Public Disclosure Authorized

HONDURAS: IMPROVING ACCESS AND QUALITY OF BASIC HEALTH

CARE SERVICES PROJECT

Public Disclosure Authorized INDIGENOUS AND AFRO-HONDURAN PEOPLES PARTICIPATION PLAN

(IAPP) 2009-2013 Public Disclosure Authorized Public Disclosure Authorized Social Safeguards

1. Social Assessment and Consultations carried out to identify, minimize and address social safeguard-related issues

Two types of consultations took place: (a) the social assessment, involving the participation of stakeholders from the public health sector, including promoters and volunteers, and traditional health care providers, i.e. midwives, traditional healers, bone- setters, AIN-C monitors; and (b) consultations between the MOH and the Indigenous and Afro-descendant Council (CONPAH) and federations. The first encounter took place in February, 2009 at Lake Yojoa, with the participation of the Confederation of Autochthonous Peoples of (CONPAH), the IDB-funded project (Autochthonous Peoples Development Project), nine Indigenous federations, and the World Bank. A consultation of the Indigenous Plan with the health specialists of the federations took place in May, 2009.

The consultations were carried out by a team of local consultants (an anthropologist and a public health specialist) in fourteen municipalities targeted by the Red Solidaria Program, including poor mestizo, Indigenous or Afro-Honduran population. The objective of the consultations was to assess health service users' and providers' perceptions about the basic health care package of services (a) the 'pertinence' of health promotion offered by providers in rural and remote areas; (b) the quality of preventive care strategies; (c) the supply of health services to respond particularly to maternal and child needs (service hours, conventional and traditional medication, infrastructure, reference and counter- reference); (d) the perceived quality of communication and empathy between health providers and beneficiaries; (e) the coordination between the conventional and the traditional providers; (f) the utilization of traditional medicine to solve common health problems (respiratory and gastrointestinal infections, skin diseases, cultural ailments) particularly of children <5 years old; (g) the use of vertical birth in ethnic groups and the demand for special installations in health units. The process and outcomes of the consultations have informed the project design. The product of the study was a proposal of Guidelines for Service Providers for the Cultural Adaptation of the Delivery of the Basic package of health services to ethnic communities. The results will be discussed by the consulting team with the MOH, donors and other guests in May, 2009.

Based on the results of the consultations, an Indigenous and Afro-Honduran Peoples Participation Plan (IAPP) was designed by the National Program for the Health of Ethnic Peoples (PRONAEH) of the MOH in consultation with the indigenous and afro- Honduran federations. The IAPP is included below.

2. Legal framework for Intercultural Health

(a) Honduras ratified ILO Agreement No. 169 on Indigenous Peoples on March 28, 1995. Art. 25 states that Governments shall oversee that adequate services are rendered and administered under the control and responsibility of Indigenous Peoples. Moreover, services should be planned and organized at the community level, jointly with the Indigenous people. Services should take into account the economic, geographic, social and cultural conditions, as well as the traditional practices for prevention, cure and medication.

(b) Honduras ratified the UN Agreement on the Rights of Indigenous Peoples in September 2007.

(c) Starting in 2000 the Honduran Government launched a commitment of inclusion of vulnerable groups within the Poverty Reduction Strategy for the attainment of the MDGs. A recently proposed Law for Integrated Development of Indigenous and Afro-descendent Peoples was submitted to Congress for approval in 2009. Art 25 proposes the following:

Acknowledgement and protection of traditional medicine. Consultations and coordination of health programs with Indigenous and Afro- Honduran peoples. Institutional adaptation of public health programs to respond to the needs of ethnic peoples, and free provision of services. Training and inclusion of Indigenous and Afro-Honduran human resources in the health sector. Nutritional support for children <5 years old, pregnant and lactating mothers. Creation of the National Directorate of Ethno-Health under the MOH, as the entity that will be responsible for the design and definition of public Health policies for Indigenous and Afro-Honduran peoples, and for overseeing the provision of said services.

3. Institutional assessment of the National Program for the Health of Ethnic Peoples of Honduras (PRONAEH).

PRONAEH was created in 1994 by Legislative Decree, with the mandate to monitor the health programs targeted to autochthonous peoples, and to ensure that the MOH responds to their needs in an adequate manner. However, the program has not been able to fulfill its goals due to, among other constraints, under-staffing and insufficient budgets. As part of project preparation, the Bank has underscored the importance of having a strong counterpart in PRONAEH, with experienced technical staff capable of articulating policy and monitoring the MOH health programs. As a response, the MOH has replaced the technical staff, and is planning to house PRONAEH at the MOH. The present IAPP will include some funds for the institutional strengthening of this program, support for the definition and training on 'intercultural health', and for the mechanisms of implementation of the IAPP. The IAPP below describes proposals to build PRONAEH's capacity to monitor the implementation of the present IAPP and those activities related to AN-C (part of the Bank-funded Nutrition and Social Protection Project), which is included in the basic health care package of services.

4. Ethnographic profile of Honduras According to population projections based on the last census (2001), the total population of Honduras is 7.48 millions in 2008 considering a population growth of 2.0 1% per year. The number of autochthonous peoples varies with the data source. Table No. 1 below shows 2001 census which estimates that the Indigenous and Afro-Honduran peoples represent 6.7% of the population, compared to estimates by the Indigenous federations, at 12.7% of the total population. A more recent census carried out by the Secretariat of Gobernacidn y Justicia (financed by IDB) calculates that there are 1.2 million autochthonous peoples living in some 144 municipalities (48%) out of 298 municipalities of Honduras, excluding urban centers (Tegucigalpa and San Pedro Sula) which include approximately 300,000 autochthonous peoples.

Table No. 1: Honduras Ethnic population by Group. Method: self-identification.

Ethnic Population Approx % Population Approx % Name@) of ~ederations~ Group Census of Total projection of Total 2001 Ethnic 2007 Ethnic Population Population 1 Lenca 279,507 63.2 878,409 73.0 ONILH, COPINH, MILH, FONDILH, Alcaldes de Vara Alta 9,6 17 2.2 43,812 3.7 FETRIXY Pech 3,848 0.8 2,895 0.2 FETRIPH Chorti 34,453 8.5 30,940 2.6 CONIMCH 46,448 10.4 108,144 9.0 OFRANEH 2.8 1 46,940 0 Miskito 5 1,607 11.5 70,000 5.8 MASTA (7 sub-federations) Tawahka 2,463 0.6 1,660 0.1 FITH ----Nahua ------19,842 1.7 Total 440,3 13 100 1,202,642 100 I Percentage 1 6.7 I 15.7 I ( of total pop. I I

5. Diagnosis of the health of Indigenous and Afro-descendant Peoples of ~onduras~

Population projections for 2005 put infant mortality rate at 30 per 1,000 live births. The last census and recent family health surveys all show a high correlation between infant

I The Census 2007 was carried out by Gobemacion y Justicia and financed by IDB (ATNIKE-9478-HO). 2 The groups are represented by Federations, recognized as legal entities by Gobernacidn. The Lencas are represented by 4 federations: Organizacidn Nacional Indigena Lenca de Honduras (ONILH), ConcejoPopular lndigena de Honduras (COPINH), Movimiento lndigena Lenca de Honduras (MILH), and (FONDIL). The Miskitos are represented by the Moskitia Asla Tawanka I.L.C. (MASTA), which is subdivided into 7 sub-federations. The Garifuna by the Organizacibn Fraternal Negra de Honduras (OFRANEH). In addition, Garifuna federations have flourished at the municipal level. The English- speaking Bay Islanders by the Native Islanders Professionals and Laborers Association (NABIPLA). The Tolupan by the Federacidn de Tribus Xicaques de Yoro ( FETRIXY) representing 30 tribes in Montafia de la Flor and Yoro. The Pech by Federacidn de Tribus Pech de Honduras (FETRIPH). The Chorti' by the Concejo Nacional Indigena Chorti de Honduras (CONICHH). The Tawahka by the Federacidn lndigena Tawahka de Honduras (FITH). Despite multiple federations within a group, only one representation of each group integrates de Technical Unit of PRONEEAAH.

Health in the Americas 2007, PAHO, 2007. mortality levels and the mother's level of poverty and education. The health status of the eight IndigenousIAfro groups of Honduras reflects their impoverishment, lack of access to basic services, and limited social participation. Of special concern are the high prevalence of Chagas' disease among the Tolupin in central Honduras, the Lenca in the Southwest, and the Chorti in the Northwest; the surge in the incidence of HIVIAIDS among he Garifuna on the Northern coast; and the high prevalence of accidents among the of Gracias a Dios. (pg. 435)

Among the communicable diseases, there were 19,000 cases of dengue in 2005, and 10 percent of those were hemorrhagic dengue fever. Malaria is endemic in Honduras, primarily affecting the northern and eastern parts of the country; there are 25 municipalities with a combined population of close to 350,000 inhabitants showing rates of more than 1,000 cases of malaria per 100,000 inhabitants. There were 1,000 cases of Leishmaniasis, 66 percent of which were in Olancho, Choluteca and Colon. A serologic survey of blood samples from school children under 15 years of age yielded a seroprevalence rate of 29 percent in La Paz, and up to 7 percent in Copan, Lempira, Intibuca, Yoro and Santa Barbara.

Of all reported cases of acute diarrhea each year, 77 percent involve children under the age of 5, with a prevalence rate of 22.5 percent in this age group and even higher rates in urban areas excluding Tegucigalpa and San Pedro Sula and rural areas, particularly La Moskitia. The most affected age group is that of children ages 6-23 months old. Most children under age 5 suffering from diarrhea are treated with drugs.

Among the chronic communicable diseases, tuberculosis-associated morbidity slowly declined from 72 per 100,000 inhabitants in 1993 to 50 per 100,000 inhabitants in 2004; 54 percent of all cases occurred among males. The incidence of HIV/tuberculosis co- infection has been on the rise since 1986.

Acute respiratory infections, including pneumonia, are still a leading cause of morbidity in children under age 5, particularly in the poorest municipalities in the country's western region. According to the findings of a 2001 survey of mothers who had lost children under 5 years of age, acute respiratory infections accounted for one out of every three deaths of children between the ages of 1 and 11 months and one out of every five deaths of children between 1 and 4 years of age. (pg. 437)

In terms of HIVIAIDS and other sexually transmitted infections, AIDS has been present in Honduras since 1985, At the end of 2005 there were just over 17,000 cumulative AIDS cases, with 970 new cases diagnosed in the year 2004 (incidence of 138 per 1 million people). San Pedro Sula and Tegucigalpa accounted for 40 percent of the new AIDS cases reported in 2005. The male-female ratio went from 2:l to 0.95 at the beginning of the last decade. The most affected age group was the population 25-34 years old, and the principal mode of transmission was heterosexual relations (88%). Nine percent of all new cases were due to prenatal exposure. In terms of the metabolic and nutritional diseases, one third of all Honduran children under age 5 are suffering from iron deficiency and from chronic malnutrition.

Table No. 2: Leading indicators of exclusion in health, by type, Honduras, 2004

Coverage Percentage Population without health care 30.1 Population without health insurance 83.1 Financial and work-related accessibility Households living under poverty line 64.5 Population with per capita income under USD llday 41.1 Workers employed in the informal sector 55.9 Cultural accessibility 38.1 5P Average number of years of formal schooling among ethnic population 2.2 Structure 1,000 population - 0.8 population 0.6 Processes Home deliveries 45.6 Pregnant women without health care during first trimester of pregnancy 43.6 Households without indoor plumbing 26.0 Source: Pan American Health Organization. Exclusion in Health in Latin America and the Caribbean. Washington, DC: PAHO. 2004

6. THE INDIGENOUS AND AFRO-HONDURAN PEOPLES PARTICIPATION PLAN (ZAPP) 2009-2013

As agreed with the National Program for the Health of Ethnic Peoples (PRONAEH) of the MOH, the objectives of the Indigenous and Afro-Honduran Peoples Participation Plan (IAPP) are (a) the inclusion of ethnic groups as project beneficiaries, and (b) to ensure that the basic health care package promoted by the project is delivered to the poor and the indigenous and afro-Honduran in a culturally-adequate manner. To this effect, the IAPP includes two parts, as follows:

(a) Guidelines for health care providers (mancomunidades, municipalities, public health units) to ensure (i) the inclusion of indigenous and afro- as project beneficiaries; and (ii) the adaptation of the basic health care package to respond better to the needs of the beneficiaries in a culturally-adequate manner (Components 1 and 2) (b) Strengthening of the PRONAEH for monitoring and social auditing of the present project and other programs of the MOH in regions inhabited by indigenous and afro-Honduran peoples. The guidelines listed below will be incorporated in the service contracts of the MOH with rnancomunidades, municipalities and other providers serving Indigenous and Afro-Honduran population. The terms of the contracts will be negotiated between the MOH and each health care provider. PRONAEH will participate in the revision and evaluation of proposals by providers. PRONAEH will monitor and support providers to ensure adequate provision of services (component 3).

A draft of the IAPP was sent to the Bank on April 30, 2009; but a final document will be sent to the Bank by May 6, 2009 and placed on the web page of the MOH. The IAPP includes the following:

Under Components 1 and 2: Expansion of Coverage of Decentralized Models, and Improvement of the quality of the provision of basic health services in the conventional model of health care

The following Guidelines will be included in the Service Contracts andlor Agreements with Mancomunidades or Municipalities (component 1) and health units (component 2):

PROMOTIONAL ACTIVITIES

Education

1. Design educational materials for health promotion with an intercultural focus, in the main language of health service users. In bilingual rural areas, communicate messages with symbols and pictographs. 2. Use regional and local broadcasting systems that are popular among autochthonous peoples. Also, promote through theatre, singing, and art. 3. Promote cultural diversity, gender equity, and environmental protection among stakeholders and beneficiaries, through sensitivity training on intercultural health. 4. Lay out the bridge between medical staff and traditional (indigenous) health practitioners through the organization of two types of encounters: between midwives and obstetricians; and between medical doctors and traditional therapists, to share knowledge and experience for mutual enrichment. Promote synergies between the official and the traditional workers. 5. Include the husband in the trainings and counseling provided to the mother, i.e. family planning, prenatal care, preparation for birthing and child care.

Promotion

1. The first visits of the provider to the communities to offer health services must be announced to and agreed on with the community leaders i.e. Auxiliary Mayor, midwives and traditional therapists. 2. Respect women's preference for birthing position (vertical or horizontal), provide the facilities for safe birthing, and allow the use of traditional diet if so desired by the patient. 3. Become knowledgeable and respectful of traditional medicine, traditional therapeutic practices and diet. Promote 'good practices' while refraining from practices that may be harmful or unhealthy. 4. Identify in each community the traditional health workers (midwives, therapists, bone-setters, etc), work closely with them, and if necessary include in the team of the rnancomunidad, knowledgeable traditional therapists who are respected in the local community.

PREVENTION ACTIVITIES

1. Hire local health workers (particularly promoters) who know the local culture and language, train them on intercultural health, and possibly in the local language. Or, ensure there is an interpreter to communicate better with patients who speak an indigenous language. 2. Promote institutional child delivery by providing the woman the choice of the participation of the midwife, and the presence of the husband (for moral support), if she so desires. 3. Train traditional midwives on early identification of pregnant women, cases of obstetric risks. Organize midwives for the accompaniment of pregnant women to the health unit for prenatal care, child delivery and post-natal care. 4. Accommodate health service schedules to those of the local users, respecting the seasonal schedule (migration). 5. Install a system of reference and counter-reference in agreement with the midwives, AN-C monitors and other traditional therapists.

CURATIVE ACTIVITIES

1. Elaborate protocols for health care of the family with an intercultural approach. 2. Be open to learning from patients about traditional practices, traditional medicine, and local diet, and establish rapport on those subjects with the patients, with due respect. Earn the trust of the patients. 3. Speak the local language, or include interpreters during curative activities. 4. Stimulate the use of safe traditional medicine, but warn against harmful practices. 5. Document the main local health problems, symptoms, and traditional curative approaches.

Under Component 3: Strengthening of the capacity of the MOH to monitor, supervise and evaluate the provision of health care services in the decentralized models of health care delivery

Strengthening of PRONAEH to steward and monitor a culturally-pertinent delivery of the health care package in communities inhabited by indigenous and afro-Honduran peoples. The objective of the subcomponent is to ensure the readiness and technical capacity of PRONAEH to support and monitor the implementation of the present project and other programs financed by the World Bank and other donors (Nutrition and Social Protection, PRAF, PROIvIESALUD, and others) targeted mostly to poor rural areas.

It includes the following activities, also summarized on Table No 3 below: (a) Monitoring and social auditing of the quality of delivery of basic health care package (components 1 and 2), including programs/strategies such as AN-C, RAMNI, STIs, HIVIAIDS, and other programs serving autochthonous peoples.4 US$100,000

(i) Social monitoring of health service delivery in a culturally-adequate manner with the use of monitoring instruments for health promotion, preventive care, and quality delivery of health care services, in coordination with MOH Directorates. (ii) Synergies and coordination with other Directorates within MOH, and with the health specialists of the indigenous and afro-Honduran federations to articulate interventions on indigenous and afro-Honduran regions. (iii) Coordination with the National Health Care Promotion Program of the MOH for the elaboration, design and production of promotional materials about intercultural health, traditional therapeutic and nutrition practices.

(b) Capacity building of health care staff to provide services in a pertinent and culturally- adequate manner that responds to the needs of the service users. (US$l10,000)

(i) Training of a technical team (within and outside MOH) on the subject of intercultural health, to carry out training, social auditing and supervision of health care services under the project. (ii) Provision of sensitivity training and promotion of intercultural health at the central, departmental, municipal, mancomunidad and local levels, particularly in regions of high concentration of indigenous and afro-Honduran peoples. Financing will be needed for: (i) design and validation of materials; (ii) production, (iii) training of providers, stakeholders and beneficiaries of health care services. (iii) Promotion of synergies between the staff of health units and the autochthonous health network, by carrying out local "Encounters for Mutual Enrichment" among (i) midwives and obstetric staff; and (ii) health specialists and traditional therapists.

(c) Mapping and census of the supply of health units and human resources serving autochthonous regions; a diagnosis of the health of indigenous and afro-Honduran peoples; and health plan to improve the health of those people. US$100,000.

(i) Mapping and census of supply of health services to plan the provision of the basic health care package and other services for autochthonous peoples and systematization of good health practices in ethnic communities. (ii) A diagnosis of the health of indigenous and afro-Honduran peoples, needed for planning at the national and regional level.

(d) Coordination with central and decentralized Directorates of the MOH in 18 departments of Honduras, other national and international agencies, and the indigenous

"he Integrated Community-based Strategy AIN-C is financed in part by the World Bank-funded Nutrition and Social Protection Project. 9 and Afro-Honduran federations to discuss the policy for adequate delivery of health services to autochthonous peoples. Strengthening of PRONAEH with human resources and equipment (US$50,000)

(i) Mesa Sectorial de Salud de 10s Pueblos Indigenas y Afro-hondurefios. PRONAEH will continue to steward the Mesu Sectorial (MOH, donors, health specialists of indigenous federations) for the formulation of indigenous and afro-Honduran people's health policy and its regulation. This effort will support the health programs implemented by the MOH, including those projects financed by the World Bank (i.e. the present project, the Nutrition and Social Protection project, the Conditional Cash Transfers (PRAF) project, the Inter-American Development Bank (PROMESALUD), and other national and international agencies in 18 departments of Honduras. (ii) Workshops with health specialists of Indigenous and Afro-Honduran federations to address health issues jointly with corresponding Directorates of the MOH.

(e) Strengthening of PRONAEH with human resources and equipment (US$40,000)

7. Description of proposals to build the capacity of institutions involved in implementation and monitoring of the plans.

The IAPP above describes in detail the proposals to build the capacity of the PRONAEH and line units of the MOH, to implement and monitor the project in a culturally-adequate manner.

8. Arrangements for funding and a schedule of implementation of the plans.

Funding for the culturally-adequate activities included in the decentralized contracts with service providers are included in the contracts signed by MOH and the providers. The institutional strengthening activities carried out by PRONAEH under the lAPP are funded by component 3 of the project, most likely with counterpart funds of the Government of Honduras.

9. Mechanisms to monitor the implementation of the agreed plans.

The MOH will develop monitoring instruments to be used by PRONAEH for the social monitoring of the quality of health care service delivery of mancomunidades and health units. Concurrently, the World Bank supervision missions will monitor the adequate implementation of the IAPP by PRONAEH in the MOH.

The following indicators are being monitored in the project:

- Percentage of health units with staff trained to provide services to indigenous population. - Percentage of health units that provide services to indigenous and afro-Honduran peoples. - Percentage of health units that follow at least 60% of guidelines to serve indigenous and afro-Honduran peoples.

10. Arrangements, including staffing and resources, for supervising the implementation of the agreed plans.

The Bank task team includes a social development specialist to oversee issues of social inclusion, governance, gender, intercultural health, social safeguard compliance, and proper implementation of the IAPP. Table 3: INDIGENOUS AND AFRO-HONDURAN PEOPLES PARTICIPATION PLAN (IAPP) 2009-2013

( Comp ( Sub-components I Activities I Modality I Responsible ( Costs ( Years -1 I US$ of coverage Include guidelines of Promotional, Preventive and Curative Guidelines to be PRONAEH and 00 5 of decentralized models Activities in the Terms of Reference and Service Agreements of included in 1 UPEG and improvement of Mancomunidades and health units to ensure providers include TORS and 1 1 quali@of provision of I intercultural health care strategies pertinent for service delivery [ service I 1 I 1 I ( basic health services in I to indigenous and Afro-Honduran communities. PRONAEH I agreements 1 I 1 1 1 I conventional model of I will review proposals and will be part of the Committee 1 1 I 1 1 1 health care / approving service agreements. I 3 1 3.4 Strengthening of the I (a) Social monitoring of the quality of delivery of basic health 1 Follow-up of I PRONAEH, 1 100,000 1 5 Capacity of PRONAEH care package including AIN-C, RAMNI, STls, HIVIAIDS, etc 1 random sample 1 UPEG I I (MOH) to monitor, (b) Capacity building of health care staff to provide services / Hands-on I PRONAEH, 1 110,000 1 5 supervise and carry out workshops UPEG social auditing of the (c) Mapping, census, diagnosis of health units and human Consultancies PRONAEH, 100,000 12 provision of health care resources serving autochthonous people, systematization of U PEG services 2ood health practices in ethnic communities (d) Coordination with MOH directorates and decentralized Meetings, forum, PRONAEH, 50,000 5 units, other national and international agencies, donors, health symposium other specialists of the indigenous and afro-Honduran federations Directorates of through the Mesa Sectorial de Salud de Ins Pueblos Indigenas MOH (e) Strengthening of PRONAEH Goods PRONAEH 40,000 5 US$ 400,000 5