PROJECT INFORMATION DOCUMENT (PID)
APPRAISAL STAGE
Report No.: 68397
Project Name
/ Household Development Agent PilotRegion / LATIN AMERICA AND CARIBBEAN
Sector / Other social services (50%); Health (35%);Pre-primary Education (15%)
Project ID / P121690
Borrower(s) / REPUBLIC OF HAITI
Implementing Agency / Economic and Social Assistance Fund (FAES)
Environment Category / [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined)
Date PID Prepared / October 26, 2010
Date of Appraisal Authorization / N/A
Date of Board Approval / N/A
1. Country and Sector Background
1. Haiti is the poorest country in Latin America and the Caribbean and among the poorest in the world. Over half of the 10 million population lives in absolute poverty (less than $1 per day) and 78 percent with less than $2 a day. Around 4.5 million are estimated to be destitute, most of which live in rural areas, with the rest living in the capital city and other urban areas[1]. Income inequality is among the highest in the Latin America and Caribbean, with a Gini coefficient of 0.65[2]. Poverty in Haiti is chronic and rooted in exposure to repeated shocks that threaten the survival of households. Since 2008, the country has faced a sharp rise in basic food and fuel prices, exceptionally bad weather conditions (four consecutive hurricanes in one year), a major decline in remittances and in international trade due to the global economic crisis, and the devastating earthquake in January 2010. Multidimensional poverty is far-reaching as evidenced by poor social indicators such as literacy, life expectancy, infant and maternal mortality and child malnutrition and Haiti was ranked 148 out of 179 in the United Nations Human Development Index in 2008[3]. Due to credit constraints and limited access to existing services, poor families in Haiti tend to under-invest in the health, nutrition, and education of their children, reducing their lifelong economic potential and human capital.
2. Education. Haiti is one of the countries with the lowest school enrollment rates in the world: 76 percent at primary level and 22 percent at secondary level, with only 23 percent for pre-school level. Around 400,000 children in Haiti did not attend school prior to the earthquake, equivalent to more than a quarter of all children 6-14 in the poorest income quintile. The literacy rate among adults and youth varies from 50 to 66 percent[4].
3. Health and Sanitation. Haiti has the highest rates of infant, under-five and maternal mortality in the Western hemisphere and only half of the population in Haiti has access to healthcare services. Under-five mortality rate was estimated at 76 per 1000 live births in 2007, twice the regional average, while the life expectancy of 60.7 years is 18 years short of the regional average. Diarrhea, respiratory infections, malaria, tuberculosis and HIV/AIDS are the leading causes of death. Limited access to other basic needs, including water and sanitation, are also extremely problematic: 40 percent of the population did not have access to drinking water, and 80 percent had no access to sanitation facilities[5].
4. Nutrition Security. Many of the nutrition problems result from the interplay of extreme poverty, the weak healthcare system, inadequate hygiene and sanitation, insufficient food supply, and poor feeding practices. Malnutrition rates in Haiti are among the worst in the region. Nearly one-third of all children under five suffer from stunted growth, three-quarters of children 6-24 months are anemic, almost 60 percent of school-aged children are iodine deficient, and one third of children are vitamin A deficient[6]. Haiti’s low levels of agricultural production and feeding practices have resulted in 60 percent of the population being undernourished. The lack of knowledge of proper feeding practices for young children and the influence of cultural norms in Haiti have led to an inadequate number of meals per day, average exclusive breastfeeding rates of only 40 percent, and an insufficient provision of nutritionally rich foods for growing children. Malnutrition takes a serious and irreversible toll, making children more susceptible to disease and death and compromising their cognitive and physical development, which results in low human capital and diminished lifetime earnings[7].
5. The 2010 Earthquake. The January 12, 2010 earthquake stripped the affected areas of Port-au-Prince, Leogane, and Jacmel of critical infrastructure, including schools, hospitals, housing, electricity, water, and telecommunications, and caused tremendous human loss. More than 300,000 people were killed; almost 300,000 injured and nearly 2 million people are homeless. Food insecurity has increased, the health and education system was further weakened and precarious health and sanitary conditions put children at further risk. Extensive migration to rural areas, resulting in a near doubling of household size in certain regions, is putting additional pressure on basic services and food availability in a context of already extreme poverty[8].
6. Decentralization and delivery of social services. The international community has been investing heavily in the social sectors for decades, however, results remain limited and many families do not have access to basic services. Service delivery in Haiti is very fragmented and the capacity of Government to deliver services in a decentralized manner is weak. There is the need for a coordinated and strategic integrated approach to bridge the gap in access and utilization of social services for the poor and most vulnerable. For more than 20 years, the Government and NGOs have used community agents to provide services for people living in very remote areas focusing predominantly on health service delivery, including HIV prevention and treatment but also social work, protection of women and children from violence and abuse and agricultural support. Community workers, because of their competencies, high number, and presence in a very large part of the country (both in the poorest rural and urban areas), constitute a huge asset with the potential to change the developmental landscape of Haiti. However, these efforts are far from being of the scale needed to cover the country.
7. The proposed Household Development Agent (HDA) pilot seeks to build on this experience with community workers, particularly in rural areas, and test, in partnership with UN agencies and NGOs[9], an innovative integrated delivery and accountability mechanism to provide selected social services directly to vulnerable families. Based on the implementation outcomes, the pilot is expected to be scaled up, both in terms of coverage and types of interventions provided, in order to progressively cover a larger array of social services. Partnering agencies will adapt their method of work, integrating the methodology and tools[10] developed through the HDA. The objective of the resulting national HDA program, as the cornerstone of a larger social protection strategy for the country, is to reduce the vulnerability of the family and increase their use of existing social services. To do so, the program will seek to improve the capacity of government, agencies and NGOs to deliver social services in a decentralized and coordinated manner, adopting a common operational strategy.
2. Objectives
8. The development objective of the HDA pilot is to test and learn lessons from a new mechanism (i) to improve family health and nutrition practices, and (ii) strengthen capacity to deliver social services directly to families in the pilot area[11]. To do so, the pilot will employ a three-pronged strategy: (i) provide nutrition and health related education to beneficiary families and improve their awareness of the availability of social programs and services; (ii) provide basic commodities and select services directly to the families; and (iii) strengthen management and monitoring of the access to social services to families.
9. The achievement of the development objective of the pilot will be measured by the following key performance indicators: (i) increase in percentage of children treated for diarrhea with oral rehydration salts (ORS); (ii) decrease in percentage of children 6-24 months with anemia; (iii) increase in percentage of children under one immunized for DPT3/Penta; and (iv) percentage of children who are weighed according to their age group. The objective to strengthen capacity to deliver social services is inherent to the achievements of the above and also directly measured by the intermediary indicators. The results framework for the proposed pilot is attached in Annex 1.
3. Rationale for Bank Involvement
10. Although the international community is investing heavily in security in Haiti and the UN Special Envoy (President Clinton) and the Minister of Planning are spearheading an effort to promote economic development, there is the need for an innovative, coordinated country-wide equivalent in human development. Recent analytical work on poverty, vulnerability, and nutrition conducted by the World Bank and UN agencies in Haiti has highlighted the lack of an operational strategy to reduce chronic malnutrition and enhance investment in human capital. The Government of Haiti, donors and NGOs are struggling to find systematic and effective ways to reach poor and vulnerable groups. The various reports underscore the proliferation of ad hoc approaches to reach those groups—most of them facility-based using schools, health clinics and health posts—and stressed the inefficiency, inadequacy and lack of evaluation of such approaches, which consistently fail to reach the poorest and most vulnerable households.
11. For the past decades the Government of Haiti, International Agencies and NGOs have trained and employed community agents, with an operating model of community outreach focusing the delivery of services around rally posts[12]. Home visits are limited to specific case management (such as tuberculosis and HIV/AIDS), and not part of core strategy for service delivery. Community workers in Haiti are therefore conceptually and effectively sectorial extension workers, responsible for an area of coverage, rather than for the welfare of a clearly identified group of families in a community, with the result that services have not been effectively reaching the most vulnerable and isolated families.
12. Furthermore, community agents in Haiti focus on a single sector, mainly health, with a small number of NGOs specialising in agriculture, food distribution projects or social work. The inefficiency of single-sector, rally-post based outreach strategy is increased by the absence of coordination between agencies engaged in either the same or different sectors within a community, resulting in uneven coverage (either duplication or no coverage).
13. The proposed pilot and ensuing program aims to respond to this fragmentation and exclusion of the poorest households by developing a network of HDAs who would work directly with families to provide information on health and nutrition practices and promote use of existing basic services to reduce their level of vulnerability. Many donors, including the UN agencies and an array of NGOs, have expressed interest in collaborating with the Bank on this initiative over the past year and see this coordinated effort as an opportunity to better meet the needs of families in Haiti. The role of the World Bank in leading the process of developing, implementing and evaluating, jointly with donors and NGOs, an operational strategy for a family and community intervention that could then be replicated country wide in Haiti is crucial for the success of the initiative[13].
14. The proposed pilot is in line with the 2009-2012 Country Assistance Strategy for Haiti and with World Bank Vulnerability Financing Facility Framework to mobilize resources to protect the poorest and help those that have been driven into extreme poverty as a consequence of the global economic crisis. Last, but not least, the pilot fully supports the Government’s post earthquake top priority to strengthen decentralized administration and authorities and reinforce service delivery in a decentralized manner as outlined in the Action Plan for Recovery and Development for Haiti, March 2010.
4. Description
15. To achieve the development objective, the proposed HDA pilot will support the following three components: (i) provision of social services to beneficiary families by HDAs under the supervision of social workers (SW); (ii) institutional strengthening in delivering social services to the poor; and (iii) project coordination, monitoring and evaluation. Activities will be implemented in four municipalities in the Central department and will cover 90,000 beneficiaries.
Component 1: Provision of Services to Families (US$ 1,062,850)
16. The objective of this component is to ensure provision of social services to families. To this end, this component will finance the payment of the HDAs and SWs and necessary supplies. The household development agent will be responsible for contractually agreed number of families in and will visit them regularly with the aim to improve information and awareness on health, nutrition and household hygiene and sanitation, provide a package of basic commodities and services and where possible refer families to other existing relevant social services and programs run by government, donors, NGOs or private sector. Certain basic commodities will be provided directly to families depending on their needs, such as micro nutrient powders, iron supplements and de-worming tablets in home visits or community gathering. Some of the commodities distributed to families by the HDA will be financed and procured by implementing partners (i.e. mosquito nets and vaccinations by UNICEF) while the HDAs will be responsible for the delivery and the proper use of the commodity. A memorandum of understanding will be signed with implementing partners on the provision and distribution of such commodities according to an agreed calendar. Additional supplies needed by HDA and SW, such as transportation and communication needs (mobile phones), training toolkits and a modular practical training itself which include the basic tools to assess family needs, office supplies, monitoring cards and behavior change education materials (posters, pictures) will be financed by this component. NGOs with extensive experience with community agents will be contracted to manage the information and service provision, under the supervision of FAES and where no NGOs with relevant experience are identified FAES would directly execute the project.
17. The principal expected results to measure progress of this component include the number of HDA and SW trained in the new curriculum, the number of children 6-24 months receiving micronutrient powders, and the number of beneficiary families sleeping under long lasting insecticide treated bed nets.
Component 2: Institutional strengthening for delivery of social services to families (US$67,950)
18. Funds for this component will be used to strengthen institutional capacity at all government levels, including central, departmental, municipal, and community, to better organize, manage, and deliver services to families. To achieve this, the pilot would finance the following; (a) development of a platform and tools for sharing information on the inventory of social services and programs among key stakeholders in the pilot area; (b) the organization of workshops at the community, municipality and department levels to identify strategies for strengthening service provision, coordination capacity of government, donors and NGOs to prevent gaps in services, and community cohesion and participation at local level; and (c) the strengthening of central coordination and support capacity to provide overall guidance for the HDA initiative and enhance government capacity to provide services to the vulnerable. During the implementation of the pilot, a multisectoral Steering Committee chaired by the Minister of Finance which includes decision-makers from key line ministries and representatives of United Nations agencies, the World Bank and NGOs will be established to provide strategic guidance to the HDA initiative. Prior to the scale-up of the pilot into the national HDA program, a centralized social protection unit will be created, under a multi-sectorial minister, responsible for tracking social initiatives, providing guidance, developing standards and policies, providing technical support, and monitoring and evaluating to social initiatives in Haiti. This unit will gradually replace the steering committee.