Page 1 INTEGRATED SAFEGUARDS DATA SHEET CONCEPT STAGE Report No.: AC849 Date ISDS Prepared/Updated: May 12, 2004 I. BASIC INFORMATION A. Basic Project Data Country: Paraguay Project ID: P082056 Project Name: Paraguay Health Project II Task Team Leader: Montserrat Meiro- Lorenzo Estimated Appraisal Date: December 3, 2004 Estimated Board Date: May 9, 2005 Managing Unit: LCSHH Lending Instrument: Specific Investment Loan Sector: Health (100%) Theme: Health system performance (P) Safeguard Policies Specialists in the task team: Yewande Awe, Sandra Cesilini Loan/Credit amount ($m.): 10 IBRD: 9 million Other financing amounts by source: 1 (Government of Paraguay) ($m) B. Project Objectives [from section 3 of PCN] At project completion, the project would have: (i) reduced exclusion and increased effective access (use) by the poor to basic and first referral mother and child services in selected areas; (ii) fostered social management of basic and first referral health services; and (iii) introduced mechanisms to increase leadership, transparency, teamwork and self-monitoring in the MOH. C. Project Description [from section 4 of PCN] The proposed project will have three components for a total of US$10.0 million over a three-year period. The costs and activities presented are indicative and will be refined during project preparation. Component 1: Increase Resources for Maternal and Child Services. (US$ 7.0 million). The objective of this component would be to increase the use of basic reproductive health and child services by the poor, in project areas. It would pilot a subsidy for a limited package of services. Following the Bolivia experience, the contents and financing mechanisms of said package foster: (i) self-selection of the wealthy out of the subsidy; (ii) increased production and efficiency of service provision; and, (iii) increased awareness of the poor regarding their entitlement (thus increase transparency of service provision). It would have the following characteristics: · It would finance some of the inputs needed to deliver services (excludes personnel salaries). · It could finance outreach activities to remote populations, and patient transportation for referrals. · It would pilot in a limited area a scheme in which resources, calculated on a per-capita basis, are transferred to the departmental level that assigns them to the health facilities on a fee-for-service basis, creating incentives to increase the number of patients. Page 2 · It could finance public and private providers, fostering competition among them. · Inputs could be allocated on the basis of performance and client satisfaction. In addition to the package, the component would finance TA, training, equipment and infrastructure repairs as needed, and pharmaceuticals (on a one-time basis) to improve reproductive and child quality of care from the supply point of view in the project areas and for 14 maternities that account for 50 percent of institutional deliveries. Specifically, it would: (i) renovate physical structures to ensure a safe and welcoming environment for patients and staff; (ii) expand social pharmacies; (iii) train staff to improve their technical skills; and (iv) develop and implement a change management strategy, directed at health service staff to modify their behaviors respect to transparency accountability, teamwork, and their interaction with patients and colleagues. Component 2: Health Sector MOH Stewardship Capacity. (US$ 1.0 million) . The objective of this component is to increase capacity to regulate, monitor, support, and evaluate the effect of the interventions of component one, by developing and implementing certain systems and tools. To ensure acceptance among staff and institutionalization of those systems and tools, the project will use methodologies that aim at increasing trust, transparency, teamwork and leadership among MOH officials. Specifically, the component would finance TA and inputs to: (i) develop and implement a scheme to promote staff behavior change;(ii) design and implement a unified surveillance system for maternal and child health status and service delivery; (iii) reengineer the procurement, and distribution systems for basic drugs and medical supplies and monitoring, inefficiency and corruption (particularly in primary health care facilities and maternities); (iv) improve the HR policies and incentives in the project areas and in 14 maternities; (v) improve the regulation and control of the quality of care for mother and child service provision. In addition, the project could provide assistance to develop systems and management practices to maintain recent investments in infrastructure and equipment. Component 3: Social Management. (US$ 2.0 million) . This component would focus on empowering communities to organize themselves to monitor, manage and even provide health services, as well as to introduce good practices regarding reproductive and child health behavior at the household and community level. Whenever possible, activities will be implemented through NGOs and local groups and organizations. Specifically, the component would finance TA, training, and information activities to: (i) develop and implement strategies to improve family and community behaviors related to Component 1; (ii) develop and implement organizational and social marketing strategies to improve community participation, management, social monitoring and auditing of mother and child health services and programs; (iii) train sanitary agents selected and paid by communities; (iv) introduce basic management skills to community-based groups. The component would also assign grants to groups for initiatives integrating education and health outcomes following operational procedures approved for MOE projects. The main project alternatives considered include different geographical scope, intervention mixes and types of lending instruments. After defining and applying an MDG exclusion index, the proposed project would limit most activities to the eight (out of 18) most excluded departments. The project focuses on the same health issues as the previous project, but in contrast to it, it will approach them from both the demand and supply sides. Also, it focuses on changing attitudes and behaviors rather than on infrastructure. Therefore, to achieve its intermediate goal of sustainable increased institutional capacity, the proposed project includes ongoing training and follow-up to the MOH staff and managers and the target population. Finally, although the project is designed as the first step in a long-term process, a SIL is proposed versus an APL, because of the country’s inherent risk level and the absence of a well-defined sector program. Despite the country’s risk rating, a LIL seems inappropriate because it requires loan effectiveness within three months of approval and is limited to a small investment. Both of those characteristics are seen as a handicap in the current Paraguay environment. Page 3 The environment and indigenous populations safeguards apply to the proposed project. Both the indigenous population and environmental assessments will be carried-out prior to appraisal, as well as a series of consultation with indigenous groups, in order to adapt the project to their cultural realities. D. Project location (if known) Tentatively most project activities would be implemented in regions to be identified on the basis of a health services exclusion index. E. Borrower’s Institutional Capacity for Safeguard Policies [from PCN] Special care will be given to the issue of medical waste. II. SAFEGUARD POLICIES THAT MIGHT APPLY Applicable? Safeguard Policy If Applicable, How Might It Apply? [X ] Environmental Assessment ( OP / BP 4.01) [ ] Natural Habitats ( OP / BP 4.04) [ ] Pest Management ( OP 4.09 ) [ ] Involuntary Resettlement ( OP / BP 4.12) [X ] Indigenous Peoples ( OD 4.20 ) [ ] Forests ( OP / BP 4.36) [ ] Safety of Dams ( OP / BP 4.37) [ ] Cultural Property (draft OP 4.11 - OPN 11.03 ) [ ] Projects in Disputed Areas ( OP / BP / GP 7.60) * [ ] Projects on International Waterways ( OP / BP / GP 7.50) Environmental Assessment Category: [ ] A [X ] B [ ] C [ ] FI [ ] TBD (to be determined) * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 4 Project activities include generation of medical waste and limited infrastructure rehabilitation. An environmental assessment will be carried out prior to appraisal and its results will be included in the project design. III. SAFEGUARD PREPARATION PLAN A. Target date for the Quality Enhancement Review (QER), at which time the PAD-stage ISDS would be prepared November 2004. B. For simple projects that will not require a QER, the target date for preparing the PAD-stage ISDS C. Time frame for launching and completing the safeguard-related studies that may be needed. The specific studies and their timing 1 should be specified in the PAD-stage ISDS. June to October 2004. IV. APPROVALS Signed and submitted by: Task Team Leader: Montserrat Meiro-Lorenzo Date Approved by: Regional Safeguards Coordinator: Juan D. Quintero Date Comments Sector Manager: Evangeline Javier Date Comments 1 Reminder: The Bank's Disclosure Policy requires that safeguard-related documents be disclosed before appraisal (i) at the InfoShop and (ii) in-country, at publicly accessible locations and in a form and language that are accessible to potentially affected persons. Page 5