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World Bank Document 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 Honduras (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 Tolupan 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 Garifuna 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 Miskito
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