IPP212 Social Assessment and Indigenous Peoples Plan (Summary)

Introduction

Public Disclosure Authorized The Panamanian government created the Red de Oportunidades program, which aims to reduce critical poverty and enhance human capital through a multisectorial approach that links improved services with conditional cash transfers to families in critical poverty. In order to qualify for the cash transfers, families are required to fulfill specific “co-responsibilities” requiring them to ensure their children maintain regular school attendance and using health services appropriate for pregnant women and children under the age of five.

While the Red de Oportunidades provides for the inclusion of poor families in urban and rural areas, the program has a particular focus on the inhabitants of indigenous reserves or comarcas. As discussed below, indigenous Panamanians represent about 10 percent of the total population, but comprise about a third of current or potential recipients of the conditional cash transfers. Since over 90 percent of populations residing in comarcas have been found to live in critical poverty, all families living in comarcas qualify for the cash transfers without submitting to a proxy means test that is used to determine eligibility for urban and rural residents. Public Disclosure Authorized This report constitutes the social analysis of the Social Protection Project and discusses the degree to which the components of the Red de Oportunidades are consistent with perceptions and expectations of recipient families residing in comarcas of the three principal indigenous groups: Ngöbe-Buglé, Kuna, and Emberá-Wounaan.

1. Indigenous peoples in Panama and legal framework

Indigenous status and identity are complex concepts related to issues of tribe, pueblos or people, place of residence, legal status and official recognition, and autoidentificación or self identity. The official definition of the indigenous population in Panama has shifted since it was first recognized as a separate category in the 1911 census, but currently, the definition is similar to that employed in other Latin American countries like Ecuador (and in the United States, for that Public Disclosure Authorized matter); the census definition of “indigenous” is based on self-identification (CEPAL/BID 2005: 27-28). This definition allows for delineating a variety of population characteristics as well as access to and use of education, health and nutrition services.

Official data on the indigenous population in Panama paints a picture that is very similar to what is known at the regional level, and leads to the general conclusion that despite some significant improvements, the indigenous population experiences levels of poverty, ill health and nutrition, and educational levels that are far below levels that characterize the general population. According to the Panamanian census (CEPAL/BID 2005), there were 285,231 indigenous people in the country in 2000, representing 10.1 percent of the population. The indigenous population is quite heterogeneous; most importantly in that it is composed of three large and several smaller specific groups, as follows: Ngöbe (59.3 percent of all indigenous people in the country), Kuna (21.6 percent), Emberá (7.9 percent), Buglé (6.2 percent), Wounaan (2.4 percent), and Teribe, Bokota, Bri Bri, and others (2.7 percent). Moreover, nearly 82 percent of all indigenous peoples Public Disclosure Authorized reside in rural areas, but this figure varies from over 91 percent (Ngöbe) to 63 percent (Kuna) and only 32 percent (Bri Bri).

Panama’s indigenous population is not stagnant, isolated from national and global trends, or passive in the face of those trends. In large part, the extent and the shape of the involvement of

1 indigenous Panamanians in the nation’s development can be understood in terms of external events and policies that have affected them and their social and cultural characteristics, which have conditioned their response to evolving conditions. Social and economic conditions in Panama’s three principal comarcas--Kuna Yala, Ngöbe-Buglé, and Emberá-Wounaan—are related to both national trends and strategies developed in response. (While there are substantial differences among the three groups, several important points of convergence are clearly discernible).

The Kuna, in particular, have been successful in maintaining a high level of political autonomy and cultural integrity, and in protecting their land base (Bourgois 1994). The ability to reassert cultural identity has since the 1970s been facilitated by a shift from concepts (and policies) of forced acculturation and homogenization and/or exclusion based on race and ethnicity to the promotion of multiculturalism, which has allowed for greater indigenous participation in national life, pro-indigenous legislation, control over resources (especially land), and enhanced consciousness or identity among indigenous peoples themselves (Horton 2006).

Full participation in national life is far from being completely resolved, and control over resources and the assertion of cultural identity is still evolving. Similarly, residents of the Ngöbe- Buglé and Emberá-Wounaan comarcas experience a dynamic tension between acculturation and assertion of ethnic identity. Nevertheless, land use in the comarcas are determined as much by isolation from roads and other external factors as by their legal status (Nelson, Harris, and Stone 2001) precisely because the state maintains substantial control over land use in the comarcas. In the past, when land use changed due to external factors, the indigenous groups have been obliged to adapt to changing circumstances.

These social, economic, and political processes are superimposed upon a rich yet evolving cultural landscape. Kuna culture, in particular, has long been recognized as one of the most resilient in the region, but it has experienced change and regeneration in recent decades. The Ngöbe-Buglé and Emberá-Wounaan have experienced similar (if less well-known) processes of cultural evolution. The relationship between culture and development nonetheless remains a controversial topic. On one hand, culture can be viewed as a resource; in the case of the Kuna, because of their participation in the production of handicrafts for the tourist market and also for export. The creation of molas (elaborate reverse-stitched embroidery), and the conservation of traditional dress (especially by women), language, and traditional leadership by the sahilias sets the Kuna apart (Howe 1991).

Official recognition of indigenous peoples in Panama is found in the country’s constitution; article 127 guarantees collective land rights and the existence of reserves (currently, comarcas represent 20 percent of the territory). Article 147 specifies the participation of indigenous peoples in the legislature. Political representation is provided by an Indigenous Affairs Committee in the national legislature, the Office of Indigenous Policy in the Ministry of Government and Justice, the National Council of Indigenous Development in the Ministry of the Presidency, and the recognition of Governors of the comarcas (CEPAL/BID 2005:17-18).

A critical element in the evolution of indigenous groups is the degree to which they have been able to control land and other productive and natural resources. The indigenous comarcas are regarded as semi-autonomous, internally regulated administrative territories under the jurisdiction of the national government (Herlihy 1988). The Comarca San Blas was officially formed in 1953 and renamed Kuna Yala in 1998; this early development reflects a long history of organization and interaction with the nation state beginning with an active revolt between 1915 and 1925, when the country’s second constitution was promulgated. In contrast, the Comarca Emberá de

2 Darién was officially formed in 1983, but recognized as the Comarca Emberá-Wounaan in 1999; at about the same time, the nearby Comarca Kuna de Madungandí was formed, and the Comarca Kuna de Wargandí was recognized in mid-2000. The Comarca Ngöbe-Buglé was recognized between 1997 and 1999. It is the largest territory, although the area granted was much smaller than what was petitioned (CEPAL/BID 2005:18).

2. Socio Economic Situation of Indigenous Communities in Panama

The relationship between indigenous ethnic status and poverty is mediated by access to basic social services. Access to basic education, health and nutrition services is highly unequal, with indigenous communities facing worse and not always culturally appropriate provision of social services. In education, indigenous communities fare much lower than the average. Completion rates among indigenous reach 70 percent in primary education and 20 percent in secondary education compared with 95 and 70 percent respectively in urban areas. In the health sector, the situation is even worse. The combination of supply and demand problems yields a highly inequitable health-care system. On average, less than one in ten indigenous individuals has a health insurance, compared with 75 percent among the population belonging to the 5th income quintile and even lower than the average of the lowest quintile (15 percent). Social indicators mirror the unequal access to services. About than half of indigenous population can read and write and the average schooling years is less than 2.5, compare with more than 80 percent and almost 7 years, respectively, for non indigenous. Chronic malnutrition (height for age) is near 60 percent in the comarcas compared with about 16 percent in the rest of the country1.

3. Assessment

a. Methodology

This section presents the results of field-based qualitative research conducted in the Kuna Yala, Ngöbe-Buglé, and Emberá-Wounaan comarcas between November 2006 and January 2007 and builds on information collected in October 2006. The methods selected for collecting data on perceptions and opinions on topics related to the conditional cash transfers were focus group discussions and individual key informant interviews2. Key informant interviews provided further information in the selected communities. These individual interviews were conducted with people in the communities who are prominent because of their influence, formal or informal leadership positions, or because they have information on the topic of interest by virtue of their position or occupation (for example, teachers or health care workers) or role in the community3.

1 For additional details, the World Bank’s Panama Poverty Assessment (2006) includes an extensive analysis of the social and economic situation of indigenous peoples in Panama. 2 The focus group is a planned exercise that is designed to elicit perceptions, opinions, and ideas from a set of individuals who normally share at least one important characteristic (for example, gender or socioeconomic status) and are provide a safe environment, in which all participants are encouraged to contribute. The group environment allows for interplay of ideas and comments that build upon one another, because individual perceptions and attitudes are shaped by their social context and are often best expressed in response to the opinion of others. The focus group setting thus represents a natural environment where the topic of conversation is directive, but at the same time, perceptions and ideas are expressed in the participants´ own terms rather than put into categories imposed by other data-gathering techniques (Krueger 1994; Marshall and Rossman 1999). 3 Key informant interviews represent an excellent source of information about the community, its organization, history, members, and relations with the state and external agencies (Marshall and Rossman 1999).

3 Question guides were developed in a workshop conducted in Panama in October 2006 with field workers, all bilingual native speakers of indigenous languages, all of whom had conducted focus groups for the Poverty Assessment earlier that year. The question guide for the focus group discussion addressed the following issues: knowledge of and general perceptions of the conditional cash transfer program, factors that could affect the capacity of recipients to satisfy the conditions or co-responsibilities (such as distance, availability, schedule, costs, treatment received, language, environmental factors, and culturally-informed beliefs), opinions regarding the best way for the transfer to be carried out and implemented in the community, perceptions on the use to which money received through the program would be used, health practices in the community (including traditional health beliefs and practices), and other factors considered relevant or important. The question guides were written in Spanish, but the focus group discussions and most key informant interviews were conducted in the respective indigenous languages.

Three teams of two field workers (two Emberá females, two Kuna females, and one male and one female Ngöbe) each conducted six focus group discussions: one with adult males and one with adult females in each of three communities. The communities were selected by the field workers in the October workshop based on their familiarity with the comarcas and using criteria of income, resource endowment, and access to roads and services in order to designate one as very poor, one as intermediate, and one as not as poor as other communities in the respective comarca. In the Emberá-Wounaan comarca an additional criterion was the selected communities should represent each of the two separate districts, Cemaco and Sambú. Prior to beginning the sessions, and usually upon arrival, local authorities were contacted and permission requested. This element is particularly important in the Kuna Yala comarca, where the approval of the traditional leader (sahila) was critical.

Using standard procedures, which were incorporated in the workshop held in Panama in October (Krueger 1994; Marshall and Rossman 1999), individual participants in each of the selected communities were screened and recruited to participate in the focus group discussions, and suitable venues (class rooms or other places free of disturbances were secured). While the optimal number of participants in a focus group discussion is about eight, the numbers varied and tended to be somewhat larger. Particularly in the Ngöbe-Buglé comarca, recruitment of participants resulted in attendance by all those present at the time, divided only by gender4.

The discussions were conducted by the two members of the field team; one served as facilitator (moderator) and led the discussion. The second team member handled logistical matters, operated a tape recorder, and took notes. The notes were used to ensure the accuracy of the transcriptions and to allow for the identification (using first name only) of individual participants in the discussion. (de Negri and Thomas 2003; Morgan 1998; Ulin, Robinson, and Tolley 2005). At the beginning of the session, the facilitator or note taker thanked the participants for attending, explained the purpose of the discussion and the rules that were to be followed (especially with respect to the validity of all opinions and the participation of all those present), and began with introductions. The members of the field team were careful not to enter into the discussions or to give their opinions regarding the topics that were discussed. Refreshments were served, but participants received no compensation.

A total of 18 focus group discussions were conducted in nine communities with a total of 224 indigenous adults (124 women and 100 men). Table 10.1 provides details on the focus group discussions.

4 In these situations, it is preferable to proceed with all participants rather than exclude some in order to achieve the optimal group size because doing so would most likely have resulted in all abandoning the session

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Table 10.1: Focus group discussions. Comarca Communities Status* Participants Kuna Yala Isla Pino A 13 women, 12 men Aligandi B 10 women, 12 men Tikantiki C 11 women, 11 men Ngöbe-Buglé Piedra Roja A 8 women, 8 men Guayabito B 21 women, 21 men Hato Chami C 29 women, 8 men Emberá-Wounaan Nuevo Belen A 6 women, 7 men Bayamón B 15 women, 11 men Lajas Blancas C 11 women, 10 men * Status: A Very poor. B. Intermediate. C. Not as poor.

In addition, 32 individual key informant interviews were conducted (at least three per location, except in one Emberá community).The individual key informant interviews were conducted in either the respective indigenous language or in Spanish, when the participant only spoke that language. As shown in Table 10.2, many interviewees were traditional local authorities, but educators, health care providers and others (indigenous and non-indigenous) were also included.

Table 10.2: Key informant interviews. Comarca No. of Interviews Positions of Interviewees Kuna Yala 11 5 local authorities; 1 health promoter; 1 nurses aide; 1 director of local NGO; 1 small business person; 1 artisan; 1 beneficiary Ngöbe-Buglé 14 4 local authorities; 2 primary school principal; 2 primary school teachers; 1 health center director; 2 local health promoters; 1 police official; 1 local government official; 1 loca researcher Emberá-Wounaan 7 7 local authorities

Transcripts of the focus group discussions were developed in the respective indigenous language from the audio tapes and were supplemented by notes. The transcripts were then translated into Spanish by the field team members, who are all bilingual native speakers. In the case of individual interviews, notes were taken. The translated transcripts and interview notes were analyzed by the author using a three-stage coding procedure. First, open coding was used to identify concepts and their properties and dimensions. This step often concentrates on response patterns to individual questions posed in the focus group discussions. Second, axial coding was used to relate the categories developed in the previous stage, further refine emerging categories, and link categories on the basis of properties and dimensions. Finally, selective coding was employed to integrate and refine the major themes and relationships among them (Strauss and Corbin 1998).

b. Summary of Main Results

(i) Knowledge and perceptions about the conditional cash transfer program. Accurate knowledge about the program was most complete in the Kuna Yala comarca not only because one of the communities had already received a cash transfer, but because despite the difficulties in transport and communication, information had been shared among the islands of the comarca. In addition, in early October, a team from the MIDES Office of Indigenous Affairs, including the director (himself a Kuna) had traveled extensively throughout the comarca to attend meetings to inform residents and their traditional leaders (sahilas) about the program. Among the Kuna, there was no difference in amount of knowledge about the program. In contrast, there was less knowledge about the

5 program in the Ngöbe-Buglé and Emberá-Wounaan comarcas, probably because communication in general is more limited, and there had been less contact by government officials.

Two perceptions of the program predominated. First, it was seen positively as necessary and potentially important. Second, general distrust of the government extended to the program because of questions as to: (a) its likely continuity (i.e., that it may not last very long), (b) political motivations (i.e., that the program’s true purpose was to garner political support at the local level), and (c) that non-indigenous people would benefit earlier or more than indigenous people. A contrasting view, expressed most often by Kuna participants, was that the money would be subject to misuse by recipients if not carefully monitored by traditional leaders and community residents themselves.

In general, the perception of the program was positive, because it would at least in part resolve problems related to poverty and limited consumption, although as noted below, there is also the perception that amount being distributed was insufficient to make a significant contribution to closing the gap between available resources and unsatisfied needs.

(ii) Factors inhibiting or promoting compliance with program requirements. Three themes emerged from this portion of the focus group discussions and were confirmed by key informants. First, access to public services is in many cases severely limited by geography and topography. On one hand, in the Ngöbe-Buglé and Emberá-Wounaan comarcas, a specific problem is distance from villages to places that health posts or centers are located. In the Ngöbe-Buglé comarca, it is often necessary to walk eight to ten hours to the nearest health center, and there are reports of people walking for two days or more. Access to primary schools is somewhat less limited in this respect.

In the Ngöbe-Buglé and Emberá-Wounaan comarcas, the many of the roads are in poor condition, so that access by vehicle is often extremely limited. Many communities are not accessible at all by road, and during the rainy season, many of the roads are completely impassable. In the Kuna Yala comarca, the problem is similar, although the limitation is not bad roads, but the distance between the islands and the mainland and between the islands. In all three cases, public transportation is available: trucks and small buses in the Ngöbe-Buglé and Emberá-Wounaan comarcas, and 16-foot motor boats in the Kuna Yala comarca. Even when weather permits, there is a limited supply of transportation, and it is expensive, in large part because of the cost of gasoline, which costs at least $4.50 per gallon in the comarcas. At times, the only feasible way to travel is by chartering a vehicle or boat, which involves renting the boat, paying a driver, and covering the cost of gasoline. This factor is critical because it means that a nominally free public service is converted into an expensive commodity.

A second barrier to compliance is related to negative perceptions about the quality of the services. The most relevant factor in this regard is that residents of all three comarcas, expressed very strong opinions about health care, particularly in regard to the lack of medications and other supplies, and to the irregular presence of health personnel. This factor is related to logistical problems noted above because people are reluctant to spend substantial time and money to reach facilities that in their experience are not prepared to provide the required services.

Similarly, there is a strong perception in all three comarcas that while primary schools are generally available and accessible, opportunities for attending school beyond the primary level (sixth grade) is very limited. This is in large part because having a child in secondary school is extremely expensive because schools beyond that level are only available in the larger towns, so that costs include transportation, rent, and food. For both primary and secondary school, the direct and indirect costs of education are considered to be high, sometimes prohibitively so; they

6 include school supplies and (most often noted by participants) uniforms and shoes, which are universally required.

Third, participants (especially in the Kuna Yala comarca—both men and women) expressed concern about the treatment received by that those who seek public health care services or who attend school. In part, this factor is related both to language and respect for cultural traditions, and is offset in some cases by the presence of indigenous education and health care and education professionals.

In spite of these crucial impediments to accessing services to comply with program requirements, and while there is considerable diversity of opinion on the use to which the cash transfer could or is to be put (see below), the perception in all three comarcas and among men and women is that the cash transfer will reduce the cost barrier to health care and education. In particular, comarca residents place enormous value on education, and parents in all three comarcas expressed impressive willingness to sacrifice so that their children can study not only at the primary level, but also in secondary schools outside of the community and in universities in the capital city.

(iii) Logistics for reception of the cash transfer. Perceptions related to this issue were remarkably uniform: given the difficulties, potential hazards, and costs of moving from one place to another, the strongly expressed preference is that the transfer be made in the recipients´ communities. Alternatively, a nearby central location could be identified. If the distance were not considerable, participants expressed willingness to travel in groups to reduce transportation costs. Particularly for the Emberá participants, it would be important that the arrival of the transfer be announced by radio. The Emberá participants also provided a second alternative: delivery by postal money order. Finally, according to respondents, the logistics of transfer in the Kuna Yala comarca must be coordinated with traditional authorities (sahilias), who can serve as facilitators and monitors of the process.

(iv) Distribution of the transfer in the communities. In the indigenous comarcas many households are composed of multigenerational, extended families, each consisting of several (often three or four) nuclear families, each consisting of two (or sometimes one) parent and children. While the extended family and kinship ties are recognized and highly valued, the nuclear family is understood to be the basic social and cultural building block. Consequently, an important theme in the focus group discussions (and confirmed by key informant interviews) was that the transfer should be made to families, not households. There are two reasons for this. Particularly in the poorer communities, the amount of the transfer was regarded as insufficient to cover either the basic needs of the family in general or even to facilitate compliance with the program’s co- responsibilities. A related issue is that of fairness and potential conflict. Dividing the money equitably within an extended household was viewed as problematic, particularly by Ngöbe-Buglé and Emberá participants, and consequently, it was viewed as likely that some members of the household would not be in agreement with decisions taken by household heads, especially because some families are larger than others, even within the same families.

Program specified that recipients would be female heads of households. This decision finds agreement in the three comarcas and, remarkably among women and men alike. There are three reasons for this: a.) Women are regarded as more able administrators, largely because they are more aware than men of the needs of the family (especially children) particularly with regard to health, nutrition, and education; b.) men are more likely to be absent and thus less able to either facilitate compliance with the co-responsibilities or be present to receive the transfer; and c.) men are viewed as quite irresponsible and likely to misspend the money on alcohol or other wasteful

7 outlets. Men expressed this opinion as much as women, but suggested that some men might be exceptions.

(v) Use of cash transfers. The use to which the cash transfers would be put can be divided into four categories: (a) costs related to compliance with the health and education co-responsibilities including, for example, transportation to services and purchase of school supplies and uniforms; (b) expenses not directly related to the program, such as food, home repair, and agriculture; (c) investment in starting small businesses; and (d) savings, especially for emergencies. While most participants viewed any necessary expense as a legitimate use of the cash transfer, others were less sure.

Many respondents, particularly women in the three comarcas, lumped together expenses for health and education (that would help fulfill program requirements with other basic needs, especially food). The ability to secure preventive health care, including vaccinations, prenatal care, and also family planning, was also recognized, and in particular, women expressed that the transfers would facilitate the payment of registration fees and the purchase of school supplies, shoes, and uniforms. The program was also seen as an opportunity to make house repairs.

Respondents in the Emberá and Ngöbe-Bugle comarcas, including men and women in the poorer communities, thought that expenditures for agriculture, small animal (especially pigs) and poultry production would be a rational response to the program. Seeds could be purchased and temporary wage labor could be employed to expand the area under cultivation. Particularly in the intermediate and less poor communities, participants recognized that the program was not certain to continue indefinitely, so that it would be wise to start a business or invest in some endeavor, even though the amount received alone would not necessarily enough for that purpose.

Participants held the view that saving part of the transfers for unplanned expenses, especially emergencies, would be an important part of their strategies. In poor rural populations this is often the case, and resources (for example, small animals) are often kept not as a source of regular income but as, in essence, a savings account. Given the uncertainty and high cost of transportation, savings was a frequently-expressed option, particularly in the poorer communities.

(vi) Health care beliefs and practices. Residents of all three comarcas under study hold traditional beliefs about health and illness and, consequently, about the appropriate steps to be taken when a person falls ill. These beliefs affect the choice of health care alternatives, and potentially intersect with compliance with the co-responsibilities of the conditional cash transfer program.

The difference between Western (or “institutional,” “modern,” or using a term employed in the comarcas, “Latino”) health care and traditional beliefs and practices is completely understood by residents of the three comarcas. This is not simply a matter of health care options or even access, although as shown above, that is an important consideration. According to Emberá, Ngöbe, and Kuna respondents, some illnesses are “ours” and are different than those experienced by non- indigenous people. Consequently, if an illness is regarded as traditional, the logical approach would be to respond with traditional medicine that can be self-administered or put into the hands of traditional health practitioners (curanderos or healers, botánicos or experts in herbal remedies, and shamanes, brujos, or jaibanas – witch doctors). In addition, child birth is often done at home, frequently with a traditional birth attendant, who in the case of the Ngöbe-Buglé comarca, may be recognized and accredited by the Ministry of Health.

All respondents reported that other things being equal; they use or would use either or both sets of health care options depending on the nature of the illness. An important defining factor is the

8 perception not only of the nature of the disease (traditional or Western) but its severity. According to most respondents, traditional medicine is the first option, but if the illness is not cured or if the case is severe, the family will go to a health center or hospital. In contrast, some respondents (women in less poor Emberá community) felt that the health center is the first resort, followed by traditional medicine if the response was not satisfactory.

A final consideration is that traditional health care is regarded as a reasonable alternative when access to and quality of Western health care in the public health centers and hospitals are perceived to be inadequate. There is evidence of the slow erosion of traditional health practice, both because younger generations are not learning the skills and beliefs related to traditional medicine or because, in the Emberá-Wounaan comarca, beliefs associated with evangelical Protestantism are viewed as antithetical to traditional practices that revolve around concepts of the supernatural.

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Indigenous Peoples Plan

This analysis delineates the social, cultural, and economic context within which residents of the indigenous comarcas would participate in the Red de Oportunidades conditional cash transfer program. In order to assure that the program be successful in implementing the cash transfer and more broadly, to ensure that the program can successfully address the twin goals of reducing poverty and increasing human capital, several specific actions should be taken.: a. Create an operational committee in each of the three comarcas. These operational committees would meet bi-monthly to discuss and share experiences on program operation, gaps in coverage and alternatives to improve participation. The committee should serve as a mechanism to receive feedback from indigenous communities, not only about the CCTs but also about health and education services providers and possible barriers related to cultural and ethnic patterns. The committee would consist of representatives of: traditional authorities of comarcas, the program, elected authorities and social services suppliers (traditional and non traditional).

The MIDES’s Office of Indigenous Peoples that will support the committee to operate The Office will be strengthened with one additional specialized professional ($50,000). b. Disburse transfers to mother-children units instead of households. The distribution of the cash transfer to mother-children units rather than extended families living in large households would be very beneficial in furthering the objectives of the program. While it is true that this change would increase the cost of the program, it is the appropriate policy to follow for reasons discussed above (budgeted under project). c. Ensure culturally appropriate provision of maternal and health services. The success of the program hinges on the provision of accessible, appropriate health and education services both to meet goals related to improving social capital and to facilitate compliance with program participant co-responsibilities. Particularly important is the provision of culturally appropriate health services. To achieve this, the following activities are proposed:

- Including as part of the training activities of Component 3 a module in intercultural approach to health care delivery for children younger than 5 by the indigenous health direction at MINSA (Elaboration of the module: US$20,000; Training: US$50,000); - Strengthening the supervision activities included in component 3 to ensure quality of intercultural approach to health (cost TBD); - Workshops with indigenous traditional authorities to agree on (i) identification of communities living in remote areas lacking health services where the PAISS+N will be introduced, and (b) promoting the program among possible local OEs for the delivery of the PAISS+N package (cost TBD); - Ensuring that OEs providing services in comarcas are fully familiar with the cultural context and include adequate bilingual staff (budgeted under project). d. Design the M&E system including appropriate modules and specific variables to follow up on the program in indigenous comarcas. MIDES and MINSA will include the variable ethnicity in their baseline data and in all databases to be used for monitoring and evaluating the impact of the project. The M&E system will be designed also to provide information

10 about process issues from the implementation of the program in indigenous comarcas, which will serve as inputs to incorporate lessons to program fine tuning. This includes:

• A monitoring component that includes two sets of parameters: outcome indicators to measure changes attributable to the program, and process indicators to be used to measure how compliance with targets is being reached. This will be complemented by information collected through specific indigenous beneficiary satisfaction surveys and processes evaluation in comarcas ($70,000); • A system of regular consultation with comarca residents and other indigenous groups. This system should include a quejas y reclamos mechanism and a system to receive frequent feedback from the community. The latter would be specifically coordinated with the respective governors and implemented through local authorities. These consultations should be implemented by the MIDES coordinators at the comarca level and should also include local health and education personnel (cost TBD). e. Design and implement a communication strategy to disseminate the program and keep communities alert. As the number of communities included in the program grows, delivery in each community will probably become increasingly challenging. This is even more important among some indigenous communities where knowledge about the program is lower. Successful transfers can be facilitated through good public communication, particularly the use of appropriate mass media channels such as radio. The communication strategy in indigenous comarcas will be culturally appropriate and delivered in Spanish and the correspondent language, using suitable means to specific context in the comarcas. The communication strategy will be assessed regularly and, if appropriate, updated over time as knowledge and experience accumulate and communication needs evolve. The outputs from the M&E will be used to adjust the strategy. (Budgeted under project).

Ensure an adequate measure of the impact of the program in indigenous comarcas. Given the significant proportion of beneficiaries living in indigenous comarcas and the disproportionate poverty incidence in these areas, the impact evaluation should involve a specific methodology to measure the effect of the CCTs in the living standards of the indigenous peoples (budgeted under project).

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