Grant Assistance Report

Project Number: 42143-01 July 2009

Grant Assistance Lao People's Democratic Republic: Developing Model Healthy Villages in Northern Lao People’s Democratic Republic (Financed by the Japan Fund for Poverty Reduction)

CURRENCY EQUIVALENTS (as of 7 July 2009)

Currency Unit – kip (KN)

KN1.00 = $0.0001174053$1.00 = KN8,517.50

ABBREVIATIONS

ADB – Asian Development Bank EA – executing agency JFPR – Japan Fund for Poverty Reduction JICA – Japan International Cooperation Agency Lao PDR – Lao People’s Democratic Republic LRM – Lao People’s Democratic Republic Resident Mission M&E – monitoring and evaluation MDG – Millennium Development Goal O&M – operation and maintenance SERD – Southeast Asia Department SESS – Social Sectors Division UNICEF – United Nations Children’s Fund VHC – village health committee VHV – village health volunteer

NOTE

In this report, “$” refers to US dollars.

Vice-President C. Lawrence Greenwood, Jr., Operations Group 2 Director General A. Thapan, Southeast Asia Department (SERD) Director S. Lateef, Social Sectors Division, SERD Team leader C. Holmemo, Poverty Reduction Specialist, SERD Team members S. Kawazu, Counsel, Office of the General Counsel B. Phommalad, Assistant Project Analyst, Lao People’s Democratic

Republic Resident Mission In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.

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LAO PEOPLE'S DEMOCRATIC REPUBLICDEVELOPING MODEL HEALTHY VILLAGES IN

NORTHERN LAO PEOPLE’S DEMOCRATIC REPUBLIC

500

Kilometers

100

N

09-1625 HR

106 00'Eo

106 00'Eo102 00'Eo

102 00'Eo

16 00'No 16 00'No

20 00'No 20 00'No

JAPAN FUND FOR POVERTY REDUCTION (JFPR)

JFPR GRANT PROPOSAL

I. Basic Data Name of Proposed Activity Developing Model Healthy Villages in Northern Lao

People’s Democratic Republic (Lao PDR) Country Lao PDR Grant Amount Requested $3 million Project Duration 3 years Regional Grant Yes / No Grant Type Project / Capacity building

II. Grant Development Objective(s) and Expected Key Performance Indicators Grant Development Objectives: The overall objective of Developing Model Healthy Villages in Northern Lao PDR (the Project) is to improve the health status of the rural population living in priority development zones, with a focus on vulnerable groups (i.e., children, ethnic groups, and women). The Project will pilot an innovative approach for developing a healthy village environment and providing essential health services. Villages will be empowered to take ownership of health promotion and disease prevention activities, and the capacity of the district health system network will be strengthened to manage and support the development of model healthy villages. The Project will target 100 villages and 10 districts in Houaphan and Xiangkhouang provinces, covering approximately 40,000 beneficiaries. If successful, the methodologies and implementation arrangements tested under the Project will be replicated in future government programs, including the Asian Development Bank (ADB)-supported Health Sector Development Program scheduled for approval in 2009. The specific objectives of the Project are to (i) strengthen village capacity for participatory planning and management of model healthy villages, (ii) implement village health plans and establish model healthy villages, (iii) strengthen the capacity of districts and health centers to support model healthy villages, and (iv) provide project management and coordination support and evaluate interventions for further replication and extension. Expected Key Performance Indicators: 1. A harmonized national approach for implementation of model healthy villages is developed. 2. Target villages achieve model healthy village status. 3. There is increased participation of the poor and vulnerable groups in village planning and

management of health services. 4. District working teams are operational and support model healthy villages.

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III. Grant Categories of Expenditure, Amounts, and Percentage of Expenditures

Category Amount of Grant Allocated in $ Percentage of

Expenditures 1. Civil Works 760,000 25 2. Equipment and Supplies 428,000 14 3. Training, Extension, Workshops,

Seminars 861,973 29

4. Consulting Services 510,400 17 5. Grant Management 166,900 6 6. Other Inputs 0 0 7. Contingency 272,727 9 Total 3,000,000 100 Incremental Cost 50,000

Background Information

A. Other Data Date of Submission of Application

4 May 2009

Project Officer Camilla Holmemo, Poverty Reduction Specialist Project Officer’s Division, E-Mail, Telephone Number

Social Sector Division (SESS), Southeast Asia Department (SERD); cholmemo@adb.org; +63 2 632 6661

Other Staff Who Will Need Access to Edit/Review the Report

V. de Wit, SESS; S. Ekelund, Lao People’s Democratic Republic Resident Mission (LRM); B. Phommalad, LRM; M. Dizon, SESS

Sector Health and social protection Subsector Health Programs Theme Social development, gender equity, capacity development Subthemes Human development, gender equity in human capabilities,

organizational development Targeting Classification Targeted intervention (TI-MDG) Was JFPR Seed Money used to prepare his grant proposal?

Yes [ X ] No [ ]

Have SRC comments been reflected in the proposal?

Yes [ X ] No [ ]

Name of Associated ADB-Financed Operation(s)

Health System Development Project, Health Sector Development Program (2009 pipeline).

Executing Agency Ministry of Health, Department of Planning and Budgeting Vientiane, Lao PDR Contact: Dr. Prasongsidh Boupha, Deputy Director General Tel: +85 6 2055 1842 2 Fax: +85 6 2122 3146 E-mail: adb2laos@loxinfo.co.th

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Grant Implementing Agencies Houaphan:

Provincial Health Department Contact: Dr. Khamvieng Vilaphanh, Director Tel: +85 6 0643 1219 8 Fax: +85 6 0643 1267 8 Mobile: +85 6 0205 5649 55 E-mail: kvanhnavong@yahoo.com Xiangkhouang: Provincial Health Department Contact: Dr. Bouason Sinouanthong, Director Tel: +85 6 0612 1182 9 Fax: +85 6 0612 1182 9 Mobile: +85 6 0202 9451 56 E-mail: snnvng@yahoo.com

B. Details of the Proposed Grant 1. Components, Monitorable Deliverables/Outcomes, and Implementation

Timetable Component A Component Name Strengthened Village Capacity for Participatory Planning and

Management of Model Healthy Villages Cost ($) 1,049,370 Component Description This component aims to increase villagers' ownership and the

effective involvement of the poor, women, and all ethnic groups in planning, implementing, and managing primary health care activities. It will focus on strengthening durable, village-level institutions and the capacity of village health volunteers (VHVs), traditional birth attendants, and village health committees (VHCs) through training and information, education, and communication activities. The VHCs and VHVs will be the focal points for the interventions, and will help coordinate with other donors, line ministries, and provincial and district governments. All target villages have a VHC, which typically comprises the village head; VHVs; chief of the health center; and representatives from the Lao Women’s Union, Lao People’s Revolutionary Youth Union, and Lao Front for National Construction. 1 The VHC selects and supervises VHVs, usually two per village (male and female). VHVs’ main responsibilities are to provide basic curative care and to run a drug revolving fund as needed. Trained birth attendants, if they are present, assist with deliveries and advise on safe delivery practices. All are expected to promote the three elements of good hygiene: clean water and food, body and clothes, and environment. VHCs will be responsible for raising awareness of community health issues; planning village primary health care development; and advising, monitoring, and coordinating village health activities. VHCwill also be the driving force for ensuring the well being of villagers, including marginalized people (e.g., patients with HIV/AIDS or other

1 The Lao Front for National Construction is part of the country’s political system and brings together political

organizations; sociopolitical organizations; and individuals representing various social classes, strata, ethnic groups, religions, and overseas expatriates with the aim of promoting a sense of solidarity and equality among the population, irrespective of social status, ethnicity, or spiritual belief.

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serious illnesses, very poor people, and malnourished children), and identifying ways to assist them. Currently, VHCs have limited experience, capacity, and regular support to carry out these tasks effectively. In addition, vulnerable groups—such as minority ethnic groups and women—are underrepresented on the committees. The VHCs will be strengthened through capacity building and training, effective involvement of women and ethnic groups, and development of clear lists of specific tasks. Villagers will contribute time for meetings and trainings as counterpart contributions to the Project (in-kind). Capacity building for VHVs will include (i) effective coordination with villagers and authorities, including holding regular meetings with VHCs on promoting model healthy village activities; (ii) providing basic health education for villagers, including the three elements of good hygiene, traditional medicine, and early diagnosis and treatment of common health problems and diseases (e.g., dengue fever, diarrhea, HIV/AIDS, malaria, and tuberculosis); (iii) collecting health data in the village, and using it for assessing village health situations and disease surveillance; (iv) training on birth-spacing services, normal delivery services, timely recognition of complicated deliveries to referral health facilities, pre- and postnatal consultations, and tetanus toxoid immunizations; (v) the importance of specific interventions for children, particularly full immunization during the first year of life, promotion of breast-feeding, deworming, and micronutrient supplements; (vi) identifying health problems that need to be referred to a health facility or a trained health worker; (vii) control and management of village drug supplies (villages with current, limited access to medicines can access the establishment of village drug kits under component B); and (viii) monitoring the health situation in the villages, and preparing regular reports. The Project will explore partnership with a private company on providing water purification tablets for participating villages. In addition, village capacity for participatory planning and engaging vulnerable groups in local-level planning processes will be strengthened through social mobilization. Villages will be supported by community facilitators to use participatory tools and approaches to collect information which will be used to design, implement, monitor, and evaluate village health plans and village health initiatives. Villages will identify their priorities and create simple, practical plans that identify opportunities and constraints and prioritize health improvement initiatives from the eight primary health care components that are part of a model healthy village. The model healthy village concept will be put into the context of overall sustainable village development, and VHCs will ensure coordination and collaboration with other sectors such as agriculture, education, and environment.

A simple, community-based monitoring and evaluation system will be put in place to support the planning process. Communities will use the system to track processes related to health planning, resulting subprojects, and changes in relevant indicators. This will include a mapping system that identifies households’ needs and health gaps, and each household will maintain a folder containing the health information of each member.

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Knowledge sharing and information, education, and communication activities will be carried out to enable understanding of the importance of healthy villages and demand-driven approaches beyond the communities directly participating in the Project. It will also provide forums for sharing lessons learned among participating villages and among particular target groups (e.g., minority ethnic groups and women) using community theater and other interactive tools. A reward system for best-performing healthy villages will also be developed.

The direct involvement of minority ethnic groups, women and other vulnerable sections of the population is a key factor in the effectiveness of the healthy village approach. Continuous training of new VHVs (including an apprenticeship program) will be developed to ensure sustainability.

Monitorable Deliverables/Outputs (i) VHCs are trained in all target villages. (ii) All target villages have two trained and equipped VHVs, at least

one of whom is female. (iii) All target villages develop village health plans, with at least 50%

representation of women and ethnic groups. (iv) There are trained female birth attendants in all target villages.

Implementation of Major Activities (Number of Months for Grant Activities)

Community mobilization: 3–27 Train VHC members: 3–27 Develop list of simple tasks for VHCs: 3–6 Train VHVs and traditional birth attendants: 3–27 Undertake regular community-based monitoring and evaluation:

3–30 Support VHCs to serve as peer educators: 6–27 Support VHCs and VHVs to undertake health needs assessments

and to raise community awareness: 6–24 Develop village health plans: 6–18 Undertake knowledge exchanges and tours: 6–36

Component B Component Name Improved Village Infrastructure for Primary Health Care Delivery Cost ($) 797,005 Component Description Following the mobilization and planning processes, villages will

have a strong sense of their development opportunities and needs in order to become model healthy villages. To translate planning into action, the Project will provide funds for initiatives identified in village health plans. Rather than supporting just one project, villages can choose health initiatives within a given budget envelope which will help each individual village best achieve improved health status. The villages can access these funds in a phased manner. The first phase gives all villages the opportunity to access a fund, estimated at $5,500 per village, for improved health and establishment of model healthy villages. Upon successful completion of the first phase and receiving model healthy village status, villages will be given an opportunity to access additional funding of up to $3,500 to further improve the health and sanitation aspects of the village. The phased approach will provide incentives for villages to perform well, and the larger allocation in the first round will ensure that any village in need of larger investments (e.g., for water supply) will be able to propose this for investment. If a village does not qualify for the second phase of funds, the money will be reallocated among the villages that do qualify. Inclusion of women and poor and vulnerable groups in all stages of project

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implementation will be an important criterion for qualifying for the second round of funding, thus encouraging communities to reach out and involve all groups in health activities.

Health initiatives to be financed under this component will be specific to the goals and actions identified by each village in its village health plan. Specifically, the services and infrastructure that villages can access will include, but not be limited to (i) additional health education; (ii) clean water and sanitation through construction of water supply systems, household latrines, or village sanitation (simple village waste management, fencing); (iii) construction of public toilets in schools, markets, or meeting halls, with separate facilities for males and females; (iv) small-scale environmental improvements, such as improved drainage along village roads and other poorly-drained areas (e.g., residential areas, markets, wats, and schools); (v) establishment or improvement of village drug kits, set up as revolving funds managed by VHVs; (vi) funds for emergency referrals for serious illnesses and childbirth; (vii) additional interventions for children, such as deworming, immunizations, and micronutrient supplements; (viii) prevention and control of diseases through various interventions (e.g., deworming, early diagnosis and treatment of common diseases, immunizations, impregnated bed nets, information dissemination, and vector control activities); and (ix) development of healthy schools.

The Project will contribute up to 80% of the costs of the village health initiatives; the provincial and district governments will contribute a total of at least 10% in the form of technical support staff and/or cash, and the village will contribute at least 10% in the form of labor, materials, and/or cash. Each village will develop an operation and maintenance (O&M) plan, including funding requirements and sourcing, and enter into an agreement with the Ministry of Health for O&M before any funds are released.

The provincial Nam Saat (Lao Water Agency) will support the villages and train them on water use and O&M, and be the focal points for O&M of water supply systems. The primary health care coordination units will manage all funds and procurement for the village health initiatives. The districts will, based on criteria developed during project start-up, be responsible for awarding and, on an annual basis, confirming model healthy village status to successful villages.

Monitorable Deliverables/Outputs (i) Villages implement health initiatives, with appropriate provisions for O&M and cost recovery.

(ii) At least 30% of jobs created for O&M of small-scale investments in each initiative are given to qualified women.

Implementation of Major Activities (Number of Months for Grant Activities):

Prepare subproject proposals, designs, and tender documents: 9–24

Build VHC capacity to undertake O&M: 9–27 Establish plans between district and villages for O&M: 12–24 Implement health initiatives: 12–27

Component C Component Name Strengthened Capacity of Districts and Health Centers to Support

Model Healthy Villages Cost ($) 606,375 Component Description This component will build human resources and strengthen district

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and health center capacity to initiate, develop, and support model healthy villages. Multidisciplinary district teams, comprising district and health center staff covering all technical aspects of primary health care, will be established. The district teams will be oriented and trained on the model healthy village strategy and development approach by experienced central- and provincial-level staff members. They will be supported by community facilitators, who will be hired by the Project to provide capacity building to the district teams and villages in community planning and management. The district teams will be provided with necessary medical equipment, supplies, audio–video equipment, and funds to carry out operations and information, education, and communication activities.

The district teams will integrate the village health plans into district health plans, which will serve as operational plans of action for how districts will support the successful establishment of model healthy villages. Based on these health plans, districts can access funding of up to $5,000 each for (i) additional human resources development and technical training for district health staff members, (ii) small-scale renovations of district health centers and hospitals, (iii) equipment for health centers, or (iv) construction of improved sanitation facilities at health centers. The Project will contribute up to 90% of costs of the district initiatives, with at least 10% counterpart contribution expected from districts in the form of support from technical staff members. Each district will develop an O&M plan, including funding requirements and sourcing, and enter into an agreement with the Ministry of Health for O&M before any funds are released. The Project will build synergy with the ongoing ADB-financed GMS Regional Communicable Diseases Control Project2 and the Piloting Community e-Centers for Better Health.3 Both of these initiatives have developed health information, education, and communication materials on topics such as communicable disease control; immunization; maternal and child health; nutrition; and VHV skills in basic curative, preventive, and promotive care. These and other experiences will strengthen the capacity of the district teams to train and support VHCs and VHVs, and direct links will be sought with the e-centers established in Xiangkhouang Province.

Monitorable Deliverables/Outputs (i) Model healthy village guidelines and health education materials are developed and distributed.

(ii) Ten multidisciplinary district teams are established and provided with medical equipment, audio–video equipment, and supplies.

(iii) Ten multidisciplinary district teams are trained in model healthy village development.

(iv) Village health plans are integrated into district health plans. (v) Small-scale district initiatives are implemented, with appropriate

O&M provisions. (vi) A system for logistics management and staff retention is

developed. 2 ADB. 2005. Report and Recommendation of the President to the Board of Directors on a Proposed Grant to Lao

People's Democratic Republic for the Greater Mekong Subregion Regional Communicable Diseases Control Project. Manila.

3 ADB. 2008. Technical Assistance to Lao People's Democratic Republic for Piloting Community e-Centers for Better Health. Manila.

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Implementation of Major Activities (Number of Months for Grant Activities)

Introduce the Project to district staff, health center staff, and other stakeholders: 1–3

Establish and train district teams: 3–9 Procure equipment and supplies: 1–6 Operationalize multidisciplinary district teams: 6–36 Develop district health plans: 9–15 Implement district health plans through district funds: 9–24 Build district team capacity to undertake O&M: 9–24 Monitor and supervise village activities and district health plans:

6–36 Component D Component Name Project Management and Implementation Support Cost ($) 547,250 Component Description This component will improve capacity for efficient project

implementation, and support management and coordination by the Ministry of Health. In addition, the ministry’s steering committee will be closely involved in the oversight of the Project. The Ministry of Health will assign staff to implement the Project and perform the following functions for this component: (i) oversee the JFPR grant and budget; (ii) procure or create required audit reports; (iii) undertake required subcontracts and oversee their implementation; (iv) ensure monitoring and evaluation activities, including financial audits; (v) ensure stakeholder exchanges are established and that lessons learned from the Project are incorporated into the design of future operations; (vi) coordinate with the steering committee; participating provinces, districts, and villages; and other stakeholders; and (vii) develop and execute a clearly defined exit strategy to ensure that the Project will be sustained and scaled up within Lao PDR. Government counterpart contributions will include staff, office space, and meeting activities.

The Executing Agency (EA) will select the Project’s 10 districts and 100 villages in Houaphan and Xiangkhouang provinces based on the following criteria, to be confirmed and adjusted as necessary during project start-up.

Five districts will be selected in each province. Each district will include three poor priority development zones with three levels of physical access difficulties. In each development zone, three or four villages among the poorest will be selected. In summary, the project area will include two provinces, 10 poor districts, 30 priority development zones, and a total of 100 poor villages.

The Project will include a high-quality independent evaluation, which will collect panel data in a representative sample of treatment and control communities, and measure project outcomes. Lessons from the evaluation will inform the scaling-up of model healthy villages in Lao PDR.

Monitorable Deliverables/Outputs (i) Project management is established, and staff members are trained and operating.

(ii) Consultants are recruited and operating. (iii) The field guide and project implementation manual are

developed. (iv) Annual work plans and personnel schedules are developed. (v) A monitoring and evaluation system is established and

operational.

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(vi) A harmonized approach for scale-up nation-wide, including the updated field guide and project implementation manual, is developed.

Implementation of Major Activities (Number of Months for Grant Activities)

Identify and train national and provincial project staff members: 1–3Mobilize international and national consulting services: 1–3 Develop field guide and project implementation manual: 1–6 Develop annual work plans for the Project: 1–3 Establish and train primary health care coordination units and

district teams: 1–6 Provide project orientation to stakeholders and technical and

management support to primary health care coordination units: 3–36

Undertake regular monitoring activities: 3–36 Undertake evaluation study: 33–36 Produce updated field guide and project implementation manual

with revised approach for further replication and scale-up: 33–36

2. Financing Plan for Proposed Grant to be Supported by JFPR Funding Source Amount ($) JFPR 3,000,000 Government 191,600 Communities 145,523 Total 3,337,123

3. Background 1. Lao PDR is a land-locked, low-income country with a scattered population of 6.2 million, with an average annual per capita income of $630 in 2007. About one third of its population is poor, and another one third is near-poor, causing major market failure and challenges in the health sector. Lao PDR has made progress in meeting the major Millennium Development Goals (MDGs) related to health: between 1990 and 2005, the child mortality rate decreased from 170 to 98 per 1,000 live births; the maternal mortality rate decreased from 750 to 405 deaths per 100,000 live births; and the prevalence of malnutrition declined from 40% in 1990 to an estimated 30% in 2005. However, further reductions—especially in maternal mortality and malnutrition rates—are needed and will require further efforts in strengthening quality primary health care services, particularly to reach more remote rural populations, many of them small ethnic groups. Maternal care is a particular priority for the Ministry of Health due to a lagging MDG linked to weak obstetric services. In addition, low safe water supply coverage, poor sanitation conditions, and poor hygiene practices increase the risk of dengue fever, diarrheal diseases, intestinal worm infections, and malaria. Diarrheal disease is the second biggest cause of mortality in children and the third among adults in Lao PDR. In 2000, malaria was ranked the number one cause of mortality and morbidity (70% of the population is at risk). Schoolchildren (ages 5–14) are especially prone to intestinal helminth (a 62% prevalence rate), which results in absences from school.

2. The Government of Lao PDR recognizes health as an integral part of the country's human capital, with major benefits for welfare, learning, and productivity. Health care is a particularly important asset for the rural poor, who commonly lose assets due to expenditures on medical care. The poor are also more vulnerable to health shocks due to the high cost of treating disease and lost work days for recovery. The health sector is one of four priority areas in the country’s Sixth National Socio-Economic Development Plan (2006–2010). The

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Government is also committed to the Health Strategy Up to the Year 2020, which is based on four health care concepts: (i) full coverage and service equity, (ii) early integrated services, (iii) demand-based services, and (iv) self-reliant services. The main vehicle for achieving this is to provide all citizens with access to primary health care, in particular the rural poor, minority ethnic groups, and women and children. 3. The primary health care policy directly addresses the MDGs through (i) expanded coverage of the health service network to peripheral areas, (ii) health care for women of reproductive age and children under the age of 5 years, (iii) full community participation, (iv) dissemination of health information to rural areas, (v) use of resources with a sound scientific basis and appropriate to actual situations and needs, (vi) collaboration with other government sectors and the private sector, (vii) further support for a more effective primary health care program, and (viii) sustainability of health care services at every level through community contributions to and ownership of the services.

4. With the support of development partners, the Ministry of Health has established a basic primary health care network of hospitals, health centers, and VHVs. However, there is still a lack of adequate resources, infrastructure, and capacity of VHVs and VHCs to improve primary health care services at the village level. In particular, services for women and infants are less accessible and often not up to standard, and additional social barriers exist for isolated ethnic groups. Common infectious diseases affecting the rural poor—particularly minority ethnic groups—can be prevented with simple, highly cost-effective interventions such as better personal hygiene, clean water supply and sanitation, insecticide-treated bed nets, timely recognition and basic treatment of common illnesses, and vaccinations. Malnutrition, a major contributor to child mortality, must also be addressed. When there are no food shortages, malnutrition is a child-care problem that primarily needs household and community intervention rather than health services. Nutrition among women and children can be improved through specific, low-cost interventions such as the promotion of breast-feeding and proper diets, family planning, kitchen gardens, and vitamin supplements. 5. To address these needs, the Government has requested ADB and JFPR to provide assistance to pilot model healthy villages in the two northern provinces of Houaphan and Xiangkhouang. These provinces were chosen out of the country's 18 provinces, because they are among the eight northern provinces covered by the ongoing Health System Development Project and have demonstrated potential for piloting the model healthy village approach. A model healthy village was defined in the Government's 2007 national health conference as a village that maintains the basic conditions needed to lead a healthy life, including the following eight primary health care elements: (i) adequate health information; (ii) clean environmental practices with basic hygiene principles such as using latrines, having safe water, and eating well-cooked food; (iii) safe motherhood; (iv) Expanded Programme on Immunization; (v) nutrition; (vi) common disease control; (vii) awareness and information of available treatments in health facilities; and (viii) availability of essential drugs or drug kits. A model healthy village has a well-functioning VHC and VHVs, and involves all villagers in community activities related to clean and healthy living. Currently, various approaches and methods for healthy village development exist in Lao PDR, but a harmonized and more community-centered approach is needed to focus on increasing access to basic infrastructure (such as water supply and sanitation), improving village ownership and capacity by creating village-level sustainable structures and mechanisms, and improving district-level human resources to support village development.

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4. Innovation

6. The main innovative features of the Project include

(i) piloting demand-driven provision of comprehensive and quality primary health care services coupled with improved access to water and sanitation in selected poor villages located in priority development zones, which are generally populated by minority ethnic groups, with a focus on women and children’s health;

(ii) developing villagers' ownership and the effective involvement of women and ethnic groups in the planning and implementation phases of establishing model healthy villages;

(iii) providing VHCs the opportunity to prioritize needs and decide on resource allocation based on their own identified needs rather than on a pre-established service package;

(iv) creating a process-oriented, community-based monitoring and evaluation system, which will empower the poor and vulnerable groups to assess and monitor their health situations; and

(v) piloting multidisciplinary district teams, building the capacity of district health system networks, and strengthening district health office capacity to support the development of community-based primary health care and to manage the delivery of high-quality primary health care services to the target population.

5. Sustainability 7. The Project will foster local ownership and sustainability through the involvement of key local actors, including community members, local mass organizations, and government institutions. At the village and district levels, sustainability will be addressed through capacity-building activities associated with the development planning processes under components A and C. A continuous program of training new VHVs (including an apprenticeship program) will also be developed. Furthermore, durable institutions that support institutionalized long-term development will be strengthened and piloted (multi-disciplinary district teams). The Project supports specific mechanisms to increase sustainability, such as revolving funds for drug kits and support for O&M of all infrastructure investments. 8. The Project will pilot health service delivery mechanisms that increase efficiency and provision of these services to remote populations on a regular and permanent basis. Successful implementation of pilot activities, including health planning and community-driven initiatives, should lead to scaling-up and institutionalization of these approaches by the Government. The Ministry of Health has expressed strong interest and willingness to incorporate lessons learned from the Project in the design of future activities. Thus, the Project’s exit strategy will be the development of a harmonized approach and scaling-up of the piloted approaches. 6. Participatory Approach 9. Comprehensive community participation to define a model healthy village and to plan and implement health activities accordingly will be essential. Participatory approaches form the basis for strengthening VHCs and VHVs, village health planning, and implementing and monitoring model healthy villages. The Project will encourage increased village ownership of health activities focused on health promotion and disease prevention with the support from a strengthened district health system network. Villages will be the implementing units for basic

12

health activities, and the direct involvement of women, minority ethnic groups, and other vulnerable populations a key factor in the effectiveness of the healthy village approach. A field guide will be developed as part of project start-up, and will include special actions to involve vulnerable groups in all processes, beginning with initial social mobilization activities and culminating in their opportunity to be centrally engaged in institutionalized structures to be strengthened under the Project. 10. Primary and other stakeholders (including any nongovernment organizations [NGOs], especially Japanese NGOs) and brief description of their involvement.

Primary Beneficiaries, Other Affected Groups, and Relevant Description

Other Key Stakeholders and Relevant Description

• Residents from 100 poor villages in priority development zones—particularly women, children, and ethnic groups—will benefit from improved and sustainable primary health care services.

• District health office and health center staff will benefit from strengthened human resources and capacity to provide comprehensive primary health care services to villages.

• Village authorities and mass organizations, such as the Lao Women’s Union and the Lao People’s Revolutionary Youth Union, will support villager ownership, involvement in health activities, and sustainability of interventions.

• Primary health care coordination unit staff will be responsible for project implementation at the provincial level.

• Other government agencies will be involved, such as those concerned with village development, particularly in the agriculture and education sectors

• The Ministry of Health will serve as the Executing Agency for the Project and provide technical support.

7. Coordination 11. Throughout project preparation, concepts and drafts have been shared with the Embassy of Japan in Vientiane, through continued discussions and e-mail exchanges since January 2008. Japan International Cooperation Agency (JICA) officers were also consulted during development of the project proposal, and their comments and feedback incorporated into the proposal design. Other development partners, in particular the United Nations Children’s Fund (UNICEF) and World Bank, have been consulted extensively, and lessons from their operations have been incorporated into the Project. 12. During project implementation, joint government and ADB project reviews will occur twice yearly or more frequently, if needed. The Ministry of Health steering committee will provide overall project oversight, and the ministry will prepare activity progress reports, together with annual project review reports, which will be shared with other development partners and representatives of the Embassy of Japan, who will be invited to participate in and observe milestone events of the Project. 8. Detailed Cost Table 13. Appendix 2 gives the detailed cost estimates, and Appendix 3 the summary cost table. Appendix 4 contains the fund flow arrangement, and Appendix 5 the implementation arrangements. The implementation arrangements and estimated costs for ensuring participation

13

of minority ethnic groups and for project benefits to accrue to these groups have been integrated into the overall arrangements and total budget of the Project. C. Linkage to ADB Strategy and ADB-Financed Operations 1. Linkage to ADB Strategy 14. ADB’s strategy for its operations in Lao PDR, the Country Strategy and Program for 2007–2011, is consistent with the Government’s Sixth National Socio-Economic Development Plan 2006–2010. Health also continues to be a priority sector for the Government. As a part of its overall assistance program for health sector development in Lao PDR, ADB will continue to support primary health care, health sector financing, and human resources development—including a series of sector interventions to improve the institutional framework, financing, human resource development, and governance in the health sector. The pipeline of the Country Operations Business Plan for 2009–2011 includes a health project that will build on previous support to the health sector. ADB has supported the expansion of Primary Health Care (PHC) in the 8 Northern provinces and strengthened institutional capacity for PHC management nationwide. To further improve the quality and use of services, the Health System Development Project4 is focusing on human resources development, and has introduced a results-based approach and health equity fund. Based on this successful approach, a health sector development program is planned for 2009. The Project will complement it and also contribute to the country strategy and program’s objectives.

Document Document

Number Date of Last Discussion Objectives

Lao People's Democratic Republic: Country Strategy and Program 2007–2011

Sec.M94-06 September 2006

Key objectives that relate to the Project are (i) promoting pro-poor, sustainable growth; and (ii) fostering inclusive social development. Specific objectives include decreasing infant and maternal mortality rates, improving access to clean drinking water, and mainstreaming gender concerns in all operations.

2. Linkage to Specific ADB-Financed Operation Project Name Health Sector Development Program Project Number 41376-02 Date of Board Approval 2009 pipeline, as indicated in the country operations business plan

2009–2011 Loan Amount Grant amount currently estimated at $20 million.

3. Development Objective of the Associated ADB-Financed Operation 15. The Health Sector Development Program aims to achieve MDG goals 4 and 5 for maternal and child mortality reduction by 2015 through improving the use and quality of primary health care in eight northern provinces and establishing and operationalizing provincial health system management nation-wide. This project builds on achievements from the Primary Health

4 ADB. 2007. Report and Recommendation of the President to the Board of Directors on a Proposed Grant to Lao People's Democratic Republic for the Health System Development Project. Manila.

14

Care Expansion Project,5 which is expanding access to primary health care in eight northern provinces and strengthening institutional capacity for primary health care management nationwide. It also builds on the Health System Development Project (footnote 4), which aims to improve primary health care delivery in the eight northern provinces and to strengthen the Ministry of Health’s capacity in health system development. 16. If successful, the proposed Health Sector Development Program will scale-up the model healthy villages set up under the Project. 4. Main Components of the Associated ADB-Financed Operation 17. The following outputs are included in the concept note for the Health Sector Development Program.

No. Component Name Brief Description 1. Increased access to services for

women and children in eight northern provinces

This will be achieved by improving availability of emergency obstetric and child services in hospitals, increasing capacity of health centers in skilled birth attendance, and expanding the healthy village model piloted under the project.

2. Affordable quality care for the poor in eight northern provinces

This will be achieved by expanding health equity funds for the poor to all eight northern provinces in coordination with other initiatives, and linking this to service standards and results-based incentives for the delivery of a package of services.

3. Improved human resources for health

This involves implementing the human resources policy and plan in coordination with other partners, including support for the University of Health Sciences, Luang Prabang family doctor school, mid-level primary health care schools, nurse and midwife schools, and continuous in-service training of staff and village health workers, with a priority for female staff in general and midwives in particular.

4. Strengthened provincial health system management nationwide

The planning process will follow a participatory approach involving the ministries of finance, health, and planning and investment; various organizations; provinces; districts; village committees; and beneficiaries. Three stakeholder workshops will be held at inception, midterm, and at completion of the design work. Baseline household and health service surveys are already being conducted. The project will support end-of-project surveys at the household level and of health services.

5. Rationale for Grant Funding versus ADB Lending

18. Lao PDR is classified as a highly-indebted poor country, and is currently eligible to receive 100% of total project financing from ADB as grants. Houaphan and Xiangkhouang provinces are among the poorest in the country, and the villages to be targeted by the Project are among the poorest in each province. The assistance is consistent with the Government's Sixth National Socio-economic Development Plan, which targets the 47 poorest districts for priority assistance. 5 ADB. 2000. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to Lao People's Democratic Republic for the Primary Health Care Expansion Project. Manila.

15

19. The Project will pilot the combination of safe water supply and sanitation with primary health care activities to establish self-reliant and sustainable model healthy villages. The Project will also establish guidelines for the establishment and scaling-up of model healthy villages in Lao PDR, which then will be used to expand the model healthy villages to the eight northern provinces under the Health Sector Development Program and nationally through other interventions. JFPR grant funding is considered appropriate for this Project given its pilot nature and large scale-up potential. The Government has indicated a large commitment to scale up the piloted interventions if they are successful; however, both interventions and implementation arrangements should be refined and proven effective before included in future Asian Development Fund grants. D. Implementation of the Proposed Grant Implementing Agency Provincial Health Offices in Houaphan and

Xiangkhouang (implementing agencies)

20. The Ministry of Health is the EA. Within the ministry, direct implementation responsibility will be with the Department of Planning and Budgeting. It will oversee project activities; facilitate coordination with provinces, district, and village authorities and other projects; and endorse annual work plans. The Ministry of Health will mobilize its provincial, district, and subdistrict health services staff to support project implementation. Provincial health offices in Houaphan and Xiangkhouang provinces will be the implementing agencies. Within these offices, the primary health care coordination units, which have responsibility for primary health care provision, will be used for project implementation. With assistance from project consultants and the Ministry of Health, they will be responsible for day-to-day coordination and supervision of project implementation. At the district level, the district health office will oversee the Project, monitor progress, review quality of the work, coordinate subprojects with the primary health care coordination units and local communities, and report on progress to the primary health care coordination units. 21. The target beneficiaries will implement the activities at the village level. To facilitate this, the Project will work through VHCs as the primary interface among the primary health care coordination unit, district, and the community in terms of participatory activity planning and decision making and collaborative management and monitoring. The Project will support the formation, capacity building, and training of the VHCs and various interest group functionaries to enable them to make informed, logical choices concerning healthy village options. Equitable representation from all gender and ethnic groups will be actively encouraged. 22. The Ministry of Health steering committee, chaired by the Minister of Health, and including vice ministers, directors of departments, and cabinet members, will provide implementation guidance, approve overall and annual work and financial plans, and monitor implementation progress. 23. A total of 401 person-months of consulting services will be recruited, 6 person-months international and 395 person-months national, including 300 person-months for district facilitators and 48 person-months for provincial financial specialists. Due to the specific needs for these specialists to be local and field-based as well as the variety of specialists needed, all consultants will be recruited on an individual basis to ensure that the most appropriate candidates are selected in the most cost-efficient manner. ADB, in consultation with the Ministry of Health, will recruit the international consultants, and the Ministry of Health will recruit the

16

national consultants in accordance with ADB’s Guidelines on the Use of Consultants by Asian Development Bank and its Borrowers (2007, as amended from time to time). All procurement under the JFPR grant will be carried out in accordance with ADB’s Procurement Guidelines (2007, as amended from time to time). The assets procured under this project will be handed over to the EA upon project completion.

1. Risks Affecting Grant Implementation Type of Risk Brief Description Measure to Mitigate the Risk Slowing down of socioeconomic development

World economic recession may affect Lao PDR and cause decreased budget allocations to the health sector.

• Cost-effective interventions • Increased efficiency for health

service delivery • Rational planning and budgeting

approach Weak integration of the Project within the general government village development and poverty reduction strategies

Although the Project contributes to the general poverty reduction strategy, they must be closely coordinated.

• Involve stakeholders at all development, planning, and implementation phases of the Project.

Low community ownership and participation

Ensuring villager ownership and getting them involved in health activities is a process that requires adapted approaches and skills.

• Develop capacity of provinces and districts in participatory development.

2. Incremental ADB Costs

Component Incremental Bank Cost Amount Requested $50,000 Justification For activities required for inception, midterm, final, and grant

completion review missions (including workshops and seminars with local stakeholders), consultants with various technical expertise will be needed to assist ADB staff in conducting thorough reviews.

Type of Work to Be Rendered by ADB Specialists and/or consultants will be engaged to assist ADB staff in conducting workshops and seminars with local stakeholders during project inception as well as regular, midterm, and final reviews.

3. Monitoring and Evaluation

24. Appendix 1 provides the design and monitoring framework.

Key Performance Indicator Reporting Mechanism Plan and Timetable for

Monitoring and Evaluation A harmonized, national approach for implementation of model healthy villages is developed.

Baseline and follow-up project surveys Progress reports Final project evaluation Updated project implementation manual and field guide

Year 1 baseline survey Year 3 follow-up survey Quarterly and annual progress reports Year 3 project evaluation Year 3 update of project implementation manual and field guide

17

Key Performance Indicator Reporting Mechanism Plan and Timetable for

Monitoring and Evaluation Target villages achieve model healthy village status.

Baseline and follow-up project surveys Progress reports Final project evaluation

Year 1 baseline survey Year 3 follow-up survey Quarterly and annual progress reports Year 3 project evaluation

There is increased participation of the poor and other vulnerable groups in village planning and management of health services.

Baseline and follow-up project surveys Progress reports Final project evaluation

Year 1 baseline survey Year 3 follow-up survey Quarterly and annual progress reports Year 3 project evaluation

District working teams are operational and support model healthy villages.

Baseline and follow-up project surveys Progress reports

Year 1 baseline survey Year 3 follow-up survey Quarterly and annual progress reports

4. Estimated Disbursement Schedule

Fiscal Year (FY) Amount ($) FY 1 300,000 FY 2 900,000 FY 3 900,000 FY 4 900,000 Total Disbursements 3,000,000

Appendix 1

18

DESIGN AND MONITORING FRAMEWORK

Design Summary Performance

Targets/Indicators Data Sources/Reporting

Mechanisms Assumptions and Risks Impact Improved health status of rural population in Houaphan and Xiangkhouang provinces.

Infant mortality rate in target provinces reduced to 80 per 1,000 live births by 2015. Maternal mortality ratio in target provinces reduced to 250 per 100,000 live births by 2015.

National statistics and census data Reports from ADB and development partners

Assumption • The Government

continues to give priority to primary health care in remote areas.

Risks • Economic or political

instability or environmental disasters

• Major epidemics and disease outbreaks

Outcome Target villages achieve model healthy village status.

At least 80% of families in target villages have access to safe water by 2013. Average sanitation coverage in target villages is at least 80%, with a minimum of 50% by 2013. At least 90% of households in target villages use impregnated bed nets by 2013. At least 80% of women in target villages have access to pre- and antenatal care, and at least 50% of births are attended by a trained birth attendant by 2013. At least 80% of the target population is fully immunized by 2013. All target villages have family planning and nutrition sessions available on a quarterly basis by 2013. All target villages have access to essential drugs, either through village drug kits or a health center by 2013.

Baselinea and follow-up project surveys Quarterly and annual project progress reports Final project evaluation Updated field guide and project implementation manual

Assumptions • Public responds to

improved primary health care delivery with stronger demand.

• Social barriers of health services, in particular for ethnic groups, can be overcome.

Risk • Health and hygiene

awareness do not result in behavior change.

Outputs 1. Strengthened

All target villages have

Baseline and follow-up

Assumptions • Provincial and district

Appendix 1

19

Design Summary Performance

Targets/Indicators Data Sources/Reporting

Mechanisms Assumptions and Risks Village Capacity for Participatory Planning and Management of Model Healthy Villages

effective VHCs with at least 50% representation of women and ethnic groups by 2013. All target villages have two trained and equipped VHVs, at least one of which is a woman by 2013. All target villages have developed village health plans, with at least 30% representation of women and ethnic groups by 2013. Community awareness of relationships among health, hygiene, and sanitation has increased by at least 50% by 2013. Participation of women and ethnic groups in village planning has increased by at least 50% by 2013.

project surveys Quarterly and annual progress reports Project training records disaggregated by sex and by ethnic group Final project evaluation

agencies are committed to community development.

• Behavioral change communication is effective.

2. Improved Village Infrastructure for Primary Health Care Delivery

All villages have implemented village health initiatives, with appropriate provisions for O&M and cost recovery by 2013. At least 30% of jobs created for O&M of small-scale investments in each initiative are given to qualified women by 2013.

Baseline and follow-up project surveys Quarterly and annual progress reports Project progress and project completion reports Final project evaluation

Assumption • Villages and districts

provide continuous and sustained O&M of infrastructure.

3. Strengthened Capacity of Districts and Health Centers to Support Model Healthy Villages

Model healthy village guidelines and health education materials are developed and distributed by 2011. Ten multidisciplinary district teams, with at least 30% female representation, are established and operational by 2011. Ten districts have prepared district operational plans of action for supporting model healthy villages by

Quarterly and annual progress reports Project progress and project completion reports Final project evaluation

Assumption • Capacity of districts and

district teams are maintained.

Risk • Retention and turnover of

staff

Appendix 1

20

Design Summary Performance

Targets/Indicators Data Sources/Reporting

Mechanisms Assumptions and Risks 2011. Ten districts have implemented small-scale investments, with appropriate provisions for O&M and cost recovery, by 2012. A system for logistics management and staff retraining is developed by 2011.

4. Project Management and Implementation Support

Project management is established, and staff is trained and operating with adequate resources by 2010. Consultants are recruited and operational by 2010. Field guide and project implementation manual and are developed by 2010. Detailed annual work plans and personnel schedules are developed. A harmonized, countrywide approach for scaling up, including an updated field guide and project implementation manual, has been developed by 2013.

Project progress and project completion reports Detailed work schedule and budget plans Project management meeting minutes Quarterly and annual progress reports Audit reports Review missions

Assumption • National, provincial, and

district agencies allocate adequate staff and resources for project operating entities.

Activities with Milestones 1. Strengthened Village Capacity for Participatory Planning and

Management of Model Healthy Villages 1.1 Undertake community mobilization, participatory workshops, and meetings,

and inform stakeholders (Q2/2010–Q2/2012). 1.2 Reinforce and train VHC members in each village throughout project

implementation (Q2 2010–Q2/2012). 1.3 Develop list of tasks for VHCs (Q2/2010). 1.4 Train VHVs and traditional birth attendants throughout project

implementation (Q2 2010–Q2/2012). 1.5 Support VHCs to serve as peer educators in community training on family

planning, disease control, nutrition, clean environment, support for vulnerable groups, and other aspects of model healthy villages (Q3/2010– Q2/2012).

1.6 Support VHVs and VHCs to undertake information and health needs assessments and to raise community awareness on health, sanitation, and links with water use throughout project implementation (Q3/2010–Q1/2012).

1.7 Develop village health plans (Q3/2010–Q3/2011). 1.8 Undertake regular community-based monitoring and final evaluation of

Inputs Total: $3.34 million JFPR: $3.00 million Government: $0.19 million Communities: $0.15 million

Appendix 1

21

activities (Q2/2010–Q3/2012). 1.9 Undertake knowledge exchanges and tours (Q3/2010–Q3/2012).

2. Improved Village Infrastructure for Primary Health Care Delivery 2.1 Prepare health initiative proposals and designs, and tender documents

progressively throughout project implementation (Q3/2010–Q4/2011). 2.2 Create plans between districts and individual villages for O&M prior to

commencing physical works in each village (Q4/2010–Q4/2011). 2.3 Improve household and village environments through small-scale health

initiatives during project implementation (Q4/2010–Q2/2012). 2.4 Build and strengthen the capacities of VHCs to undertake O&M of project

facilities and services (Q3/2010–Q2/2012). 3. Strengthened Capacity of Districts and Health Centers to Support

Model Healthy Villages 3.1 Introduce project to district staff, district health center staff, and other

stakeholders (Q4/2009). 3.2 Establish and train multidisciplinary district teams (Q1/2010–Q3/2010). 3.3 Train district teams and other district staff in planning and management of

model healthy villages (Q1/2010–Q1/2012). 3.4 Procure equipment and supplies (Q4/2009–Q2/2010). 3.5 Develop district health plans (Q4/2010–Q3/2011). 3.6 Implement district health plans through district funds (Q4/2010–Q1/2012). 3.7 Build and strengthen the capacities of district teams to undertake O&M of

project facilities and services (Q4/2010–Q1/2012). 3.8 Monitor and supervise village activities and district health plans

(Q1/2010– Q3/2012). 4. Project Management and Implementation Support 4.1 Identify and train national and provincial project staff prior to project start

(Q4/2009). 4.2 Mobilize international and national consulting services (Q4/2009). 4.3 Develop field guide and project implementation manual for project

implementation (Q4/2009–Q1/2010). 4.4 Develop annual work plans for the Project (Q4/2009). 4.5 Establish and train primary health care coordination units and district teams

prior to project start (Q4/2009–Q1/2010). 4.6 Provide project orientation to stakeholders, and provide technical and

management support to primary health care coordination units throughout project implementation (Q1/2010–Q3/2012).

4.7 Undertake regular monitoring of project activities (Q1/2010–Q3/2012). 4.8 Undertake evaluation study (Q3/2012). 4.9 Produce updated field guide and project operation manual and with revised

approach and strategy for further replication and scaling-up (Q3/2012). JFPR = Japan Fund for Poverty Reduction, O&M = operation and maintenance, Q = quarter, VHC = village health committee, VHV = village health volunteer. Note: a Baseline data in each village will be collected as part of project start-up, and will be used for planning purposes and

to assess achievement of outcome and outputs. ___________________________ ____________________________ Director, SESS Director General, SERD

DETAILED COST ESTIMATES($)

Code Supplies and Services Rendered Unit Quantity Cost TOTALUnits Per Unit $

Amount Method of Procurement

Component A. Strengthened Village Capacity for Participatory Planning and Management of Model Healthy Village 1,004,496 953,973 0 50,5231.1 Capacity Building of VHVs

1.1.1 Training VHVs Person 200 1,000 200,000 189,632 10,3681.1.2 Training traditional birth attendant Person 100 600 60,000 54,816 5,1841.1.3 Equipment and supplies VHV Set 300 600 180,000 180,000 Shopping1.1.4 Drugs, supplies, and equipment for diseases contro Lump sum 100 1,000 100,000 100,000 Shopping1.1.5 Printing of training materials Lump sum 600 10 6,000 6,000 Shopping1.1.6 Bicycles for VHVs Set 200 200 40,000 40,000 Shopping

1.2 Capacity Building of VHCs1.2.1 Training of VHCs VHCs 100 870 87,000 75,480 11,5201.2.2 Printing of VHC manual Lump sum 600 10 6,000 6,000 Direct purchase

1.2 Village Development Planning1.2.1 Print healthy village guideline Set 600 10 6,000 6,000 Shopping1.2.2 Village baseline data collection, health needs assessment, and planning Village 100 1000 100,000 100,0001.2.3 Village community meetings Meeting 1,200 80 96,000 75,264 20,736

1.3 Community-Based Monitoring and Evaluation1.3.1 Train and establish village-based monitoring team Village 100 500 50,000 50,0001.3.2 Developing monitoring tools Lump sum 1 3,496 3,496 3,496 Direct purchase1.3.3 Printing of monitoring tools Tools 1,000 10 10,000 10,000 Shopping

1.4 Knowledge Sharing and Exchanges1.4.1 Village Exhanges Villages 100 500 50,000 47,285 2,7151.4.2 District exchanges Districts 10 1,000 10,000 10,000

Component B. Improved Village Infrastructure for Primary Health Care Delivery 928,550 724,550 114,000 90,0002.1 Village Health Initiatives

2.1.1 Village health initiatives phase 1 Village 100 5,500 550,000 440,000 Shopping, NCB 55,000 55,0002.1.2 Village health initiatives phase 2 Village 100 3,500 350,000 280,000 Shopping, NCB 35,000 35,0002.1.3 Technical supervision counterpart staf Person-months 120 200 24,000 0 24,0002.1.4 Travel and per diem for technical supervision staf Person-days 350 13 4,550 4,550

564,850 551,250 8,600 5,0003.1 Capacity Building of Basic District Working Teams

3.1.1 Training of district teams in model healthy villages concept Teams 10 1,500 15,000 15,000Training - health and nutrition Teams 10 1,500 15,000 15,000Training - water and sanitation Teams 10 1,500 15,000 15,000

3.1.2 Training - gender and ethnic groups Teams 10 1,500 15,000 15,0003.1.3 Training - village planning Teams 10 1,500 15,000 15,0003.1.4 Training in operation and maintenance Teams 10 1,500 15,000 15,0003.1.5 Training M&E Teams 10 1,500 15,000 15,0003.1.5 Printing of guidelines and materials Set 10 500 5,000 5,000 Shopping3.1.6 Transport allowance for district teams Person-days 3,000 13 39,000 39,0003.1.7 Audio-video equipment Set 10 2,000 20,000 20,000 Shopping3.1.8 Medical equipment for district team Set 10 4,000 40,000 40,000 Shopping3.1.9 Provision of health services at the village level Villages 100 1,000 100,000 100,000

Component C. Strengthened Capacity of Districts and Health Centers to Support Model Healthy Village

Costs ContributionsJFPR Government Communities

22 A

ppendix 2

DETAILED COST ESTIMATES($)

Code Supplies and Services Rendered Unit Quantity Cost TOTALUnits Per Unit $

Amount Method of Procurement

3.1.10 District facilitators Facilitators 10 12,000 120,000 120,0003.1.11 Motorbikes for district facilitators* Motorbikes 10 1,500 15,000 15,000 Shopping3.1.12 Maintenance and operation of motorbikes Motorbikes 10 400 4,000 4,000

3.2 District Health Planning3.2.1 Planning exercise Teams 10 1,500 15,000 15,000

3.3 Small-Scale District Investments3.3.1 District health initiatives for upgrading and equipment/supplies Grant 10 5,000 50,000 40,000 Shopping, NCB 5,000 5,0003.3.2 Technical supervision counterpart staf Person-months 12 300 3,600 0 3,6003.3.3 Travel and per diem for technical supervision staf Person-days 250 13 3,250 3,250

3.4 Equipment and Supplies3.4.1 Computer Set 10 1,000 10,000 10,000 Shopping3.4.2 Photocopier Set 10 2,000 20,000 20,000 Shopping3.4.3 Printer Set 10 500 5,000 5,000 Shopping3.4.4 Other office equipment Set 10 1,000 10,000 10,000 Shopping

Component D. Project Management and Implementation Support 566,500 497,500 69,000 04.1 Technical Assistance

4.1.1 International consultant - Operations manual and field guide Person-months 3 15,000 45,000 45,000 ICS 4.1.2 International consultant - Project review and development of scale-up Person-months 3 15,000 45,000 45,000 ICS4.1.3 National consultant - Operations manual and field guide Person-months 3 2,000 6,000 6,000 ICS4.1.4 National consultant - Project management/community health specialist Person-months 30 2,000 60,000 60,000 ICS4.1.5 National consultant - Social and gender specialist Person-months 10 2,000 20,000 20,000 ICS4.1.6 National consultant - M&E 10 2,000 20,000 20,000 ICS4.1.7 Financial specialist provinces (2) Person-months 48 300 14,400 14,400 ICS4.1.8 Travel and per diem for consultants Lump sum 1 50,000 50,000 50,000 ICS4.1.9 External audit Audit 3 5,000 15,000 15,000 ICS

4.1.10 Baseline survey and impact assessmen Lump sum 1 100,000 100,000 100,000 ICS

4.2 Equipment and Supplies4.2.1 Computer, photocopier, and printer for national level Set 1 5,000 5,000 5,000 Shopping4.2.2 Computer, photocopier, and printer for provinces Set 2 5,000 10,000 10,000 Shopping

4.3 Project Operational Costs4.3.1 Counterpart staff Person-month 108 500 54,000 54,0004.3.2 Office utilization Months 36 400 14,400 14,4004.3.3 Office support staff (finance, administration, and drivers) Months 45 400 18,000 18,000 Direct purchase/hire4.3.4 Incremental office running costs Months 36 400 14,400 14,4004.3.5 Travel and per diem for management and support staff Person-day 1,500 25 37,500 37,5004.3.6 Project steering committee meetings Meeting 6 300 1,800 1,200 600

4.4 Trainings and workshops4.4.1 Project workshops Workshop 4 3,000 12,000 12,0004.4.2 Project introduction and briefings for provinces and districts Workshop 2 3,000 6,000 6,0004.4.3 Midterm workshops Workshop 3 3,000 9,000 9,0004.4.4 Final evaluation workshops Workshop 3 3,000 9,000 9,000

Contributions

JFPR Government Communities

Costs

Appendix 2 23

DETAILED COST ESTIMATES($)

Code Supplies and Services Rendered Unit Quantity Cost TOTALUnits Per Unit $

Amount Method of Procurement

Components A to D = Subtotal 3,064,396 2,727,273 191,600 145,523

Contingency (Maximum 10% of total JFPR Contribution) 272,727 272,727 0 0

TOTAL Grant Costs 3,337,123 $3,000,000 191,600 145,523

Incremental Cost Details:Cost inception, Midterm and Final Reviews, and Grant Completion Mission Lot Lot 50,000 50,000 50,000

TOTAL Incremental Costs 50,000 50,000

Source: Asian Development Bank estimates.

*The cost of purchasing vehicles (eight motorbikes) has been included in the budget to ensure effectiveness and efficiency during Project implementation given the remoteness of project target villages.

Leasing or rental costs of required vehicles over the life of the project would be higher compared to direct purchase.

ICS = individual consultant system, JFPR = Japan Fund for Poverty Reduction, M&E = monitoring and evaluation, NCB = national competitive bidding, VHC = village health committee, VHV = village health volu

Costs Contributions

JFPR Government Communities

24 Appendix 2

SUMMARY COSTS TABLE($)

Component A. Strengthened Village

Capacity for Participatory Planning and

Management of Model Healthy

Villages

Component B. Improved Village Infrastructure for

Primary Health Care Delivery

Component C. Strengthened Capacity of

Districts and Health Centers

to Support Model Healthy

Villages

Component D. Project

Management and Implementation

Support

Total (Input) Percent

1. Civil Works 0 720,000 40,000 0 760,000 252. Equipment and Supplies 348,000 0 65,000 15,000 428,000 143. Training, workshops, seminars, public campaigns 605,973 0 220,000 36,000 861,973 294. Consulting Services 0 0 135,000 375,400 510,400 175. Grant Management 0 4,550 91,250 71,100 166,900 66. Other Inputs 0 0 0 0 0 07. Contingencies (0%–10% of total estimated grant fund) Use of Contingencies requires prior approval from ADB 95,397 72,455 55,125 49,750 272,727 9

Subtotal JFPR Grant Financed 1,049,370 797,005 606,375 547,250 3,000,000 100Government Contribution 0 114,000 8,600 69,000 191,600 6Other Donor(s) Contributions (e.g. from NGOs, multi-and bilateral aid agencies) 0 0 0 0 0 0

Community's Contributions (mostly in kind) 50,523 90,000 5,000 0 145,523 4Total Estimated Costs 1,099,893 1,001,005 619,975 616,250 3,337,123Incremental Costs 50,000NGO = nongovernment organization.

Inputs / Expenditure category

Grant Components

Inputs / Expenditure category

Grant Components

Appendix 3 25

Appendix 4

26

FUND FLOW CHART

ADB = Asian Development Bank, PHCCU = primary health care coordination unit.

ADB

Ministry of Health

Imprest account at Bank of Lao People’s Democratic Republic

PHCCUs (2)

Second-generation imprest accounts

(maximum $75,000 each)

Output A: Village capacity for participatory planning and management of model healthy villages is strengthened.

Output B: Village infrastructure for primary health care delivery is improved.

Output C: Capacity of districts and health centers to support model healthy villages is strengthened.

Replenishment advance approved by Executing

Agency

Liquidation of advance prepared and submitted by PHCCUs, and approved by Executing Agency

Request for replenishment and liquidation prepared and submitted

by Executing Agency

Deposit of advance or replenishment

Output D: Project management and implementation is supported.

Appendix 5

27

IMPLEMENTATION ARRANGEMENTS 1. Executing Agency. The Department of Planning and Finance in the Ministry of Health will be the Project’s Executing Agency. It will oversee project activities; facilitate coordination with provinces, district and village authorities, and other projects; and endorse grants and annual work plans. The ministry will appoint a Japan Fund for Poverty Reduction (JFPR) project director to facilitate coordination with and among national, provincial, and district departments. 2. Steering Committee. The Ministry of Health steering committee, chaired by the minister of health, and including vice ministers, department directors, and cabinet members, will provide overall implementation guidance, approve overall and annual work and financial plans, and monitor implementation progress. 3. Implementing Agencies. The provincial health offices in Houaphan and Xiangkhouang provinces will be the implementing agencies. Within these offices, primary health care coordination units—which have responsibility for primary health care provision—will be responsible for day-to-day coordination and supervision of project implementation. 4. At the district level, district health offices will oversee the Project, monitor progress, review quality of the work, coordinate health initiatives with primary health care coordination units and local communities, and report on progress to primary health care coordination units. The target beneficiaries will implement activities at the village level. To facilitate this, the Project will work through selected village health committees (VHCs) as the primary interface among the primary health care coordination units, district, and community in terms of participatory activity planning, decision making, and collaborative management and monitoring. The Project will support the formation, capacity building, and training of the VHCs and various interest groups to enable them to make informed, logical choices concerning healthy village options. Equitable representation from all gender and ethnic groups will be actively encouraged. 5. Financial Arrangements. JFPR funds will be managed and disbursed in accordance with Asian Development Bank (ADB) guidelines. ADB will channel JFPR funds directly to a special JFPR imprest account that will be opened and maintained by the Ministry of Health. Each of the two primary health care coordination units will open a second-generation imprest account (SGIA). Financial transaction forms will be submitted from the provincial accounts via the Ministry of Health to ADB. The flow, replenishment, and management arrangements of the JFPR funds will be detailed in the JFPR Letter of Agreement to be signed by the Government of the Lao People’s Democratic Republic and ADB. The primary health care coordination units, in consultation with the participating district health offices and villages, will draft a 6-month inception plan during which they will prepare project administration and financial plans for the project duration. Physical and financial reports will be consolidated and prepared quarterly. 6. The imprest accounts will be managed, replenished, and liquidated in accordance with ADB’s Loan Disbursement Handbook (2007, as amended from time to time). The advance to the Ministry of Health imprest account will be based on 6-month estimated expenditures to be financed from the imprest account, or 10% of the JFPR grant, whichever is lower. The advance to each of the primary health care coordination unit SGIAs will be based on 6-month estimated expenditures to be financed from the imprest accounts, or $75,000, whichever is lower, with specific reference to the annual work plans and budgets approved by the Ministry of Health. The statement of expenditure procedure may be used for the imprest accounts (including SGIAs), and is applicable only to small payments and contracts below $30,000. Both the Executing Agency and primary health care coordination units have used similar arrangements for two

Appendix 5

28

ADB-financed projects (Primary Health Care Expansion Project and Health System Development Project)1 and are assessed to have adequate capacity to use imprest account and statement of expenditure procedures. The use of statements of expenditure will be audited by auditors acceptable to ADB, and external audits will be conducted on an annual basis. The audit report should provide a separate opinion on the use of imprest accounts and statement of expenditure procedures and should be submitted not more than 6 months following the end of the fiscal year or project closing date, whichever is first. The report should include certified copies of the audited accounts and financial statements and the report of the auditors relating to said statements, including the auditors’ opinion on the use of the JFPR funds. Audit reports will be submitted to ADB, the Executing Agency, and Ministry of Finance. 7. Interest earned on the JFPR imprest account can be used for the Project, subject to ADB’s approval, within the approved total amount of JFPR. Upon completion of the Project and before closing the JFPR imprest account, any unutilized interest should be returned to the JFPR account maintained at ADB. If the remittance fee and other bank charges are higher than the amount of interest earned, there will be no need to return such interest to the JFPR account maintained by ADB. 8. Consulting Services. All consultants will be recruited on an individual basis. ADB, in consultation with the Ministry of Health, will recruit international consultants in accordance with ADB’s Guidelines on the Use of Consultants (2007, as amended from time to time). The Ministry of Health will recruit national consultants also in accordance with ADB’s Guidelines on the Use of Consultants. A total of 401 person-months 2 of consulting services (6 person-months, international; and 395 person-months, national) will be provided. 9. Procurement. All goods and civil works will be procured in accordance with ADB’s Procurement Guidelines (2007, as amended from time to time). National competitive bidding (NCB) and Shopping will be the procurement methods to be used. Goods and civil works equivalent to or below $100,000 will be procured using ADB’s shopping procedure, and those above $100,000 will be procured using ADB’s national competitive bidding procedure. No international competitive bidding is envisaged under the Project. The assets procured under this Project will be handed over to the Executing Agency upon project completion.

1 ADB. 2000. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to Lao

PDR for Primary Health Care Expansion Project. Manila; ADB. 2007. Report and Recommendation of the President to Board of Directors on a Proposed Grant to Lao PDR for Health System Development Project. Manila.

2 This includes 300 person-months of national consultants for district facilitators in the 10 target districts and 48 person-months for two provincial financial specialists.

Appendix 5

29

PROJECT ORGANIZATION STRUCTURE

Ministry of Finance Ministry of Health (Steering Committee)

Other Ministries

Other Departments Department of Planning and

Financing

Department of Organization and

Personnel

Provincial Health Offices Primary Health Care Coordination Units

District Health Offices District Committee for Health

Health Centers

Villages Village Health Committees

Appendix 6

30

SUMMARY POVERTY REDUCTION AND SOCIAL STRATEGY

Country/Project Title: Developing Model Healthy Villages in Northern Lao People’s Democratic Republic Lending/Financing Modality: Japan Fund for Poverty Reduction (JFPR) grant Department/

Division: SERD/SESS

I. POVERTY ANALYSIS AND STRATEGY

A. Links to the National Poverty Reduction Strategy and Country Partnership Strategy The Lao National Growth and Poverty Eradication Strategy1 outlines the Government’s commitment to improving health and sanitation services as key to reducing poverty. The strategy’s operational framework comprises four main sectors: agriculture, education, health, and infrastructure. In the health sector, priorities include strengthening and improving the quality of health care at the grassroots level, particularly in underserved areas and for vulnerable groups including women, children, and ethnic groups. The strategy has been integrated in the Sixth National Socio-Economic Development Plan (2006–2010),2 which aims to grow the economy 7.5%–8.0% annually; reach $700–$750 gross domestic product per capita; create about 652,000 productive jobs; and reduce the number of poor households to 15% of the population. Furthermore, one of its objectives is to strengthen the positive links between economic growth and social development in addressing social issues such as poverty. The plan’s indicators and targets coincide with most of the Millennium Development Goals (MDGs). The goals for the health sector are to (i) develop a nationwide health delivery service that is fair and equal according to gender, age, social rank, tradition, religion, ethnicity, and geographic location; (ii) provide basic health services that respond to the peoples’ needs and expectations and that gain peoples’ trust; and (iii) achieve substantial improvement in peoples’ health status, especially of the poor. To do so, the plan aims to (i) reduce the incidence of diseases including communicable diseases such as dengue fever, diarrhea, leprosy, malaria, and tuberculosis; (ii) reduce maternal and child mortality rates; and (iii) provide health care services and enable people to access high-quality medical services. ADB’s new country strategy and program for the Lao People’s Democratic Republic (Lao PDR) (2007–2011)3 is anchored in and closely aligned to the Sixth National Socio-Economic Development Plan. A results-based strategy, it focuses on sustainable economic growth, accelerating progress in non-income MDGs, building capacity for good governance, promoting regional cooperation and integration as an engine of progress, and fostering national development through the country’s own strategy and plans. ADB is committed to supporting initiatives to improve the delivery and management of health and sanitation services in a sustainable manner. In line with ADB and government strategies, the Project seeks to improve the health status of the target population living in remote areas, with a particular focus on women and ethnic groups through human resources development and provision of primary health care services. B. Poverty Analysis Targeting Classification: TI-MDG Key Issues. Lao PDR is one of the poorest countries in the region. The per capita gross domestic product is $490, and one third of the population is poor. A small domestic market, the subsistence nature of the rural economy, skills shortages, and the remoteness and isolation of much of the population are constraining growth and poverty reduction. However, the economy has grown and diversified in the last 5 years, based on the country’s natural resource base for hydropower, mining, and tourism; and the poverty incidence was reduced from 46% to 33% between 1992 and 2003. The health sector plays a major role in poverty reduction due to the high burden of diseases, its major impact on productivity, a high level of poverty requiring government intervention to make services available and affordable, and income erosion due to poor quality of care. Health is a key factor in achieving sustained economic growth, poverty reduction, and gender equality. The poor suffer from high rates of infant and maternal mortality, lower access to health and education services, higher illiteracy, lower access to electricity and clean water, and less involvement in the market economy. Improved health reduces income losses and expenditures due to illness or disease, and indirectly protects the labor force and production of food and cash crops. In education, children with good health and nutrition learn faster and miss school less frequently due to illness. Design Features. The Government is committed to poverty reduction and achieving the MDGs, and, as per the Sixth National Socio-Economic Development Plan, has identified the health sector as one of four priority sectors. The Project aims to improve health status of the target population living in remote areas with a particular focus on vulnerable groups (children, ethnic groups, and women) through delivery of comprehensive primary health care services. The Project will work directly with individual households, villages, health centers, and district and provincial health offices to develop model healthy villages and to ensure that people practice basic hygiene principles of having safe water, eating well-cooked food, and maintaining clean housing. The Project is expected to contribute to reduced infant and maternal mortality rates and the achievement of the MDG goals for Lao PDR. The Project primarily targets the rural poor, women, children, and ethnic groups suffering from high levels of mortality and morbidity, and resulting lagging MDGs. Targeting them with highly cost-effective interventions through developing model healthy villages will result in immediate impacts on key indicators, and assist Lao PDR in achieving its MDGs.

1 Government of Lao PDR. 2004. Lao PDR: National Growth and Poverty Eradication Strategy (NGPES). Vientiane. 2 Committee for Planning and Investment, Lao PDR. 2006. The Sixth National Socio-Economic Development Plan,

2006–2010. Vientiane. 3 ADB. 2006. Country Strategy and Program: Lao People's Democratic Republic (2007–2011). Manila.

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31

The Project supports the Health Strategy Up to the Year 20204 and its objectives of ensuring full health care service coverage, justice, and equity to increase the quality of life of all Lao ethnic groups. It contributes directly to poverty reduction with its focus on improving primary health care. The Project will work through prevention; priority is given to primary health care with emphasis on high-risk groups; child immunization; recommendations on the use of safe and sanitized water; management and the control of transmittable diseases such as dengue fever, diarrhea, malaria, and tuberculosis. The Project will have a direct impact on the health and living conditions of the target villages, and residents will benefit from improved health, savings in health care costs, and ultimately income benefits from expanded access to clean water and sanitation services. Water supply and sanitation will particularly benefit women by reducing the time and money spent on purchasing, collecting, treating, and storing water; and improving hygiene and health of families and communities; and reducing health care expenditure. An increased role for the poor, women, and ethnic groups in local planning, consultation, and decision making will be achieved through representation on village health committees, located within existing village development committees.

II. SOCIAL ANALYSIS AND STRATEGY

A. Findings of Social Analysis Lao PDR lags behind on several non-income MDGs—life expectancy at birth is low (61 years), child malnutrition is high (30%), and infant mortality (60 per 1,000 live births) and maternal mortality rates (350 per 100,000 live births) are very high compared with other countries in the region. One third of the adult population, and nearly half of all females, cannot read or write, and just 14% of the population has completed primary schooling. Lao PDR is also lagging behind on the MDG water and sanitation targets. The impacts of the lack of health and sanitation services are significant, and water-related diseases are significant contributors to poor health status, lost work and school time, high expenditures on medicines and health care, increased workload for women, and poverty entrenchment. Diarrhea continues to be the second-biggest killer of children and the third-biggest killer of adults in the country. Malaria is the number one cause of mortality overall, with 70% of the population at risk. As it will not be cost effective to expand the network of health centers to remote areas, the strategy will be to bring basic services to the village level through (i) making health information available by training villagers and providing adapted education materials; (ii) offering basic care in the village through village health volunteers (VHVs) and drug kits; and (iii) providing access to more technical services (e.g., first birth-spacing visits, pre- and postnatal visits, consultations, immunizations, and bed net impregnation) through regular visits of district teams. Any possible cultural barriers for the provision of health education will be addressed through adapting education materials to local needs. Cultural barriers to access basic services will be addressed through the training of VHVs and the provision of drug kits in the village. Furthermore, the selection of at least one woman as a VHV will be emphasized in each village. The Project will target poor villages where villagers have a low capacity to pay and where physical access to care represents significant direct and indirect costs. Making services available at the village level decreases the cost of services and thereby increases access. B. Consultation and Participation Consultation and Participation Process during Project Preparation. The Project was designed following a participatory approach and involved consultations with provincial, district, and village officials; village residents; and key informants at the national, provincial, and district levels. Activities included (i) reconnaissance visits to villages to consult district and village officials about the Project and to conduct informal interviews with villagers; (ii) meetings to inform local officials and residents about project policies and procedures; (iii) meetings with various representatives, the Ministry of Health, and other donors and organizations involved in the health sector; and (iv) workshops with national and provincial stakeholders to review design issues. What level of consultation and participation (C&P) is envisaged during the project implementation and monitoring?

Information sharing Consultation Collaborative decision making Empowerment Was a C&P plan prepared? Yes No During implementation, a field guide will be prepared to detail the implementation arrangements and use of participatory methods. The Project promotes participatory and consultative processes for all residents including women, ethnic groups, and poor households, and seeks to maximize community participation and ownership by transferring control for decisions and actions to communities. It aims to achieve (i) improved community representation in village development; (ii) community capacity to organize themselves for local improvements and plan, design, operate, supervise, and maintain local infrastructure in partnership with local authorities and agencies; and (iii) improved knowledge and awareness of village residents in basic health, hygiene, and sanitation. Efforts will be made to link project-related hygiene and clean environment activities to larger campaigns with schools. Funding and technical assistance will be provided for communities to improve village and household health and sanitation facilities and to undertake priority small-scale community improvements.

4 Ministry of Health, Lao PDR. 2000. Health Strategy Up to the Year 2020. Vientiane.

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32

A participation strategy will be incorporated into the overall project design. Villagers, especially women, will participate in the strengthening of village health committees. Community participation will be an essential activity to define a model healthy village and to plan health activities accordingly.

C. Gender and Development Key Issues. Promoting gender equality is an important national goal as reflected in the 1991 Constitution, Lao National Growth and Poverty Eradication Strategy, Sixth National Socio-Economic Development Plan, and several of the country’s international commitments. The Lao National Commission for the Advancement of Women was established in 1991 to help ensure women’s equal access to basic services and productive resources. It is responsible for implementing national strategies and reports directly to the Government, while the Lao Women’s Union helps with implementation on the ground. However, women in Lao PDR remain more vulnerable and deprived than men because of their unequal access to land, food, education, health care, and their long working hours. While gender roles vary within rural communities, women from ethnic groups tend to be the most disadvantaged. Compared with men, women have far lower average literacy, enrollment, and completion rates, and education gaps widen at higher levels of schooling. In 2004, girls were 30% less likely to participate in upper-secondary education and 40% less likely to participate in tertiary education than boys. Although women own and operate most registered small businesses, they have limited access to market information, technical training, and financial services. Women are key beneficiaries from investments in health and sanitation as they are primarily responsible for taking care of daily household needs and family health. Women spend up to 2 hours per day collecting water, and have most responsibility for water and sanitation domestic duties such as cooking, cleaning, and taking care of dependents, in addition to their income-generating activities. Key Actions. Measures included in the design to promote gender equality and women’s empowerment (access to and use of relevant services, resources, assets, or opportunities and participation in decision-making process):

Gender plan Other actions/measures No action/measure

The Project will emphasize the needs of women, particularly reproductive health and access to health services. The following will be made available to women:

(i) Access to birth-spacing services (oral contraceptives to be available from VHVs with drug kits). (ii) Access to pre- and postnatal care (through establishment of district hospital mobile teams). (iii) Access to traditional birth attendants (training of VHVs and skilled birth attendants in health centers and district

hospitals). (iv) Early recognition of complicated deliveries and transport to adapted health facilities (to be linked with activities such as

training of VHVs and traditional birth attendants). (v) Immunization of women (at health centers and through district teams).

One of the Project’s main goals is to improve the health conditions of women by making various health-related services available in a gender-sensitive manner. Activities will be further designed and implemented in a participatory manner.

III. SOCIAL SAFEGUARD ISSUES AND OTHER SOCIAL RISKS

Issue

Significant/ Limited/No

Impact Strategy to Address Issue

Plan or Other Measures Included in

Design Involuntary Resettlement

No impacts expected.

A resettlement framework has been prepared to address any impacts that may arise from small-scale investments. Limited, if any, impacts are expected.

Full Plan Short Plan Resettlement

Framework No Action Uncertain

Indigenous Peoples Significant impact

The Project includes several strategies to ensure that small ethnic groups will also benefit, including targeted inclusion of these groups in village planning to increase their capacity and knowledge about common diseases and health care; participatory tools for mobilization and planning to ensure participation of all groups; and inclusion of women and poor and vulnerable groups in all stages of project implementation as criteria for qualifying for the second round of funding for village infrastructure, thus encouraging communities to involve all subgroups in health activities.

All district and health center staff members will be trained in gender and participatory development, including consideration of ethnic groups. In addition, a national gender and social development consultant will

Plan Other Action Indigenous

Peoples Framework

No Action Uncertain

Appendix 6

33

be engaged for 6 person-months to support the Project. Labor

Employment Opportunities

Labor Retrenchment Core Labor Standards

No impact The Project is not expected to impact labor policy, labor law, or broader labor issues adversely. It will lead to better-skilled health staff at the provincial, district, and village levels. Interventions will strengthen district and health center staff capacity to manage and support the development of model healthy villages.

Plan Other Action No Action Uncertain

Affordability No impact The Project provides targeted support to the poor and ethnic groups, particularly women and children, to expand access to health services.

Action No Action Uncertain

IV. MONITORING AND EVALUATION

Are social indicators included in the design and monitoring framework to facilitate monitoring of social development activities and/or social impacts during project implementation? Yes No