Peru - Basic Health and Nutrition Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 11801-PE STAFF APPRAISAL REPORT PERU BASIC HEALTH AND NUTRITION PROJECT JANUARY 7, 1994 MICROGRAPHICS Report No: 11801 PE Type: SAP Human Resources Division Country Department I Latin America and the Caribbean Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EOUIVALENTS (as of November 1993) Currency Unit: Sol US$1.00 = Soles 2.1 US$0.48 = lSol FISCAL YEAR January 1 to December 31 PRINCIPAL ACRONYMS USED BCG Bacillious Calmette-Guerin vaccine DPIT Diphtheria, Pertussis and Tetanus ELISA Enzyme Link Immunoabsorbent Assays ENDES Encuesta Demografica de Salud Familiar Demographic and Health Survey FONCODES Fondo Nacional de Compensacion y Desarrollo National Social Compensation and Development Fund GDP Gross Domestic Product INAN Instituto Nacional de Alimentacion y Nutricion National Institute on Feeding and Nutrition IEC Information, Education and Communications INEI Instituto Nacional de Estadistica e Informatica National Statistical and Information Institute INN Instituto Nacional de Nutricion National Nutrition Institute IU International Units MCH Maternal and Child Health MINSA Ministerio de Salud Ministry of Health NGO Non-governmental Organization PANFAR Programa de Alimentacion y Nutricion a la Familia en Alto Riesgo (Feeding Program for High Risk Families) PLSS Peru Living Standards Survey PRISMA Proyectos en Informatica, Salud, Medicina y Agricultura Projects in Infonnation Systems, Health, Medicine and Agriculture PRONABCE Programa Nacional de Control del Bocio y Cretinismo Endemico National Goiter and Endemic Cretinism Control Program SOE Statements of Expenditure TBA Traditional Birth Attendants TFR Total Fertility Rate UDES Unidad Departmental de Salud Department of Health Administration Unit UNDP United Nations Development Programme UNIPAC UNICEF Procurement and Assembly Center UNICEF United Nations Children's Fund UTES Unidades Territorial de Salud Territorial Health Administration Units WHO World Health Organization  FOR OMCL4CL USE ONLY PERU BASIC HEALTH AND NUTRITION PROJECT STAFF APPRAISAL REPORT TABLE OF CONTENT 1. Introduction ................................. 1 2. Background, Issues and Strategy .......... . 2 A. Background ......................... 2 B. Issues ............................. 8 C. Govemment Strategy ....... ............ 10 D. BankRoleandStrategy ...... ........... 11 E. Rationale for Bank Involvement ..... ....... 12 F. Lessons Learned ....... .............. 13 3. The Project ..14 A. Objectives .14 B. Project Area .14 C. Project Components .15 D. Project Implementation .26 4. Project Cots, Fnancing, Procurement and Disbursements .28 S. BenefitsandRisks .37 6. Agreemenrs Reached and Reconmendation .39 7. ANNEXES ................................... Annex 1: Selected Health and Demographic Data .41 Annex 2: Project Area: Population, Infrastructure and Human Resources .50 Annex 3: Description of Protocols .52 Annex 4: Project Management .58 Annex 5: Indicators of Project Performance and Impacts . .. 61 Annex 6: Selection Criteria for NGO Contracts .64 Annex 7: Project Cost Tables .68 Annex 8: Documents Available in Project Files .70 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  -ii- TABLES IN MAIN REPORT Table 4.1 Project Cost Summary by Summary Accounts ... .... 30 Table 4.2 Project Cost Summary by Components .... ........ 31 TAble 4.3 Financing Plan by Disbursement Category .... ...... 31 Table 4.4 Summary of Proposed Procurement Arrangements ... .. 35 This report is based on the findings of an apprasal mission which visited Peru in Juay 1993 and comprised Theresa P. Jones (rask Manager), Karen Cavanaugh, Sandra Rosenhouse and Marco Polo Torres (Consultant, IEC Specialist). Messrs. AUain Coliou and Ramer Stecwkan were, respectively, the managing Division Chief and Department Director for this operaton. The local preparation team was coordinated by Lic. Maria Rodriguez de Tello, Technical Director of the Office of Planning of the Ministy of Health. The team members were Ing. Pedro Dongo, Dr. bmael Cornejo-Rossello, Dr. Carlos Bardales, Dr. Jose Lizarraga and Dr. Milagos Nunez.  -ii- PERU BASIC HEALTH AND NUTRITION PROJECT LOAN AND PROJECT SUMMARY Borreur: Government of Peru EMauing Agency: Ministry of Health Amoumt: US$34 million Terms: Payable in 20 years, including a five year grace period, at the Bank's standard variable interest rate ProWest ObJetiv and Descr: The objective of the project is to improve health and nutritional status in the project area, particularly among poor women and children, by: (a) increasing the use of matenal and child health and nutrition services by extending access and improving the quality of services; and (b) promoting better health and nutition practices, with an emphasis on preventive care and education. The project area covers 15 provinces in three regions (Grau, Nor Oriental del Marafion and Inka) and one area of greater Lima (San Juan de Lurigancho district). Most of the populations in the provinces are mountain communities which include a significant share of indigenous people and of the extremely poor. In Lima, the district covered by the project is one of the poorest of the city. The emphasis in the project will be on preventive care in the areas of reproductive health and the health of inmnts and young children. In addition to strengthening activities such as the follow-up of pregnant women, child growth monitoring and micronutrent supplementation, more demand for preventive services will be generated through an integrated information, education and communications (IEC) component. The proposed project would finance basic medical equipment (for maternal and child health services at about 60 health centers and 200 health posts and for roughly 2,200 community health workers); vehicles for supervision; medicine, micronutrients and  - iv - other supplies; computers; office, printing and laboratory equipment; and basic instructional materials for health facilities. The project would futhermore cove, the costs of operational research and technical assistance aimed at strengthening services and testing innovative strategies to improve delivery and quality. The project would finance services contracted to develop and conduct mass media campaigns as well as the production and distribution of printed and audiovisual materials for the IEC program. It would also finance training and impact studies. Benefits: The demand for key preventive services and better health practices will be promoted through the IEC campaign. The resulting changes in behavior and ncreased demand, coupled with the greater access by the population in the project area to basic health and nutrition services and improvements in the quality of those services, should improve health and nutrition status. Also, the project would promote policy and program changes that would improve the effectiveness of the delivery of primary health and nutrition services by supporting research and other analysis. Risks The main risk is that implementation by the Government will be weak. This is addressed in two ways. First, the project focuses on a small number of programs most critical for the poor, thereby minimizing the number of activities to be managed. Second, the project envisages the use of experienced NGOs to supplement the Government's capacity. A second risk is posed by the possibility that the Government may revise the process of decentraliztion of health services during project implementation. The project addresses this risk by channelling funds through the central government. In addition, any change in implementation responsibilities for the project would need to be agreed with the Bank. A third risk is the history of poor outreach by public health facilities. The project focuses on this aspect by funding the incremental recurrent costs of increased supervision (on a declining basis); including supervision in the key indicators of project implementaton; and promoting changes in attitudes and practices through an integrated  IEC campaign. A deterioration in security conditions is a risk to all projects in Peru. The project confines its activities to areas of the country which are not classified as emergency zones. The selection of these sites will be kept under review and would be subject to change depending on security developments. Fstimated Costs: Project Cost Sunnar (US$ million) :- : - - - ~~~~~. . stimated Costs l Pr|ject .m n J Foreign Tl1 A. Matermal and Child Health 8.0 10.0 18.0 B. Nutrition 1.7 1.1 2.8 C. Tuberculosis 0.1 0.0 0.1 D. Information 11.0 5.8 16.8 E. Project Management and Eval. 1.5 0.6 2.1 TotalWBEINEOTS . 2 3 17.5 39.8 Physical Contingencies 0.4 0.6 1.0 Price Contingencies 2.0 1.7 3.7 Total ?kOJECE COSTS 24.7 44tS (M vI... a~ 43 .  - vi - EimnPncn : - - - :a. . (US$ milion) Government 9.5 1.0 10.5 Proposed IBRD Loan 15M 34.0 Estimated Disbursements: (US$ million) Bank Fiscal Year- 1994 1995 1996 1997 1998 1999 2MO Annual 2.0 5.8 7.4 6.8 5.6 4.5 1.9 Cunulative 2.0 7.8 15.2 22.0 27.6 32.1 34.0 Rate of Retum:, Not appHcable Poverty Categorv: Program of