PROJECT INFORMATION DOCUMENT (PID)

APPRAISAL STAGE

Report No.: AB1905

Project Name

/ GUATEMALA Maternal and Infant Health and Nutrition
Region / LATIN AMERICA AND CARIBBEAN
Sector / Health (75%);Other social services (25%)
Project ID / P077756
Borrower(s) / GOVERNMENT OF GUATEMALA
Implementing Agency
Government of Guatemala
Guatemala
Ministry of Health
Guatemala
Environment Category / [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined)
Date PID Prepared / October 25, 2005
Date of Appraisal Authorization / November 28, 2005
Date of Board Approval / January 19, 2006
  1. Country and Sector Background

Guatemala needs to invest in the development of its human capital of its poor population to achieve sustained economic growth and reduce chronic poverty.[1] Despite important progress in the social sectors over the last decade, Guatemala’s human development indicators still lag well behind other countries’ in the region. This gap is particularly problematic in certain areas where expected progress has not been sustained in the last few years. Maternal and infant mortality rates and particularly chronic malnutrition are among the highest in the world, and much higher than expected given Guatemala’s per capita income (Figure 1). Along with poor schooling, they constitute severe constrains for human capital accumulation and the achievement of key MDGs in the country.[2] Chronic malnutrition and the poor health status of young children cause irreversible losses of human capital formation, affecting current and future generations and undermining economic growth.

Figure 1. Prevalence of Child Malnutrition and Maternal Mortality in Guatemala and LAC

Sources: WDI; Guatemala, ENSMI 2002; CIEN.

Improving the nutritional and health status of infants, young children, and pregnant mothers constitutes the starting point to overcoming one of the major obstacles in the chain of human capital accumulation and to breaking the intergenerational transmission of poverty. Government efforts to increase human capital should focus on tackling chronic malnutrition and promoting maternal and infant care among the most underserved families. Rural residents and indigenous communities, where poverty incidence is over 75 percent, are particularly vulnerable. Most of the improvements in health indicators in recent years have been enjoyed disproportionately by the non-indigenous. Between 1987 and 2002, the rate of decline in the infant mortality rate among the non-indigenous has been four times faster than among the indigenous. Similarly, the rate of decline in the prevalence of chronic malnutrition among the indigenous has been half that among the non-indigenous. Investing in the human capital of poor young children has among the highest economic and social returns of any type of investment: not only will child mortality be reduced significantly,[3] but also school achievement and future productivity will largely depend on improvements in the nutritional and health status of infants and pre-schoolers. Thus, an integral strategy to improve and sustain human capital in Guatemala should (i) pay special attention to rural and indigenous children younger than 24-36 months and pregnant women; (ii) focus its efforts on providing an adequate package of health and nutrition services emphasizing preventive measures even before birth; and (iii) introduce interventions and incentives to promote demand for these services and encourage rural and indigenous families to take advantage of them, especially those living in remote areas.

Despite a difficult history and a complex country context, the Peace Agreements signed in 1996 (?) after a 36-year civil war created a unique development opportunity for Guatemala, and the objectives set forward in the Peace Plan continue to guide the development of the country. With a multi-ethnic population of more than 12 million and a per-capita GDP of about $1,760, Guatemala is the largest economy in Central America. Yet Guatemala faces a challenging legacy of high poverty and inequality, poor social indicators, and deep social and political divisions. These are only slowly being overcome, as the country continues to consolidate democracy and address issues of equity/inclusion, growth and the establishment of credible public institutions. A significant step was the end of the internal armed conflict in 1996 and the corresponding Peace Agreements, which defined a clear and unified vision of Guatemala’s mid-term development. The current administration, in office since early 2004, acknowledges the importance of the Peace Agreements and social reforms.

Inequality levels in Guatemala are among the highest in Latin America, and as a result large share of the population faces high rates of vulnerability.[4] Guatemala's high poverty and relatively poor social indicators can be traced back in large part to a highly unequal distribution of income, and access to social services and opportunities. Guatemala’s Gini coefficient of 0.57 is the second highest in Latin America (after Brazil) and one of the highest in the world. Guatemala also lags behind in the evolution of the epidemiological transition. Guatemala’s demographic and epidemiological transition is still characterized by high fertility rates, a low proportion of adults within the population, high infant and maternal morbidity and mortality, high and extreme prevalence of chronic malnutrition, and heavy incidence of infectious diseases—in particular diarrhea and respiratory infections (Gragnolati and Marini, 2002).

For the last 15 years, Guatemala has shown some improvement in basic health indicators. However, the results of a recent worldwide analysis that predicted actual life expectancy and infant mortality based on GDP found that among the Central American republics, only Guatemala has poorer actual health outcomes than those predicted by the model (Todd & Hicks, 2003). With half of preschool children chronically malnourished, Guatemala has—by far—the highest prevalence of chronic malnutrition (stunting) in the region and only a handful of other countries in the world exceed its rates. Moreover, with a rate of 153 maternal mortalities per 100,000 births in 2004,[5] Guatemala was 35 points above the median rate of countries in the third quintile for income (118 per 100,000) The high mortality rate showcases the serious structural limitations of the obstetric network, and maternal mortality constitutes a key priority for the sector.

Child mortality and malnutrition can be linked initially to poor pre-natal conditions in Guatemala. One in five pregnant women has no pre-natal care at all and only 50 percent have their first pre-natal care visit during the first trimester of pregnancy. The rate of attended births grew to 42 percent in 2002 from 34 percent in 1995, but Guatemala still needs to improve obstetrics services. Currently, the proportion of births with no specialized attention or lack of transportation in case of emergency is very high. About four in 10 pregnant women receive qualified services. Low birth weights (currently affecting 12 percent of newborns), deliveries under unsafe conditions, malnutrition, infectious digestive diseases (diarrhea) and respiratory infections generate these deaths and require a more structured and better quality primary mother-child network (World Bank, 2004). Finally, exclusive breast feeding is in decline, according to the maternal and infant health survey of 2002. These issues combined, all preventable, constitute a major cause in the perpetuation of chronic malnutrition and high infant mortality rates.

Government Strategies

The Government has prioritized strengthening the Program for Extension of Coverage (PEC) and guaranteeing the universal provision of an improved basic package of services in the 111 municipalities, as defined in Guate Solidaria Rural (GSR). This strategy is being targeted to the poorest municipalities in two phases. The first phase, currently under implementation as a pilot, targets the poorest 41 municipalities, while the second phase is focused in the following 70 municipalities. This Project will support government efforts to implement the second phase.

Consolidating and scaling up PEC requires addressing two weaknesses the program faces. On the one hand, the current Ministry of Public Health and Social Welfare’s (MSPAS) mother and child referral network is inadequate and unable to respond to the needs of the population and the demand for services generated by the PEC. On the other hand, the current package of services provided through the PEC is insufficient to address chronic malnutrition effectively. The proposed project would support government’s priorities of strengthening and scaling up the PEC program by addressing these weaknesses. In addition, strengthening PEC will involve measure to ensure sufficient public funds to finance an enhance package of services, target the program to the rural areas of the most vulnerable municipalities, and putting in place practices to guarantee an adequate approach to indigenous populations.

The Government has prioritized strengthening the Program for Extension of Coverage (PEC) and guaranteeing the universal provision of an improved basic package of services in the 111 municipalities, as defined in phases 1 and 2 of Guate Solidaria Rural. Consolidating and scaling up PEC requires addressing two weaknesses the program faces. On the one hand, the current Ministry of Public Health and Social Welfare’s (MSPAS) mother and child referral network is inadequate and unable to respond to the needs of the population and the demand for services generated by the PEC. On the other hand, the current package of services provided through the PEC is insufficient to address chronic malnutrition effectively. The proposed project would support government’s priorities of strengthening and scaling up the PEC program by addressing these weaknesses.

Accordingly, as part of Guate Solidaria Rural’s emphasis on improving the impact of PEC, the authorities have decided to complement the package with two interventions: (i) in all municipalities and jurisdictions in which the PEC is providing services, the basic health package will be modified to include or strengthen the Atención Integral a la Niñez y Mujer - Comunitario (AIMN-C) strategy to prevent chronic malnutrition through a community-based program; and (ii) in the most vulnerable communities of the 111 municipalities (about 30-40 percent), the GOG is implementing the Creciendo Bien strategy complementing other social interventions, but especially health and nutrition programs through training and capacity development at the individual, household and community level.

Characteristics and distribution of PEC, AINM-C and Creciendo Bien financed by the Project

PEC / AINM-C / Creciendo Bien
Program to provide basic health services in rural areas through contracting NGOs / Strategy to prevent chronic malnutrition through a community-based program:
1. Training of monitoras.
2. Monthly Growth Promotion Sessions.
3. Home visits to sick or not adequately growing children
4. Referral of children.
5. Monthly meetings for coordination of activities
6. Strengthening community participation / Strategy to complement health and nutrition programs including:
1. Individual training and counseling to women in reproductive age.
2. Household level education on good health practices and economic growth.
3. Community level communication activities
Before the Project
(phase 1 GSR) / In the Project area: 111 municipalities / 41 municipalities / 40% of lugares poblados inthe 41 municipalities covered by PEC/AINM-C
Project's support through Component 2
(phase 2 GSR) / Already covered by the Government (MSPAS) / 70 municipalities / 30% of lugares poblados in the 70 municipalities covered by PEC-AINM-C

1.  Rationale for Bank involvement

  1. Objectives

Building on the experience of the PEC, the proposed Project aims to support the Government of Guatemala to: (a) increase the capacity and quality of the maternal and infant health referral network in the entire countryproject’s area of intervention; (b) tackle chronic malnutrition among children younger than 2 years of age by implementing an Expanded Brand of Community Integrated Care for Children and Women (AINM-C) in the 111 poorest municipalities; and (iii) support Government efforts to define, implement, and consolidate a medium-term cross-sectoral policy to prevent chronic malnutrition, and institutionalize its implementation.

Specifically, the main outcomes of the project would be: (i) to reduce the indigenous/non indigenous infant mortality ratio and maternal mortality ratio by 10 percent (from 1.3 and 3 to 1.17 and 2.7 respectively), by increasing access to culturally appropriate and supervised health services to improved the rate of safe, assisted births, and access to rehydration treatment centers and acute respiratory therapy services for children under 5; (ii) to reduce the prevalence of chronic malnutrition in children under 5 by 25 percent in five years in the areas of intervention, through implementing an adequate model of AINM-C and giving special attention to the most vulnerable and indigenous children; and (iii) to formulate and implement a comprehensive mid-term strategy to scale up interventions to prevent chronic malnutrition.

The project would also contribute to strengthening the multi-sectoral approach to malnutrition and the ongoing health reform, including the system of purchasing of services from NGOs, improving the quality, monitoring and supervision of the PEC.

Finally, the proposed project would foster the demand for health and nutrition services as a complement to improving the quality and provision of basic health and nutrition services (supply side). The proposed project would support the introduction of inter-culturally accepted practices within Maternal and Infant Integral Health Care Centers (“Centros de Atención Integral Materno Infantil” / CAIMIs) to promote safe institutional deliveries, involving traditional birth attendants as a key actor to increase the demand for reproductive health services. At the same time, the proposed project would support government efforts to strengthen community-based programs to provide basic health and nutrition services. These programs, which have proven to be very effective in reaching extremely poor population—in the case of Guatemala through the PEC program (MSPAS) and recently through Creciendo Bien (SOSEP)—are based on contracting NGOs to reach small communities and regularly provide basic health and nutrition services. The project would support the government to improve the PEC model through introducing the AINM-C strategy, in coordination with the Creciendo Bien program.

The Guatemalan Government, with the support of multilateral and bilateral agencies, has committed to provide a policy framework and implement a national program to improve maternal and infant health and achieve the MDGs. In 2004, MSPAS set forth its long term vision (to the year 2015) in “Lineamientos Básicos y Políticas de Salud.” This document identifies eight policies and strategies, and 17 priorities for the period 2004-2008.

Period 2004-2008[6]
1.  Strengthening the MSPAS’s steering role;
2.  Satisfying the health needs of the Guatemalan population through delivery of health care services with quality, warmth, equity, and with an inter-cultural and gender focus throughout the different levels;
3.  Strengthening the de-concentration and decentralization process for competencies, responsibilities, resources, and decision-making power to health administrative areas and hospitals;
4.  Timely procurement and provision of inputs required for the development of actions in promotion, prevention, and health recovery;
5.  Modernizing the financial-administrative management and planning systems of the MSPAS, as a core element of support for health services provision;
6.  Strengthening the development and administration of health human resources;
7.  Promoting actions in support of a healthy environment to improve the population’s quality of life; and
8.  Protecting the population against risks inherent to the consumption and exposure of foodstuffs, drugs, and other substances detrimental to health.
Health priorities
Primary
1.  Maternal and neonatal mortality.
2.  Acute respiratory illnesses–ARIS
3.  Water and food borne diseases
4.  Malnutrition
5.  Vector transmitted diseases
6.  Immune and preventable diseases
7.  Rabies
8.  HIV/AIDS/STIS
9.  Tuberculosis
10.  Oral health / Secondary
11.  Accidents and violence
12.  Chronic and degenerative diseases (cancer, diabetes and hypertension)
13.  Disasters
14.  Addictions (alcoholism, smoking, drug addiction)
15.  Meningitis
16.  Intoxication due to pesticides
17.  Mental health

Within these priorities, the Government is making a special effort on the first four through the strengthening and expansion of the PEC, the development of a mother-child reference network, and the creation of the “Front Againstagainst Hunger” for inter-sectoral coordination .coordination.