JAPAN SOCIAL DEVELOPMENT FUND - GRANT PROPOSAL

Transcription

1 JAPAN SOCIAL DEVELOPMENT FUND - GRANT PROPOSAL FY10 ROUND 31 A. Basic Information A.1 Beneficiary Country Belize A.2 Grant Recipient Ministry of Health, Government of Belize.As the Grant Recipient, the Ministry of Health's role will be strictlythat of project oversight and not management. In this regard, the MOHwill sign the service level agreement with the Toledo District HealthCounc A.3 Name and Address of Implementing Agency Toledo District Health Council (DHC) Office of the Mayor Jose Maria Nunez Street Punta Gorda Town, Toledo District - Belize A.4 Is the Implementing Agency a Government Yes entity? #(in case of joint implementation by government and NGO(s), please provide details on the legal status of each agency under Grant Implementation Arrangements below) A.5 Administrator International Bank for Reconstruction and Development A.6 Grant Name ROUND 31: BELIZE - IMPROVING CHILDREN'S HEALTH AND NUTRITION IN POOR MAYAN COMMUNITIES IN TOLEDO A.7 Grant Amount in USD (includes incremental 2,996,144 Bank costs) A.8 Does this grant proposal qualify for the No special allocation for Africa? B. Grant Development Objectives The objective of this Grant is to improve the health and nutrition of children in poor Mayan communities in Toledo, Belize THROUGH AN EARLY CHILDHOOD DEVELOPMENT APPROACH FOCUSING ON PRE-NATAL CARE, NUTRITION MONITORING IN THE CRITICAL WINDOW OF OPPORTUNITY, AND SCHOOL HEALTH INTERVENTIONS AT THE PRIMARY SCHOOL LEVEL. C. Eligible Expenditures List all applicable eligible expenditures below in one or more categories as necessary. Eligible expenditures include consultant services (including audits), local training and workshops, small civil works, goods, sub-grants and incremental Bank costs. Category Amount (US. Dollars) Percentage of Expenditures to be Financed GOODS 843, % 28% CONSULTING 294, % 10% TRAINING 998, % 33% CIVIL WORKS 517, % 17% OPERATING COSTS 100, % 3% Total Grant to Recipient 2,752,894 Incremental Bank Cost 243,250 8% Total Grant Amount 2,996,144 Percentage of Grant Amount 1

2 Grant Supplementary Information Section 1 - Administrative Information Trust Fund No. (For CFPTO Use Only) TF Resubmission No JSDF Grant Type Project Sector Code Health, Nutrition and Population Grant Approval Date (For CFPTO Use Only) Task Team Leader Ms Carmen Carpio TTL ccarpio@worldbank.org TTL Phone Number Was a JSDF Seed Fund used to prepare this No grant? If so, please indicate the TF number. Section 2 - Details of the JSDF Grant Section Grant Components and Activities Briefly describe the specific activities (limit 300 words) to be carried out under each component Component 1 Prevent and address malnutrition in children under 5 years of age by empowering the local community. Cost (USD) 169,850 With specific regard to malnutrition, indicators including height and weight indicate that Mayan children experience lower height and weight than their counterparts throughout the rest of Belize, and are now experiencing increased levels of obesity and overweight in childhood. Based on a consultation session with the Toledo local government officials, community health officials working specifically with the Mayan community of Toledo District, and civil society representatives who are part of the Toledo District Health Council, including, most significantly, the Toledo Maya Women's Council, agreement was reached that ECD interventions, based on WHO growth charts, will provide the framework for defining an easily understandable nutrition monitoring tool allowing parents to readily recognize their child's growth progress and to gauge the child's advances in height and weight in relation to internationally recognized standards. Component 1 is composed of five activities aiming to empower the local community to address malnutrition afflicting Toledo's Mayan children 5 and under through community-based ECD interventions. The specific activities are: (i) PROMOTE GOOD NUTRITION IN PREGNANT WOMEN THROUGH HEALTHY WEIGHT GAIN IN THEIR REGULAR ACCESSING OF PRE-NATAL CARE THROUGH THEIR COMMUNITY HEALTH WORKER. This activity will strengthen the dialogue between the Community Health Worker and Community Nurse Aides (CNAs) working at the village-level who will actively engage with each village to ensure pregnant women do have regular access to ante-natal care and support with monitoring of the mothers' health. (ii) PROMOTE SOUND INFANT AND YOUNG CHILD FEEDING THROUGH OPTIMAL BREASTFEEDING PRACTICES, ADEQUATE INTRODUCTION AND CONSUMPTION OF COMPLEMENTARY FOODS AND RESPONSIVE FEEDING. As part of pregnant women's ante-natal care visits, the CNAs will be empowered to continue the dialogue and monitoring of the mother#s health and complement this with education awareness to ensure mothers are aware of the importance of proper infant feeding practices. (iii) Develop an easily understandable nutrition monitoring tool based on internationally recognized WHO growth standards. Community-based growth monitoring will be instituted with each village appointing a parent leader, preferably a mother, who will be trained on nutrition monitoring practices and, with the guidance of the local health worker and community nurse aid (CNA), who act within villages and communities, will develop a simple monitoring system that will be posted in a location accessible by all community members that will record and track the growth of each child in the community under 5 years of age. THE PARENT LEADER WILL ALSO WORK IN PARTNERSHIP WITH THE CNA TO MONITOR THE ANTE-NATAL CONSULTATIONS OF EACH OF THE COMMUNITY'S PREGNANT WOMEN. (iv) Hold a consultative, technical workshop with community health promoters, educators, parents, and local government officials to increase understanding of WHO Growth Standards and nutrition monitoring tool at the community level. Before implementing activities, the team will hold a consultative technical workshop with, in a first instance, the Mayan community of the District of Toledo to ensure the implementation plan is developed in a culturally sensitive manner to the 2

3 Mayan culture, and in a second instance will bring together the Mayan community with the local health promoters, educators, parents, and local government officials to further discuss and finalize the implementation plan and to define and increase understanding and ownership of internationally-held growth standards at the community level AND TO IDENTIFY COMMUNITY-DEFINED INDICATORS, IN ADDITION TO THOSE ENUMERATED IN THIS PROPOSAL, TO GAUGE PROGRESS. (v) Increase knowledge on nutrition growth and monitoring within the community and among health workers though a roll-out a training-of-trainers (TOT) program. The development and introduction of such community-level growth monitoring charts within the Mayan community of Toledo will be accompanied by a training-of-trainers (TOT) program targeted at parent leaders in the community, and particularly mothers, to develop a sustainable, community-owned program empowering trained parents to train newer parents on how to apply the validated standard in the monitoring of their child's growth. THE TOT WILL ALSO INCLUDE BEHAVIOR PROMOTION MESSAGES THAT WILL STRESS THE NEED FOR OPTIMAL BREASTFEEDING PRACTICES ACCOMPANIED BY ADEQUATE INTRODUCTION AND CONSUMPTION OF COMPLEMENTARY FOODS AND RESPONSIVE FEEDING. Monitorable Deliverables/Outputs 1 community validated nutrition (growth) standard, 85% of villages with community-based growth monitoring system, 102 trained community parent leaders, increased use of pre-natal health services Component 2 Develop Healthy Lifestyles Programs for Primary School Children in their eight years of primary education Cost (USD) 1,007,650 This component is made up of activities that aim to empower local primary schools to encourage "Healthy Lifestyle" practices targeting Toledo's Mayan children 5 and above. The specific activities are: (i) Introduce a Health Day throughout primary schools in Toledo that would include weekly iron supplementation and deworming every 6 months. A designated Health Day will be established throughout schools in Toledo whereby, on a fixed day/once a month, schools will facilitate the administration and provision of BASIC HEALTH SERVICES IDENTIFIED THROUGH DISCUSSION WITH PROPOSED BENEFICIARIES AT THE SCHOOL AND COMMUNITY LEVELS TO INCLUDE immunization, deworming, nutrition monitoring and MICRONUTRIENT SUPPLEMENTATION as well as educational activities/messages focusing on hand-washing, and HEALTHY-EATING. Each Health Day will be administered by the Community Nurse Aide (CNA) who will also be responsible for monthly visits to the school. The task team fully agrees that food based approaches are key to improving nutritional status and should be promoted. However, the availability, accessibility and consumption of highly nutritious foods in remote and poor areas often poses a challenge that takes time to address. In populations were anemia and other micronutrient deficiencies are highly prevalent, other complementary approaches, such as supplementation through iron fortification and deworming pills, being provided through this Grant, are recommended to restore / promote optimal nutritional status and are recommended by the World Bank in its nutrition approach. (ii) Develop a plan to scale up school feeding at the regional level in Toledo, and coordinate and standardize the implementation of school feeding programs with BALANCED MENUS THAT INCLUDE DAILY CONSUMPTION OF VEGETABLE AND FRUITS. Based on the findings of an assessment of national school feeding programs currently being conducted in Belize, a plan will be developed to scale school feeding at the regional level in Toledo WITH UNIVERSAL COVERAGE THROUGHOUT PRIMARY SCHOOLS IN TOLEDO, THUS TARGETTING THE MAYAN POPULATION BUT PROMOTING SPILL-OVER EFFECTS FOR OTHER POPULATIONS IN TOLEDO SCHOOLS AT THE SAME TIME. Through the existing School Feeding Committee of Toledo District, which includes local representation to the school level, current school feeding programs will be coordinated and standardized for improved nutritional value of the meals served, greater efficiency, oversight and reach. (iii) Strengthen school health messages focusing on proper nutrition, HEALTHY WEIGHT MAINTENANCE, REGULAR PHYSICAL ACTIVITY, and overall healthy lifestyles. In addition, to further support school health programming in schools, the existing school curriculum of Health and Family Life Education (HFLE) implemented in all primary schools throughout Belize, will incorporate strengthened school health messages around proper nutrition, HEALTHY WEIGHT MAINTENANCE, REGULAR PHYSICAL ACTIVITY, and overall healthy lifestyles with a specific focus on handwashing. The role of the HFLE coordinator will be emphasized in these efforts AS WILL THE SIGNIFICANCE OF ENGAGING PARENT TEACHER ASSOCIATIONS (PTAs) AND OTHER COMMUNITY-BASED ORGANIZATIONS DEALING WITH SCHOOLS. (iv) Ensure functioning and well-maintained toilet and handwashing facilities in all 21 Toledo primary schools, and ensure separate toilets for boys and girls. Finally, ADDRESSING A COMMUNITY-LEVEL CONCERN, work will aim to ensure a safe and sanitary school environment in all 21 primary schools in Toledo through the provision and/or revitalization of water and sanitation systems as needed. To ensure the maintenance and sustainability of such systems, roles and responsibilities for the upkeep of toilets and handwashing facilities will be clearly communicated at national, regional, village and school levels. Efforts will also be made to work with parents, community members and school administrators as appropriate to ensure provision of gender-sensitive toilets in all 21 schools. Monitorable Deliverables/Outputs iron supplementation and deworming pill for students, community managed school feeding program in Toledo's 21 primary schools, community-managed system for mgmt. of sanitary facilities 3

4 Component 3 Strengthen access and QUALITY of community-based health services in support of maternal and child health. Cost (USD) 1,053,444 This component is designed to give voice to the community to participate in the design and vetting process of identifying and surfacing key health service areas (technical and geographic) that require improvements in order to provide the community with the health services they require and are lacking. THE COMMUNITY WILL LEAD THE DISCUSSION AND FACILITATE THE DECISION-MAKING WITH THE COMMUNITY HEALTH WORKERS TO WORK WITH LOCAL AND REGIONAL HEALTH REPRESENTATIVES TO ENSURE THE 51 VILLAGES IN THE TOLEDO DISTRICT PROVIDE QUALITY MATERNAL AND CHILD HEALTH SERVICES FOCUSING ON PRENATAL CARE AND THE 0-2 VULNERABLE AGE GROUP IN THE WINDOW OF OPPORTUNITY. The specific activities are: (i) Based on discussions with the community and indigenous leaders, there is a need to strengthen the capacity of the local health care workers and CNAs, but also to provide them with sensitization training that will provide them with the insight to deliver health services and care respective of the local community's indigenous culture and traditions. In response to this, this activity will develop a training curriculum to strengthen capacity of Community Nurse Aides (CNAs) and community-based health care workers to include sensitization training on Mayan culture and practices. Discussion with members of the District Health Council CONFIRMED a need for continuous training for the community nurse aides (CNAs) and community-based health care workers in Toledo, which can serve as an incentive for village and community residents, particularly the indigenous population, to access health services and facilities knowing that their tradition and culture will be respected. The training curriculum will be based on good practice and evidence-based interventions and developed through a consultative, technical workshop which would give voice to the community/village and indigenous leaders, CNAs, community-based health care workers, and civil society representatives to share the challenges in the delivery of and access to quality health services in the District. Ministry of Health and Ministry of Education officials will provide input on what training programs are available from which a tailored curriculum responding to the community needs will be developed which will include cultural sensitization training for CNAs and community-based health care workers on Mayan traditions and practices that affect their seeking of health services. (ii) Provide the community with health technical expertise not available at the community-level through tele-health approaches that will connect CNAs and community-based health care workers with the latest clinical knowledge and training opportunities, in line with developed curriculum, to increase local capacity and the quality of services being required and requested by the community. To further support the delivery of timely, quality health expertise to the communities, particularly due to the remote nature of community health workers and CNAs, the community leaders and civil society expressed a specific interest in being able to introduce innovative tele-health approaches to strengthen local capacity and ensure the villages are being provided with current clinical knowledge and care practices. This would entail including hands-on training and seminar-style learning in the curriculum, the latter to be provided through tele-health techniques, on a monthly basis at the District hospital and through the polyclinics which would connect the CNAs and community-based health care workers with training hospitals within and outside of Belize willing to offer educational/training programs via tele-health techniques. This undertaking will entail the purchase and installation of videoconferencing (VC) equipment in the Toledo District hospital and the District's four polyclinics and will be accompanied by technical training to a team at each facility for proper use and maintenance of the VC tools. (iii) Strengthen the community's access to timely health knowledge by providing the CNAs and community-based health care workers with hand-held radios. An additional tele-health approach requested by the community and civil society representatives, particularly for those living in the more remote and predominantly indigenous villages, is to ensure the community health workers and CNA is always connected to the District's health expertise. This can be accomplished by introducing simple, yet effective technologies such as the hand-held radios. THIS WILL STRENGTHEN THE COMMUNICATION FROM THE VILLAGE LEVEL TO THE DISTRICT HEALTH CARE SYSTEM IN TOLEDO, PARTICULARLY ALLOWING FOR REGULAR CONTACT AMONG THE DISTRICT HOSPITAL, POLYCLINIC, AND SATELLITE CLINICS IN EACH VILLAGE WITH THE CNAS AND COMMUNITY-BASED HEALTH CARE WORKERS. THIS WILL FACILITATE THE CNAS AND COMMUNITY-BASED HEALTH CARE WORKERS' DIRECT ACCESS TO HEALTH EXPERTISE AND KNOWLEDGE. (iv) BASED ON THE HEALTH SERVICE NEEDS AREAS ARTICULATED BY THE COMMUNITY, UNDERTAKE A TECHNICAL ASSESSMENT OF THE 51 SATELLITE (REMOTE) CLINICS IN THE TOLEDO DISTRICT (ONE CLINIC FOR EACH VILLAGE) TO DETERMINE THE EQUIPMENT, SUPPLIES, AND REFURBISHING REQUIRED TO ENSURE ALL 51 SATELLITE CLINICS ARE ABLE TO PROVIDE ESSENTIAL MATERNAL AND CHILD HEALTH SERVICES THAT THE COMMUNITY FEELS ARE CURRENTLY NOT AVAILABLE TO THEM AND HAVE BEEN DISCUSSED WITH THE LOCAL HEALTH OFFICIALS. As indicated in the safeguards section of the proposal, the refurbishings will not generate medical waste and will only consist of basic upgrades generating standard construction debris to be appropriately disposed of in line with country regulations. The assessment will first be carried out to determine the priority maternal and child health services that are lacking as articulated by the community in discussion with the health officials and from there determine what equipment and supplies need to be purchased for each of the 51 satellite (remote) clinics which will include identifying those requiring refurbishing. Monitorable Deliverables/Outputs 4

5 training curriculum for community-based health care workers, 102 community health workers trained on Mayan cultural practices, 102 hand-held radios, 51 properly equipped satellite (remote) clinics Component 4 Promote behavior change in communities by increasing understanding of community's attitude and perception towards health Cost (USD) 89,150 This component aims to promote behavior change in communities by increasing understanding of community's attitude and perception towards health and develop culturally adapted health promotion interventions. This component looks to implement a knowledge management approach to better understand and incorporate Mayan cultural practices in relation to health services and support efforts aimed at ensuring the Mayan community are accessing the essential maternal and child health services without interfering in their cultural practices: (i) Take stock of behavioral practices of the Mayan community in relation to seeking health services and health education. BASED ON COMMUNITY-BASED SENTIMENTS IDENTIFYING THE MARGINALIZATION OF THE MAYAN COMMUNITY OF TOLEDO, Component 4 will build on the preceding components with, first, a stock-taking of the behavioral practices of the Mayan community with a view to better understanding cultural barriers that may prevent the Maya from accessing health services. THE STOCKTAKING WILL HAVE A SPECIFIC FOCUS ON CULTURAL BEHAVIORS AROUND PREGNANCY, CHILD BIRTH, INFANT AND YOUNG CHILD FEEDING PRACTICES, GROWTH MONITORING AND PROMOTION AND ADOPTION OF HEALTHY LIFESTYLE SUCH AS GOOD NUTRITION AND PHYSICAL ACTIVITY. The stocktaking will also explore practices and beliefs related to school attendance and parental attitude that impact a child's ability to participate in school and to access health education and services through schools. (ii) Identify key behavioral bottlenecks affecting the Mayan children's ability to access health services and to health education. Based on the findings of the stocktaking, effort will be made to isolate key behavioral bottlenecks affecting the Mayan children's ability to access health services and education with a view to working at community level, with community stakeholders and the District Health Council to address these bottlenecks. (iii) Develop culturally sensitive communications tools. Incorporating findings of the stocktaking as well as internationally accepted research, Component 4 will support the development of culturally sensitive communications tools including visual pamphlets/brochures and a video (modeling successful experiences of community-driven health promotion interventions in Peru, Ecuador, and Guatemala) to provide parents with the knowledge that all children, regardless of race or ethnicity, have standard development benchmarks - the achievement of which are particularly important during the first five years of life. COMMUNICATION TOOLS WILL ALSO PROMOTE GREATER UNDERSTANDING OF THE IMPORTANCE OF ADEQUATE GROWTH OF CHILDREN UNDER THE AGE OF 2 AND SCHOOLING IN DIRECTLY CONTRIBUTING TO INCREASED HEALTH AND ECONOMIC OUTCOMES AT THE HOUSEHOLD AND COMMUNITY LEVELS. (iv) Conduct informational education sessions with parents, village leaders, and CNAs and community-based health care workers directly serving Mayan communities. Finally, under the leadership of the trained parent leaders described in Component 1, and using the culturally sensitive communications materials, the project will conduct informational education sessions throughout the Mayan community of Toledo District on how to apply the WHO validated standard for monitoring a child's growth and development on a continuous basis. This will be part of the broader effort to underscore the importance of the life cycle approach to health services - beginning with regular monitoring through pregnancy, giving birth at health facilities, ensuring monthly height and weight monitoring for children in the first two years of life, practicing exclusive breastfeeding during the first six months, introducing appropriate complementary feeding after six months, and prioritizing schooling for children. Monitorable Deliverables/Outputs stocktaking report, 51 community education sessions on how to apply WHO validated nutrition monitoring standard Component 5 Strengthen monitoring and evaluation, project management, and project administration. Cost (USD) 432,800 Component 5 aims to strengthen monitoring and evaluation and project management and administration by supporting the Toledo District Health Council, the implementing agency, with training to support their timely and transparent monitoring of project activities, supporting the gathering of quantitative and qualitative data for evaluation purposes, strengthening the Toledo DHC's capacity for fiduciary reporting and overall project management, providing M&E training to support the design and development of the participatory M&E program at the community/village level, and ensuring a coordinated effort at the local and national level to allow lessons to be surfaced and disseminated across the country and be explored for potential scale-up. The activities under this component are: (i) Monitoring and Evaluation. TO ENSURE TIMELY, TRANSPARENT, AND EFFECTIVE MONITORING AND EVALUATION OF ALL ACTIVITIES COVERED BY THIS GRANT, A CONSULTING FIRM WILL BE HIRED BY THE PROJECT TEAM TO PRODUCE A BASELINE SURVEY THAT WILL COLLECT QUALITATIVE AND QUANTITATIVE DATA USING A REPRESENTATIVE SAMPLE OF HOUSEHOLDS WITH PREGNANT WOMEN AND/OR YOUNG CHILDREN. THE WORLD BANK, THE MOH, AND THE TOLEDO DHC WILL WORK CLOSELY WITH THE CONSULTING FIRM TO ENSURE A MANAGEABLE, YET REPRESENTATIVE SAMPLE SIZE. At the end of the 5

6 project, an impact evaluation will be conducted to objectively assess changes in behavioral practice and an Implementation Completion Report (ICR) will be written to assess the performance of the program and the implementing agency. This will be complemented with a qualitative study based on focus groups and community consultations. Regular monitoring will be conducted through quarterly progress reports on the overall program to be provided by the Toledo District Health Council (DHC) and through community-based monitoring that will be conducted by the community nurse aide and community school official who through monthly updates in the first year and transitioning to quarterly updates in the 2nd to 4th years will feed regular updates on activity progress to the DHC based on simple, locally developed templates. The continuous participatory monitoring exercise at the community level will complement and give validity to the progress reports as they will provide the on-the-ground results being monitored at the village level. This data will be key in surfacing lessons from the implementation of an innovative approach that introduces ECD interventions at the community-level that act in harmony with one another in addressing health as a continuum of a child#s life instead of as isolated stages. The regular reporting and documentation will allow lessons to be extracted and disseminated at a national level and among JSDF programs. In addition, the development of culturally sensitive communications tools will establish communication mechanisms to maintain knowledge dissemination across the villages and will also improve accountability since village residents will be empowered with the knowledge to know what constitutes proper nutrition and health for their community and will thus be able to demand quality health services from their authorities. To strengthen local capacity on M&E, the DHC, the community nurse aides, and the selected village parent leaders from Component 1, activity (v) will be provided with training and materials to strengthen their monitoring and reporting capacity and will participate in setting outcomes and community-level targets documented through user diaries. To ensure the progress and results from this program benefit Belize as a nation, the MOH and MinEDU M&E Officers will also be part of the M&E design and consultations and will be invited to M&E trainings to ensure data from this program is captured nationally which whill allow lessons emerging from this experience to be shared on a national level and be explored for potential scale-up. (ii) Management and Administration. Program coordinators will be supported through this component. To ensure sound management, this component will also offer fiduciary training covering procurement, financial management, disbursement, and operational issues, to be offered to the DHC, the local implementing agency, in order to ensure smooth implementation and compliance with World Bank fiduciary regulations. Transparency and accountability will be enforced through the undertaking of annual financial audits that will be carried out by a firm hired on a competitive basis. Re-assessments of processes following such audits will strengthen outcomes of the project. Finally, operating costs will cover office materials, supplies, and the hiring of local consultants as needed to support the executing unit with relation to procurement and financial issues. Monitorable Deliverables/Outputs Baseline survey, Impact Evaluation, 51 community/village leaders trained on M&E to set community outcomes/targets, 3 officials trained on M&E and 2 on fiduciary areas to act as trainers for community Summary Description for Grant Agreement Based on consultations held in Toledo, Belize with the local government officials, indigenous community representatives, and local Ministry of Health officials, agreement was reached to embark on an Early Childhood Development (ECD) approach which would address the continuum of childhood development from pre-natal prevention and treatment interventions through school age as opposed to looking at child health as a series of isolated stages in a child's life. In order to effectively provide the quality health interventions throughout this continuum of child development, the Toledo District Health Council (DHC) -as the voice for the health sector for the local government officials, village/community leaders, indigenous representatives, community-based health workers, and local NGOs and community-based organizations - has prioritized the need to complement the ECD approach with strengthening the quality and delivery of community-based maternal and child health services available in the Toledo District. To achieve the development objective the proposed program will consist of five main components: a. Component 1. Prevent and address malnutrition in children under 5 years of age by empowering the local community through Early Childhood Development (ECD) interventions. These interventions will be based on WHO growth charts that will provide the framework for defining an easily understandable nutrition monitoring tool allowing parents to readily recognize their child's growth progress and to gauge the child's advances in height and weight in relation to internationally recognized standards. b. Component 2. Develop Healthy Lifestyles Programs for Primary School Children in their eight years of primary education. This component aims to empower local primary schools to encourage "Healthy Lifestyle" practices targeting Toledo's Mayan children 5 and above. c. Component 3. Strengthen access and QUALITY of community-based health services in support of maternal and child health by giving VOICE to the community to participate in the design and vetting process of identifying and surfacing key health service areas (technical and geographi) that require improvements in order to provide the community at the village level with the health services they require and are lacking. 6

7 d. Component 4. Promote behavior change in communities by increasing understanding of community's attitude and perception towards health and develop culturally adapted health promotion interventions. This component looks to implement a knowledge management approach to better understand and incorporate Mayan cultural practices in relation to health services and support efforts aimed at ensuring the Mayan community are accessing the essential maternal and child health services without interfering in their cultural practices. e. Component 5. Strengthen monitoring and evaluation and project management and administration by supporting the Toledo District Health Council, the implementing agency, with training to support their timely and transparent monitoring of project activities, supporting the gathering of quantitative and qualitative data for evaluation purposes, strengthening the Toledo DHC's capacity for fiduciary reporting and overall project management, and providing M&E training to support the design and development of the participatory M&E program at the community/village level. Section 2.2 Incremental Bank Costs The costs of normal supervision are expected to be covered through the administrative budget and fee provision. Under exceptional circumstances, if additional resources are needed to facilitate community participation or NGO collaboration under particularly difficult conditions, incremental Bank costs can be requested up to 9 percent of the total grant amount. Amount requested in USD 243,250 Incremental costs (GFR 5899) are being requested to help cover the support that will be provided by WB staff and consultants as well as travel costs to the Mayan villages in the Toledo District of Belize where the proposed project will be implemented. The Bank is just re-engaging with Belize after a more than ten year absence and, as the country's implementation capacity is being strengthened, it will be critical to provide support to our local counterparts through intensive supervision. Bank staff/consultants are expected to participate in the approval of the work plan of the implementing agency to ensure it meets the Grant objectives and is coordinated with national program priorities and Bank projects; monitor, evaluate, and quality control of the activities through field visits, ensure a link to international expertise in other countries; and supervise grant execution according to Bank policies and procedures. It is estimated that 8 weeks of support will be provided by three Bank technical staff, 4 weeks of support will be provided by one Bank FM staff, and a total of 184 STC days shared among 4 consultants with specialties in the following four areas: health, indigenous issues, operations, and procurement. In addition, a total of 42 missions will be carried out in the life of the project divided among the technical staff and consultants and fiduciary staff and consultant. Part of the TTL's time and travel in the first year will be covered by departmental budget and the rest through the proposed Grant. Section Rationale and Participatory Approach Briefly present (a) the origin and rationale for the proposal; (b) participatory activities which led to the proposal concept; (c) its innovative features in responding rapidly to the needs of the poor and vulnerable groups; (d) describe the intended beneficiaries and provide an estimated number of beneficiaries and cost per beneficiary. The Toledo district is the most underdeveloped and rural district in Belize. This is partly due to the relative geographic isolation and inaccessibility of southern Belize to the rest of the country and its economic centers. MALARIA IS ENDEMIC, WORM INFESTATIONS AFFECT THE MAJORITY OF CHILDREN, AND POOR FOOD CONSUMPTION PATTERNS AMONG CHILDREN IN THE TOLEDO DISTRICT CONTRIBUTE TO THE DEVELOPMENT OF MALNUTRITION. TOLEDO HAS THE HIGHEST RATES OF POVERTY AND NUTRITIONAL DEFICIENCIES AMONG ALL DISTRICTS IN BELIZE. THE TOLEDO DISTRICT RECORDED THE HIGHEST RATE OF NEONATAL MORTALITY IN THE COUNTRY (11.3/1,000 LIVE BIRTHS), THE ONLY DISTRICT IN THE COUNTRY WITH FIGURES IN THE DOUBLE DIGITS, AND THE COUNTRY'S HIGHEST UNDER 5 MORTALITY RATE (22.6/1,000 LIVE BIRTHS). NUTRITION INDICATORS FOR TOLEDO ARE WORRISOME AS THE DISTRICT CLAIMS THE HIGHEST NUMBER OF LESS THAN ONE YEAR OLDS WITH OBESITY, 452 OUT OF A TOTAL OF 1,150 REPORTED FOR THE ENTIRE COUNTRY. Infant mortality is 21.8 per thousand, the highest in the country and this number may be even higher in rural areas where infant mortality often goes unrecorded. Statistics on poverty and child growth indicate that Mayan children are poorer and more poorly nourished than other Belizean children. A GOVERNMENT-LED STUDY CONFIRMED HIGH PREVALENCE OF WORM INFESTATION IN THE REGION WITH UP TO 60% SCHOOL AGE CHILDREN INFECTED WITH ONE OR MORE SOIL TRANSMITTED HELMINTHES (STH). OF THOSE STUDENTS SURVEYED WHO WERE UNDERWEIGHT FOR THEIR AGE, 64% ALSO SUFFERED LOW, MODERATE OR HEAVY WORM INFESTATION (18% WITH MODERATE OR HEAVY INFESTATION). SIMILARLY, OF THOSE STUDENTS WHO SHOWED SIGNS OF STUNTING, 67% WERE FOUND TO HAVE LOW, MODERATE OR HEAVY WORM INFESTATION (18% MODERATE OR HEAVY INFESTATION). Despite these critical health challenges, health services in the Toledo district are limited and the lack of potable water is a significant risk to public health. Malnutrition increases the likelihood of falling sick and the severity of disease as undernourished children who fall sick are 7

8 much more likely to die from illness than well-nourished children. Ensuring a good nutritional status and feeding habits of pregnant and lactating women as well as children under 2 years old can have significant impact reducing mortality, undernutrition and obesity as well as preventing the development of chronic diseases in adulthood. Some of the most common health conditions of school age children also affect their education, often perpetuating a cycle of poverty that has at its core a lack of quality education and learning. Malaria and worm infections may reduce enrolment and increase absenteeism, while hunger and anemia may affect cognition and learning, thus exacerbating the problems even for those children who do go to school. The preexisting infrastructure of the educational system can support the delivery of health interventions to address malnutrition in primary school-aged children. In response to this, the proposed program aims to undertake an early childhood development approach to improve the quality of health services for Belize's children in the Toledo District, with a focus on the Mayan population, which requires a life cycle approach to intervention, starting in utero and continuing through to adulthood. This requirement implies a sequence of programs to promote maternal and reproductive health, to manage childhood illness, and to provide good early nutrition and stimulation. Improving the quality of health services is a critical start to early childhood development to ensure pregnant mothers follow a regular, medical routine with health check-ups for their own health and of their unborn baby. Improved quality of health services remains just as critical once the baby is born, to commence regular growth and height monitoring of the baby, particularly in the first two years of life, to ensure proper nutrition for cognitive development. Once of school aged, schools can support the healthy development of children through effectively implemented, quality school health programs. TELE-HEALTH WILL PLAY A KEY ROLE IN CONTRIBUTING TO IMPROVING THE QUALITY OF HEALTH SERVICES PARTICULARLY FOR PREGNANT MOTHERS AND INFANTS IN THE 0-2 YEAR AGE GROUP BY ENSURING COMMUNITY-BASED HEALTH WORKERS AND CNAS IN REMOTE LOCATIONS HAVE ACCESS TO CRITICAL TIMELY INFORMATION AND KNOWLEDGE. Analytical Background. According to Marini, A. et al (2009), #Growth Promotion to Prevent Chronic Malnutrition: Community-based Strategies in Central America#, since the 1990s Central American countries have developed various programs to address chronic malnutrition. The main characteristic of these initiatives is their community basis that has allowed them to address a wide variety of causes of malnutrition. Community based growth promotion programs (PCBC for their acronym in Spanish) have been shown as an ideal tool to adequately respond to the objective of fighting against malnutrition and have shown both their potential and challenges. According to Griffiths, M. and McGuire, J. (2005), #A New Dimension for Health Reform # The Integrated Community Child Health Program in Honduras#, community-based growth promotion programs that put the responsibility of selecting volunteers for nutrition counseling and monitoring in the community#s hands, have proven to be the most effective for addressing malnutrition in Central American countries. Specific to the Mayan communities, the experience of Guatemala#s community-based nutrition program, Atención Integral a la Niñez y Mujer en la Comunidad (AINM-C), underscores the importance of developing resource and communication materials in Mayan indigenous languages (K#iche# and Kakchiquel) to support the nutrition counseling to include growth monitoring, breastfeeding practices, complementary feeding, as well as vaccinations and preventing disease through proper hygiene and clean water and food. Specific to Belize, considering 60% of school age children suffer from worm infestation, Dr. Andrew Hall quoted in the Lancet describes the importance of addressing deworming with supplementation, #If micronutrient supplements or extra food are not available then deworming alone may not have much of an effect, or it will be very slow, and this may lead to a loss of enthusiasm among the governments who will, in the end, have to pay for anthelmintic treatments.# This analytical background and evidence has been taken into consideration in the design of the proposed program where a community-based approach would be implemented under the leadership of community members themselves in an integrated approach incorporating nutrition counseling, growth monitoring, and hygienic practices. Experience from Other Donors and the Government. The experience of other donors and the Government has not met the success it has hoped for. The government itself undertook a study on the worm infestation problem in 2005, but has not been able to fully address the issue. Today, with a partnership of the social sectors including health, education, and human development, approaches and interventions are being implemented in a coordinated manner with the hopes of greater success and sustainability. This proposed program will be a direct beneficiary of this country partnership in the social sectors which will act as a supporting platform in the implementation of this integrated approach where interventions to address malnutrition at the health facility and primary schools will be implemented. Other donors such as Plenty Belize and Feed the Hungry have had activities in the area of school feeding, but without a coordinated Toledo District strategy and coordinated program covering the primary schools, it was difficult to ascertain appropriate distribution channels and the impact of their programs. These organizations continue to have activity in the country, but on a small-scale helping schools grow vegetables and providing rice and other essential grains. Other donors such as the Inter American Development Bank (IADB), the Caribbean Development Bank (CDB), and the European Union (EU) have been engaged in the health sector, but their focus has been on the national stage in supporting the health sector reform process and not community-level interventions. As a reaction to the recent decentralization of the health sector in Belize, particularly the creation and empowerment of 8

9 Regional Health Authorities, the local government, in coordination with the Ministry of Health and Ministry of Human Development organized a technical discussion/consultation with community leaders including local government officials, CSO/NGO representatives, Mayan community representatives, and health sector representatives to identify bottlenecks in the delivery of health services affecting the community's development with particular emphasis on the need to focus on the community's children for timely interventions. This consultation led to the development of the proposed program, with the objective of empowering the community through its schools and health facilities to improve delivery of maternal and child health services and to reach out to the poorest, most vulnerable families. Agreement was reached that ECD interventions will provide the framework for the program. Before implementing activities, the team will hold a consultative technical workshop with, in a first instance, the Mayan community of the District of Toledo to ensure the implementation plan is developed in a culturally sensitive manner to the Mayan culture, and in a second instance will bring together the Mayan community with the local health promoters, educators, parents, and local government officials to further discuss and finalize the implementation plan and to define and increase understanding and ownership of internationally-held growth standards at the community level. AS SUGGESTED IN DISCUSSION WITH COMMUNITY-BASED REPRESENTATIVES INCLUDING FROM THE TOLEDO MAYA WOMEN'S COUNCIL, the proposed program embraces an innovative approach to Early Childhood Development (ECD) which addresses nutrition and height and weight monitoring in young children, but supports this with continued interventions under a continuum of childhood development from pre-natal interventions through school age. This approach is innovative because it looks at child health as a continuum as opposed to looking at it as a series of isolated stages in a child's life. Traditionally, ECD interventions have been conducted in isolation of one another, but this program brings an innovative way to address ECD, by pulling together the different pieces as part of a development continuum approach where ante-natal care services are being offered and monitored in line with infant care and care for primary school-age children. THE PROPOSAL ALSO INCLUDES INNOVATIONS AROUND THE DIRECT INVOLVEMENT OF BENEFICIARIES IN THE PROJECT CYCLE; THROUGH PLANNING, IMPLEMENTATION AND MONITORING STAGES. Community scorecards WILL PROMOTE THE DIRECT AND CONSISTENT INVOLVEMENT OF THE BENEFICIARIES AND WILL SUPPORT ONGOING evaluation IN RELATION TO CHILD DEVELOPMENT. COMMUNITY MONITORING WILL ALSO BE ENCOURAGED THROUGH THE EMPLOYMENT OF user diaries. The proposed program would introduce innovative tele-health activities to strengthen the quality of health services provided and available at the community/village level by strengthening the capacity of the health work force in line with a training curriculum which would provide community health workers in Toledo access to international education and expertise. The tele-health activities will also enhance the health communication network in Toledo, allowing for regular contact among the District Hospital, Polyclinic, and Satellite Clinics to provide just-in-time health expertise and knowledge at the village/community level. SURVEYS WILL BE CONDUCTED ON A REGULAR BASIS TO SUPPORT CONTINUOUS EVALUATION AND RE-DESIGN OF IMPLEMENTATION METHODS AS NEEDED. Tele-health activities are currently not in place in Toledo, Belize but are being implemented in developing countries with rural, remote populations such as in Bolivia for expanding and strengthening the quality of health services and in Trinidad and Tobago for accessing international knowledge and expertise for local capacity building. The intended beneficiaries would be children in the 0-12 year age group and pregnant women of Mayan descent in Toledo, Belize who due to their remote location have historically had limited access to maternal and child health services. Beyond the women and children of Mayan descent, the project will benefit all children in the District's 21 primary schools through the healthy lifestyle school interventions and the Toledo community at-large by improving the quality of maternal and child health services provided at the 51 villages. Beneficiaries include: 5,000 children in the 0-12 age range; 4,000 women of child-bearing age; 24,700 community residents residing in rural areas of Toledo to benefit directly or indirectly from the improved quality of health services at the village level and from increased knowledge on nutrition growth and monitoring; 71 community-based health care workers; Cost per beneficiary: US$2,752,894 / 33,778 beneficiaries = US$81.49/beneficiary The project is expected to lead to: (a) increase in community's use and access of health services particularly during the neo-natal and 0-2 year infant stages, (b) significant reduction of worm infestation of children in the target communities through accessible and effective community-based interventions through schools; c) trained community-based health care workers with proper equipment to provide primary health services to community ; d) facilitate local decisions on budget allocation for health services by sharing nutrition and school attendance results with Local Governments and Communities, and e) increase accountability for maternal and child health services, as a result of the pressure from families who are aware of the standards that their children should achieve. Section Sustainability 9

10 Indicate the mechanism for sustainability of the proposed activities after the completion of the grant. This should include a description of the exit strategy and mechanism for long-term sustainability with specific measures and cost. The proposed program has been designed with the direct participation of REPRESENTATIVES OF INDIGENOUS LEADERS OF THE MAYAN COMMUNITY OF TOLEDO DISTRICT. THE PROPOSAL PUTS FORTH ACTIVITIES DERIVED FROM DISCUSSION WITH INDIGENOUS REPRESENTATIVES, LOCAL CSO/NGOS INCLUDING TOLEDO MAYA WOMEN'S COUNCIL, COMMUNITY-BASED HEALTH WORKERS, THE TOLEDO DISTRICT HEALTH COUNCIL, THE TOLEDO LOCAL GOVERNMENT, THE MINISTRY OF HEALTH, THE MINISTRY OF HUMAN DEVELOPMENT, AND THE Ministry of Education all committed to engaging in a multi-sectoral human development strategy and who have discussed their role and participation in the implementation of the proposed program. Furthermore, through consultation discussions with UNICEF, the proposed program would strengthen and build on interventions IMPLEMENTED THROUGH EXISTING COMMUNITY STRUCTURES and would benefit from the direct participation of the local NGO TOLCA - being supported by UNICEF - who can provide technical assistance to the implementation of school health activities. EFFORTS WILL ALSO BE MADE TO FACILITATE DIRECT PARTICIPATION OF THE MAYAN COMMUNITY OF TOLEDO IN THE NATIONAL COMMITTEEE FOR FAMILIES AND CHILDREN (NCFC), THE ADVISORY BODY TO THE GOVERNMENT OF BELIZE ON FAMILY AND CHILDREN'S ISSUES, TO PROMOTE SUSTAINABLE REPRESENTATION OF TOLEDO'S MAYAN COMMUNITY IN DIALOGUE AROUND THE DEVELOPMENT OF VULNERABLE COMMUNITIES IN BELIZE. ADDITIONALLY, the Government is committed to the decentralization of health services as underscored with the recent health reform which established and empowered Regional Health Authorities to be responsive to community health needs. This program builds on the decentralization by further empowering the MAYAN COMMUNITY OF TOLEDO DISTRICT AND THE Toledo District Health Council to implement activities targeting key health challenges being faced by the community. THE PROGRAM INTERACTS AND SUPPORTS THE FOLLOWING ONGOING GOVERNMENT PROGRAMS THAT WILL BE STRENGTHENED OR ENHANCED THROUGH THE PROPOSED PROGRAM: # HEALTH SECTOR REFORM PROGRAM. A KEY ASPECT OF THE HEALTH SECTOR REFORM PROGRAM IS THE DECONCENTRATION OF OPERATIONAL AUTHORITY TO HEALTH REGIONS. THE PROPOSED PROGRAM ALIGNS WITH THIS ONGOING GOVERNMENT PROGRAM AS IT WILL FURTHER EMPOWER THE SOUTHERN HEALTH REGION, OF WHICH THE TOLEDO DISTRICT HEALTH COUNCIL IS A PART OF, IN MANAGING THE PROVISION OF QUALITY HEALTH SERVICES AT A LOCAL LEVEL AND WILL STRENGTHEN LOCAL CAPACITY WHICH IS CRITICAL AS THE GOVERNMENT CONTINUES TO INCREASE AUTONOMY AND SHIFT DECISION-MAKING AUTHORITY FOR THE HEALTH SECTOR TO THE REGIONAL, LOCAL LEVEL. # NATIONAL HEALTH INSURANCE. THE GOVERNMENT OF BELIZE HAS ROLLED-OUT ITS NATIONAL HEALTH INSURANCE PROGRAM TO THE SOUTHSIDE OF BELIZE CITY AND THE SOUTHERN HEALTH REGION, OF WHICH THE TOLEDO DISTRICT HEALTH COUNCIL IS A PART OF, AND OFFERS A BASIC PACKAGE OF HEALTH SERVICES TO THOSE SEEKING CARE AT THE LOCAL LEVEL. THIS PACKAGE INCLUDES OBSTETRIC AND MATERNAL AND CHILD HEALTH CARE SERVICES WHICH THIS PROGRAM SUPPORTS AS IT WILL IMPROVE THE QUALITY OF THESE HEALTH SERVICES AND WILL STRENGTHEN THE HEALTH MESSAGES AND PREVENTIVE HEALTH SEEKING BEHAVIOR AT THE COMMUNITY-LEVEL. AND AS PART OF AN EXIT STRATEGY, THE FOLLOWING APPROACHES WILL BE TAKEN TO ENSURE SUSTAINABILITY: # COMPONENT 1 ON ADDRESSING MALNUTRITION INCLUDES A TRAINING OF TRAINERS PROGRAM THAT WILL TRAIN A CADRE OF PARENT LEADERS ON PROPER NUTRITION GROWTH AND MONITORING. THE SPECIFIC EXIT STRATEGY ON THIS ACTIVITY WILL BE TO ENSURE THAT EACH COHORT OF TRAINED COMMUNITY PARENT LEADERS CONDUCTS THE SUBSEQUENT TRAINING UNTIL AT LEAST 102 PARENTS ARE TRAINED (2 PER 51 VILLAGES). THIS WILL ENSURE THE PARENT COMMUNITY LEADERS HAVE RECEIVED TRAINING, BUT MORE IMPORTANTLY ARE ALSO GAINING EXPERIENCE IN CONTINUING THE TRAININGS TO THE LARGER COMMUNITY. # COMPONENT 2 ON ENCOURAGING HEALTHY LIFESTYLES WILL SUPPORT REGIONAL DISCUSSIONS TO FEED THE NATIONAL DIALOGUE FOR THE DEVELOPMENT OF A NATIONAL SCHOOL HEALTH POLICY THAT WILL SERVE AS THE FRAMEWORK FOR THE GOVERNMENT AND LOCAL AGENCIES TAKING ON THE SCHOOL HEALTH PROGRAMS. # COMPONENT 3 WILL SUPPORT THE DEVELOPMENT OF A TRAINING CURRICULUM FOR CNAS AND COMMUNITY-BASED HEALTH CARE WORKERS AND WILL FACILITATE THE DISTRICT'S CONTACT WITH AND ESTABLISHING OF MOUs WITH INTERNATIONAL TRAINING INSTITUTIONS IN ORDER TO FORMALIZE ONGOING TRAINING PROGRAMS AND LEARNING EVENTS. # COMPONENT 4 WILL PROVIDE THE COMMUNITY-BASED HEALTH CARE WORKERS AND CNAs WITH A BETTER UNDERSTANDING ON THE CULTURAL BARRIERS THAT PREVENT THE MAYAN COMMUNITY FROM SEEKING HEALTH SERVICES AND IN SO DOING WILL PROVIDE THEM WITH AND EMPOWER THEM WITH KNOWLEDGE TO CONTINUE REACHING OUT TO MAYAN AND OTHER MARGINALIZED, VULNERABLE POPULATION GROUPS. # THE SERVICE DELIVERY CONTRACTING BETWEEN THE NATIONAL AND DISTRICT LEVEL FOR TOLEDO WILL BE GUIDED AND FINANCED BY THE NATIONAL HEALTH INSURANCE PROGRAM CURRENTLY ACTIVE IN TOLEDO WHICH PROVIDES THOSE SEEKING CARE IN THE DISTRICT WITH THE BASIC PACKAGE OF HEALTH SERVICES. # COMMUNITY BASED HEALTH CARE WORKERS WILL BE FINANCED THROUGH THE SOUTHERN HEALTH REGION WHICH IS TAKING ON MORE DECISION-MAKING AUTHORITY AS PART OF THE HEALTH SECTOR REFORM. THE EXACT REMUNERATION 10