ladino population (57 percent) while among the indigenous is only 19 percent (Table 1.4). These differences contribute to the sharp inequities that exist in maternal mortality, where the rate of 153 per 100,000 at the national level masks rates of 70 per 100,000 among the non-indigenous population versus 211 per 100,000 for the indigenous women.

FIGURE 1.2. PERCENTAGEREDUCTIONS IN THE INFANTMORTALITY RATE AND \UNDER5 MALNUTRITION PREVALENCE AMONG INDIGENOUS AND NON-INDIGENOUS PEOPLES IN GUATEMAJA, 1987-2001

50% I- O 40% t- #, 3 30%

.Ic 20% zn Y 8 10% 2 tL" 0% indigenous Non-Indigenous 0 Infant Mortality Rate Malnutrition (stunting) Source: Calculations based on DHS, 1987, ENSMI, 2002

Government Response - There is dire need to improve the effectiveness and the efficiency of the Guatemalan health sector and a multisectoral approach to reduce chronic malnutrition. The GoG has been facing in the last decade three categories of interrelated problems that continue to contribute to poor performance of the health sector and worsening in the health conditions in the country: (i)low level and inequality of health service provision, (ii)inefficient allocation of resources, and (iii)inefficient execution of resources in public agencies. Particularly womsome is the insufficient and decreasing sectoral

31 financing. Even though social spending significantly grew between 1996 and 2000, it slowed down in the following 3-4 years and currently Guatemala has the lowest level of public spending in health in Central America (2.1 percent as a proportion of the GDP), and well below the average of Latin America. Per capita public expenditure in Health (MSPAS budget only) in Guatemala reached only $26 in 2002, the same level than in the late 1990s, and the MSPAS budget felt as a proportion of the public spending from 8.8 percent to 6.4 percent between 1997 and 2003.

The Government has designed and implemented very innovative and cost-effective interventions which need to be strengthened and consolidated. The MSPAS started in 1997 the Program for Extension of Coverage (PEC) that purchases NGOs services to provide basic health care services. The program, currently purchasing services from more than 100 NGOs and providing services to more than 3.6 million persons (Figure 1.3), has proven to be an effective alternative for delivering primary health care to target at low income, rural and peri-urban communities with limited or no access to MSPAS facilities.

In spite of its potentiality, the PEC program has been largely underpinned over the last few years. Like the rest of the health sector, after an initially rapid scaling up the program suffered severed budget constraints affecting not only its geographical targets, but also undermining the package of services, as FIGURE 1.3. PEC - COVERAGEEXTENSION 97-03 1 the per capita cost was gradually reduced 1 between 2000 and 2004. By 2004, the MSPAS i 3.5-- paid each NGO the equivalent of US$5 per capita, which however did not cover the cost of 3- 1 services included in the package. The lower 2.5- cu i per capita allocation also limited supervision. 0 2- This together with the need to strengthen the technical level of supervisors, delays in 1.5- I payments to the NGOs in 2003, and some 1- i complaints about the process by which the 1 0.5.- i NGOs were selected adversely affected the -’ quality of services provided in the Program, 1997 1998 1999 2000 2001 2002 2003 while extension of coverage somewhat stagnated.

The effectiveness and potential of PEC also requires complementary intervention in the health system. However the program’s potential cannot be fully attained given the lack of a reference network capable of providing a quality response to the health problems identified by the PEC, which require a higher level of resolution. The MSPAS mother and child referral network is unable to satisfactorily respond to the needs of the PEC. For instance, while it is possible to implement a program of prenatal controls, access to a safe delivery is very limited, on occasion chaotic, and responsible for a large portion of more than the 500 maternal deaths that occur each year in Guatemala. A similar situation characterizes the MSPAS mother and child referral networks ability to resolve the two main causes of infant mortality: acute respiratory infections and digestive diseases (diarrhea).

The new administration in Guatemala has decided to consolidate the PEC improving the package of services, increasing the per capita cost paid to NGOs, and extending coverage according to national targeted areas. However the program’s potential cannot be fully attained given the lack of a reference network capable of providing a quality response to the health problems identified by the PEC, which require a higher level of resolution. The MSPAS mother and child referral network is unable to satisfactorily respond to the needs of the PEC. For instance, while it is possible to implement a program of prenatal controls, access to a safe delivery is very limited, on occasion chaotic, and responsible for a large portion of more than the 500 maternal deaths that occur each year in Guatemala. A similar situation characterizes the MSPAS mother and child referral networks ability to resolve the two main causes of infant mortality: acute respiratory infections and digestive diseases (diarrhea).

32 Child Malnutrition

Chronic malnutrition (measured as height for age) has been one of the traditional problems of infancy in Guatemala. As stated above, the chronic malnutrition rate in Guatemala is not only among the highest in the world (compared only with those levels found in Nepal, Pakistan, or Rwanda), but also its progress has stagnated over the last 10 years, according to National Maternal and Infant Health Surveys (Figure 1.4).

FIGURE 1.4. GUATEMALA- CHRONIC MALNUTRTION1987-2002

80

G 70

.30 Y *c 60 Y 1 G 50 I 9 40 -8 30 E: 8 2o 10

0 1987 1995 1999 2002 Total Indigenous

Source: Calculations based on ENSMI, 1987, 1995, 1998/99, and 2002

In 2002, the percentage of children under 5 years old according to height for age under 2 standard deviations was 49 percent, while in the rural areas the prevalence reached 56 percent with higher prevalence in the North East (68 percent) and in the North (61 percent) regions. In relation to the ethnical differences, the prevalence of malnutrition among children of indigenous populations was even higher (70 percent). Although the national prevalence of acute malnutrition (weight for size -2 standard deviations) is apparently low (1.6%), as in the case of chronic malnutrition it hides higher regional prevalence rates. Of the 331 municipalities in the country, 207 are considered of high risk (World Bank, 2004).

Among the main determinants of malnutrition is poverty. As observed in Figure 1.5, over the last ten years real progress in tackling chronic malnutrition has concentrated in children belonging to families in the fourth and fifth income quintiles only, with little change among poor families. The indigenous and rural populations are the most affected.

L

33 FIGURE1.5. RATES OF REDUCTION IN THE PREVALENCE OF MALNUTRITION IN GUATEMALAFROM 1995 TO 1999, BY HOUSEHOLD INCOME QUINTILE

38 % 40% L P) 3 35% L 30% E 2 E 25% 2 -e * 20% 2 $ 9 5 15% 51s 2 0 10% Y 5% u3 L 0% a" -5%

Source: Calculations based on DHS, 1987, ENSMI, 2002

The age of higher nutritional vulnerability is between the 6" and 24" months of age, which is the period when complementary feeding starts (figure 1.6). From this age on, there is an increase of nutrition needs which can not be met by exclusive breast feeding, and until 24 months of age it is the period where malnutrition becomes a chronic disease with long-term effects on learning capacity and productivity; after 24 months of age, reducing malnutrition is very difficult. There is need for complementary diets which in many cases, due to the conditions of poverty and the lack of education of the parents, are of poor nutritional quality and inadequately prepared.

FIGURE1.6. LATIN AMERICA -PREVALENCE OF MALNUTRITIONBY AGE -SELECTED COUNTRIES 70

60

:E 50 Y a E 3 40 E y3 0 30 m Y E u" 20 L, a" 10

"0 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 36 Age (months)

The nutrition habits and practices determine to large extent the manifestation of malnutrition in the first months of life. The practice of exclusive breast feeding is in decline, according to the maternal and infant health survey of 2002. The rates of exclusive breastfeeding are only 40 percent in children under 6 34 months of age. One positive aspect in the indigenous population is the high prevalence of exclusive breast feeding around the 5“ month of age. Nevertheless, a negative issue is the early and inadequate introduction of other liquids (including coffee) which starts around the 2”d month, particularly among the poorest and indigenous population.

Another important cause of malnutrition in Guatemala is the recurrent diseases of the infancy, especially gastrointestinal and respiratory infections. As mentioned above, these illnesses demand the highest care and attention from health services and are the main causes of death in the population under 5 years of age. The situation results from the interactions between the precarious hygiene conditions in which most of the poor families live, the low utilization of health services, and the higher biological vulnerability of the children which is increased by malnutrition.

Among other problems related to malnutrition in Guatemala, there is the inadequate intake of micronutrients such as Iron, Vitamin A, Niacin, Riboflavin, and Vitamin C. The public program to control the lack of micronutrients (Iodine, Iron and Vitamin A) has gone backward in the last years. Only 65 percent of the salt used by the households in Guatemala has adequate levels of Iodine (above 15 ppm). The prevalence of anemia caused by lack of Iron in children between 6 to 59 months (below 1lmg.dl) is of 40 percent and in children between 6 and 11 months is of 65 percent (ENSMI 2002). The prevalence of anemia among pregnant women is of 22 percent and in non-pregnant women in fertile age is of 20 percent. The lack of Vitamin A in children under 5 years old is of 16 percent (seric retinol of 20 ug/dl) according to the Micronutrients Survey which was conducted in 1995 (Marini and Gragnolati, 2002).

Institutional Response of Infant Malnutrition - Nutrition as a priority in the health sector has gone up from number 12 in 1996 to the fourth position in 2004. The Food and Nutrition Security Program of the MSPAS has a four pronged strategy to address the nutritional problem: (i)promotion and monitoring of growth, which includes monitoring of growth from pregnancy to 5 years old, (ii)supplementation program with micronutrients (Iron, Vitamin A, and folic acid) with universal coverage for all children, (iii)social management of food and nutritional security, and (iv) development of human resources in nutrition.

As mentioned above, the MSPAS is strengthening nutritional activities through Health Centers and Outposts, as well as through the PEC platform (“Programa de Extensi6n de Cobertura del Sistema Integrado de Atenci6n en Salud”). This is an initiative of the MSAPS in which alliances with NGOs form teams consisting of institutional and community personnel that offer basic health packages (SBS) to rural and isolated populations, which traditionally would not have access to the health services network. As part of the SBS strategy, micronutrients are offered to children and pregnant women, immunizations are conducted, and maternal and infant diseases are diagnosed, treated or referred. As part of the PEC, in 200 1 the MSPAS strengthened nutrition and maternal health interventions and initiated the AINM-C, Atencidn Integral a la NiAez y a la Mujer en la Comunidad, which focuses on growth promotion activities and individual counseling to mothers.

As part of a national effort to address malnutrition, the SOSEP (“Secretaria de Obras Sociales de la Esposa del Presidente”) has been working in the development and implementation of the “Programa Creciendo Bien which aims to improve the infant nutritional status of vulnerable communities through an integrated strategy of improvement of family determinants. The SOSEP program has a multisectoral approach which facilitates and promotes interventions to improve Food and Nutritional Security at the family level, with emphasis at the development of the women. Among the Creciendo Bien actions the ones which are most related to the health sector are (i)health education; (ii)nutritional education of mothers and of others responsible for the care of children; (iii)monitoring of the physical growth; and (iv) promotion of other health services available locally.

35 Government Strategy

Government Strategy. The Government has prioritized strengthening the Program for Extension of Coverage (PEC) and guaranteeing the universal provision of an improved basic package of services in the 11 1 municipalities, as defined in Guate Solidaria Rural (GSR). This strategy is being targeted to the poorest municipalities in two phases. The first phase, currently under implementation as a pilot, targets the poorest 41 municipalities, while the second phase is focused in the following 70 municipalities. This Project will support government efforts to implement the second phase.

Consolidating and scaling up PEC requires addressing two weaknesses the program faces. On the one hand, the current Ministry of Public Health and Social Welfare’s (MSPAS) mother and child referral network is inadequate and unable to respond to the needs of the population and the demand for services generated by the PEC. On the other hand, the current package of services provided through the PEC is insufficient to address chronic malnutrition effectively. The proposed project would support government’s priorities of strengthening and scaling up the PEC program by addressing these weaknesses. In addition, strengthening PEC will involve measure to ensure sufficient public funds to finance an enhance package of services, target the program to the rural areas of the most vulnerable municipalities, and putting in place practices to guarantee an adequate approach to indigenous populations.

Government’s priorities emphasize strengthening the Program for Extension of Coverage and guarantee universal provision of improved basic package of services in the 111 municipalities comprised in phases 1 and 2 of Guate Solidaria Rural. Government’s strategy to consolidate and scale up PEC requires addressing two weaknesses the program faces. On the one hand, the current MSPAS’s mother and child referral network is inadequate and unable to respond to the needs of the population and the demand for services generated by the PEC. On the other hand, the current package of services provided through the PEC is insufficient to address chronic malnutrition effectively. The proposed project would support government’s priorities of strengthening and scaling up the PEC program by addressing these weaknesses.

Accordingly, in the framework of Guate Solidaria Rural to improve the impact of PEC, the authorities have decided to complement the package with two interventions: (i)all municipalities and jurisdictions in which the PEC is providing services, the basic health package will be modified to include the AINM-C strategy to prevent chronic malnutrition through a community based program; and (ii)in the most vulnerable communities of the 111 municipalities (about 30-40 percent), the GOG is implementing the abovementioned Creciendo Bien strategy complementing other social interventions, but specially health and nutrition programs.

36 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 2: Major Related Projects Financed by the Bank and/or other Agencies

1. The Guatemala Maternal & Infant Health & Nutrition Project is the first health or nutrition investment project in Guatemala supported by the World Bank. However, the Bank is also supporting a similar model in other countries. The Bank has identified alternatives for collaboration in the social areas, and in particular in the health and nutrition sector to support government’s efforts to effectively addressed chronic malnutrition, which is one of the most worrisome red flags in human development in Guatemala, as well as the Government’s strategy to reduce poverty. The project represents the initial phase of a concerted effort to consolidate a successful and cost-effective government strategy to tackle prevalent malnutrition sustainable. Other Bank-financed projects address complementary areas, such as basic education. The Guatemala Maternal and Infant Health and Nutrition Project is part of an agenda that also includes projects such as:

Improve coverage at the primary school level, as Basic Education well as improving the quality of education. Project I IP-MS

Related projects by other international agencies include.

2. The Inter-American Development Bank (IDB), as well as other agencies such as: FAO, PNUD, UNFPA, UNICEF, EUROPEAN UNION, and USAID, funded interventions that are complementary to Infant Health and Nutrition, as part of the Poverty Reduction Strategy in Guatemala.

Project Name Amount Loan Approval Sector Issue Number Date LOANS

Health services 55,400,000 122UOC- Nov. 17- Improve the health status of the Guatemalan improvement program, GU 99 population, through an increase in the basic Phase I1 health services coverage, institutional reforms and hospital investments emphasizing on mother and child improved services.

a To be Technical Assistance by the Government of Quetzaltenango determined Japan through delivery in the short and long term of specialists in improving mother-child health, volunteers (nutritionists), training courses ifi Japan for 2 people, donation of equipment.

PAHO (Pan-American There are six These interventions have the following interventions: objectives: (i)technical cooperation toward 1. Technical strengthening the Health Sector in prioritized Cooperation municipal districts; (ii)to contribute to Decentralized and development of Health Public policies under 37 Approval Sector Issue Date innovative in normal & emergency circumstances; (iii)to prioritized areas; strengthened the capacity of the MSPAS to 2. Environmental increase access to quality of health services; health, sustainable (iv) to strengthen the Institutional and Civil development and Society groups operation skills to meet the alimentary and Health and Nutrition objectives of the MDG’s; nutritional security; and (v) to strengthen health analysis skills & 3. Universal Access to health information systems to prevent and services and health control priority health issues in prioritized technology; 4. Family , populations and municipal districts. and Community Health; 4. Prevention and Control of Diseases which are Health Priorities; and 5. Operation and Support to National Development of Health UNDP (United Nations evelopment I )gramme) Re-settling and re- 3,340,607 GUA/97/ To contribute to the compliance of peace insertion: attention of L17 objectives, particularly the Accord for re- integral emergencies in settling of populations uprooted by civil war, health by means of providing basic services in communities with the major concentration of uprooted population. 5,804,844 GUA/O1/0 Jan-07-00 To support the Executing Unit of the project Women and Children in 09 “Better Health for Women and Children in the Rural Areas Rural Areas of the Ministry of Public Health and USAID (Agreement 520-0428). The project GUA/01/009 will allow speeding up the allocation and execution of the Government funds for the implementation of health actions for beneficiaries. 3,93 1,192 GUN0 1/O Jan-08-01 To Support The Ministry of Health in the Prevention 10 compliance of the objectives of the National Program ITSNIWSIDA for education, prevention, epidemiologic surveillance and research by means of creating a mechanism for the timely investment of national resources. 4,277,043 GUA/02/0 Jan- 12-01 Implementation in 103 prioritized municipal Reduction of 08 districts (16 departments) which by their Malnutrition situation of procrastination, poverty and extreme poverty require immediate attention to modify their current health status. These will be classified in 2 groups according to their level of procrastination, rate of unsatisfied needs and alimentary vulnerability Program to Improve 10,9680,000 GUA/02/0 Jan-07-02 To improve the health status of Guatemalan health Services, Phase 10 population through out increases in coverage of basic health services, institutional modernization and investment in hospital services focused in mother-child care. 1,043,300 GUNO3I0 Jan-08-03 Reduce poverty and improve the health in the Health Project for 09 most vulnerable groups of the population by vulnerable groups, means of improving the access and utilization of health services. 38 Project Name Loan Approval Sector Issue Number Date UNFPA (United Nation Fund for Pop ation Activ jties) There are five 740,525 These interventions have the following interventions: objectives: (i)to expand the coverage, quality 1. Accessibility to and access to basic public health services; (ii) birth-control drugs; to improve the delivery of reproductive health 2. Strengthening of services, in selected areas, to attend birth Reproductive Health emergencies, to prevent cervical cancer, and Services and Reduction to locally improve the implementation of of Maternal Mortality; programs and policies in reproductive health 3. Reduction of in 7 departments; (iii) to offer assistance Maternal Mortality; 4. through APROFAM to those women needing Strengthening the health-related services and reproductive care; process of detection and (iv) to provide training based on the Law and treatment of cases of Social Development with special focus on of violence against reproductive health. women; and 5. Promotion campaign of the Law of Social Development UNICEF (United Natio i Children’s E id) There are two 331,454.13 These interventions have the following interventions: objectives: (i) to improve the current 1. Strengthening the nutritional status of 0-5 year old children and strategy of the reproductive-age women living in high-risk Secretary of Social towns and villages; and (ii)to improve Work of the First Lady; practices of breastfeeding and child nutrition and toward improving the children’s quality of life 2. Promotion campaign and contributing to drastically reduce child to inform about mortality rates. adequate practices of proper child nutrition and breastfeeding. Strengthening the strategies of the Healthcare Sector to improve the nutritional condition of 0-5 year old children EUROPEAN UNION PRRACIGISEIO 11043 7,550,000 Sep-07-00 PRRAC-Salud is making an effort to improve Expansion of the I the health conditions of the citizens of Izabal, primary assistance Jutiapa and Santa Rosa, by supporting the health system in Ministry of Health and local authorities.

Guatemala I I I USAID (United States gency for International Development) Project of promoting 1,750,000 Apr-28-05 To increase the number of nurses that work in nursing as a form of rural areas of Central America, by providing primary health primary health assistance. To raise the assistance in Central capacity of the participants to develop an America atmosphere that promotes nursing in the I context of primary health assistance. Strategic objective 3 27,421,894 I I Sep-14-04 I To expand the coverage, quality and Grant agreement effectiveness of basic health and education 520-0436 services, focusing especially on rural areas, Social investment: the poorest indigenous people and girls, and to Healthier and more strengthening the nutrition programs for 0-2 educated Deovle vear old children. 39 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 3: Results Framework and Monitoring

Results Framework

improve maternal and infant indigenoushon indigenous infant mortality ratio in project health in the project’s 40 areas area of intervention: indigenoushon indigenous maternal mortality ratio in project area Lessons for strengthening % of institutional deliveries in the areas of intervention health and nutrition services and for scaling reduce chronic malnutrition % of children under 2 with weight for age < -22 in projects strategies among children younger than 2 area years of age in the rural areas of % of children under 2 with height for age -22 in projects the 70 municipalities targeted < area by the project.

Component One: Strengthening of the Maternal and Number of secondary level services with comprehensive Infant Health Network health services “cartera ampliada ” & operating room fully operational Number of secondary level services with comprehensive health services, but without operating room, fully Monitor implementation Operational of interventions in the % of pregnant women receiving pre-natal care within the project areas first 20 weeks of pregnancy in the areas of intervention o/o mothers receiving post-natal care within 10 days of delivery in the areas of intervention % of indigenous families attended by the facility Component Two: Nutrition: Reduce chronic % of children under 2 years old who participate in the malnutrition & implement weighing sessions in the areas of intervention Creciendo Bien % of children for whom change in weight is measured in the areas of intervention Monitor implementations % of families attended by Creciendo Bien in areas of of interventions in the intervention project areas Integrated strategy for the implementation of the three programs % ofjurisdictions with AINM-C I Component Three: Design and implementation of a Monitoring and Evaluation of the project done with regular communication, M&E and reports from the information system providing the data Monitor implementations auditing system (reports should have the data disaggregated by area, region, of interventions in the municipality, indigenous and non-indigenous, rural and project areas urban)

40 Arrangements for results monitoring

Data Co Frequency Outcome Indicators

indigenoushon indigenous infant mortality ratio in - 10% To be project area Beginning determined -1 intermediate indigenoushon indigenous by and final maternal mortality ratio in individual - 10% Survey project area CAIMI’s -5% baseline I % of institutional deliveries in the areas of survey I Yearly 0 5% 20% intervention lo% 15% - I I + % of children under 2 with 1.5 I MSPAS weight for age -22 in -I-4.5 1.5 11 15 e perc + + + projects area percen percen percen percen enta Yearly tage tage tage tage % of children under 2 with To be ge point point point point height for age < -22 in poin determined M&E projects area t by baseline - system +1 survey I perc +3 +5 +I + 10 enta percen percen percen percen Yearly ge tage tage tage tage poin point point point point t

1 Outputs Indicators for Each Component 1

Component One : Number of secondary level services with cartera ampliada & 0 8 8 8 8 8 operating room fully operational Number of secondary level services with cartera ampliada, but 0 10 20 12 10 32 without operating room, SIGSA fully operational Yearly SIGSA - reports % of pregnant women with at least one prenatal 60% 100% care in project areas % mothers receiving post- Baseline natal case within 10 days survey of delivery in the areas of intervention (information 0 5% 10% 15% 20% to be gathered from CAIMI and PEC) -

41 Component Two : % of children under 2 I years old who participate in the 0 40% 55% 65% weighing sessions in the areas of intervention % of children for whom UPS-1 change in weight is 0 40% 55% 65% reports measured in the areas of intervention UPS-1 % of families attended by 1 Creciendo Bien in areas o 0 80% intervention

Integrated strategy for the Availa By de end of Program N/A implementation of the ble the project documents three programs Number of jurisdictions 0 112 with AINM-C 30 112

I Component Three : Monitoring and Evaluation of the project done with regular reports from the information system M&E providing the data 0 1 2 3 3 3 MSPAS (reports should have the reports data disaggregated by area, region, municipality, indigenous and non-indigenous, rural and urban)

42 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 4: Detailed Project Description

The proposed project seeks to support, during a five year period, the ability of the Government of Guatemala to reduce the Infant Mortality, and Maternal Mortality rates and the prevalence on chronic malnutrition among those that present the highest rates, the poorest, the rural and the indigenous people. A project of US$49.0 million31is proposed, with four components, to be implemented over a five-year period.

Component 1. Strengthening of the Maternal and Infant Health Network (US$22.8 million) This component would support the development of a Maternal and Infant Health Referral Network, promote the demand for maternal and infant health care, and contribute to increase the proportion of safe institutional deliveries, the referral of obstetric emergencies directly from the community, and access to a referral system for children with acute respiratory and digestive diseases. This component is divided in four subcomponents:

1.1 Maternal and Infant Health Promotion from the community. This sub-component would focus on the community perception of the maternal and infant health problems, thereby promoting the demand for health services. A healthy community for pregnant women, mothers and newborns is an informed, participatory and supportive community, supporting access to the PEC and the CAIMIs, as well as promoting healthy maternal and newborn-related behaviors. The role of men and other influentiaYdecision-makers is a key factor to promote healthy community programs, and would be essential in this subcomponent.

A community based approach would contribute to enhance the inclusion of the alienated indigenous and rural population in health service provision, and ensure critical behavioral change and demand for health services. Specifically, this subcomponent would:

0 Support community organization by promoting the involvement and participation in decision-making processes on maternal and infant health issues, including the promotion to provide culturally accepted interventions. This support includes technical assistance and local workshops involving local NGOs and authorities to i)create a list of existing community organizations, ii)develop a plan to articulate the existing organizations, and iii)develop local plans to promote synergies.

0 Develop a strategy to increase men’s and local leaders’ participation in maternal and infant health promotion. Men are key decision-makers in attitudes towards maternal and infant care-seeking. They need to understand the needs, risks and the danger signs of pregnancy, childbirth and postpartum periods to support women. Promotion of the role of men as partners and fathers is essential for their involvement and support. Health care workers need to be prepared to work with men and other key local decision makers as well as with women, to support them in their roles. The necessary change in the maternal and infant care-seeking behavior will be achieved mainly through culturally appropriate education programs for men and women, (adolescents and adults), and health workers. The Project would finance preparation of training materials and workshops.

0 Design a communication and training strategy on responsible motherhood and fatherhood This activity would be connected with the Communication Program in Component 3. Considering local strategies to disseminate parent rights and responsibilities, the project would: i) design

31 Including Front End Fee US$122,500 43 communication contents and materials, ii) coordinate with Component 3 (the communication strategy) for the promotion of responsible motherhood and fatherhood, iii)prepare training guides and iii)conduct trainings and workshops.

Engage community groups and, traditional birth attendants to identify obstetric emergencies better and to refer them in a timely manner to the CAIMIs. Community leaders, family members, Traditional birth attendants (TBAs), and other influential community members need to be positive agents for supporting women and newborn health emergencies. A simple program to train local key actors on identification of obstetric and infant health emergencies would be implemented with the participation of local health workers and trained community workers.

1.2 Strengthening capacity of the secondarv health level. This subcomponent would develop a higher level of resolution of maternal and infant health services, to support and provide responses to the health problems identified by the PEC.

Specifically this subcomponent would: Finance the upgrading of 40 health units to CAIMIs (Maternal and Infant Health Centers), distributed in key strategic points of the Maternal and Infant Health Care Referral Network. These CAIMIs would be created mainly through rehabilitation of existing health facilities. All these CAIMIs would include: delivery rooms, rehydration treatment units and acute respiratory therapy services. In addition, eight of these CAIMIs would have surgery facilities to allow caesareans. These CAIMIs would be added to the already five CAIMIs under development financed by the MSPAS to complete on average two CAIMIs per department. Three of the CAIMIs under development have surgery facilities to allow caesareans (table 4.1). Strengthen the demand for reproductive health services by disseminating messages on safe motherhood, including the timely referral of obstetric emergencies and promoting the participation of traditional birth attendants as integrated human resources in the CAIMIs. Training to build a network team. The project would support a systematic and constant process of capacity building of skilled personnel in order to build a strong network team. This strategy would include the PEC personnel going for training at the CAIMIs on a regular basis, and the CAIMI teams going on a regular basis to the referral hospitals. This strategy not only ensures that these teams have appropriate up-to-date skills, but also it increases the level of efficiency by giving teams an opportunity to network, get to know each other and become more efficient as the climb the learning curve of knowing how to work with each other. This training would emphasize culturally appropriate and supervised health services to increase safe births assisted rates, access to rehydration treatment and acute respiratory therapy services for children under 5 years. The subcomponent would also support the training of professional obstetrics. Determine the maternal and infant health indicator baseline for each new CAIMI. Finance contracting out of laboratory services when this option is superior to developing the MSPAS’s services.

1.3 Strenpthening the referral system. This subcomponent would focus on the articulation of the PEC and CAIMIs and CAIMIs and the hospitals, and support the creation of Maternal Homes (“Hogares Maternos”) to facilitate access to safe deliveries to those women living in isolated areas.

Specifically this sub-component would:

Finance radio communications and ambulances to support the referrals from the PEC’s units and directly from the communities for obstetric emergencies. The support will also strengthen the referral system from the CAIMIs to main hospitals;

44 0 Support a clear definition of treatment protocols, identification of facility standards and norms for each level of care that establishes criteria for when to refer patients; 0 Support five regional blood banks for the regular provision of blood units to the CAIMIs.

1.4 Creation of Maternal Homes [ “Hogares Muternus ”). This subcomponent would support municipalities to create Maternal Homes ( “Hugares Maternus ’I). These Maternal Homes would facilitate access to safe deliveries to those women living in isolated areas. Specifically this subcomponent would support non-medical equipment - e.g. furnitures, home appliances - for Maternal Homes; each of these Maternal Homes will be linked to a CAIMI. The MSPAS will establish agreements with the municipalities to ensure operation and sustainability of Maternal Homes. The operational manual will include a standard model for this agreement.

It is estimated that CAIMIs would provide Maternal and Infant secondary health to 1.26 million inhabitants in 2,329 small communities, an average of 3 1,400 inhabitants per CAIMI.

Tentative locations of CAIMIs were selected considering maternal and infant health indicators, lack of access to secondary services and communications. Final locations would be defined through local workshops involving local organizations, communities and local authorities. (See the list of tentative locations below).

Overall, this component would support (i)civil works, medical and non-medical equipment, training, technical assistance, radio communication equipment, ambulances, grants for the developments of the maternal homes and promotion of community involvement during the entire project, and (ii)laboratory services and incremental human resources on a declining basis during the first two years of each CAIMI. The human resources would be contracted using the same selection process used by the MSPAS. The salaries and benefits of these personnel would be also equivalent to the MSPAS personnel to facilitate the later transference to the MSPAS. The component will not finance drugs and medical supplies.

45 Table 4.1: Tentative CAIMI locations

A Number of communities in the reference area B CAIMIs with surgery room C Locations were agreed during community workshops. (The remaining workshops would take place during the project execution)

46 Component 2. Nutrition - Implementation of the AINM-C and “Creciendo Bien” Strategy (US$ 21.9 million) This component aims to address the problem of child malnutrition in the selected 70 municipalities by expanding coverage of community-based growth promotion and basic health services. In a country like Guatemala, where half of the children are chronically malnourished and where acute malnutrition is relatively low, concerted actions are needed in the areas of health, access to basic services, education, and specific nutritional interventions. Here more than in any other Central American country tackling the main determinants of chronic malnutrition on a long term basis requires a multi-sectoral approach and addressing issues such as: mother’s nutritional status; family planning including pregnancies at a young age, number of children and intra-birth spacing; low rates of exclusive breastfeeding; incidence of illness in young children including diarrhea and respiratory infections; and household consumption and parents’ nutritional information. Most of these determinants of chronic malnutrition can be prevented through community-based interventions appropriately linked to the health system, which have been successfully proven in other countries of Central America and which have been recently incorporated in the MSPAS’ PEC program in Guatemala.

In addition, this component will expand community-based capacity-strengthening of mothers and families in the most vulnerable and indigenous communities. In order to seriously tackle the issue of malnutrition in the country, there is need to ensure that special attention is given to indigenous communities. On average, 70 percent of indigenous children are malnourished in Guatemala. It has been shown that indigenous children are significantly smaller than non-indigenous children, even after controlling for income, education, and infrastructure, all of which the indigenous population has less of than the non- indigenous population. Large differentials in chronic malnutrition by ethnicity may reflect social exclusion or other forms of differential access to services, or the existence of traditional practices that may inte$ere with adequate growth of children. A successful approach to preventing malnutrition therefore needs to focus on the most vulnerable population and consider two issues: i)ensure that demand for services is generated; and ii)make sure that those targeted can best respond to intervention. For this purpose, the project will focus on improving the capacity of vulnerable and indigenous women and families, a key objective of the Creciendo Bien program coordinated by SOSEP in Guatemala.

This component consists of 3 sub-components: (1) Strengthening the basic AINM-C package of services including preventive activities (growth monitoring, neo-natal care, early stimulation), basic curative activities (management of prevalent childhood diseases and referral of severely malnourished children), and appropriate individual counseling to mothers including community volunteers; (2) Extending the Creciendo Bien activities aimed at strengthening women’s, families’ and communities’ capacity in the most vulnerable and indigenous communities of the 70 municipalities, increasing demand for basic social services through informing families living in the targeted areas about their rights related to these services and encouraging them to utilize them; (3) Ensuring appropriate supervision of nutrition activities. Therefore, this component is expected to have a significant impact, not only in terms of the extension of nutrition services to the poorest municipalities, but also because it is expected to produce positive spillover effects through increased demand for social services in very vulnerable areas.

2.1 Strengthening the basic AINM-C package of services The Project will support the MSPAS’ efforts to improve the basic health and nutrition service package provided through the PEC. The project will provide financing and technical assistance to strengthen and consolidate the preventive health and nutrition program of the MSPAS (the AINM-C program) to engage both families and communities to monitor and maintain the adequate growth of children younger than age two and pregnant and lactating women, and treat and refer children younger than five who are ill. Child health and nutrition activities previously provided under the Creciendo Bien strategy will be consolidated under the PEC through the AINM-C strategy. Growth monitoring activities will be standardized around the protocols and materials already developed and used by the PEC. In particular, (i)adequate monthly

47 weight gain (a dynamic measure, particularly for children under two) will be used as key indicator.32This is a departure from the traditional focus on nutritional status (a static measure of attained growth).33 A child’s failure to attain the expected weight gain (independently of where he is on the growth chart) is now used as a triggering device for applying a diagnostic analysis to identify the causes of inadequate weight gain and is combined with formative-research based protocols that address the causes of the problem. (ii)In addition, weight measurements will be collected monthly while height measurement should be taken twice a year for monitoring purposes).34

Services under this project will be provided by the NGOs contracted by the MSPAS for the PEC. The NGOs will provide services for the AINM-C through well trained community workers (monitoras), normally mothers volunteering for the program and supervised by local and regional health staff35. The monitoras will work closely with the community health workers (vigilantes) of the PEC to monitor the growth of children under two years old; counsel mothers on proper care for their babies and toddlers; advise and monitor pregnant and lactating women and refer them to the health team or health center when they suspect other medical or health problems exist. Different from the vigilantes, the monitoras will not receive a salary but in-kind incentives for their work (such as a cap, an apron, etc.) and formal recognition within the local health team. The vigilantes of the PEC, typically men, ensure that mothers and children participate in the monthly activities and provide the necessary preventive and curative primary health care services to children at risk of malnutrition. The NGO will be responsible, along with the community, to identify the monitoras, provide them with training, support and supervision. The monitoras will organize growth promotion activities to best accommodate mothers of the communities during the course of the month36.When the mobile health team comes to the communities (typically once a month) the monitoras will ensure follow up of those children that are found not to be growing well. The mobile health team must find the time to participate to and supervise counseling activities of the monitoras at least twice a year (figure 4.1).

32 A mother is told the weight that the child should be in a month, based on a scientifically determined table of expected weight gain. It has been shown that the motivated mother then tends to be eager to know whether the child made it . 33 Often children with any weight gain are thought to be doing well while actually there is a slow erosion of their growth rate over time because the weight gain was not enough. A child’s failure to gain weight is often a first sign of an early underlying problem. 34 Height measurements are much more complicated and require more capacity; weight for height indicators are more difficult to interpret; moreover, mistakes happen more often in height measurements of infants. Finally, height changes much more slowly than weight: it makes less sense to use height to monitor short term changes in nutritional status. 35 The AINM-C strategy is currently implemented by vigilantes of the PEC strategy, whose activities are often limited to making sure that mothers and children participate to the health and growth monitoring sessions as they are part of the PEC team and therefore busy with many other tasks. In addition, the fact that the vigilantes are normally men makes them unsuitable for individual counseling to mothers, particularly on topics like breastfeeding and birth. 36 Counseling to mothers by the monitoras takes some time and cannot be done in the same day when the mobile health team comes to the community. 48 Figure 4.1. Supervision estructure of AINM-C

RR.HH. Dei MSPAS para atender una Jurisdiccion de 10,000 Habitantes

Tecnico

I r 67 VigilantedMonitoras d e S a I u d 1

1 Vigilante/Monitora es responsable de 1 sector de 20 6 30 familias

Finally, community participation is the cornerstone of this program. The community is systematically engaged by carrying out its own analysis of why the kids are having problems and the actions it needs to undertake as a community to improve it. This is based on the recognition that many problems causing inadequate child growth go beyond the power of individual families. Poor quality water, lack of sewage and garbage disposal, poor health centers outreach can be tackled effectively through organized community actions.

Activities: Implementation of the AINM-C protocol will consist of the following activities: 1. Training ofmonitoras.Technica1 trainers on nutrition (educadoras) will join the health team to provide training to monitoras on topics such as breastfeeding, complementary feeding, family feeding, basic health and hygienic practices. 2. Monthly Growth Promotion Sessions (growth monitoring and individual counseling) for children younger than two years of age and pregnant women. Monitoras and vigilantes will, on a monthly basis, i) weigh children and women; ii)control adequate weight gain; iii)provide individual counseling to mothers on different topics such as childcare, promotion of exclusive breastfeeding for children under six months, appropriate complementary feeding after six months, home hygiene, water usage, cooking demonstrations; iv) check for major illnesses and refer children to the health posts if needed; v) check for other major health actions (immunizations, essential micro-nutrients such as Vitamin A, iron and folic acid37,deworming).

37 Vitamin A supplementation will be financed through the AINM-C while iron and folic acid are part of the basic PEC package. 49 3. Home visits to sick or not adequately growing children and pregnant women. Monitoras and vigilantes will provide more frequent contact with those children that have showed problems or do not attend the weighing sessions. 4. Referral of children to the health centers for immunizations, prenatal checks, severe malnutrition, sickness (children or mothers). 5. Monthly meetings with the local health personnel for coordination of activities and continuous education of the monitoras and vigilantes. 6. Strengthening community participation - Bi-annual meetings with the whole community and local authorities to discuss main problems of health and nutrition in the community and find solutions together. The communication strategy of SESAN will be coordinated with these activities.

Implementation - Expanding the AINM-C model will consist of the following initial steps: i) identification of participating jurisdiction; ii) incorporation of a technical trainer on nutrition (“educadora ”) to the primary level health team (two educadoras every 10,000 people) and a supervisor every 30,000 people); iii) organization of a local health training team that includes women representing language and cultural diversity; iv) training of the local health team in technical (breastfeeding, complementary feeding, family eating habits, hygiene, etc) and methodological aspects (communication techniques); 4 validation of programs with the communities and local leaders to reinforce their responsibility; vi) selection of community nutrition volunteers (mothers) in agreement with the whole community; vii) training of community volunteers; viii) census of all children under age two conducted by the health workers and the community nutrition volunteers in their target zone the first two months of the program and once every year thereafter; ix) identification of a location for the nutrition activities; XI provision of tools for growth monitoring, counseling and recording of data and activities (AINM-C materials of MSPAS) to the local teams.

2.2 Extending the Creciendo Bien Program in the most vulnerable communities This subcomponent will improve dissemination about social services available to families living in the poorest communities, encourage families to utilize these services and strengthen the capacity of the most vulnerable populations to implement the AINM-C program successfully. In the most vulnerable and indigenous communities, the project will finance self-esteem and training activities coordinated by the Creciendo Bien program, a two year long strategy designed to develop the capacity of women and families for the prevention of malnutrition. This training will support the creation of demand for services and a better understanding and acceptance of the activities offered by the AINM-C strategy. The project will finance the expansion of the Creciendo Bien program in 30 percent of the most vulnerable communities in the 70 municipalities covered by PEC, with a particular emphasis on the indigenous communities.

The program will develop a sequence of activities (see below) over a period of two years to develop capacity at the individual, household and community level with the final objective of preventing child malnutrition successfully, establishing healthy food habits in the households and strengthening communities’ abilities to address the determinants of malnutrition that are outside the control of the family. Community and municipal participation will contribute to improving the implementation strategy and guaranteeing future sustainability. For this purpose, the program promotes community self management and participation and builds on inter-institutional coordination. The community, after having developed its own analysis of the determinants of malnutrition, will decide on which actions it needs to undertake as a community to improve it.

The program will provide a field officer (“te‘cnico de campo”) for every 6 communities. In each community, working groups of 20 to 30 mothers will be formed. The field officers (“te‘cnicos de campo”) will work closely with the vigilantes de salud and the monitoras. The field officers responsibilities will 50 include (i)training on the main themes of Creciendo Bien i.e. self-steem, hygiene, gender issues; (ii) household visits to follow up on practices and behavioral change; (iii)individual counseling, particularly for mothers and households in which specific problems were identified; and (iv) coordination with and follow up of programs and activities implemented by other agencies such as MAGA, MINED, and the Violence Household Program (“Programa de Violencia Familiar”) of SOSEP. The field officer will coordinate the activities with the monitoras to ensure adequate follow up especially of the growth monitoring element.

Activities: Specifically, expansion of the Creciendo Bien program will consist of the following activities: 1. Individual training and counseling to women in reproductive age on topics not covered by the AINM-C program such as self esteem, gender equality, education, child care, home care and strengthening the messages of the AINM-C. 2. Household level education on good health practices and economic growth, responsible fatherhood, intra-household violence, food and nutrition security, family economics, hygiene, food habits, family and reproductive health. 3. Community level communication activities on leadership, importance of nutritional health unit, use of natural resources and environment, basic community health, emergency plans, self management for community development. The communication strategy of SESAN will coordinate to ensure that the message and content will be in line with the content of the training of Creciendo Bien program.

Implementation plan: Expanding the Creciendo Bien programs in the most vulnerable communities will consist of the following steps: i) identification of the target communities by SEGEPLAN in coordination with MSPAS ii) local validation of community by SOSEP iii) identification, hiring, and training of field officers by SOSEP iv) promotion of the program at the community level by the field officer with the support of SOSEP’s departmental director v) organization of women working groups in the community by the field officer vi) launching of the program and signature of a formal agreement with local authorities (“acta de compromiso y aprobaci6n”) vii) implementation of program activities, Le., capacity building, household visits, individual counseling, and coordination with and follow up of other agencies programs viii) training of individuals, households, and communities in implementation of program activities as described above

All the activitites to implement Creciendo Bien will be included as part of the contracts with NGOs providing the PEC and AINM-C.

The Creciendo Bien program will be geographically scaled up in two steps. An initial step will expand the program in a subset of the 30 percent of the most vulnerable and indigenous communities of the 70 municipalities. After the mid-term evaluation to assess the cost-effectiveness of the Creciendo Bien intervention in the target communities is completed, the MSPAS, together with the SOSEP and the World Bank, will agree on the timing and coverage of the second step geographically scaling up.

2.3 Supervision of nutrition activities The objective of this subcomponent is to provide support and technical assistance to the MSPAS to consolidate an institutional structure that can guarantee proper monitoring of the provision of basic health and nutrition services. The current supervision system is designed to follow up on the quality of service provided and monitor families’ patterns behaviors regarding child care and nutrition.

The project will strengthen the MSPAS to supervise the NGOs contracts. The MSPAS has prepared a Manual for Supervision of the Expansion of Health Services under the existing service provision and will also be using this for the contracts under this project. For each group of 8 to 10 field officers, SOSEP will

51 provide a supervisor who will coordinate his activities with the MSPAS supervisor at the departmental level.

In addition, the community health council will systematically (at least twice a year) meet with the NGO team and a representative from the regional health teams to discuss the provision of health and nutrition services in the past period and alternatives to improve services in the future to meet the needs of the population and address the main causes of malnutrition as they emerge during the AINM-C and Creciendo Bien acti~ities.~~

Institutional responsibilities The MSPAS through UCPYP and supported by the SIAS will be responsible for implementation of the AINM-C strategy and for standardizing the activities in the communities currently served by the Creciendo Bien program. The MSPAS prepared a Project Implementation Plan. SEGEPLAN will ensure that the poorest and most vulnerable communities are targeted first and that appropriate control communities can be selected for the evaluation study. UCPYP will coordinate the implementation of the Creciendo Bien intervention in close collaboration as per the institutional agreement established with SOSEP (details in the operations manual) and SEGEPLAN for the identification of communities. In particular, SOSEP will be responsible for establishing contacts with communities, providing technical inputs, organizing and managing the training activities, and in particular ensuring inter-institutional collaboration.

Financing The project will finance contracts with NGOs for the provision of the basic package of AIM-C and Creciendo Bien services. The AINM-C package of services provided by the NGOs will include: Information, Education, and Communication (IEC) equipment and material; growth monitoring material (scales, meters); equipment for cooking demonstrations; in-kind incentives to the monitoras (basic equipment such as cap, apron, bag); micro-nutrients (Vitamin A); training and re-training (once a year in addition to the initial one) of monitorus and health vigilantes; administrative costs. The Creciendo Bien package of services provided by the NGOs will include basic equipment for participating mothers (basic hygiene accessories such as dental kit, soap, comb, mirror), recruitment training and salary of the technicians who will provide weekly support to Creciendo Bien communities, IEC equipment and material; training and re-training (once a year in addition to the initial one) of the technicians; administrative costs. Finally, the project will strengthen the supervision capacity of the MSPAS by financing (i)technical assistance, (ii)training activities, (iii)Information Technology (IT) equipment, (iv) transportation equipment, and (v) other operating costs.

Normally the NGOs providing services under the Creciendo Bien are the same NGOs that provide the AINM-C under the PEC basic package.

The project will finance two types of contracts with NGOs. The first type, in jurisdictions where NGOs are already offering PEC services, will be a contract with the same NGOs that adds to the provision of basic health services through the PEC and the provision of AINM-C and Creciendo Bien services39.The second type of contract, for jurisdictions where NGOs do not qualify to be recontracted, will offer contracts to NGOs selected according to procedures established in annex 8.

The cost of the AINM-C package of services has been established based on the experience of the existing activities by the MSPAS. The average per capita cost is around US$11 for five years (about US$2.2 per year) and is consistent with the cost studies done in preparation for previous projects. The average per capita cost of the Creciendo Bien component is estimated at US$19.3 for two years (normal duration of

38 These activities are different from the activities of auditoria social. 39 This contract is subject to the NGOs offering good quality services and to the fact that the selection process used by the MSPAS to select NGOs is acceptable to the Bank. 52 Creciendo Bien activities). Payments to NGOs will be apportioned quarterly based on the progress in meeting the targets, including a 10% overhead fee paid to the NGOs.

Indicators For the AINM-C: participation to growth monitoring activities, percentage of children who have been growing adequately, percentage of children who have been not growing adequately, percentage of children who have not been growing adequately twice in a row; height for age patterns and weight for age. For the Creciendo Bien: proportion of committed and participating mothers, number of technical personnel trained.

Component 3. Monitoring, Evaluation, and Communication ($2.4million). This component seeks to: (i)provide support to poor families to learn about nutrition and health programs, encourage poor and indigenous population to utilize health and nutrition services, promote changes in pattern of behavior, disseminate te population’s rights to utilize services, and encourage social auditing; (ii)design and implement a comprehensive monitoring and evaluation system for the nutrition and health interventions; and (iii)measure the Project’s impact on targeted population welfare. In accomplishing these objectives, the component includes three sub-components: A Communication Strategy, a Monitoring and Evaluation System, and the Impact Evaluation of the Project.

3.1 Communication Strategy (US$1.O million). The objectives of the communication strategy supported by the Project will include (i)influencing and promoting ownership and sustainability of activities to prevent malnutrition at the community level; (ii)informing targeted populations about health and nutrition services and encouraging poor families to utilize them; (iii)promoting social audits of health and nutrition services; and (iv) disseminating the importance of nutrition preventive activities and fostering pro-active work with communities by health staff responsible for providing services. The communication strategy will be designed ensuring its coherence with, and promoting the AINM-C and Creciendo Bien interventions.

The communication plan will emphasize the utilization of adequate means and communication channels taking into account cultural, ethnic, and gender particularities in targeted areas. It is expected that the strategy will reach at least 80 percent of mothers participating in the AINM-C strategy, and from these least 60 percent has put in practice no less than one of the activities suggested through the communication plan.

The project will support, through community leaders, the dissemination of those SESAN’ s nutrition strategies that are consistent with the objectives defined under component 2.

The communication strategy, which will be contracted to a specialized firm through a competitive bidding process, consists of four stages as follows:

Audience identification, including mothers with children younger than five, volunteer mothers, mid- wives (comadronas), fathers and other relatives caring and feeding young children, supervisors, health staff involved in nutrition services (nurse, community and institutional facilitators, ambulatory doctors and staff in health centers and posts, among others). Identification of behaviors to be changed. An initial set of behaviors will be agreed with the MSPAS and SOSEP, the communication strategy intends to influence include home practices regarding infant and maternal health and nutrition, utilization of health and services, and social audit of quality of health and nutrition services, among others. Communication strategies. The communication strategy will emphasize community means to send messages and reach the targeted population. It will include, mass media through local radio, press media, educational material, training and workshops, and others.

53 0 Resources. Implementing the strategy will require human resources and equipment. The strategy will involve mainly staff from the MSPAS, SESAN, and SOSEP at central level, and health staff involved in service provision at sub-national level. The SESAN will be responsible for supervision of all processes and stages of the communication strategy. The strategy will also require (i)equipment and material to produce messages, operating costs, and other materials. 0 Monitoring and evaluation of the strategy. The Monitoring and Evaluation system of the project will include a module to evaluate the effectiveness and impact of this communication strategy.

To achieve this, the strategy will include the following activities: (i)Mass dissemination of key messages through diverse communication means previously agreed between SESAN and MSPAS, with particular emphasis on the role of the volunteer mothers and individual counseling; (ii)mass dissemination of key messages to promote health and nutrition services among targeted areas and encourage poor families to utilize them; and (iii)workshops and training at the health district level.

3.2 Monitorinp and Evaluation KJS$0.6 million). This sub-component will support the design and implementation of a results-based monitoring and evaluation system for health and nutrition programs, within the efforts that the Government of Guatemala is making in moving towards a national integrated results-based monitoring and evaluation to sustain its social policy. At the moment there is no integrated M&E system for social programs in Guatemala and the institutional arrangements, including the mandate and responsibilities of each actor, are in the process of clarification. Hence this component will fund activities to help with the inventory of existing inter-governmental partnerships for M&E of health and nutrition programs, and the development and operationalization of an adequate organization of the information system for health and nutrition programs. In order to speed up the process of implementation, some of these activities will start before the beginning of the project.

This sub-component will assist in the efforts to establish an M&E system for the project and generally for health and nutrition programs. There is a need for close coordination among the several institutions that will be involved with the M&E for the nutrition component, MSPAS, SEGEPLAN, INE, SESAN, SOSEP, in terms of data collection and monitoring of indicators.

In particular the activities of this sub-component will be aimed at: 0 Coordinating and integrating the information system for health and nutrition indicators, in order to guarantee the flow of information and the collection of variables needed; 0 Implementation monitoring, through the organization of a system of indicators that track the project’s physical and financial progress during implementation; 0 Assessing the process implementation, to determine the program performance in the domains of service utilization and program organization; 0 Results monitoring, to gather information on the direction, pace and magnitude of change in the variables of interest and to identify unanticipated changes; 0 Assess the impact of the interventions to determine what portion of the documented changes the intervention caused, and what might have come from other events or conditions.

The results and findings of these activities systems are meant to: (a) inform the design and prioritization of health and nutrition programs and policies; (b) improve organizational management; (c) inform the process of budgetary allocation; (d) improve transparency and accountability.

Coordination of information system, Implementation monitoring and process evaluation

Given the large number of sources of information that will be used, the integration of numerous databases will be critical for the successful M&E of the project. To this purpose, an assessment of the roles and responsibilities in data collection and outcomes monitoring will be carried out by an external consultant who will identify the existing data collected by each agency, their frequency and their use. The consultant

54 will also recommend and help design a database system to gather and process in a timely fashion the information that is crucial for project management and implementation supervision.

The information system would strengthen the efficacy of health and nutrition programs by supporting the generation of ongoing information on the direction, pace and magnitude of change, and thus allowing for keeping track of the inputs, activities and outputs used to achieve a given outcome. The information system will gather and process information held by MSPAS, SESAN, SOSEP, SEGEPLAN and MAGA. Regular reports will be prepared and sent to key policy makers at the municipal and community level in the project areas, and at the different agencies. The objective of this database will be: (a) to facilitate the process of information storage and documentation; (b) to contribute to the statistical and econometric analyses; (c) to contribute to the monitoring process, which will require the timely input and transfer of data; (d) to permit the transfer of information from one system to another; (e) to develop a system that can store the maximum amount of data with the greatest use-friendliness.

The process evaluation will investigate how well the program is operating, how consistent the services actually delivered are with the goal of the program, whether services are delivered to appropriate recipients, and the effectiveness of program management. Indeed monitoring data do not give the basis for attribution and causality for change. They do not provide evidence of how changes are corning about, and cannot address the strengths and weaknesses in the design of the project. A program has to be well implemented and executed in order to have the ability to improve the situation. For this reason this component will include an assessment of program process at the end of the first year of implementation, to assess the fidelity and effectiveness of the program’s implementation. Clearly the process evaluation is indispensable in assessing the impact of the program and critical to ensure the credibility of the results in case of a positive impact. Indeed information on product outcomes that evaluations of impact provide is incomplete and ambiguous without knowledge of program activities and services that produced those outcomes.

The process evaluation will be particularly meaningful since both components have proven their effectiveness in other countries (AIN-C in Honduras, and CAIMIs). Hence, good implementation can be presumptive evidence that the expected outcomes are produced as well. Moreover, this evaluation will provide the feedback to allow the program to be managed for high performance, and the associated data collection and reporting of key indicators may be institutionalized in the form of a management information system to provide routine, ongoing performance feedback. There will be two types of indicators: “provision indicators” that measure the capacity of the institution to provide promised services, and “utilization indicators” that measure the level at which the new resources are being used. See table below for a list of these two types of indicators.

This sub-component would support: (a) design, training of staff and implementation of this database; (b) software and hardware equipment for the database; (c) system management and updating; (d) operational costs for project period; (e) baseline surveys for component 1.

Provision indicators Utilization indicators > Number of secondary level facilities that refer to an P Number of women with prenatal visits Number of institutional deliveries maternal home P P Number of neo-natal visits P Number of municipios that counts with a systematic training process for TBA ( comadronas) P Number of centers with ambulances P Number of secondary level services with comprehensive health services & operating room and those without

55 Component 2

Provision indicators Utilization indicators 9 Number of training of local health team 9 Number of children under 2 years old who participate in the weighing sessions 9 Number community volunteers (mudres monitorus) chosen and trained 9 Number of pregnant women monitored 9 Number of nutritionists to the primary level health team 9 Number of children monitored (growth) (per person) 9 Number of children who receive vit A supplements 9 Number of technical personnel trained 9 Number of children who receive iron supplement 9 Number of census of all children under 2 conducted 9 Number of women who receive folic acid supplement 9 Number of tools for growth monitoring, counseling and 9 Number of women with exclusive breastfeeding recording of data and activities provided to local teams 9 Number of women trained (mujeres capacitadas) 9 Number of training in community participation 9 Training in productive activities 9 Number of jurisdictions with educatior in the basic health team 9 Number of jurisdictions with certified census and entered in the automatized system 9 Number of jurisdictions that maintain a report for monitoring of pregnant women 9 Number of jurisdictions tha maintain a report for monitoring of children under 2 years old 9 Number of jurisdictions that implement an automitized system for monitoring of indicators for service delivery 9 Number of communities that signed commitment minutes (acta de compromise) with the program 9 % home visits 9 % communities started to process of decentralized rural development

Component 3

Provision indicators 9 Data sources and institutional responsibilities for M&E identified 9 Information system implemented 9 Training of staff in M&E 9 Process evaluation performed 9 Number of TV and radio messages on maternal and infant health and nutrition delivered 9 Number of TV and radio messages on health services and social auditing delivered

3.3 Impact Evaluation (US$0.8 million). This component will coordinate a rigorous mid-ter and final evaluations to measure the impact of the project in reducing chronic malnutrition in the targeted areas. Given that malnutrition is such a dire problem for Guatemala, assessing the impact of the project on reducing malnutrition is crucial, not only because the country is in need of proven interventions to tackle malnutrition, but also for the “demonstration” effect and the political support that it could provide. The

56 objective of this kind of evaluation is the documented change in the outcome variable. It will be implemented through contracting a specialized firm through international bidding under the category of consultant services.

Before implementation, a baseline survey will be conducted to define the initial condition against which future change of key variables can be tracked. The main outcome of interest to measure the impact of the AINM-C program will be weight for age. Since in some locations the project will finance implementation of an additional program -Creciendo Bien-, it will also be necessary to evaluate the effects of the interaction between the Creciendo Bien component and the AINM-C program carefully and rigorously. In particular, given the high cost of the Creciendo Bien, it was agreed that it will first be implemented in a sub-sample of the targeted communities before scaling up, in order to assess its cost effectiveness.

In terms of impact evaluation methodologies, it will be critical to survey a “control” group of similar non- participant, so as to generate comparison data of those with and without the program. In the pilot there will be three groups: a group that receives AINM-C only, one group that receives AINM-C plus Creciendo Bien and one control group. The control group is essential as it is the only way in which the changes can be attributed to the existence of a program or project. The group that receives both treatments allows the assessment of whether the strategy of community integrated attention to children and women faces constraints that can be overcome only by the simultaneous improvement of women’s self-esteem. The possibility of a synergy of interaction between the two intervention packages has important implications for decision makers, because it affects the cost effectiveness of the project and future expansion strategies for the program. Before implementation, the choice of the control group will be defined, and a baseline survey will be conducted. Moreover, in order to ensure the best evaluation of the program, it will be important to assess the presence of similar or complementary programs in the project and control areas to be able to control for them.

There will be no impact evaluation for Component 1. The reason is that the activities supported by this component have already shown to be effective in reducing maternal and infant mortality. Moreover, given the limited magnitude size of the effect to be detected, the sample size would have to be excessively large, and thus too expensive.

Component 4. Institutional Strengthening (US$1.7 million). This component, will support the institutional capacity of the Ministry of Health to implement and administer basic health and nutrition services. In particular, the project will support the UCPYP, UPS 1, and UPS2 consultant services by providing technical assistance and equipment, for an approximate cost of US$1.4 million. The Project will also support the recently created SESAN to improve its institutional capacity to administer the information management system of SESAN. The Project will finance consultant services, equipment, and workshops and training (approximately US$0.3 million).

57 Annex 5: Project Costs Guatemala: Maternal-Infantil Health and Nutrion Project

Project Cost By Component and/or Activity (US$ Million) Foreign Local Total A. 1.0 Strengthening of the Maternal and Infant Health Network 1.1 Maternal and Infant Health Promotion from the community 0.01 1.39 1.40 1.2 Strengthening of capacity of the secondary health level 3.93 14.01 17.94 1.3 Strengthening the referral system 0.30 1.87 2.16 1.4 Maternal Homes "Hogares Maternos" 0.35 0.35 Subtotal 1.0 Strengthening of the Maternal and Infant Health Network 4.23 17.62 21.85 B. 2.0 Nutrition - Implementation of the AINMC- and "Creciendo Bien" Strategy 2.1 Strengthening the basic AINM-C Package of services 0.0 14.07 14.07 2.2 Extending the "Creciendo Bien" Program 0.0 7.37 7.37 Subtotal 2.0 Nutrition - Implementation of the AINMC- and "Creciendo Bien" Strategy 0.0 21.44 21.44 C. 3.0 Communication, Monitoring, Evaluation and continuous Auditing System 3.1 Communication System 0.02 0.98 1.oo 3.2 Monitoring and Evaluation System 0.01 0.58 0.59 3.3 Impact Evaluation 0.00 0.80 0.80 Subtotal 3.0 Communication, Monitoring, Evaluation and continuous Auditing 0.03 2.36 2.39 D. 4.0 Institutional Strengthening 0.03 1.61 1.63 Total BASELINE COSTS 4.28 43.03 47.31 Physical Contingencies 0.22 .58 0.80 Price Contingencies 0.1 1 0.66 0.77 Front-end fee 0.12 .12 PROJECT COSTS 4.73 44.27 49.00

cost The World Project Cost Summary including % of Bank Yo of (US$ Million) contingencies total Financing Financing

A. 1.0 Strengthening of the Maternal and Infant Health Network 1.1 Maternal and Infant Health Promotion from the community 1.44 2.9 1.44 100.0 1.2 Strengthening of capacity of the secondary health I 18.82 38.4 18.82 100.0 1.3 Strengthening the referral system 2.20 4.5 2.20 100.0 1.4 Maternal Homes (Hogares Maternos) 0.35 0.7 0.35 100.0 Subtotal 1.0 Strengthening of the Maternal and Infant Health Network 22.81 46.5 22.81 100.0 B. 2.0 Implementation of the AINMC- and"Creciend0 Bien" 2.1 Strengthening the basic AINM-C Package of services 14.52 29.6 14.15 100.0 2.2 Extending the "Creciendo Bien" Program 7.42 15.1 7.42 100.0 Subtotal 2.0 Implementation of the AINMC and "Creciendo Bien" 21.94 44.8 21.94 100.0 C. 3.0 Communication, Monitoring, Evaluation and Continuous Auditing Systems 3.1 Communication System 1.01 2.1 1.01 100.0 3.2 Monitoring and Evaluation System 0.61 1.2 0.61 100.0 3.3 Impact Evaluation 0.83 1.7 0.83 100.0 Subtotal 3.0 Communication, Monitoring, Evaluation and Continuous Auditing Systems 2.45 5.0 2.45 100.0 D. 4.0 Institutional Strengthening 1.68 3.4 1.68 100.0 Front end fee 0.12 0.3 0.12 100.00 Total PROJECT COST 49.00 100.0 49.0 100.0

58 Republic of Guatemala Maternal-lnfantil Health and Nutrition Project Project Components by Year -- Totals including Contingencies (US$ Million) 2007 2008 2009 2010 2011 Total A. 1.0 Strengthening of the Maternal and Infant Health Network 1.1 Maternal and Infant Health Promotion from the community 0.19 0.37 0.32 0.30 0.27 1.44 1.2 Strengthening of capacity of the secondary health level 8.68 5.37 4.76 - 18.82 1.3 Strengthening the referral system 0.81 0.64 0.49 0.12 0.13 2.20 1.4 Maternal Homes "Hogres Maternos" -~~~-~0.16 0.1 1 0.09 0.35 Subtotal 1.0 Strengthening of the Maternal and infant Health Network 9.84 6.49 5.66 0.42 0.40 22.81

B. 2.0 Nutrition - Implementation of the AINMC- and "Creciendo Bien" Strategy 2.1 Strengthening the basic AINM-C Package of services 3.96 2.31 2.82 2.64 2.79 14.52 2.2 Extending the "Creciendo Bien" Program --~~--1.88 1.88 1.82 7.42 Subtotal 2.0 Nutrition - Implementation of the AINMC- and "Creciendo Bien" Strategy 5.84 4.19 4.64 4.48 2.79 21.94

C. 3.0 Communication, Monitoring, Evaluation and Continuous Auditing Systems 3.1 Communication System 1.01 1.01 3.2 Monitoring and Evaluation System 0.16 0.1 1 0.1 1 0.1 1 0.1 1 0.61 3.3 Impact Evaluation ~~______--0.24 0.33 0.25 0.83 Subtotal 3.0 Communication, Monitoring, Evaluation 1.41 0.1 1 0.44 0.37 0.1 1 2.45

D. 4.0 lnstitutionalng Strengthening 0.52 0.28 0.29 0.29 0.30 1.68 Front End Fee 0.12 0.1 2 TOTAL PROJECT COSTS 17.73 11.07 11.03 5.57 3.60 49.00

59 Republic of Guatemala Maternal-lnfantil Health and Nutrition Project ExDenditure Accounts by Years -- Totals Including- Contingencies (US$ Million) 2007 2008 -~2009 201 0 201 1 Total I. Investment Costs A. Civil Works 5.33 2.65 2.23 10.20 B. Equipment, furniture and materials Equipment and furniture 1.73 0.50 0.34 2.57 0.10 Materials 0.10 ~~ Subtotal Equipment, furniture and Materials 1.83 0.50 0.34 2.66 C. Consulting Services Nutrition Service Providers 5.84 4.19 4.64 4.48 2.79 21.94 Local consultants 0.45 0.39 0.36 0.32 0.33 1.86 Firms 0.42 0.20 0.54 0.31 0.05 1.52 Non-consulting services 0.89 0.13 ~___0.07 0.05 0.02 1.18 Subtotal Consulting Services 7.60 4.91 5.62 5.17 3.20 26.50 D. Personal CIAMIS, CAPS and “Blood Banks” Personnel ClAMlS 1.16 1.17 1.19 3.53 Personnel CAPS 1.10 1.32 1.13 3.55 Personnel Blood Bank 0.06 0.04 0.04 0.13 Subtotal Personal CIAMIS, CAPS and “Blood Banks” 2.32 2.53 2.36 7.21 E. Training Workshops 0.13 0.08 0.08 0.08 0.08 0.45 0.05 0.05 0.05 0.21 Forums 0.02 0.05 ~~ Subtotal Training 0.15 0.12 0.13 0.13 0.13 0.66 E. Grants 0.16 0.1 1 0.09 0.35 F. Operational Cost 0.22 0.25 0.27 0.27 0.28 1.29 Front End Fee 0.12 0.12 TOTAL PROJECT COSTS 17.73 11.07 11.03 5.57 3.60 moa

60 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 6: Implementation Arrangements

1. Introduction

The proposed project is part of the interventions the GOG is implementing in the framework of the Guate Solidaria Ruraf’. Specifically, this project is intended to support the goals of improving maternal and infant health and reducing malnutrition of young children and pregnant women. These objectives would be supported by the proposed Project through the implementation of Component 1: Strengthening the Maternal and Infant Network, and Component 2: Implementing and scaling up the AINM-C strategy and the Creciendo Bien intervention. These activities would be supported by improved M & E systems, a comprehensive communication strategy at the community level, and strengthened capacity building of implementing agencies.

The MSPAS would be the implementing agency and would have overall responsibility for all Project components. The MSPAS has demonstrated that it has the administrative and organizational capacity to implement interventions to provide basic health services throughout the country. Specifically, the Ministry has shown flexibility and innovation to go beyond institutional and traditional structures to provide basic health services and has been one of the pioneers in Latin America in introducing innovative and cost/effective alternatives to reach very poor and remote areas through the PEC. Lower than expected progress in health and nutrition indicators, especially since the early 2000s, cannot be attributed to the PEC model itself but to external factors that undermine its effectiveness, including: i)insufficient public spending in health and nutrition as a proportion of GDP compared to Latin America average, ii)deficient targeting, iii) incomplete package of services, and iv) lack of proactive approach to involve indigenous communities. The Government has acknowledged these weaknesses and the proposed Project involves measures to support the MSPAS in addressing them.

Therefore, implementing and sustaining basic health and nutrition intervention as included in this project may be challenging for the Ministry. The Project would support the MSPAS to enhance its capacity to scale up, administer, and supervise basic health and nutrition interventions (including Creciendo Bien activities), involving the abovementioned aspects; i.e., enhancing the basic package of services, focusing the intervention in targeted areas, increasing public spending in health and nutrition, and adopting inter- cultural methodologies to reach indigenous communities. The MSPAS would implement the Project in close collaboration with the Secretariats of Social Work Secretariat of the President’s Wife (SOSEP), and of Food and Nutrition Security (SESAN).

The Project would not create any new agencies or units but would utilize the existing institutional and implementation arrangements established within the Ministry of Health, adequately supported by technical specialists and equipment as needed. Accordingly, the Project would not create a project coordination unit separated from the ongoing administrative organization within the MSPAS. On the contrary, technical aspects and financial, administrative, and procurement matters would be executed by the respective departments or units at the central and sub-national levels (“areas de salud”) of the Ministry. In doing so, the Project includes the abovementioned actions to support monitoring and evaluation and to strengthen current institutional capacity and administrative structures as well as support government to improve coordination mechanisms to consolidate a single nutrition strategy throughout the country.

40 Even though Guate Solidaria Rural is designed as a two-year integral intervention targeted to the extremely poor families (Segeplan (nd) Estrategia de Reducci6n de Pobreza Guate Solidaria -Rural-), investments within this Project are intended to create permanent extension of coverage of basic services, as explained in Annex 4. 61 The recently created Program and Projects Coordination Unit ( “Unidad Coordinadora de Programas y

Proyectos ”- UCPYP) within the MSPAS is responsible for the administrative, financial, and procurement aspects of all programs implemented by the Ministry and financed with external funds, including this project. Accordingly, this Unit would operate on the basis of the inputs prepared by, and in coordination with the existing technical units of SIAS within the Ministry. In the case of this project, the UCPW would interact with the technical units of SIAS, and with the Unit responsible for Monitoring and Evaluation within the Ministry. Accordingly, technical units would prepare the annual operating plans (POAs), define and enforce technical norms and regulations, develop terms of reference as needed, supervise progress, and in general would be the primary responsible for project implementation. On the basis of such inputs, and in close coordination with the technical Units, the UCPYP Unit would have all for the project.

2. Institutional Arrangements by Components

Even though all Project components respond to specific objectives included in Guate Solidaria Rural and carrying them out would be under the responsibility of the MSPAS, institutional arrangements would vary slightly for each component. Under the above mentioned general framework, each component would be implemented under the following specific institutional arrangements:

Component 1. Activities to strengthen the maternal and infant health network would be the responsibility of the SIAS (“Sistema Integral de Atenci6n en Salud”) within the Ministry. The SIAS functions in relation to this project include to (i)organize the referral system at municipal levels in coordination with the PEC units and hospitals, and (ii)coordinate with local authorities and communities for the implementation of the maternal homes and the “Maternal and Infant Health Promotion from the community’’ sub-component. The Reproductive Health Program (Programa dee Salud Reproductiva) will be responsible for (i) definition of the technical protocols for the secondary level, and (ii)definition, administration and supervision the training program included in Component 1. The Office of the Minister (Despacho Ministerial), taking into account the areas with higher infant and maternal mortality and consultation with the community and local authorities, will be responsible for the definition for the final location of CAIMIs and select those that would have a surgery room. The subnational level through the “areas de salud” will be responsible for administration, supervisision, and regulation the CAIMIs.

Component 2. The SIAS would be the Unit within the Ministry of Health responsible for the expansion of AINM-C and the implementation of Creciendo Bien intervention - with the support of SOSEP. The combined strategy has been under implementation since 2005 as a pilot program in the 41 most vulnerable municipalities through a dual scheme: the Ministry of Health provides AINM-C in the jurisdiction (“jurisdicciones”) rural areas of all municipalities, and SOSEP implements Creciendo Bien in the most vulnerable communities of those areas -about 40 percent of the communities. To scale up the strategy, the Ministry of Health would be the single implementation agency, working in close coordination with SOSEP. SEGEPLAN will be responsible for the identification of the most vulnerable communities where Creciendo Bien will be implemented. The reasons to introduce such adjustment include: (i)to ensure the integration of nutrition-related interventions; (ii)to provide targeted communities with a single and coherent package of services; and (iii) to guarantee sustainability of interventions while the implementation, administrative, and procurement capacity of SOSEP is still in the process of being strengthening.

Scaling up each sub-component in the 70 municipalities targeted by the Project would follow a similar pattern, but would be under the responsibility of the Ministry of Health. Implementing and scaling up of the AINM-C strategy would adopt the geographical targeting mechanism at the municipal level established by the Guate Solidaria Rural to reach universal coverage of the most vulnerable, according to

62 the Vulnerability Index41built by SEGEPLAN. The Creciendo Bien intervention would be implemented as a complement to the AINM-C strategy and focused on the most vulnerable and remote communities within the targeted municipalities, as explained in Annex 4. Carrying out this intervention would also adopt geographical targeting, but at the community (lugares poblados) level using SEGEPLAN’ s Priority index for communities42. Following this ranking, the Guate Solidaria Rural’s Steering Committee43 would define the communities within the 70 municipalities that would benefit from the Creciendo Bien intervention.

AZNM-C. The proposed Project would support the extension of AINM-C coverage in the rural areas where the basic package of health services is provided through the PEC in targeted areas. The AINM-C strategy would be implemented by improving the basic health package of services provided through the PEC program. Accordingly, the basic health package would include additional activities, particularly strengthening individual counseling provided by volunteer mothers selected from the beneficiary communities. Therefore, as appropriate, the same service providers of the PEC packages (Le., through NGOs contracted under non-consultant services scheme) would be responsible for providing the AINM-C intervention. The SIAS would be responsible for (i)review the basic package of services to include the interventions to be provided by this project, (ii)review the criteria for selecting service providers when needed, (iii)defining the criteria for selecting volunteer mothers for providing individual counseling, (iv) coordinate with SESAN and SOSEP to define key messages, means, and strategy for the communication and dissemination plan included in Component 3 of this Project, and (v) at the sub-national level, interact with local jurisdictions and communities to ensure proper involvement in the AINM-C strategy.

Creciendo Bien. The SIAS would be responsible for the implementation of this intervention in close coordination with SOSEP and SEGEPLAN. Services provided under the Creciendo Bien package would be included in the AINM-C and PEC basic package in order to guarantee a single provider (Le., an NGO) in each beneficiary community and avoid unnecessary coordination issues. SOSEP would supply the SIAS with technical inputs to provide services within the Creciendo Bien interventions as specified in Annex 4. Specially, the Secretariat would support the Ministry through SIAS in the following issues: (i) establishing contact with intervened communities (lugares poblados) and agreeing with them on activities and social audit; (ii)preparing and implementing training and workshops for communities and mothers; and (iii)supervising the Creciendo Bien intervention.

In order to ensure that the impact of Creciendo Bien is as high as possible, the Ministry of Health would scale it up gradually. Incorporation of communities would be divided in “cohorts. A close monitoring and evaluation would accompany the first set of communities in the intervention in the 70 municipalities so that subsequent “cohorts” of communities can benefit from any adjustments to the intervention.

Component 3. While the Ministry of Health would be the implementing agency, each of the sub-components included in the Communication, Monitoring and Evaluation component requires different coordination arrangements. In order to implement each sub-component, the following arrangements are being put in place:

The Communication, Education and Traininn at Community level Strategy (CETC), which seeks to design and implement a strategy to complement Government’s interventions in nutrition and health, would be the responsibility of SESAN, MSPAS and SOSEP. This sub-component would utilize the institutional arrangements currently in place. Accordingly, the communication strategy, its content, main

41 The Vulnerability Index is built on the basis of three set of variables: (i) Food Security situation (40 percent), including extreme poverty incidence, chronic malnutrition rate, and food availability; (ii) Natural Risks (25 percent), including droughts, floods, and ice; and (iii) Coping Capacity (35 percent), including roads rate and crop usable fields (Segeplan (2005) “Estrategia de Reduccidn de la Pobreza Guate Solidaria -Rural-). 42 In order to rank communities (lugares poblados) SEGEPLAN built the index for prioritization of rural communities based on the unmeet basic needs at the community level. Only communities with 30 or more households can be included as targeted communities. 43 Food Security and Nutrition Committee (Mesa Tkcnica de Alimentacidn y Nutricidn). 63 messages and general coordination would a result of the joint effort of MSPAS, SESAN, and SOSEP. The Ministry of Health, through the UCPYP, would contract a specialized firm using competitive bidding to implement the strategy. The MSPAS would be the implementing agency not only because it is administratively advisable (since SESAN is a new executing agency in the process of being strengthened), but also because coordination is crucial to guarantee unified and opportune messages, as well as adequate means (Le., rural and community radio).

The Monitoring and Evaluation System. Several institutions will be involved in the M&E of the system, for data collection and monitoring of indicators, especially for the nutrition component of the Project (MSPAS, SEGEPLAN, SESAN, and SOSEP). At the moment there is no integrated M&E system in place and the institutional arrangements, including the mandate and responsibilities of each actor, are unclear. Hence this component will fund technical assistance and training to help with the inventory of existing inter-governmental partnerships for M&E and the development and operationalization of an adequate organization of the information system. In order to speed up the process, some of these activities will start before the beginning of the project and will be financed by the Japan PHRD fund and the World Bank Institute (WBI).

The Impact Evaluation of the Project would be implemented with a contract awarded to a specialized firm under international bidding in the category of consultant services. To ensure the quality of the evaluation, the MSPAS may hire a specialized consultant to prepare the Terms of Reference of the Impact Evaluation. The contracting activities will be responsibility of the UCPYP from inputs from SIAS technical units.

Component 4. The MSPAS would also be responsible for procuring activities to strengthen the institutional capacity of the Ministry and SESAN. These activities, consisting mainly of consultant services, equipment, and operating costs, would be the responsibility of the Ministry. In the case of SESAN, corresponding activities (hiring consultants and purchasing equipment) would be the responsibility of UCPYP under a cooperation agreement (“acuerdo de cooperaci6n”) between the MSPAS and SESAN.

Participating Agencies and Units

Overall responsibility Ministry Public Health and The MSPAS would be the implementing agency and would have overall Social Welfare (MSPAS) responsibility for all Project components. Project and Program This Unit would be responsible for the administrative, financial, and procurement Coordination Unit (UCPYP) aspects of all programs implemented by the Ministry and financed n,ith external funds, including this project. This Unit would operate on the basis of the inputs prepared by, and in coordination with the existing technical units n,ithin the Ministry. “Sistema Integrado de This Unit - n,ith the support of its technical units - would support the UCPYP to Atenci6n a Salud” SIAS - prepare the annual POAs, define and enforce technical norms and regulations, Component 1 develop terms of reference as needed, and supervise progress. “Sistema Integrado de This Unit - with the support of its technical units - would prepare the annual Atenci6n a Salud” SIAS - POAs, define and enforce technical norms and regulations, develop terms of Component 2 reference aj needed, supervise progress, and in general \vould be the primary responsible for the implementation of Component 2. SEGEPLAN This Central Government Agency will be responsible for: i) targeting mechanism to implement Creciendo Bien, and ii) the overall coordination of the M&E system. Secretariat of Food Security The Secretariat will i)be responsible for coordinating the communication strategy, and Nutrition (SESAN) and ii) participate in the design and implementation of the M&E in coordination with MSPAS and SEGEPLAN. Secretariat of Social Works The Secretariat will support MSPAS to implement and supervise the Creciendo of Wife’s President (SOSEP) Bien strategy of the component 2 of the project.

64 The graphic below represents schematically the institutional framework.

Schematic representation of institutionalframework

General Directorate Integrated System of Health Attention Administration

I - UCPYP

I I I I

65 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 7: Financial Management and Disbursement Arrangements

Summary Conclusion of Financial Management Assessment On the basis of the assessments performed, the financial management team presents the following conclusions: (i) The executing agency, MSPAS, will be responsible for managing the fiduciary aspects of the proposed project, through a new unit, the unit for coordination of projects and programs financed with external funds (UCPYP), located within MSPAS.

(ii) As MSPAS has ongoing experience managing externally-financed projects, it has in place a basic administrative structure, which puts it in a good position to take over the financial management functions of the proposed project (currently, MSPAS is managing a project financed by the IDB, albeit with the help of UNDP). However, the FM capacity assessment (FMA) has identified project-specific actions in order to strengthen the financial management (FM) capacity of UCPYP and enable it to carry out the financial activities of the proposed project effectively .

(iii) Therefore, assuming that MSPAS carries out the proposed action plan presented in this assessment, it would have in place adequate financial management arrangements that meet the Bank’s minimum fiduciary requirements to manage the specific financial activities of the proposed project.

Organizational Arrangements The loan borrower will be the Republic of Guatemala, represented by the Ministry of Finance (MINFIN). Overall project coordination and administration will fall under the Ministry of Public Health (MSPAS). Within MSPAS, the unit for coordination of projects and programs financed with external funds (UCPYP), in coordination with MSPAS’ s General Management and MINFIN’ s National Treasury, will be directly in charge of financial management (FM) tasks for the proposed project. These will basically include: (i)budget formulation and monitoring; (ii)cash flow management (including processing loan withdrawal applications); (iii) maintenance of accounting records; (iv) preparation of in-year and year-end financial reports; (v) administration of underlying information systems; and (vi) arranging for execution of external audits.

It is important to note that, even though UCPYP was established by the “Acuerdo Ministerial SP-M- 2358-2005”, the unit is not yet operational. The plan is to staff this unit with technical and administrative & financial specialists (which will also be responsible for coordinating with MSPAS’ financial management department (GDAF) and ensuring that project financial information is properly recoded). It is expected that staff within UCPYP’s administrative & financial department will be dedicated to specific projects and that staff from the existing administrative & finance department in charge of the administration of PMSS financed by IDB will be transferred to UCPYP, and continue to provide assistance with PMSS. As a result, the terms of work of PMSS financial staff will need to be broadened in connection with the new responsibilities under UCPYP, which will also need to be strengthened with at least two additional Accounting Assistants (eligible for loan financing under component IV) to handle the prospective increase in the number of financial transactions.

Budget Planning The aggregate medium-term project expenditures will be incorporated by MSPAS into its multi-annual budget, and will inform the annual budget formulation process. Between January and April of each year, MSPAS will prepare its tentative investment program for the next year. The program should be consistent

66 with the budget policy provided by MINFIN, be incorporated into the national public investment system (SNIP), and -once approved- be reflected in MSPAS’s budget proposal. This budget, in turn, will be incorporated by MINFIN into the general state budget for its approval to Congress.

On the basis of the approved budget, MSPAS will adjust as needed its project annual work (POA) and procurement plan, which will be reviewed by the WB.

Accounting and Financial Reporting Accounting Policies and Procedures. The main FM regulatory framework for the project will consist of (i)the Organic Budget Law (LOP) and its Regulations, which norm the public sector FM systems, Le. budget, accounting, treasury, and public credit; (ii)the annual Law of the General State Budget; (iii) MINFIN’s manuals based upon the cited laws; and (iv) the Unit’s operating norms (currently in draft form).

Project-specific FM arrangements that are not contemplated in the documents cited above will be documented in a concise FM section of the project’s operational manual. Among others, specific reference will be made to: (i)the contractual and payment terms of basic health and nutrition services; (ii) the internal controls (e.g., payment terms and clearance of advances) related to agreements with communities; and (iii)the formats of project financial and audit reports.

Information Systems. In compliance with regulations, MSPAS will operate financial transactions using its Integrated FM System for Executing Units (SIAFI), which will contain modules for budgeting, treasury, and accounting functions. SIAFI is being developed and should be linked to the government- wide integrated accounting system (SICOIN). It will be the responsibility of UCPYP to maintain accounting records specific to the project and ensure that project implementation information is recorded into SLAFI and SICOIN. However, at this moment, it is unclear whether the UCPYP will be able to do that through an automatic SIAFI-SICOIN link. In’ the meantime, data will be processed directly in SICOIN, supported by a simple system to compile project financial statements on the basis of SICOIN’s balances. The PMSS unit has a computerized financial management system (Nautilus designed specifically for the accounting of externally-funded projects), which is adequate for the accounting of projects with external financing.

Financial Reports. On a semi-annual basis, MSPAS will prepare and submit to the WB an unaudited interim financial monitoring report (FMR) for monitoring purposes, containing: (i)a statement of sources and uses of funds and cash balances (with expenditures classified by subcomponent); and (ii)a statement of budget execution per subcomponent (with expenditures classified by the major budgetary accounts). The FMRs will be submitted not later than 45 days after the end of each semester.

On an annual basis, MSPAS will prepare project financial statements including cumulative figures, for ,the year and as of the end of that year, of the financial statements cited in the previous paragraph. The financial statements will also include explanatory notes in accordance with the Cash Basis International Public Sector Accounting Standard (IPSAS), and MSPAS’s assertion that loan funds were used in accordance with the intended purposes as specified in the Loan Agreement. These financial statements, once audited, will be submitted to the WB not later than six months after the end of the Government’s fiscal year (which equals the calendar year).

The supporting documentation of the quarterly and annual financial statements will be maintained in MSPAS’s premises, and made easily accessible to WB supervision missions and to external auditors.

Flow of Funds WB Disbursement Method. Loan proceeds will be withdrawn by MSPAS using the advance method with supporting documentation based on interim statements of expenditures (SOEs). When using statements of expenditures (SOEs), the SOE threshold will be consistent with the

67 procurement prior review thresholds (as described in Annex 8) and described in the disbursement letter. All supporting documentation for payments using SOE procedures and other payments in general for project activities will be retained by the Ministry for audit purposes and made available for the Bank’s supervision.

Other Procedures. For certain large contracts of goods (if required under the applicable procurement rules), there may be a need for the use of direct payments or special commitment procedures. Should the need arise during implementation, the WB will evaluate it and, if granted, agree to the use of the cited procedures with the Borrower via reference to the Disbursement Letter.

WB Designated Account. MINFIN’ s National Treasury Directorate (Treasury) will open and maintain a segregated account in US Dollars in the Bank of Guatemala (BANGUAT), to be used exclusively for deposits and withdrawals of loan proceeds for eligible expenditures. After the conditions of effectiveness have been met, and the designated account has been opened, MSPAS will submit its first disbursement request to the WB, together with the expenditure and financing needs forecast for the next four months. For subsequent withdrawals, MSPAS will submit the disbursement request along with the Statement of Expenditures (SOE). At any time, the undocumented advance to the designated account cannot exceed the authorized allocation to be established in the WB’s Disbursement Letter.

Flow of Funds - In General. The project intends to incorporate a flow-of-funds model that relies more heavily on country systems, thus helping reduce transaction costs in relation to management of parallel payment systems, and helping preserve the integrity of the budget management system by preventing off- budget execution of WB funds. The proposed flow-of-fund is still under discussion with the Ministry of Finance.

Therefore, for the flow of funds for the proposed project, at least at the beginning, the “traditional” method will be used. Therefore, in addition to the designated account in BANGUAT in US dollars managed by MINFIN’s Treasury, MSPAS/UCPYP will open an operational account in Quetzales in a commercial bank, funded on the basis of advances from the designated account, to execute payments. UCPYP will be the entity responsible for preparing documentation for expenditures and record expenditures ex-post (“regularizaci6n”) in SICOIN.

Alternatively, the project could use the proposed flow-of-fund (based on ongoing discussions with the Ministry of Finance), which is for the Treasury to execute payments -ordered by the MSPAS through SICOIN- out of the National Treasury Single Account (CUN). The Treasury will simultaneously reimburse the paid amounts to the CUN from the WB’s designated account. In other words, withdrawals from the designated account will be to cover expenditures financed out of the CUN.

Flow of Funds - Specifics. The contracting and payment terms for basic health and nutrition packages will be detailed in the project’s operational manual. In brief, the payments will be based on a contractually agreed per capita rate, with a maximum advance not exceeding commercial practice, followed by quarterly payments and advance clearances against invoices and service delivery reports.

WB Disbursement Schedule

Expenditure Loan % of Expenditures to be Category Amount (US$) Financed 1. Goods and associated services 3,000,000 100% 2. Works and associated services 9,650,000 100% 3. Consultants’ services, training and audits 5,200,000 100% 4. Health Services (a) under Component 1 of the Project 7,000,000 100% (b) under Component 2 of the Project 2 1,490,000 100% 15. ODeratinn costs 1.290.000 1 100% 6. Front-end fee 122,500 Amount payable pursuant to section 2.04 of the loan agreement 7. Unallocated 1.247.500 Total 49,000,000 I

Audit Arrangements

Internal Audit. In the course of its regular internal audit activities vis-8-vis the institutional budget, MSPAS’s internal auditors may include project activities in their annual work plans. MSPAS will provide the WB with copies of internal audit reports covering project activities and financial transactions.

External Audit. The annual project financial statements prepared by MSPAS will be audited following International Standards on Auditing (HA), by an independent firm (or the Controller General of Accounts, subject to prior agreement with the Bank) and in accordance with terms of reference (TORs), both acceptable to the WB. The audit opinion covering project financial statements will contain a reference to the eligibility of expenditures.

In addition, memoranda on internal controls (“management letters”) will be produced on a semestral basis.

The audit work described above can be financed with loan proceeds. MSPAS will arrange for the first external audit within three months after loan effectiveness. Each audit engagement is expected to cover at least two years.

Financial Management Action Plan

Action Responsible Completion Date Entity 1. Prepare and reach agreement on the format of MSP.4SNB Before negotiations financial monitoring reports (FMRs). 2. Prepare draft FM section of the project operational MSPAS Before negotiations manual. 3. Finalize audit TORs. MSPAS Before negotiations 4. Finalize and present the approved structure of MSPAS Before effectiveness I UCPYP, its operating norms,-and the formal plan for I I transfer of personnel to this unit. 5. Refine proposal and choose, in agreement with MSPASNINFINI Before effectiveness MINFIN and WB, the internal payment system (i.e., WB through Treasury or through an operational account). 6. Identify and, if possible, incorporate required MSPAS Before effectiveness incremental FM staff assistance. 7. Finalize the chart of accounts for the project and MSPAS Before effectiveness incorporate it into the accounting system. 8. Contract external auditors. MSPAS 3 months after effectiveness

WB FM Supervision Plan. A WB FM Specialist should perform a supervision mission prior to effectiveness to verify the organization and staffing strengthening of UCPYP and the FM system. After effectiveness, the FM Specialist must review the annual audit reports, should review the financial sections of the quarterly FMRs, and should perform at least one supervision mission per year.

69 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 8: Procurement Arrangements

A. General Procurement for the proposed project would be carried out in accordance with the World Bank's "Guidelines: Procurement under lBRD Loans and IDA Credits" dated May 2004; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated May 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Loadcredit, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. Procurement of Works: Procurement of works under the project amount to approx. US $9.36 million. These include upgrading or rehabilitations of 40 health centers to CAIMIs (Maternal and Infant Health Centers). The works involve delivery theaters, dehydration treatment units and acute respiratory therapy services. In addition eight of these CAIMIs would have surgery facilities to allow caesareans. The procurement will be done using the Bank's Standard Bidding Documents (SBD) for all ICB and SBD agreed with or satisfactory to the Bank for NCB and shopping. Procurement of Goods: Goods procured under this project would include: medical and non medical equipment, radio communication equipment and materials, ambulances, laboratory equipment, tools for growth monitoring and recording of data, basic hygiene accessories, etc. The procurement will be done using the Bank's SBD for all ICB and SBD agreed with the Bank for National Competitive Bidding and shopping. Procurement of non-consulting services: Non-consulting services include training, workshops, laboratory services, support to radio communications. The procurement will be done using the Bank's SBD for all ICB and SBD agreed with the Bank for National Competitive Bidding and shopping. Selection of Consultants: incremental human resources, support five regional blood banks for the regular provision of blood units, promotion of community involvement, communication strategy -including investments in mass media (community radio, TV, press) and educational material, monitoring and evaluation, national and international consultants to assist with the design and oversight of the M&E system, impact evaluation Short lists of consultants for services estimated to cost less than $ 200,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines.

The selection process for individual consultants that will be contracted for strengthening the capacity of the health sector shall be clearly detailed in the Operational Manual. The selection process used by MSPAS can be used if found acceptable to the Bank. Salaries and benefits of these personnel would be equivalent to the MSPAS personnel to facilitate the later transfer to the MSPAS. Procurement of Health Services: Procurement of Health Services involves the hiring of NGOs. Health services are considered "non-consulting services" and as such procurement of these

70 services will not follow the procedures established in the Procurement Guidelines “Selection and Employment of Consultants by World Bank Borrowers”. Instead procedures for Shopping, National Competitive Bidding (NCB) and International Competitive Bidding (ICB) will be followed. The thresholds for each procurement method are indicated in Table 8.1 below and the procedures will be established in the Operations manual. In most cases the NGOs are presently providing health services for the Ministry of Health in the geographic areas where the project will be involved. The selection method that the Ministry applied in the selection of these NGOs has been reviewed and found acceptable to the Bank. Likewise, the task team has confirmed that subject to satisfactory performance, operationally and technically it is justified to employ these same NGOs. Selecting new NGOs through a competitive process would represent any value added neither from the procurement nor the technical point of view. NGOs will be contracted for the provision of the basic health and nutrition service packages (for both, Creciendo Bien and AINM-C), including preventive activities (growth monitoring, neo- natal care, and early stimulation), curative activities (management of prevalent childhood diseases) and individual counseling to the mothers. Normally the NGOs providing services under the Creciendo Bien are the same NGOs that provide the AINM-C under the PEC basic package. Operating Costs: Operational costs have been identified in the procurement plan. These costs have been reviewed and found acceptable to the Bank. They will be procured using the Bank’s procurement procedures. These include consultant services, computer equipment, procurement specialist, etc.

The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for works and goods procured, are presented in the Operations Manual.

71 TABLE 8.1 Prior Review Thresholds

Contracr value Expenditii re threshold Procirrenient catego? (US$ thousands) nierhod Contracts subject to prior review

...... processes each calendar

First two processes each calendar year(request for quotations and evaluation

All contracts above US$25,000 >500 ICB All contracts Health services 5002 <200 NCB All contracts (NGOs) First two processes each calendar year 4 200 Shopping All contracts above US$50,000 Non-consulting >150 ICB All contracts services (incl 502 450 NCB First two processes each calendar year training) 5 50 Shopping First two processes each calendar year QCBS Whole process for each contract above ...... >loo Consulting 1002 40 Q~-S/LCS/CQ ’ $100,000 and all single source contracts (firms) a ...... First two processes each calendar year for 5 50 Lcs/cQ each selection method. Consulting I Section V in the All cases above US$50,000 and all single- 1 (individual) a 1 Guidelines source contracts I Direct contracting All cases regardless of the amounts involved All cases regardless of the amounts involved Agreements

Notes: Thresholds for consulting include the sum of the original contract and all extensions.

The thresholds will be reviewed when the PCU gains experience in Bank’s rules and regulations. All single-source selection of goods and works, regardless of the amount of the contract, will be subject to prior review by the Bank.

B. Assessment of the agency’s capacity to implement procurement Procurement activities will be carried out by the Unit for Managing Project Financed with External Funds (Unidad Coordinadora de Programas y Proyectos -UCPYP-) within the MSPAS. The agency is staffed by ten people (10) contracted for the IDB project: a Coordinator, a Financial Manager, an Administrative Manager, a Procurement Manager, two auditors, one inventory controller, one procurement auxiliary, one administrative auxiliary and one assistant for procurement. Therefore, the procurement function is staffed by three (3) people, none of which have World Bank’s experience. An assessment of the capacity of the Implementing Agency to implement procurement actions for the project has been carried out in October 2005. The assessment reviewed the organizational structure for implementing the project and the interaction between the project’s 72 staff responsible for procurement Officer and the Ministry’s relevant central unit for administration and finance. The key issues and risks concerning procurement for implementation of the project have been identified and include no experience in World Bank’s knowledge of guidelines and procedures, poor capacity in infrastructure issues and technical assistance in doing specifications. The corrective measures which have been agreed are contracting a procurement officer and one assistant if the workload so requires with experience in World Bank’s procedures as well as a civil engineer and architect to provide technical support during critical stages of the procurement process and supervision and monitoring of civil works. The overall project risk for procurement is HIGH.

C. Procurement Plan The Borrower, at appraisal, developed a procurement plan for project implementation which provides the basis for the procurement methods. This plan has been agreed between the Borrower and the Project Team on December 2, 2005 and is available at MSPASLJCPYP in Guatemala. It will also be available in the project’s database and in the Bank’s external website. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.

D. Frequency of Procurement Supervision In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the Implementing Agency has recommended semestral supervision missions to visit the field to carry out post review of procurement actions.

73 E. Details of the Procurement Arrangements Involving International Competition

1. Goods, Works, and Non Consulting Services

(a) List of contract packages to be procured following ICB and direct contracting:

1 2 3 4 5 6 7 8 9

Ref. Contract Estimated Procurement P-Q Domestic Review Expected Comments No. (Description) cost Method Preference by Bank Bid- (yedno) (Prior / Opening Post) Date Health us $ 66 Direct no Prior services 5,23 1,988.82 contracting (NGOs) of NGOs

(b) All ICB contracts and all direct contracting will be subject to prior review by the Bank.

2. Consulting Services

(a) List of consulting assignments with short-list of international firms.

1 2 3 4 5 6 7

Ref. No. Description of Estimated Selection Review Expected Comments Assignment cost Method by Bank Proposals (Prior / Submission Post) Date None

(b) Consultancy services estimated to cost above US $ 100,000 per contract and all single source selection of consultants (firms) will be subject to prior review by the Bank. (c) Short lists composed entirely of national consultants: Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract, may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines.

74 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT Annex 9: Economic and Financial Analysis

Rationale for Public Sector Involvement in Maternal and Child Health and Nutrition in Guatemala

Introduction: Overview of health patterns and key financing trends. Maternal and infant mortality rates and particularly chronic malnutrition in Guatemala are among the highest in the world, and much higher than expected, given the country’s per capita income. Malnutrition among pre-school children, in particular, is a major public health concern in Guatemala. Results from the latest Demographic Health Survey (DHS) survey show that almost half of the children are stunted, 1.6 percent is wasted and 22.7 percent underweight. The nutritional status of women is also poor. Even more worrisome is the fact that the progress over the last ten years has stagnated. The country’s poor progress in health has been constrained by the low level of health expenditure and particularly by the level of financing and expenditures of the MSPAS. At the same time progress has been constrained by inefficient allocation of resources, particularly by how MSPAS allocates its resources and how the resources are used to provide services. Under the status quo, existing sources of funds are insufficient to provide basic level of health care. In 2003 the overall expenditures of the MSPAS amounted to US$212 millions or US$17.6 per capita, one of the lowest in LAC and are expected to decrease by approximately 6 percent in 2005 to US$201 million or US$15.8 per capita. Approximately half of the budget is devoted to hospitals and curative care at the expense of preventive and low cost curative care delivered outside the hospitals (Figure 9.1).

Figure 9.1 Relative Measures of Health Expenditures in Central America, 2002

16%

14%

12%

10%

6%

4%

2%

0% Guatemala Honduras El Salvador Nicaragua

Source: Fiedler, 2005.

The discussion below presents the standard framework and arguments used for the selection of the project intervention in the health sector in Guatemala. This analysis seeks to provide a convincing economic rationale for why a maternal and infant health and nutrition project should be undertaken by the government of Guatemala. Initially, the arguments that justify how public investment in the area of nutrition and health in the 70 municipalities is justified are presented: to improve efficiency, equity and because of the high payoffs. Secondly, the main criteria that drove the choice of the particular investment - the AINM-C and the CAIMIs - are outlined. 75 I.There are strong economic arguments for public financing nutrition intervention in Guatemala. First, public investment in nutrition is iustified on equity grounds: since malnutrition is particularly concentrated among the poorest and most vulnerable segments of the population (preschool children, pregnant and lactating women), investments targeted to the most malnourished are addressing the well- being and health status of the poorest. By reorienting resources towards more preventive care and towards the most vulnerable people the project aims at improving equity. Benefit incidence analysis has revealed that currently the MSPAS expenditure is regressive and the poor, indigenous and rural populations receive less than a proportionate share of resources, exacerbating the health inequities (Table 9.1).

Table 9.1: Distribution of Total Consumption and Net Health Subsidy across Income Quintiles

Q1 Q2 Q3 Q4 Q5 Share of Per Capita Consumption 3% 6% 9% 18% 63% Share of Net Health Subsidy 11% 14% 17% 30% 28%

One reason for this finding is that most health services are not inferior goods (goods whose consumption decreases as income rises) and consumption of health services tend to increase as income rises. Part of the reason is also that in Guatemala a large portion of health services is financed by out of pocket expenditures, making it less accessible to the most vulnerable segments of the population. It is estimated that in 2002, 45 percent of all health expenditure were out of pocket expenditureu. Despite the fact that only one-third of the population pays for health services, studies show that about 60 percent of Guatemalans indicate lack of resources as the reason for not using health fa~ilities~~.The project will benefit mainly vulnerable households, such as rural, poor and indigenous households. This way the project will contribute to a better distribution of resources by increasing the overall spending on preventive care by approximately 10 percent with respect to 2005 figures. At the same time, by strengthening the AINM-C which is part of the PEC, the project aims at reallocating resources more effectively as they currently are concentrated in hospital care and curative care, and over-concentrated in metropolitan Guatemala.

Second, public investment in nutrition is iustified on the need to address market failure deriving from imperfect information. The malnourished often are not aware of the consequences of their condition on health status and future productivity, do not have complete knowledge of the choices available to them and are less able to articulate the demand for services. This is even more of an issue in Guatemala, where the large indigenous population (40 percent of the total population) often has limited access to health systems because of geographical, economic and linguistic barriers. Indigenous children are twice as malnourished as non-indigenous children, and indigenous women are about one and a half times as likely to be severely stunted as non-indigenous women. These differences are not due to genetic differences and a large differential persists even after controlling for individual, household and community characteristics. Indigenous people are often suspicious of the government and are often isolated socially and linguistically and do not have complete knowledge of the choices available to them. An important component of the project aims at improving individual and household’s knowledge on the consequences of malnutrition and ways to address it with available means. Through the Creciendo Bien strategy the project will strengthen the capacity of vulnerable and indigenous people, thereby increasing the demand for basic services and encouraging them to utilize the services. Moreover, indigenous households and communities will be active partners in establishing the nutrition programs and influencing activities through participatory methods. Finally, the content and language of the project will be tailored to the needs and constraints of the indigenous people.

44 Fiedler, 2005. 45 Gragnolati and Marini, 2002. 76 Finally, investments in nutrition have very high payoffs, particularly in countries like Guatemala where half of the children are malnourished. An extensive body of literature has dealt with the implications of child malnutrition on human performance and child health and survival. In particular, there is substantial evidence that malnutrition has potentially irreversible consequences on growth attainment, morbidity, mortality, educational achievement, productivity and adult chronic diseases. Addressing malnutrition and making use of the effective interventions that exist and have been implemented in a few countries would translate into mortality rates that are far lower than current levels.

Malnourished children have a much higher probability of dying than normal children, as documented by Pelletier et al. (2003), who, when adding the impact of poor nutritional status to that of low birth weight, estimate that 56 percent of deaths among pre-school children are attributable to malnutrition, 83 percent of which are due to mildly or moderately malnutrition rather than most severe.

Supplementing vitamin A twice a year to all preschool children would reduce under-five mortality by 23 percent.46If they are not malnourished, children would be half as vulnerable to diarrhea and respiratory infections:’ and they would be less exposed to morbidity in general. For example, if exposed to malaria, the severity of their episodes would be strongly diminished and they would be less likely to die.48 In individuals infected with HIV the morbidity rates would be much lower and the probability of survival would be much higher if they were not wasted.49

Nutritional status significantly affects children’s learning capacity and school performance. Healthier and stronger, children would be able to enter school at the right age and not miss years of education. Children would be able to attend school regularly. Their cognitive functions would not be diminished and their school performance would improve. As a result, they would be more productive and more successful in their future jobs5’ and improve the performance and cost-effectiveness of the school system. After controlling for different characteristics, it has been shown that malnutrition is associated with reduced earnings as adult^.^' Ifchildren were not chronically malnourished, their height as adults would not be permanently reduced.52Taller and healthier mothers would be less likely to deliver low birth children, Better weight at birth would in turn imply higher probability of survival53 and lower probability of becoming stunted and of suffering cognitive and neurological impairment. Moreover, there is growing recognition that malnutrition in early life is associated with higher probability of adult non communicable disease54.

Preventing low weight at birth therefore translates into large direct benefits for the society, such as lower health costs and increased cognitive ability. Such savings are estimated to amount, on average, to about US$580 per year.55256In Guatemala the estimated present value of all productivity losses due to chronic malnutrition of all children younger than age 2 today amounts to US$102 million57,which translates to expected savings of about US$9 million in the area of intervention of the project. This clearly

46 Beaton et al., 1993. 47 Mc Guire (1996) reports that vitamin A deficient children can be two to four times more susceptible to respiratory infections and twice more susceptible to diarrhea. Moreover, she estimates that undernourished children can suffer a 10 to 45 percent increase in incidence of diarrhea (and a 30 to 55 percent increase in duration). 48 Caulfield, L. et al., 2004. 49 Piwoz and Salama, 2004. 50 Horton and Ross, based on a survey of existing studies, estimate that one-half of a standard deviation decrease in scores on various tests of cognitive achievements is associated with a 4% decrease in hourly earnings (Horton and Ross, 2003). 51 Deolalikar, 1998; Behrman and Deolalikar, 1989; Haddad and Bouis, 1991; Behrman, 1993; Foster and Rosenzweig, 1993; Schultz, 1997; Strauss and Thomas, 1998; Thomas and Strauss, 1997. 52 Martorell, 1990. 53 It is estimated that low birth weight infants are 40% more likely to die in the neonatal period than their normal weight counterpart (Berhman et al., 2004). 54 Barker and Osmond, 1986; Barker and Osmond, 1987; Barker et al., 1991. 55 Alderman et al., 2004 56 Long time ago Mc Guire and Austin (1987) estimated that undernutrition contributed to more than 1.1. billion days of illness per year worldwide. 57 Fiedler, 2005. 77 underestimates the total value of productivity lost as it does not include the losses that have been incurred by all age groups. Moreover, it does not include the additional costs imposed on the education system because malnourished children enter school late; have higher repetition rates and lower performance levels. Finally, these costs do not include the additional expenditures needed because of the higher utilization rates of health facilities of malnourished children, who normally have higher morbidity and mortality rate.

11. Choice of intervention: cost-effectiveness and feasibility. Once established that funding nutrition is a sound investment for Guatemala, project interventions were based on their respective cost-effectiveness, as known from international literature, and their implementation feasibility in the country. The project includes a 5-year multi-sectoral support to the AINM-C, a project that promotes an inter-sectoral approach to improving nutritional status through growth promotion, micronutrients and strengthening individual capacity. It has been documented in the literature that interventions such as the AINM-C and in general nutrition education and micronutrient supplementation programs are among the most cost effective ways of preventing malnutrition (Table 9.2)58. Table 9.2. Estimated Returns from Nutrition Investments

Cost per Returns to Cost per Life Saved Program Discounted Dollar Healthy ($1 (in wages) Life Year Gained ($) Undernutrition Interventions Food Supplements 18,337 1.4 234 Nutrition Education 797 32.3 10.2 Integrated PHC-N 9,966 2.6 127 Food Subsidies 42,552 0.9 375 School Feeding __ 2.8 534 Iron Deficiency Supplementation of pregnant women only 800 24.7 12.8 Fortification 2,000 84.1 4.4 Iodine Deficiency Supplementation 1,250 13.8 18.9 (repro-aged women only) Supplementation 4,650 6.0 37.0 (all people under 60) Fortification 1,000 28 7.5 Vitamin A Deficiency Supplementation (under five only) 130 50 4.0 Fortification 400 16 12.3 Source: Me Guire, 1996.

Programs like the AINM-C would imply major savings in terms of lower utilization of health facilities, generated mainly by i) diminished morbidity and ii) substitution effects from mothers going to the community centers rather than the health clinic for monthly growth monitoring of the child. In Honduras, a country with similar socio-economic conditions but a lower rate of chronic malnutrition (29%), the AIN-C project is expected to generate cost savings of about 1.5 million per year or US$2.3 per capita because of the lower utilization of health facilities and as a result of mothers and caretakers of children substituting the AIN-C monitoras care for the MSPAS preventive and curative health provision. Using similar calculations and the same parameters for Guatemala would lead to estimated cost savings of US$2.5 million for the 70 municipalities in areas of project intervention.

58 Fiedler, 2003; Alderman, Behrman and Hoddinott, 2004; Mc Guire, 1996, World Development Report, 1993 78 Additionally, in order to respond to safe deliveries, the primary cause of maternal mortality in the country, and to address the two major causes of mortality, diarrhea and acute respiratory infections, the project is also strengthening the maternal and child referral network, which has been so far unable to respond to the needs of the PEC. Exempting pregnant women from having to pay for emergency obstetric care when referred by a trained provider addresses the market failure of the insurance market. In Guatemala health insurance coverage is unavailable to approximately 90% of the p~pulation~~.The network is expected to have a significant impact on the reduction of maternal mortality, low birth weight and treatment of children with diarrhea and respiratory infections.

In conclusion, the above arguments not only suggest that there are strong economic reasons for the government to invest in maternal and infant health in Guatemala but also make the investment in the CAIMIs and the AINM-C an attractive economic option.

Fiscal impact and sustainability. The total nominal cost of the project will be US$62.3 million6'. The first component of the project is expected to cost US$22.8 million while the nutrition component will cost US$22.1 million, which amounts to about US$3.6 per capita per year, and US$3.0 per capita per year respectively. The total annual incremental recurrent cost after completion of the project is US$7.43 million. The major share of this cost is expected to be generated by the maternal and infant health component estimated at US$5.19 million per year which amounts to US$4.13 per capita . Sustaining the AINM-C implies an incremental cost estimated in US$2.2 million or about US$1.2 per capita per year after the project closes. The government is expected to continue its contracts to NGOs, which mainly involve material and equipment that needs to be reinvested, continuous training and retraining of community nutrition volunteers (madres monitoras) and their non monetary incentives.

In accordance with established and estimated disbursement flows, the fiscal impact of this project would be quite modest. Recurrent project costs to be assumed by the MSPAS after the Project disbursements are completed represent approximately 2.3 percent of projected MSPAS expenditures. Table 9.3 indicates the recurrent costs after project completion. The government is committed to assume all the recurrent costs generated by the project.

Table 9.3. Financing- of InvestmentLtecurrent Cost and Financial Charges,- by Year (US$ Million) Project Implementation Period 2007 2008 2009 2010 2011 Total 2012011 I. Investment Costs Gov. Guatemala (total) IBRD 14.14 8.90 9.19 5.34 3.73 41.3 Total Investment Costs 14.14 8.9 9.19 5.34 3.73 41.3 II. Recurrent Costs Gov.of Guatemala 0 1.14 2.61 5.08 5.19 13.3 7.43 IBRD 2.32 2.53 2.36 0 0 7.21 Total Recurrent Costs' 2.32 2.53 4.91 5.08 5.19 20.51

Total IBRD Financing with Front End Fee 16.95 11.43 11.55 5.34 3.73 49.0 Total IBRD Finacing without Front End Fee 16.46 11.43 11.55 5.34 3.73 48.5 1

Total Project Costs 16.5 11.4 14.2 10.4 8.9 61.8 Percentage Recurrent to Total Proiect Costs 14% 22% 35% 49% 58% 33%

59 Gragnolati and Marini, 2002. 6o Including front end fee of US$490,000 79 As a proportion of GDP, project costs represent a relatively small amount, about 0.2 percent of GDP. The increase in spending does however represent an important increase with respect to the overall spending on preventive care which in 2005 amounted to US$ 44.8 millions. Prospects for additional resources are possible. The Government of Guatemala is planning to increase overall social spending to 6% which would imply half of overall government expenditure. At the same time health spending by the MSAPS is expected to increase by 200% between 2006 and 2008 (Table B). Currently the proportion of the estimated increase in budget that is not allocated to human resources is 14% or US$16.0 million, which does not leave a major fiscal space for new interventions. It is therefore of extreme importance that there is government commitment to sustain such support and to build it into its annual planning framework.

The support provided by the Bank will help the government to address these challenges by reorienting resources towards preventive care. This support will then help to minimize inequality in spending - but only in a limited way - as the World Bank support will form only a relative small proportion of overall annual MSPAS expenditure (about 5%). In addition, cost effectiveness derives from incorporation of nutrition activities within health services and particularly the PEC. The PEC already has an extensive network of well trained people dispersed through the most remote areas of the country. The health vigilantes already have the contacts, the structures, and the skill to contribute to improving nutrition within their existing activities (table 9.4).

Table 9.4. Back-of-the-Envelope Analysis of Public Expenditures in the Health Sector in Guatemala

% Increase 2005 2006 2007 1 2008 1 2005-2008 Investments I Nominal (Millions of Qtz) I 59.0 I 74.0 I 124.0 I 182.0 I 208.5 I Real (Millions of Qtz) 59.0 I 68.1 I 105.1 I 142.1 I 140.8 I Per Capita (Qtz) 4.7 I 5.3 I 7.9 I 10.4 I 123.0 I Per Capita ($ USD) 0.6 I 0.7 I 1.0 I 1.4 I Human Resources I I Nominal (Millions of Qtz) I 1,808.0 I 1,990.0 I 2,308.0 I 2,546.0 I 40.8 I Real (Millions of Qtz) I 1,808.0 I 1,832.4 I 1,956.9 I 1,987.8 I 9.9 I I Per Capita (Qtz) 143.5 I 141.7 I 147.5 I 146.1 I 1.8 I Per Capita ($ USD) 18.8 I 18.6 I 19.3 I 19.1 I

Sources

Barker DJ, Osmond C, 1986, Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales. Lancet 1986; i:1077-1081. Barker DJ, Osmond C, 1987, Death rates from stroke in England and Wales predicted from past maternal mortality. Br Med J 1987; 295: 83-86. Barnum, 1995, chapter in Handbook of Economic Analysis of Investment Operations. May, 1996. Beaton, G.H., R. Martorell, K.A. L’Abb6, B. Edmonston, G. McCabe, A.C. Ross and B. Harvey, 1993, Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing Countries, New York, U.N. Administrative Coordinating Committee/Subcommittee on Nutrition. (ACC/SCN State of the Art series, Nutrition Policy Discussion Paper No. 13). Behrman, J. The economic rationale for investing in nutrition in developing countries, World Development, Volume 21, Issue 11 , November 1993, Pages 1749-1771.

80 Behrman, J., H. Alderman and J. Hoddinott, 2004, Hunger and Malnutrition, forthcoming in Global Crisis, Global Solution, by B. Lomborg, Cambridge, Cambridge University Press. Shantayanan Devarajan, Lyn Squire, Sethaput Suthiwart-Narueput, 1996 Beyond Rate of Return: Reorienting Project Appraisal, Policy Research Dept, the World Bank. Caulfield, L.E., S.A. Richard and R.E. Black, 2004, Undernutrition as an Underlying Cause of Malaria Morbidity and Mortality in Children Less than Five Years Old, Am. J. Trop. Med. Hyg. 7 (Suppl 2), pp. 55-63. Fiedler, J., 2005, Malnutrition in Central America: The Nature of the Problem and Some Strategic Programmatic Considerations. Gragnolati, M. and Marini A., 2002, Health and Poverty in Guatemala, World Bank Policy Research Working Paper 2966, The World Bank. Hales CN, Barker DJ, Clark PM, Cox LJ, Fall C, Osmond C, Winter PD, 1991, Fetal and infant growth and impaired glucose tolerance at age 64. Br Med J 1991; 303: 1019-1022. Horton and Ross, 2003, The Economics of Iron Deficiency, Food Policy, 28, pp 51-78. Martorell, Reynaldo (1990) Importance of Childhood Retardation for Adult Body Size. Statement Before the Expert Meeting on Economic Consequences of Health Programs in LDCs, Committee on Population, National Academy of Sciences, June 25-26, 1990. Mc Guire, J., 1996, The Payoff from Improving Nutrition, mimeo, World Bank. Mc Guire, J. and J.A. Austin, 1987, Beyond Survival: Children’s Growth for National Development. UNICEF. Pelletier, D.L., and E.A. Frongillo (2002), Changes in Child Survival are Strongly Associated with Changes in Malnutrition in Developing Countries, FANTA, Washington D.C. Philllips, M. and T.G. Sanghvi, 1996, Economic anlaysis of nutrition projects, guiding principles and examples, WB’s nutrition toollut #3. Piwoz, E. and Salaman, 2004, Food Nutrition and Aids: Evidence and Priority Actions for HIV prevention, Care and Treatment Programs, Summer Seminar Series, USDA Washington DC, August 2004. World Bank, Guatemala Public Expenditure Review.

81 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 10: Safeguard Policy Issues: Environmental and Social Assesments

1. Social Assessment and Indigenous Peoples Plan (IPP)

Social Assessment

The social assessment took place in September 2005, and consisted of (a) a bibliographical review of information concerning general, demographic, and socioeconomic indicators, and on existing projects, emphasizing information about indigenous peoples; and (b) a participatory evaluation with a sample of the target population to understand their perceptions, experiences, expectations, attitudes, capacity and willingness to participate in programs similar to those proposed in the Project. This evaluation was undertaken by a local team, supported by the Ministry of Public Health and Social Welfare (MSPAS), with technical assistance from the World Bank (WB). The sample consisted of six rural communities6’ (four Mayan indigenous6* communities, one Ladino, one Garifuna). The information obtained from focus groups (FG) of the project’s target population (women and community) and health service providers (midwives, institutions, entities, and NGOs) was used to understand: (a) the practices and cultural values that women develop during the different stages of pregnancy, childbirth and postpartum, (b) health practices at home and infant nutrition, and (c) factors that are obstacles and/or facilitate access to health services for the maternal and infant population. Additional information was obtained from in-depth interviews with the women who participated in the FGs.

The Indigenous Peoples of Guatemala a. Composition of the Guatemalan Indigenous population

Guatemala is a multi-ethnic, pluri-cultural, and multi-lingua country where indigenous populations of Mayan origins, Xincas of non-Mayan origins, Garifunas of African origins and Ladinos or mestizos of Spanish and indigenous origins live.

Mayans descend from the same migratory wave and share a common language (protomaya), which disappeared as it was transformed into various linguistic communities over the past thousand years. Currently, 21 linguistic communities exist in Guatemala of the 30 different linguistic communities of the Mayan people63,located in Mexico, Belize, Honduras and El Salvador.

Mayans are found in almost all of Guatemala’s 193 municipalities that are considered indigenous and make up 58 percent of the total municipalities of the country (Table 10.1). There are four major groups: the K’ichC, Q’eqchi, Kaqchikel and Mam.

“ An indigenous community refers to a region, department, municipality, county, township, or neighborhood, either big or small, with a high number of indigenous people. 62 According to OP 4.10, the term “indigenous peoples” is a generic name for a distinct group, that is vulnerable socially and culturally, with the following characteristics of varying degrees: (a) Self -identification with members of a distinct indigenous culture,and recognition by others of this identity; (b) Attachment as a collective to distinct geographical habitats or ancestral lands, and to the natural resources of these habitats; (c) having their own political, social, cultural and economic institutions, separate from the dominate culture and society; and (d) having a different indigenous language or idiom, different from the official language of the country or region. 63 The expression “Mayan People” is defined in the Recognition and Rights Agreement of the Indigenous Peoples as excluding sovereignty over land (World Bank, Profile of Indigenous Peoples, 1998). 82 Table 10.1: DeDartments where Mavan Languages are sDoken Language DEPARTMENTS K'ichz' El QuichC, Huehuetenango, Quetzaltenango, Suchitepequez, Totonicapan y San Marcos Q'eqchi Alta Verapaz, El PetCn, El QuichC e Izabal Mam Huehuetenango, Quetzaltenango, San Marcos y Reatahuleu Kaqchikel Baja Verapaz, Chimaltenango, Escuintla, Guatemala, Satacatepeques, Sololfi y Suchitepequez Pocomchi Alta Verapaz, Baja Verapaz y El QuichC Q'anjo-b'al Huehuetenango Tz' tui il Solo16 v SuchiteDeaues Chuj Huehuetenango Ixil El QuichC Poaomam Escuintla. Guatemala v JalaDa Akateco Huehuetenango Jakalteco Huehuetenango Ch'orti Chiquimula y Zacapa Awakateco Huehuetenango Achi Baja Verapaz Uspanteco El QuichC Mopan El Peten Tektiteko San Marcos Sipakapense San Marcos Sakapulteco El QuichC Itza' El PetCn

The Xincas are non-Mayan indigenous peoples. There is little information on their origins. They currently live in Chiquimulilla, San Juan Tecuato, Taxisco, Santa Maria Ixhuath, Guazacaph and the villages of Jumaitepeque, municipalities of Santa Rosa, and Yupiltepe, a municipality of Jutiapa.

The Gan'funas origins are African, arawak, and caribeno or kallinagti, and they have been in Guatemala for less than 200 years. They currently reside in Livingston, Puerto Barrios, El Estor Morales and Amates, municipalities of Izabal.

The Ladinos, or mestizos, are a mix of Spanish and Indigenous origins for the most part. The mestizo population has grown with migratory currents that have produced new generations of mestizos of German. Chinese and Middle Eastern descent.

In Guatemala, 24 languages are spoken: 21 Mayan dialects, Xinca, Gan'funa, and Spanish, which is the official language.

The Guatemalan population is distributed in the following areas of the country, according to the National Survey of Living Conditions (ENCOVJJ64 2000 (Table 10.2):

64 National Survey of Living Conditions, ENCOVI 2000. (Encuestu Nucionul de Condiciones de Vidu) 83 Table 10.2: Imposition of POI lation by area

Population AL AR

N % Urban Rural

%

TOTAL 11,385,441 100.0 38.6 61.4

K’iche 1,036,5 19 9.1 30.5 69.5 Q’epchi 7 1 1,770 6.3 15.5 84.5 Kaqchikel 959,225 8.4 38.2 61.8 Mam 899,474 7.9 14.0 86.0 Other Maya 976,628 8.6 19.5 80.5 Garifuna 10,722 0.1 100.0 0.0 Xinca 16,393 0.1 32.1 67.9 Non-indigenous 6,757,9 13 59.4 48.2 51.8 (Ladino) 16,799 0.1 80.9 19.1

Other countries

Indigenous 4,610,729 40.5 24.4 75.6 Non-Indigenous 6,774,7 12 59.5 48.3 51.7

* ENCOVI 2000 used self-identification with the relevant ethnic group. The indigenous ethnic groups were the three Mayan, Gan’funas and Xincas. b. Legislation

The Guatemalan Constitution, Article 66, established that the State must recognize, respect, and promote the life, customs, traditions and social organizational forms of its indigenous populations. In addition, within the framework of the Peace Agreement there are 12 sub-agreements, several specifically mentioning indigenous peoples including: the Recognition and Rights of Indigenous Peoples Agreement, the Socioeconomic Factors sand Agrarian Condition Agreement, and the Strengthening of Civil Power and Function of the Army.

The Recognition and Rights of Indigenous Peoples Agreement states that Mayan, Xinca and Garifuna peoples need to be recognized in order to build national unity based on respect and the exercise of political, cultural, economic and spiritual rights for all Guatemalans. The indigenous peoples have especially suffered from discrimination, exploitation, injustices based on their origins, culture and language, and inequalities due their social and economic condition.

Ine enrorcement ana impiemenrarion or tnis agreement ana otner iegai instruments ratiriea ~y matemala, like the International Labour Organization (LO) Agreement No. 169 on indigenous and tribal peoples, Agreement No. 50 on recruiting indigenous workers, No.64 on work contracts, the International Agreement for the Elimination of all Forms of Racial Discrimination, the Agreement for Elimination of Discrimination against Women, and other relevant agreements and declarations to eradicate discrimination, are absolutely necessary for the eradication of problems caused by discrimination, exploitation and injustice which still persist.

84 Demographic and Socioeconomic characteristics of the target population65

Guatemala’s population is highly concentrated in rural areas, where 6,987,587 people live (61 percent of the total population), according to the ENCOVI 2000. Of the 6,397,903 people considered poor (56 percent of the total population), 82 percent live in rural areas, and make up the majority of the extremely poor.

Women represent 51 percent of the total population, and over half live in rural areas, equal to the men. Poverty affects women and men equally, with slightly more women in extreme poverty (52.2 percent compared to 47.8 percent of men).

The indigenous population is 40.5 percent of the total population and is concentrated in rural areas where 75.6 percent live. The indigenous population is poorer than non-indigenous populations (55.7 percent compared to 44.3 percent), and of the poor, 70.2 percent of the indigenous people live in extreme poverty. In contrast, 79 percent of the non-indigenous live above the poverty level.

Guatemala has a young population with an average age of 22.8 years. Over half are less than 18 years old, and more young people live in rural areas than adults (63.8 percent compared to 56.5 percent of adults). This young population is the most affected by poverty, making up 58.1 percent of the poor, with the youngest from 0 to 5 years of age having the highest number of poor, 67.2 percent, and those 6 to 18 years of age with 60.9 percent of the poor.

Illiteracy affects 31 percent of the population 7 years old and older, affecting women more, as well as indigenous peoples (46 percent) and the rural population. Poverty affects 75 percent of the illiterate population.

The Guatemalan economy is highly dependent on agriculture (39.4 percent of the labor population) of which a large proportion is non-qualified laborers working their own farms, day workers or farmhands, and family help without pay, largely women and children. More than half of the workers are in the informal sector (67.5 percent) and only 11 percent work as qualified professionals, directors, technicians or office workers. Poverty affects half of the workers, proportionally the same between men and women; 70 percent of the poor are rural workers, and 70 percent are indigenous workers.

Child labor figures prominently in the employment structure of Guatemala, with those between the ages of 5 and 14 years of age more affected than adolescents aged 15 to 17, as shown by ENCOVI 2000. Almost one million children and adolescents participate in the PEC (20.3 percent) mostly in rural areas (77 percent of those under 14 years of age, and 68 percent adolescents). A majority of beneficiaries are indigenous (56.4 percent compared to 47 percent non-indigenous). Poverty affects 73.5 percent of the child laborers and 62.5 percent of the adolescent laborers.

Respiratory diseases affect 47.5 percent of the children from 0 to 5 years, and diarrhea affects 31.3 percent. Of those affected, 70 percent live in conditions of poverty, and are cared for informally by parents, family, pharmacists and people of the communities.

Chronic malnutrition in those below 5 years of age is 43.1 percent, occurring more frequently in rural areas than in urban (49.1 percent compared to 30.7 percent), and more significantly in indigenous populations than non-indigenous (57 percent compared to 3 1.4 percent). Of the children affected by chronic malnutrition, 80.8 percent live at the poverty level and 32 percent live in extreme poverty.

Women in the reproductive years have an average of four children, according to ENCOVI 2000. Poor women have two more children than non poor. Of the women of reproductive age, 38 percent are

65 Results from ENCOVI 2000. 85 indigenous, and have the highest average of live births (5.3 in extreme poverty and 4.9 in poverty), while indigenous women above the poverty level have less children on average.

Care for the pregnancy depends on the availability of health services in rural areas, as well as traditions, customs, and poverty conditions. Women do seek care from doctors and gynecologists, but in rural and indigenous areas, midwives and local birth attendants are significantly higher. Those in poverty experience their pregnancies in informal systems with local attendants in greater proportion to those above poverty who have access to doctors and gynecologists.

A majority of women (60 percent) give birth accompanied by midwives, or women within the household, and this figure is significantly higher for rural and indigenous areas. All of the women assisted by household members are poor, as well as 80 percent of those assisted by midwives, in contrast to those above poverty who are assisted by doctors or gynecologists.

The average size of the household is 5 people, and the poorest households have the highest numbers, for example, there are 7.6 members for households in extreme poverty, while those above poverty levels have 4.2 members. Poverty affects 45.8 percent of the households, and is found mainly in rural and indigenous households.

According to the ENCOVI 2000 survey, 40 percent of the homes in Guatemala have dirt floors, 30 percent have no plumbing, 60 percent are not connected to a drainage system, 80 percent lack adequate garbage disposal, and the average number of persons per room is 3.1. These conditions are found mostly in rural and indigenous homes.

Results of the Participatory Evaluation

This evaluation took place in six rural communities, covering: the communities Maya K’iche’ of Joyabac, Q’eqchi of San Pedro de CarchB, Mam in La Democracia, Kaqchikel in Santa Cruz La Laguna, Garifuna in Livingston and Ladino in Olota. Mothers, community members and health service providers participated in the three focus groups.

I. Women ’s perceptions

Diagnosis of Pregnancy. The K’iche’ , Q’eqchi, Mam, Kaqchikel, Garifunas and Ladino women interviewed had similar practices for diagnosing pregnancy: from common signs and symptoms that many women have experienced directly, and share as grandmothers, mothers, or mothers in the community, by oral tradition. The process of identifying the signs takes between 3 to 6 months, until pregnancy is confirmed for the Mayan women by a visit to the midwife, by the Garifunas by health clinics and Ladinos by either a midwife or a visit to a clinic.

Pre-natal care during pregnancy. Like the diagnosis, care during pregnancy begins late, after confirmation of their condition. For Mayan women, care during pregnancy is based on tradition and customs, where some western practices are accepted, such as the process of qualifying traditional midwives. The midwife’s care is, a cultural practice learned with socialization, so most of indigenous use midwives during this stage, going only to health clinics if recommended by midwives. Some do not accept the addition of western practices to their traditions, and refuse to go to health clinics even when the midwives say it is necessary to do so. Some Garifuna women incorporate traditional aspects into the care, which is primarily Western. This practice is probably due to the fact that Garifuna women live in urban areas near health service providers, and have incorporated health care with formal service providers. For Ladino women, care during pregnancy is determined by the concept of nudity, and preserving intimacy where “feeling shame” that a strange man would “see my (private) part” is the decisive factor in looking for care with a midwife or with health services.

86 Care by midwife. Almost all the women interviewed had the support of midwives. For Mayan women, care involves preparing for birth with the midwife, who essentially locates the fetus by heating around the waist, and massaging the stomach. This is a practice that is transmitted from generation to generation with K’iche’ women: “There is a custom used by the midwives of warming the waist in order to get the placenta to let go.” For Q’eqchi: “. . .allowing kneading so that the baby can be in a good position” and in Mam women: “if the stomach has dropped or is sideways at 6 to 7 months, the stomach is kneaded.” Garifunas women look to midwives or women with experience in locating the fetus and believe that: “During pregnancy, the midwife kneads”, and the Ladinos also believe in this practice, and recount that: “there are midwives who massage and arrange the position so that the baby is born well.”

The care-takers, risks, illnesses, and treatments during pregnancy are both traditional and non-traditional. The majority of women keep their daily food the same with little change, which is related to poverty, except for the introduction of foods associated with the traditional concepts of cravings, and the elimination of certain foods considered to cause harm to the baby.

Labor. Mayan women use traditional practices to accelerate labor, for example, K’iche’ women bathe the mother in a type of steam bath, or ternasca166 and drink herbal tea with various plants as well as alcohol. The Q’eqchi women eat chili pepper plants to make labor more active, Mam women take chamomile tea with chocolate to keep up their strength, and Kaqchikel say that they take nothing, because the midwife does not let them. The Garifuna women also take chili water to accelerate labor, and Ladino women take herbal infusions of basil, fluoride water, and soot with salt so the child will come into position (a remedy that is only used when labor pains are very strong). Labor is supervised by midwives in most communities.

Childbirth. A large majority of the Mayan and Ladino women interviewed help with the birth with the midwife, and in many cases with the husband. They recognize the risk of death, and their greatest fear is that the placenta is not born. Women state that they prefer to give birth kneeling, where the midwife catches the child in outstretched hands, because they have more privacy. They prefer to “give birth at home where they can maintain their traditions, and not to go to the hospital, because they are not allowed to use a kneeling position, for fear of the baby falling” (a Q’eqchi’ woman). At home they can be accompanied by their husbands, while at the hospital, there is little tolerance for them, they fear having a c-section, and they feel a lack respect for their beliefs. Husbands and midwives are not allowed to accompany them during labor, and they are made to feel ashamed because their husbands are waiting for them. They also wony about costs and access. The Garifuna women interviewed begin labor at home often accompanied by a midwife who helps to accelerate labor, and then they give birth in the hospital.

Postpartum. While the Kaqchikel and Ladino women interviewed begin daily activities eight days after birth, K’iche’, Q’eqchi, Mam and Garifuna women have 40 days to rest with only easy tasks that are introduced little by little. Women begin traditional practices during the postpartum period: the Mayans take steam baths, the Garifunas cover their heads to keep their ears warm, do not go out, and rest for three months. Ladinos “are massaged with oil by the midwife, and given a special cover for their stomachs, they cover the head to keep out the cold, and put cotton over their ears, and wait to bath for 8 days.”

Nursing. The Q’eqchi and K’iche’ women interviewed share similar breastfeeding practices, which they start as soon as the baby is born, because they realize the benefits from colostrum. The Q’eqchi recount that they “begin to breastfeed as soon as they are born, and the wash the nipple and give breast milk, which protects against diseases”. The K’iche’ say that they breastfeed “from birth, since the first milk is purifying and helps to cleanse the baby’s stomach”. The Mam say they do not have a clear understanding of breastfeeding, and believe that “when the baby is born, and there is no milk, you give the baby boiled water while the milk drops, and if there is another mother nearby who is also breastfeeding, give the baby to her, but if not, the boiled water.” The Kaqchikel think that colostrum is bad and: “...the first milk should not be used, because it is dirty, or so they have been taught” and begin breastfeeding on the third

66 Temascal is a bath with vapor used by the Mayans, which the Mam call chuj. 87 day, after lactation starts. The Garifunas, like the Mams, have no fixed idea about the benefits of breastfeeding, but believe that one should begin at birth. Finally, the Ladino women do not have a fixed idea about it either, some begin when the baby is born, while others throw out the first milk because it is dirty.

Most women have never heard about breastfeeding exclusively. Mayan and Ladino women breastfeed exclusively for 6 months, and can continue up to 18 months, or until a new pregnancy, while Garifunas begin to feed their babies food at three months, and will breastfeed if the baby wants to, up to 18 months. The K’iche’, Ladino and Garifuna women cite use of several practices for washing out the baby’s stomach during the first days after birth. For example, the K’iche’ give the baby herbal tea and chicory; the Ladinos make “pacifiers with anis, cilantro and rue, for colic” and Garifunas give bottles with cornstarch paste to wash the stomach on the third day (after birth); then two weeks later: anis, garlic, honey, and oils are given as a kind of pacifier to wash the stomach, when the feces is black, until it comes out yellow.”

The weaning process. Due to economic problems, after nursing stops or is less frequent, mother’s milk is rarely ever replaced, although women recognize that the children start to lose weight. K’iche’ women say that “to give other kinds of milk depends on one’s means ...in local communities, they give coffee, and only rarely do they use a bottle”. Mam women state that “after they stop breastfeeding, they lose weight, and depending on the care they may be given whey so they do not lose weight.” Ladinos give mixtures of corn, but no milk. When they get sick, and lose weight, they take them to be weighed and get vitamins.”

Childhood diseases. All the women interviewed said that children mainly suffered from diarrhea, coughs, flu and lung congestion. They try household remedies, and if they do not work, then they go to health clinics. Children can often wait five days before receiving adequate care. Women realize that illnesses tend to persist due to poor hygiene at home: “They don’t wash their hands and wait until the child is close to death before going to the clinic” (K’iche’), “. . .they get sick with diarrhea, vomiting, fever, due to lack of cleanliness, not boiling water, not washing hands, and the food eaten” (Q’eqchi), or “they aren’t clean, they don’t wash, the water is dirty, and they eat fruit without washing it”(Mam). Only Ladino women identify infant malnutrition as a problem for their community.

Perception of health services. The Mayan women interviewed fear the attention of health services, because, like the K’iche’ women say: “they fear operations (referring to cesareans), feel ashamed of taking off their clothes, and especially dislike having to see a male doctor.” They prefer giving birth at home because the hospitals do not respect their customs, feed and care for them like they do at home. Some do not go to the hospital because if they arrive late, they are not seen and they do not have the money for the trip. There is only one doctor, who does not give medicine, and “....sometimes they have to bring the child, and the providers have no patience”. Some go to the hospital because the midwife has sent them and others go for tetanus shots and vitamins. Almost all women recognized the advantages of health services in the case of complications. Garifunas went to hospitals for prenatal visits as well as childbirth, and have confidence in the services, even though there are problems with it, and people complain about not being seen. Some Ladinos share the same viewpoint as the Mayan women and feel fear and shame, while others go once a month for check ups, and a few have given birth in hospitals.

The Mayan and Ladino women interviewed are familiar with the facilitators and health providers in their communities, and go to them when they have problems. They get information about immunizations there, but it does not seem sufficient. They suggest using the radio to spread information or warnings more quickly, and for getting ambulances to arrive” (Q’eqchi). Garifunas are familiar with health personnel in their communities, like the nurse aids, doctors and nurses, and commented that the only home visit that they make is for vaccinations.”

Q’eqchi women are unaware of any malnutrition in their community, but do know about CARE programs: “. , .they give baby food each month to the families with little children and weigh them in order to give them food.” Kaqchikel women have a nutritional program in their community for pregnant and 88 nursing mothers where they receive supplements from the first month of pregnancy. Ladino women state that they “receive some food for malnourished children from Caritas, they pay Q15.00 and get rice, flour, oil, beans, but this is not help because if you don’t have money, they give nothing”. There is also help from a Cuban medical team, which “gives food that those households don’t need and prefer to give it to animals while others need it. ” All women were open to participating in health programs.

2. Perception of the community

Health practices. The most frequent illnesses, identified by Mayan women, are coughs, fevers, vomiting and diarrhea, mostly due to lack of maternal care, hygiene, and money to pay for medicine. Gan’funa and Ladinos add colds, fever, and asthma. These illnesses are first treated by traditional methods, such as home remedies, then going to a local healer (K’ichesmayan). If these do not work, they try to visit a health clinic (Gan’funa go after home remedies fail), but often this is difficult due to the road conditions, or because the rivers are high, or the cost of traveling. The main problem is getting to the centers or clinics, and once they arrive, they say they are not seen. A second problem that affects the household is loss of pay since if one of the parents cannot work while they stay with the child or if they are traveling back and forth for treatments (Mayan, Ladino).

Problems of malnutrition. Mayan women realize that infant malnutrition is a problem, due to lack of food (for economic reasons, or size of household) though there is also the traditional view that it might be the mother’s fault, if she is “nervous and therefore does not produce enough milk” (K’iche’). Mayan and Ladino women both recognize that their communities are very poor, with few resources for dealing with the problem. Garifuna women indicate that there is no problem.

Health services. Mayan communities are reserved about the care provided by health services, because they feel scolded. They are told that “they don’t care for their children, but if one works, what there to do?”, they are not seen if they arrive late, and have to come back the following day. They give a prescription but no medicine, and the women cannot afford to buy the necessary drugs. The reasons most people in the community do not go to service providers are because they feel a lack respect for their beliefs, they suspect that perhaps the providers cause the illness by all the tapping they do on the child, and they find it hard to understand the doctors because many do not speak castilla (Spanish). The Garifunas reiterate that “at the health centers, the main problem is that there is only one doctor, and when he is on vacation, the nurses see them, but they don’t have as much confidence in the nurses”, they do not keep the schedule, and do not give medicines. Ladinos state that “the people here live by the coffee harvest, and have no money to pay”, there are no medicines, and if they are hospitalized they have no money to pay.

3. Viewpoint of health care providers

Prenatal checkups. Health care providers in Mayan communities say some women have check ups, but no more than two, because the midwife looks after them. They state that due to “their traditions, they won’t see a man, and if asked about menstruation, they are too ashamed to answer” (K’iche’). They suggest that some women do not have prenatal care because their husbands do not approve.

K’iche’ and Kaqchikel women confirm pregnancy very late, in the fifth or sixth month. As mentioned above, the clinic’s scheduling is a problem, because if they arrive after 8:OO am, they are not seen. The Garifuna women have prenatal visits and give birth in the centers, and look to midwives “only to know the position of the baby”. They receive information on the birth process and brochures. Ladinos rarely have pre-natal care, and go very late if it is the first pregnancy because they feel embarrassed.

Reasons for not going for checkups include: lack of information, language difficulties, distance, road conditions, transport, lack of economic means, and time. Other causes relate to traditions and customs, like the Kaqchikel indicate: “The community is very delicate, with much shame. They do not like to be

89 touched on the stomach or take off their cloths. Midwives do not make them take them off, do not uncover them. If it is the first time, they are afraid or embarrassed that people know that they are pregnant, so they wait until the eighth or ninth month”. Ladinos say that “because they feel ashamed, and do not like to be examined, and touched so they do not return for the next visit.”

ARIs and diarrhea. Respiratory problems and diarrhea persist, despite public information campaigns about them, because hygiene in the households has not changed: “...if there are three episodes of respiratory disease and diarrhea, and they persist, they insist on cleaning, bathing, and boiling water to wash the children” (K’iche’). “Many mothers do not clean, or change their child, so they need to be oriented in how to improve infant care, that way they will be sick less often”(Q’eqchi).

Indigenous Peoples Plan

Previous Projects. The Maternal-Infant Health and Nutrition Project for vulnerable groups targets strengthening the secondary level of care, as well as interventions for decreasing maternal mortality and infant malnutrition. The Project concentrates on: 1) strengthening the secondary level of health care and 2) nutrition. The target population is rural indigenous communities with the highest maternal and infant mortality rates, and infant malnutrition. Within this context, the Project will concentrate on the problems of these communities, with the goal of diminishing the disparity between indigenous and non-indigenous populations, between rural and urban areas, promote acceptable intercultural practices, and remove barriers to health services and nutrition.

Box 1: Main characteristics of Indigenous Peoples in Guatemala

Comprises 40.5% of the country’s total population; Lives mainly in rural areas (75.6%); Is poorer than non-indigenous populations (55.7% to 44.3%); Lives in extreme poverty affecting 70.2% of the population, in contrast to the 79% non-indigenous population who lives above poverty; Suffers from high illiteracy rates (46%); Has 70% of indigenous workers affected by poverty; Has a high occurrence of child and adolescent labor (56.4% and 47% respectively); Suffers from chronic malnutrition, significantly affecting 7 out of 10 indigenous children (69.5% in contrast to 35.7% non-indigenous); Of the 38% of women in the reproduction age, has the highest number of average births; 5.3 children for those in extreme poverty and 4.9 children in poor conditions; Receives prenatal care mainly from midwives and local people in rural and indigenous areas; Has a significantly higher rate of childbirth assisted by midwives, local facilitators or members of the household, 63.7%; Is affected by poverty in 45.8% of the mainly rural and indigenous households; Live in houses with the lowest condition and quality indices in the country, with a high percentage of dirt floors, no running water or plumbing, no sewer system, or adequate garbage disposal services. The average person per room is 3.1, mostly in rural and indigenous houses. In 46% of the houses, are households living in poverty, mostly rural and indigenous.

The difficulties of including the target population in the project are largely due to the negative perceptions that different Mayan groups have about maternal and child health services and access and the acceptance of traditional practices.

90 e Pregnancy is confirmed very late, between three and six months, at which time Mayan women visit a midwife. e Likewise, prenatal care begins late, and is based on cultural traditions, with some western influence due to the process of qualifying midwives, who are the traditional care providers. All women are looked after by a midwife, some only go to health clinics if the midwives send them, while others reject the introduction of western practices and refuse to go to health services even when the midwife considers it necessary. e For Mayan women, prenatal care means preparation for birth, which the midwife handles. They rely on the midwife to locate the position of the fetus through warming the waist, and massaging67the stomach. e The care, risks, diseases and treatments during pregnancy are viewed both traditionally and nontraditionally, and are taken care of by midwives in the community. e The majority does not change their daily diet, mostly due to poverty, and associate introducing new foods with the traditional concept of cravings, and the elimination of some foods because they feel they cause harm to themselves or the baby. e Almost all the Mayan women interviewed, except the Q’eqchi, turn to traditional ideas and treatment of diseases associated with pregnancy. When they see signs of danger, with the exception of Kaqchikels, they go to midwives for treatment in the traditional way. e Mayan women use traditional practices to accelerate labor; for example, K’iche’ women take steam baths and herbal infusions mixed with alcohol, Q’eqchi take chili to activate labor, Mam women take chamomile with chocolate for strength, and Kaqchikel follow the advice of their midwives and take nothing. Some use practices such as inducing vomiting to help “push hard”. They are accompanied and supervised by the midwife during labor. e Birth takes place largely at home with midwives and often the husband, even though they are aware of the risk of death, and fear that the “placenta will not be born.” e Women prefer to give birth kneeling, while remaining covered for privacy, and in this position, the midwife can receive the baby with outstretched hands. e Home birth is preferred by most women, since women can use the kneeling position, be accompanied by their husbands, mothers, and midwives, which they are not allowed to have in the hospitals. Also, they feel the hospital has little patience for them because of language difficulties, they fear a cesarean section, dislike being seen by male doctors, and worry about cost and access. e Most recognize the advantages of the health services when complications arise and there is a need to act rapidly. e During the postpartum period, K’iche’, Q’eqchi, and Mam women interviewed said they took care of themselves for 40 days, with light work introduced little by little. Kaqchikel began their daily activities 8 days after birth. Steam baths are one of the main healing practices. They go to health clinics for children’s vaccinations. Problems with postpartum in general are treated by midwives not health services. Q’eqchi and K’iche’ women interviewed begin breastfeeding as soon as the baby is born. When the lactation has not yet started, they use boiled water, or give the baby to a lactating mother to be fed. Kaqchikel think that the first milk is bad, and wait until it is clean before breastfeeding, according to the traditions of their ancestors. e Due to economic problems of the households, mother’s milk is rarely replaced in the weaning process, with the result that the child loses weight. Giving milk depends on the financial means available, according to K’iche’ women. The Q’eqchi women only give food after they stop breastfeeding, usually at 18 months, and replace milk with coffee. The Mam give whey so that they do not lose weight. Kaqchikel women do not have a weaning age, and wait until the babies will no longer take it, or if they become pregnant again. They find that the babies lose weight and begin to get diarrhea and fevers. They replace mother’s milk with a corn mix (atol, rnosh) or coffee.

67 The women referred to this as “sobar o dar rnasajes sobre el estdrnago de la rnujer embarazada para acornodar la posicidn del feto”. 91 Women do not see malnutrition as a problem, as least not openly, but they do accept the idea that food nourishment is poor and insufficient for the infant population. Yet, the community does recognize infant malnutrition and perceives that it is due to lack of food, based on the economic situation facing most families, and size of families, but also by the traditional view that the mother is nervous (called enfermedud de susto), and cannot lactate, so the babies do not get filled. They recognize the main infant and childhood diseases are diarrhea, coughing, flu and pneumonia. They try home remedies first, then take them to the health services if they do not improve, sometimes delaying adequate care for days. They recognize that diseases continue due to poor hygiene practices at home. Only Mam women identify infant malnutrition as a problem in their community. Mayan women fear being cared for by the public health service, especially having to have a cesarean, and the embarrassment of undressing and being seen by a male doctor. They feel more comfortable at home where they can have their husbands, midwife, and other women to help take care of them and feed them in traditional ways. Language is a barrier as their language is not spoken in the health clinics. Access is limited, because if they are late they are not seen and there is usually only one doctor. Cost and transportation are a factor, since they may not have money for the trip and they are not given the medicines. Bringing other children with them seems to make health providers impatient. Some women go for immunizations, like tetanus, and for vitamins provided, and because the midwife told them to go.

Key factors for the success or failure of the Project

The cultural and socioeconomic factors that can either facilitate or obstruct project implementation are outlined below.

Mayan women and communities interviewed perceive discrimination and exclusion when asking to be treated at health service facilities, which creates an impediment for accessing services and constitutes an obstacle in project execution.

1. Although they realize the usefulness of the health service centers, they encounter cultural and social obstacles to receiving care and point to the need to have their customs and traditions recognized.

2. For prenatal care during pregnancy and childbirth, they depend on the midwife as a source of knowledge and as care-givers. Some of the trained midwives have changed their ideas about health services, and encouraged them to go seek public health services.

3. In this context, they do not attend health centers for prenatal care due to cultural and language obstacles and say that providers:

- Do not speak their language (“Maya”). - Do not understand them. - Do not respect their customs. - Do not respect their beliefs. - Do not treat them well, scold them, do not attend to them, and do not examine them. - Do not explain what they will do, which causes fear. - Do not allow the midwives to accompany them. - Ask them to undress in front of male doctors, and this makes them feel embarrassed.

Women also choose not to attend the health services because:

- Their husbands will not allow them. - They do not trust the services because of what others have told them.

92 4. Women also find it difficult to go for prenatal care and check ups for socioeconomic reasons related to the health service centers which:

- Do not give medicine, only prescriptions, and they have no money to fill them. - Do not see them if they arrive late due to the distance they have to travel, and do not give them a time, so they have to come back the next day. - Do not keep appointments on time, and only give up to forty consultations in the morning. - Do not provide information, and even when there are informational campaigns, many do not know where to find it.

Women also do not go for check-ups due to:

- Cost of the trip - Transportation - Difficulties in access - Distance.

5. Similar obstacles prevent those who become sick, but are too young from going for care.

Some health care practices of pregnant Mayan women need to be strengthened rather than questioned.

6. Cultural and social practices Mayan women use during pregnancy that do not carry risks for the mother and/or fetus; these practices strengthen the project strategy, and should be reinforced. These include:

a. Respect for beliefs that do not carry risks for the mother or the fetus, such as: the influence of natural phenomena, unknown forces, and feeling cravings. b. Dietary changes which do not affect normal development, like introducing beneficial or new foods. c. Identification of risks, such as the risks of abortiodcarrying heavy things. d. Perceptions about treating diseases during pregnancy that do not affect the mother or fetus, like: not taking anything for the baby, practices which do not call for physical interventions like using handkerchiefs for headaches, herbal infusions for pain, taking linseed oil, onion water, rice water, or pipe water, and external practices, like taking seated bathes with vinegar for vaginal flow.

7. Cultural and social practices used by Mayan women during pregnancy that might create difficulties in project implementation, and should be discouraged are:

a. Changes in diet which affect the production of iron. b. Introduction of dangerous physical practices because they perceive that while doing this pain disappears, for example, if “they feel pain, they cut wool, start to sweat, then the sweat makes them sleepy.” They do this because “the midwives have told them to get exercise, so they cut wool.” c. Consume infusions in high risk situations, like hemorrhaging.

8. Childbirth practices used by Mayan women that strengthen the project strategy include: recognizing and validating the kneeling birthing position, being able to have a midwife present, recognizing risks during at home births, and the perception that health services minimize risks.

9. Childbirth practices used by Mayan women that make the project implementation more difficult and should be discouraged, are:

93 a. Practices for accelerating labor, such as using drinks and infusions like “hot water with chamomile and albahaca, or a shot of rum or boiled beer ... or pepper water with a little liqueur.. . or some chamomile for composure.. . chamomile and chocolate for energy.. . half a bottle of olive oil for rapid birthing, after only taking chamomile tea ... taking medicine mixed with plants and/or doing physical activities to produce vomiting and accelerate contractions. b. Labor practices which involve physical actions by the midwife in order to make the placenta drop. c. Fear of going to the hospital, lack of respect for traditions, lack of resources and difficulties in access.

10. The project should consider postpartum practices of Mayan women such as the need to begin working eight days after giving birth, because there is no one to help them take care of things. Other practices should be reinforced, such as a rest time of 40 days, respect for traditions and customs, and changing perceptions to make it known that follow up visits prevent maternal mortality.

11. Nursing practices of Mayan women that could be an obstacle include washing (internally) infants’ stomachs, treating mastitis, and colostrum.

12. Practices that support project implementation include the recognition of the benefits of colostrum, breastfeeding exclusively the first two weeks, lactating for 6 months, and taking care to guarantee milk production, and respect for traditions and customs.

13. The acceptance and recognition of community facilitators and health guardians strengthens project implementation in communities, because people have confidence in them, and go to them with their problems. They inform the community of vaccination campaigns, but this is considered insufficient, and those interviewed would like to obtain information by radio in their own language. Also, they would like the facilitators and vigilantes to have more resources at the community’s disposal in order to provide better services.

14. Another factor which strengthens the project implementation is the participation of women and the community in different health and nutrition projects, and their continued willingness to participate. Yet, implementation is more difficult given the criticism that other projects only helped a few people in the community and created internal conflicts.

Recommendations:

Based on the factors mentioned above, the following recommendations are provided for Component 1 and are being included in the Operational Manual:

To increase demand for health services within the target community, a health module on “Intercultural understanding and Indigenous peoples” should be developed, which includes information on traditional practices in managing reproductive health and care for the infant population, as well as the traditions and customs that constitute barriers to access. This module should be developed through radio programs (oral) and illustrated advertisements.

To strengthen community confidence in the health services, introduce corrective measures to current practices that limit access, such as improving the treatment (better communication and respectful treatment), hours of service, priority care for those living far away.

94 3. Strengthen training of health service providers (men and women) at main health centers for networks that serve the referral clinics in the community, in order to change attitudes and perception about services and increase demand.

4. Similarly, introduce modifications to guarantee the provision of medicines in these centers.

5. Include a module on Information and Dissemination by radio during accessible hours and in the Maya language of the targeted area, before and during program execution, in order to strengthen communication of health services to the community and to educate the community about health practices, identifying danger signs of risks, nutrition and hygiene.

6. Train midwives on prenatal care and birthing to strengthen their skills so that these become safer.

Due to the lack of trust and the perception of public health care services, it is important to incorporate an indicator that reflects the percentage of indigenous women who attend to the health centers and feel motivated to use the program’s health services.

The recommendations for Component 2 include and are being included in the Operational Manual:

1. In order to understand current practices and promote hygiene, an anthropological study should be conducted on understanding, attitudes and practices on health and nutrition in indigenous communities.

2. Include a training module for health personnel (doctors, nurses, aids and promoters) and health providers (midwives, vigilantes, and facilitators) on Training in Health and Nutrition focusing on the multicultural and intercultural environment.

3. Strengthen the capacity of health providers (men and women) of the larger centers that serve as outreach for the health services-community network, to initiate change in household practices, especially related to infant care, as well as hygiene and health in the home and community.

4. Nutrition programs should be designed based on the gastronomic practices of the indigenous communities of the targeted area.

5. For both components, the same personnel selection criterion should prevail: basic knowledge of the linguistic and cultural context. In areas with high monolingual population, the civil servants should be native Mayan-speakers in the Region.

2. EnvironmentalAssessment

The most relevant environmental issues resulting from the implementation of this project are the increase in the production of Health Care Waste (HCW).

2.1 Hospital Waste Management in Guatemala.

Review of existing legislation regarding hospital waste management The Health Code, Decree 90-97, was approved by Congress on October 2, 199768.Section IV, Article 106 on hospital waste establishes that the Ministry of Health and Social Assistance has the authority to devise rules and regulations for hospital waste disposal.

Health Code, Decree 90-97, http://www.mspas.gob.gt/DGRVCS/DRPSA/Inicio.htm 95 Based on this faculty, the MSPAS produces the Rules for Hospital Solid Waste Management and puts them in effect under Government Agreement No. 509- 2001.

Since then, the formative framework has been updated with several government agreements:

Ministerial Agreement 88-2003 (12/03/20031: Creates the Multisectoral Commission for Support and Coordination of Hospital Waste Management (COMUCADESH).

Ministerial Agreement No SP- M- 2220- 2003 (7/11/2003): Defines standard procedures for approval certification of hospital solid waste management plans and registry of generating entities. It contains a definition of administrative procedures in order for the Regulation Department for Health and Environment Programs to certify and approve the management plans for hospital solid waste and for the registry of generating entities.

Ministerial Agreement No SP - M- 2221-2003 (7-11-2003): Issues standard procedures for qualification and accreditation of professionals in management of hospital solid waste. The agreement establishes administrative procedures in order for the MSPAS’ Regulation Department for Health and Environment to qualify, accredit and maintain a registry of professionals authorized to provide technical assistance to generating entities and companies involved in transportation, treatment and final disposal of hospital solid waste.

Ministerial Agreement No SP - M- 2232-2003 (I7/11/2003: Defines standard procedures to monitor compliance of regulations for management of hospital solid waste. Its objective is that the MSPAS’ Regulation Department for Health and Environment establishes coordination and control mechanisms to monitor compliance with regulations for management of hospital solid waste through the Health Area Offices, by the generating entities, transportation companies, treatment system, company for treatment and disposal of hospital solid waste, public and private.

Ministerial Agreement No SP - M- 1612-2005 (18/03/2005): Published in Diario de Centro Ame‘rica No. 47 on Tuesday, April 5,2005. Issues manual of internal rules and procedures of the Multisectoral Commission for Support and Coordination of Hospital Solid Waste Management. This manual appropriately updates the contents of previous agreements.

Field visits. The following visits took place as part of this evaluation: Roosevelt National Hospital; ECOTERMO company, which has authorization to carry out the final disposal of hospital solid waste; and Palencia Health Center.

Roosevelt National Hospital has an adequately implemented pathogenic waste management plan. The waste is selected and deposited in proper bags per type of waste and evacuation routes are signaled. Waste is temporarily stored in a warehouse; it is classified by content in red, white and black bags, and sharp objects are placed in small containers. Waste is picked up, weighed and labeled in four shifts and a company picks it up three times a week for final disposal.

The company ECOTERMO adequately processes hospital waste by incineration (half an hour in a chamber at 850°C and another half hour at 1200°C where all incinerated contents are reduced to ashes).

The situation at Palencia Health Center is different. Compliance is limited. While pathogenic waste is selected and picked up in adequate packaging, the Center does not have a vehicle to transport waste to the Ministry of Public Health’s National Collection Center in area seven, where it is picked up weekly by the contracted company (ECOTERMO). This causes accumulation of waste for periods longer than those defined in the rules. Also, it became evident that there was a need to train personnel who

96 did not consider certain residues pathogenic when they in fact were and deliver organic remains to family members for final disposal.

Conclusion The regulatory framework pertaining to the Disposal of Hospital Solid Waste is adequate, but the environmental assessment carried out during Project preparation reveals that its compliance requires the improvement of MSPAS’ control capacity, which includes meeting the staffing needs of the office in charge of monitoring this regulatory framework, avoiding personnel rotation and ensuring the availability of equipment for supervisions. Nursing and cleaning personnel in assistance units also require training to apply solid waste management regulations. This is especially needed in rural areas where supplies to comply with regulations are even more limited.

The recommendations are:

1. To promote coordination with municipalities to build a pit in local cemeteries to place pathogenic waste (placentas and surgical intervention waste). The pit must have: i)enough depth to ensure an economic life of at least 4 years; ii)waterproofing to avoid percolation to the groundwater table, and covering with a substance to render them inert, such as a layer of lime.

11. For sharp objects, it would be most appropriate for the center to rely on an autoclave for treatment and subsequent shipment of treated waste to a final disposal center. ... 111. Pathogenic materials could be incinerated in secure furnaces in the Center and ashes would be disposed of in the municipality’s sanitary landfill, or they could be stored for up to a week in an adequate warehouse to be sent to the company in charge of final disposal.

iv. Implement a training plan for all personnel-if possible-in health posts and CAIMIs, for selection, disposal and temporary storage of hospital waste.

V. Carry out a plan to monitor or supervise the implementation of the Rules for Hospital Solid Waste Management a minimum of three times per year in each health post or CAIMI.

vi. The MSPAS should consider the budget required to purchase the packaging stipulated in the rules to supply health posts and CAIMIs, or negotiations with waste disposal companies should stipulate that they provide the packaging.

2.2. Strategies to mitiyate the Environmental Impact of the Project.

Improvement of 40 health posts that will become Centers for Integrated Maternal-Child Care (Centru de Atencio’n Integral Mutemo Znfuntil or CAIMIs) will result in the production of more hospital solid waste, and it is necessary to guarantee compliance with the regulatory framework.

In light of the aforementioned, the MSPAS designed a Hospital Solid Waste Disposal Plan for CAIMIs that includes the abovementioned recommendations. The Waste Management Plan for CAIMIs has been disclosed and is available in the MSPAS Web Page: http:/lwww.mspas.gob.gt/dgrvcsldrpsd .

97 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT Annex 11: Project Preparation and Supervision

Planned Actual PCN review 07112/05 07112/05 Initial PID to PIC 0711 8/05 07/27/05 Initial ISDS to PIC 0711 8/05 07/27/05 Appraisal 11/28/05 11/28/05 Negotiations 12/05/05 12/07/05 BoardRVP approval 0 111 912006 Planned date of effectiveness 0611512006 Planned date of mid-term review 06/2008 Planned closing date 1119/20 10

Key institutions responsible for preparation of the project: Ministry of Public Health and Social Welfare - Guatemala Bank staff and consultants who worked on the project included:

Name Title Unit Marcel0 Bortman Task Manager LCSHD Manuel Salazar Sr. SP Specialist (co-Task Manager) LCSHD Alessandra Marini Economist LCSHD Patricia Orna Language Program Assistant LCSHD Manuel Vargas FM Specialist LCOAA Aracelly Woodall Project Costing Specialist LCSHD Luis Prada Sr. Procurement Specialist LCOPR Monica Lehnhoff Procurement Analyst LCOPR Suzana Nagele de Campos Abbott Operations Officer LCSHD Morag Van Praag Sr. Finance Officer LOAGl Solange Alliali Sr. Counsel LEGLA Isabel Rocha Pimenta Consultant WBIHD Anna Fruttero Consultant LCSPP Ver6nica Ramirez Consultant (Environmental issue) LCSHD

Bank funds expended to date on project preparation: 1. Bank resources: US$203,391.75 2. Trust funds: US$342,261.87. 3. Total: US$545,653.62.

Estimated Approval and Supervision costs: 1. Remaining costs to approval: US$115,724.00 2. Estimated annual supervision cost: US$94,170.00

98 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT Annex 12: Documents in the Project File

a. World Bank documents and assessments

1. World Bank. Poverty in Guatemala, October 2003 2. World Bank. Guatemala Public Expenditure Review, 2005 3. World Bank. Guatemala. Nota EstratBgica para 10s Sectores Sociales. April, 2004 4. World Bank. Environmental Health and Traditional Fuel Use in Guatemala. 2005 5. World Bank (2005) Honduras Nutrition and Social Protection Project, Project Appraisal Document, Report No. 3 1828-HO. 6. Gragnolati, M. and A. Marini, Health and Poverty in Guatemala, World Bank Policy Research Working Paper 2966. 7. Marini A., and M. Gragnolati, Malnurition and Poverty in Guatemala, World Bank Policy Research Working Paper 2967. b. GUATEMALA documents and resolutions

8. MSPAS, Policies, Strategies and Priorities for the period 1996-2000, brochure, 1996 9. MSPAS, “National Health Plan 2OOO-2OO4”, 2004 10. MSPAS. Strategic Planning Unit, “Basic Health Policies and Guidelines 2004-2008”, 2004 11. Ministerio de Ambiente y Recursos Naturales. Reglamento de Evaluacih y Seguimiento Ambiental, Acuerdo Gubernativo n23-2003. 12. MSPAS - Direcci6n General de Regulacih, Vigilancia y Control de la Salud. Plan de manejo de 10s desechos s6lidos hospitalarios de 10s CAIMIs, October, 2005. 13. PRRAC-SALUD. Inequidades GeogrAficas en la Mortalidad Infantil en Guatemala: Magnitud y factores asociados. April 2005 14. Proyecto Salud BBsica - MSPAS. Diagn6stico de necesidades de abastecimiento de agua y saneamiento en Areas urbano marginales de las ciudades de; Guatemala y 6rea conurbana, Chiquimula, Cob& Puerto Barrios, Quetzaltenango y Escuintla. April, 2005 15. Proyecto Salud BAsica - MSPAS. Diagn6stico de la situaci6n de recursos de comunicacih y transporte en el Sistema de Referencia y Respuesta en 10s Servicios de Salud. June 2005 16. Proyecto Salud BAsica - MSPAS. Categorizacidn de 10s servicios de salud del segundo nivel de atenci6n. July 2005 17. Proyecto Salud BAsica - MSPAS. Opciones Financieras y Operativas para la ImplementacGn de Hogares Maternos y Maternidades Comunitarias en Guatemala. June 2005 18. Proyecto Salud BBsica - MSPAS. Perfil epidemiol6gico de la poblaci6n no cubierta con servicios bBsicos de salud y propuesta de modalidades para la entrega de un paquete basic0 en el primer nivel de atenci6n en Areas urbano-marginales de la ciudad capital y en 5 departamentos de Guatemala: Escuintla, Alta Verapaz, Quetzaltenango, Chiquimula e Izabal.

99 19. Proyecto Salud BAsica - MSPAS. Evaluaci6n del Sistema de Referencia y Respuesta de la Emergencia ObstCtrica. June 2005

20. Proyecto Salud BAsica - MSPAS. Mapeo digital de la categorizacidn de servicios de salud del segundo nivel de atenci6n del Ministerio de Salud Publica y Asistencia Social. July 2005

21. Proyecto Salud Bdsica - MSPAS. Opciones de tecnologia apropiada para el abastecimiento, tratamiento y desinfeccidn del agua para consumo humano en las comunidades con mayores tasas de mortalidad por diarrea en Guatemala. 2005

22. SEGEPLAN - Plan de Implementacibn. Estrategia de Reducci6n de Pobreza - Guate Solidaria - Rural - Guatemala, Mayo 2005

23. SEGEPLAN - Estrategia de Reducci6n de Pobreza - Guate Solidaria - Rural - n.d.

24. MSP - Metodologia de Auditoria Social Anual y de Proceso de la Provisi6n de Servicios BAsicos de Salud -Julio 2005

25. SEGEPLAN - Implementaci6n de la Estrategia de Reducci6n de la Pobreza - Reporte TCcnico - n.d. c. Other

26. IDC. Evaluaci6n del Gasto Pliblico en el Sector Salud. October 2003. 27. Griffiths, M. and J. S. Mc Guire, 2005, Dimension for Health Reform: the Integrated Community Child Health Program in Honduras, in Health System Innovations in Central America. 28. Johnston, F.E., M. Borden, and R.B. MacVean. 1973. “Height, Weight and Their Growth Velocities in Guatemalan Private School Children of High Socioeconomic Class” Human Biology 45:627-641. 29. Martell et al., 1981, Crecimiento y Desarrollo en 10s dos Primer0 Mos de Vida Postnatal, Washington DC, OPS. 30. Martorell R., 1990, Importance of Childhood Retardation for Adult Body Size, Brief Statement prepared for the Expert Meting on Economic Consequences of Health Programs in LDCs, Committee on Population, National Academy of Sciences, June 20, 1990. 31. Martorell et al., 1994, Reversibility of Stunting: Epidemiological Findings in Children from Developing Countries, European Journal of Clinical Nutrition 48 Suppl. 32. Rao, D.H. and J.G. Sastry. 1977. “Growth Pattern of Well-to-Do Indian Adolescents and Young Children” Indian .I.Med. Res. 66:950-956.

100 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT Annex 13: Statement of Loans and Credits

Difference between Last ISR expected and actual Supervision Rating Original Amount in US$ Millions disbursements

Project Furpose Development Implementation Fiscal IBRD IDA Cancel. Undisb. Orig. Frm. ID Obiectives Prozress Year Rev'd

PO55084 GT COMPETITIVENESS HS HS 200 I 20.30 0.00 0.00 16.87 16.87 0.00 PROJECT PO74530 GT FINANCIAL SECTOR S S 2002 150.00 0.00 0.00 50.00 50.00 0.00 ADJUSTMENT LOAN PO76853 GT FINANCIAL SECTOR S S 2002 5.00 0.00 2.00 2.07 4.07 0.00 TA LOAN PO94365 GT GROWTH PDL 1 S S 2006 100.00 0.00 0.00 100.00 100.00 0.00 PO661 75 GT INTEGRATED S S 2002 29.75 0.00 0.00 17.07 11.29 0.00 FINANCIAL MNGT 111 - TA PO47039 GT JUDICIAL REFORM S S 1999 33.00 0.00 0.00 11.57 11.57 0.00 PO496 16 GT LAND S S 1999 31.00 0.00 0.00 5.00 5.00 5.00 ADMINISTRATION (APL) PO49386 GT RECONSTRUCTION & S MS 1999 30.00 0.00 7.10 4.10 11.20 0.00 LOCAL DEV. PO35737 GT RURAL & MAIN S S 1998 66.70 0.00 0.00 16.20 16.20 0.00 ROADS PO55085 GT SECOND RURAL AND MS MS 2003 46.70 0.00 0.00 4423 21.98 0.00 MAIN ROADS PROJECT PO48654 GT TAX ADMIN TAL S S I998 28.20 0.00 0.00 14.18 14.18 4.58 PO48652 GT UNIVERSALIZATION MS MS 2001 62 16 0.00 0.00 36.87 36.87 0.00 OF BASIC EDUCATION

Total 2002 60281 000 9 10 318 16 29923 9 58

Guatemala Statement of IFC's Held and Disbursed Portfolio As of 08/3 U200.5 (In US Dollars Millions)

Held Disbursed

FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 2003 Cuscatlan Guatem 0 01000 0 10 0 1994 Fabrigas 0 0100 010 2000 Frutera 2.8 0 0 0 2.8 000 2002 GDO 13.62 0 0 10.88 13.62 0 0 10.88 1998 LaFragua 11.58 0 0 0 11.58 000 2004 Montana 45 0 0 045 000 2002 Occidente 0 01000 000 1997 Orzunil 8.2 1.17 0.2 6.67 8.2 1.17 0.2 6.67 2000 Orzunil 1.6 0 0 0 1.34 000

Total Portfolio: 82.8 1.17 21.2 17.55 82.54 1.17 11.2 17.55

Approvals Pending Commitment Loan Equity Quasi Partic

101 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT Annex 14: Country at a Glance

Guatemala at a glance 8125105

Latin Lower- America middle- POVERTY and SOCIAL 3evelopment diamond” Guatemala & Carib. income 2004 Population, mid-year (millions) 12.6 541 2,430 Life expectancy GNI per capita (Atlas method, US5) 2,130 3,600 1,580 GNI (Atlas method, US5 b!llions) 26.9 1,948 3,847 I Average annual growth, 1998-04 Population (%) 2.6 1.4 1.o GNI Gross Labor force (%) 34 0.9 0.7 per primary Most recent estimate (latest year available, 1996-04) capita enrollment Poverty (% of population below national poverty line) 56 Urban population (% of total population) 47 77 49 Life expectancy at birth (years) 66 71 70 Infant mortality (per 1,000 live births) 35 28 33 Child malnutntion (% of children under5) 23 11 Access to improved water source Access to an improved water source (% ofpopulation) 95 89 81 Literacy (“A of population age 154 69 89 90 Gross pnmary enrollment (“9 of school-age population) 108 123 114 Guatemala Male 110 126 115 Lower-middle-incomegroup Female 102 122 113

KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1984 1994 2003 2004 ~ Economic ratios. GDP (US$ bilhons) 9.5 13.0 24.7 27.5 11.6 15.7 16.7 Gross capital formatiodGDP Trade Exports of goods and SeNiCedGDP 13.0 17.5 16.3 Gross domestic savings/GDP 9.4 8.4 5.1 Gross national savings/GDP 7.5 10.2 12.4

Current account balancelGDP -4 0 -5.4 -4.3 Domestic Capital 0.8 0.8 0.8 Interest payments/GDP 10 savings formation Total debVGDP 25 1 23.9 20.6 20.0 Total debt sewice/exports 21 5 12.4 7.5 Present value of debt/GDP 19.7 i Present value of debtlexports 79.1 I Indebtedness 1984-94 1994-04 2003 2004 2004-08 (average annual growth) GDP 33 34 2.1 2.7 GDP per capita 08 07 -0.5 0.1 Exports of goods and services 42 36 5.2

STRUCTURE of the ECONOMY

(% of GDP) Agriculture 25.6 24.5 22.3 Industry 19.8 19.7 19.3 Manufacturing 15.9 14.3 12 8 Services 54.8 55.8 58.5 Household final consumption expenditure 82.9 86.1 90.0 General gov’t final consumption expenditure 7.7 5.6 4.9 Imports of goods and services 15.2 24.9 27.9

1984-94 1994-04 2003 2004 1 Growth of exports and imports (?/.) (average annual growth) 1 Agriculture 2.9 2.4 1.4 Industry 3.3 3.4 1.9 Manufacturing 2.2 2.2 1.9 Services 3.5 4.1 2.5 Household final consumption expenditure 3.3 3.7 3.0 General gov’t final consumption expenditure 4.1 5.7 5.7 Gross capital formation 7.1 6.6 -7.7 Imports of goods and services 8.8 7.8 2.9

Note: 2004 data are preliminary estimates. This table was produced from the Development Economics LDB database. * The diamonds show four key indicators in the country (in bold) compared with its income-group average. If data are missing, the diamond will be incomplete.

102 Guatemala

PRICES and GOVERNMENT FINANCE 1984 1994 2003 2004 Domestic prices (“5 change) Consumer prices 3.4 10.9 5.3 Implicit GDP deflator 4.1 11.7 5.7 8.2 Government finance (“h of GDP, includes current grants) Current revenue 7.6 11.2 99 00 01 02 03 041 1 Current budget balance 0.6 2.1 -GDP deflator -0’CPI Overall surplusldeficit -1.6 -1.6

TRADE 1984 1994 2003 2004 (US$ millions) Total exports (fob) 1,132 1,687 2,787 8.W 7 Coffee 366 31 8 Sugar 71 172 Manufactures 984 1,750 Total imports (cif) 1,279 2,781 6,300 Food 86 557 Fuel and energy 300 201 Capital goods 203 706 1,483 98 99 w 01 02 03 04 Export price index (2000=100) 8 64 108 1 Import price index (2000=100) 10 68 106 I Exports 8 Imports Terms of trade (ZOOO=lOO) 83 93 101

BALANCE of PAYMENTS 1984 1994 2003 2004 j Current account balance to GDP (%) (US$ millions) Exports of goods and services 1,228 2,279 4,025 Imports of goods and services 1,428 3,222 6,885 Resource balance -199 -943 -2,860 Net income -207 -143 -350 Net current transfers 28 386 2,136 Current account balance -378 -700 -1,074 Financing items (net) 395 760 1,454 Changes in net reserves -1 7 -60 -380 Memo: Reserves including gold (US5 millions) 296 659 2,667 Conversion rate (DEC, loca//US$) 1.o 5.8 7.9 8.0

EXTERNAL DEBT and RESOURCE FLOWS 1984 1994 2003 2004 Composition of 2004 debt (US$ mill.) (US5 millions) Total debt outstanding and disbursed 2,377 3,105 5,082 5,499 IBRD 151 177 428 478 A 478 IDA 0 0 0 0 Total debt service 273 322 461 510 IBRD 26 60 37 46 IDA 0 0 0 0 Composition of net resource flows D 1,568 Official grants 22 89 150 Official creditors 87 81 -13 22 Private creditors 5 28 251 364 Foreign direct investment (net inflows) 38 65 116 Portfolio equity (net inflows) 0 0 0 F 1,359 E 511 World Bank program Commitments 50 0 30 47 A - IBRD E - Bilateral Disbursements 8 29 45 79 B - IDA D - Other multilateral F - Private Principal repayments 14 44 18 29 C - IMF G - Short-term Net flows -6 -15 27 50 Interest payments 12 16 19 17 Net transfers -18 -31 9 33

Note: This table was produced from the Development Economics LDB database. 8125105

103 GUATEMALA MATERNAL-INFANT HEALTH AND NUTRITION PROJECT

Annex 15: Map IBRD 33413

104 IBRD 33413

91°W90°W89°W88°W GUATEMALA SELECTED CITIES AND TOWNS DEPARTMENT CAPITALS NATIONAL CAPITAL MEXICO RIVERS GUATEMALA PAN AMERICAN HIGHWAY MAIN ROADS 18°N 18°N RAILROADS DEPARTMENT BOUNDARIES PaxbPaxbánán INTERNATIONAL BOUNDARIES

92°W

n Pedr Sa o PETPETÉNÉ N Tikal El Naranjo Melchor de Mencos L. Petén Itzá BELIZE 17°N 17°N

Flores n á Us p um o ac in La Libertad M ta

To MEXICO Tuxtla Gutiérrez ión as P SayaxchéSayaxché uilá aq ch a M s a Gulf n i San Luis l a of S Honduras én ncu 16°N Ca 16°N n arstún á S c

x

I Barillas hiyú Modesto LLívingstonívingston C MMéndezéndez uz PuertoPuerto HUEHUETENANGO ALALTATA VERAPVERAPAZAZ ta Cr San Barrios . CahabCahabónón Sie ra de IZABAL QUICHE a Mts r S am habó El Estor e Ch a n l Chajul C L. de eg ua Coban Izabal Morales Huehuetenango Polochic S N Los Amates ier egro SAN ra a de otagu MARCOS los M Chu BAJA VERAPVERAPAZAZ Santa Cruz acú TTajumulcoajumulco TOTONICAPTOTONICAPANAN s Salama ZACAPZACAPAA 15°N (4220 m) Del Quiche EL 15°N San Marcos TotonicapanTotonicapan Motagua Zacapa To PROGRESO To Tonalá S El Progresso S O El Progreso u i G

c

h e N Quezaltenango Solola GUAGUATEMALATEMALA Chiquimula

i A

a Nr t

e LE SOLOLA Chimaltenango A r TENANGO CHIQUIMULA EZ a U L.Atitlan Jalapa Esquipulas Q Mazatenango SACASACATE-TE- GUAGUATEMALATEMALA HONDURAS Retalhuleu M Antigua JALAPJALAPAA Ocós CHIMALCHIMALTENANGOPEQUEZ Guatemala a d RETRETALHULEUALHULEU r e Jutiapa Escuintla Cuilapa Champerico JUTIAPJUTIAPAA SUCHITEPEQUEZ SANTSANTAA ESCUINTLA ROSA 14°N 14°N

Sipacate San José

Las Lisas EL SALSALVADORVADOR

0 20 40 60 Kilometers To La Unión

0 10 20 30 40 50 Miles To La Unión

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information PACIFIC OCEAN shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 13°N 13°N 92°W 91°W90°W89°W 88°W

SEPTEMBER 2004