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1 Public Disclosure Authorized LATIN AMERICA AND CARIBBEAN Peru Social Protection & Labor Global Practice IBRD/IDA Specific Investment Loan FY 2011 Seq No: 8 ARCHIVED on 10-Oct-2015 ISR20075 Implementing Agencies: Ministry of Economy and Finance Public Disclosure Authorized Key Dates Key Project Dates Board Approval date:08-mar-2011 Planned Mid Term Review Date:15-Apr-2015 Original Closing Date:31-Mar-2016 Project Development Objectives Effectiveness Date:12-Jan-2012 Actual Mid-Term Review Date:07-Apr-2015 Revised Closing Date:31-Mar-2016 Public Disclosure Authorized Project Development Objective (from Project Appraisal Document) The proposed operation has been designed to support the demand, supply, and governance of nutrition services provided by the Government of Peru (GoP), organized under the Articulated Nutrition Program (PAN). The objectives of the proposed operation are to: (i) increase demand for nutrition services by strengthening the operational effectiveness of the Juntos Conditional Cash Transfer (CCT) program; and (ii) improve coverage and quality of the supply of basic preventive health and nutrition services in the communities covered under the PAN including Juntos. Activities to support both objectives include a strong emphasis in promoting good governance to monitor the impact of the Government Programs and of the proposed intervention in nutrition outcomes. Has the Project Development Objective been changed since Board Approval of the Project Objective? No PHRPDODEL Components Public Disclosure Authorized Name Component 1: Strengthening and consolidating of the Juntos CCT program for families with children under 36 months.:(cost $5.50 M) Component 2: Improving coverage and quality of the provision of basic preventive health and nutrition services in the Juntos areas.:(cost $5.50 M) Component 3: Strengthen the GoP's capacity to influence nutritional outcomes by improving budgetary planning and monitoring of resul ts for selected activities of the PAN.:(Cost $14.00 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory 10/10/2015 Page 1 of 9

2 Overall Risk Rating Moderate Moderate Implementation Status and Key Decisions Overall, the team considers that the contributions of this intervention have been of significant relevance to the client. This is mainly due to three factors: (a) a positive contribution to the national strategy to fight against chronic malnutrition thanks to teh alignment with the policy objectives of the Early Childhood Development strategy, an aspect that has been recognized by the Government; (b) positive externalities derived from the implementation of activities supported by the Project such as the use of social monitoring to articulate different levels of government in following nutritional indicators, and the establishment of the Nominal Census of Children ("Padron Nominado") as a planning instrument at the local level, providing real-time information to MINSA and MEF; and (c) an improvement in access to basic services and enrollment of children to SIS in two out of three regions covered by the Project: Cajamarca and Huanuco, which led to an increase in the number of CRED checkups. Nevertheless, the Amazonas region still poses an important challenge given the very specific conditions to operate in this territory. The MTR field mission corroborated that the Project s PDO relevance is still strong in the public agenda. Senior authorities of key entities in the achievement of PAN s objectives and goals, including the Ministry of Health (MINSA), the Ministry of Inclusion and Development (MIDIS,) and the Ministry of Finance (MEF) stressed their commitment to sustain Peru s remarkable achievements in the reduction of Children Chronic Malnutrition (CCM). On the other hand, the field mission and the assessment of data revealed the persistence of considerable gaps in the coverage and quality of the supply of basic preventive health and nutrition services in general, but particularly critical in the poorest rural districts where Juntos operates. MINSA officials expressed their commitment to support the required actions to improve the implementation of component 2 of the project and ensure the availability of critical nutritional and health inputs. Similarly, MIDIS senior officials committed to streamlining Juntos procedures to ensure the Program s early affiliation of newborns (younger than 30 days), and verification of health co-responsibilities of children younger than 36 months as a means of increasing the demand of nutritional services in Juntos districts. One of the most successful activities supporting the PDOs is the strengthening of the GoP s capacity to influence nutrition outcomes by improving budgetary planning and monitoring of results. Furthermore, there is an important political willingness to narrow the gaps in the regional variation of nutrition outcomes by implementing differentiated strategies based on the use of intercultural and territorial approaches with a strong focus on the lowlands (La Selva). 10/10/2015 Page 2 of 9

3 Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Low Moderate Macroeconomic -- Low Low Sector Strategies and Policies -- Moderate Moderate Technical Design of Project or Program -- Moderate Moderate Institutional Capacity for Implementation and Sustainability -- Substantial Moderate Fiduciary -- Moderate Substantial Environment and Social -- Low Low Stakeholders -- Low Low Other Overall -- Moderate Moderate Results Project Development Objective Indicators PHINDPDOTBL % of Juntos Children under 12 months that have received the complete CRED scheme according to their age in the areas of intervention of the Juntos CCT Program targeted by this operation. (Percentage, Custom) Value Date 31-Dec Dec Jun Mar /10/2015 Page 3 of 9

4 There was an important progress in this indicator, which reached 78.7% of coverage by June 2015 after major setbacks between 2012 (67.9%) and December 2014 (60.7%). Past difficulties were related to changes in the affiliation procedures of SIS which were overcome thanks to efforts of the Juntos program and SIS to promote early affiliation. PHINDPDOTBL % of Children under 36 months that have received complete CRED scheme according to their age in the areas of intervention (Percentage, Custom) Value Date 31-Dec Dec Jun Mar-2016 Current value (June 2015) is an estimation based on the information provided by INEI on CRED coverage of children under 36 months in the three regions, along with INEI s projection on number of children under 36 months old in 2015 in the same territories (unofficial data). Overall The first PDO indicator (% of Juntos Children under 12 months that have received the complete CRED scheme according to their age in the areas of intervention of Juntos) measures the degree of success of the Juntos CCT Program in strengthening the demand of registered households for the timely access of their children to CRED in the areas targeted by the operation (demand-side indicator). CRED checkups encompass a package of prioritized interventions including regular height and weight check-ups, counseling to mothers on feeding and caring practices, provision of iron supplementation, immunizations, etc. The second PDO indicator (% of Children under 36 months that have received complete CRED check ups according to their age in the areas of intervention) measures the overall coverage of health and nutrition services through the provision of CRED in the same targeted areas (supply-side indicator). The evolution of both PDO indicators since 2011 shows current values (June 2015) above their respective baselines. Nevertheless, during 2014, PDO indicators suffered an important setback due to some factors external to the project. A critical factor was the severe social unrest linked to mining conflicts that affected Cajamarca, which is, by far, the largest of the three target regions of the project. From 2012 to 2014 that region experienced strikes, blockades and curfews that paralyzed the provision of transport and public services. Cajamarca s results dragged down the average indicators of the two PDOs. This situation has been normalized in 2015 and PDO indicator 2 showed an important improvement in the region from 66.9% in December 2014 to 70% in June Other external factors were: changes introduced in the 2011 Budget Law established more stringent requisites to enroll in SIS and Juntos programs, such as the possession of the National Identity Document (DNI) and the eligibility certificate of the Household Targeting System (SISFOH). The coverage of the population with DNI is still suboptimal in rural areas, particularly in the Selva regions; and SISFOH uncovered delays and exclusion errors in the identification of eligible households in areas of difficult access. Therefore, by December 2014, PDO indicators dropped due to the impact of this change in the legal framework. This situation was corrected by the establishment of the early affiliation strategy for children younger than 30 days, who are no longer required to prove registration to SISFOH or to present the National ID (a livebirth certificate provided by the health center suffice) to be affiliated to SIS. Hence, by June 2015 a recovery in PDO indicators is visible (by December 2014, the first PDO was at 60.7% while in June 2015 it reached 78.7%). Nevertheless, it is important to highlight that some of these elements may still imply a risk for the achievement of PDO end targets in the future. For instance, the frequent turnover of Juntos management that has prevailed in the past three years may continue to affect the overall performance of the program, hence reducing its role as an incentive in strengthening the demand for the timely access of its beneficiary households to CRED checkups and services. Finally, the Project has achieved important progress in Intermediate Results Indicators, especially in the percentage of Juntos beneficiaries below 24 months old registered in the information system with birth certificate, CUI, SIS affiliation, that moved from 18 percent to 77 percent; Juntos children registered at its information system before 30 days (more than 22 percentage points of improvement); health facilities attended through the administrative management system - SIGA (that already met the target of 100 percent); and number of districts in the first quintile with Social Forums based on the social monitoring, that increased to 72 percent, very close to the end-target of 75 percent. Thanks to these elements, and especially considering the important contributions made by the Project through the establishment of the Padron Nominado as an important tool for planning in the field and the expansion of the social monitoring, the Project is still considered by the Government as a key component for 10/10/2015 Page 4 of 9

5 successful implementation of the national CCD and ECD policies. Intermediate Results Indicators Percentage of Juntos beneficiary children under 24 months registered in the Juntos information system (SITC) with birth certificate, identity document or CUI, and SIS affiliation. (Percentage, Custom) Value Date 31-Dec Dec Dec Mar-2016 Percentage of children born each year in Juntos households and registered in the SITC before 30 days. (Percentage, Custom) Value Date 31-Dec Dec Dec Mar-2016 Percentage of Children younger than 36 months affiliated to SIS and with complete and timely CRED scheme in the areas of intervention of Juntos in Amazonas, Cajamarca and Huánuco. (Percentage, Custom) Value Date 31-Dec Dec Dec Mar-2016 Percentage of mothers in Juntos families, with children under 24 months, who have assisted at least to one demonstrative session in Amazonas, Cajamarca and Huánuco. (Percentage, Custom) Value Date Dec Mar-2016 Thanks to the project, the 2014 Demographic Health Survey ENDES survey started monitoring this indicator in Peru for the first time. Baseline value is 0 because there was no collection of this information before the Project. 10/10/2015 Page 5 of 9

6 Percentage of health facilities with basic equipment to give CRED and vaccines in Juntos districts (Percentage, Custom) Value Date 31-Dec Dec Dec Mar-2016 Baseline is 0 because this data was collected for the first time as part of the project. None of the health facilities visited by ENCRED pollsters complied with the threshold of minimum requirements of critical inputs. This finding is a strong warning on the necessity to measure not only the services coverage but also the minimum quality standards to have positive effects on the nutritional status of children. Percentage of health facilities with updated and complete asset information in SIGA (Percentage, Custom) Value Date 31-Dec Dec Dec Mar-2016 Number of districts in the first quintile where there have been discussion forums about CRED coverage and vaccines (social monitoring) and are registered on MEF s web page (Number, Custom) Value Date Dec Dec Mar-2016 Baseline is 0 because this data was collected for the first time as part of the project. None of the health facilities visited by ENCRED pollsters complied with the threshold of minimum requirements of critical inputs. This finding is a strong warning on the necessity to measure not only the services coverage but also the minimum quality standards to have positive effects on the nutritional status of children. 10/10/2015 Page 6 of 9

7 Percentage of health micro-networks annually verified because they meet the certification criteria in Amazonas, Cajamarca and Huánuco (Percentage, Custom) Value Date May May Mar-2016 Baseline is 0 because this data was first collected by the Project. The Project supported the creation of the ENCRED survey which is verifying the capacity of health micro-networks. A health micro-network meets the certification criteria when it meets at least 60 percent of the defined conditions. The Ministry of Health is revising the criteria focusing on inputs and procedures that are critical to meeting the necessary standards to achieve the nutrition objectives of the Project. Number of newborns registered in SIS before 30 days in Juntos districts in the areas of intervention of the operation. (Number, Custom) Value Date 31-Dec Sep Dec Mar-2016 The dramatic drop of newborns registered in SIS after 2011 is explained by the new affiliation criteria of the program (the child must have a DNI and having passed through the targeting system). However, 2014 data shows a recovery of the affiliation trend due to recent changes through the early affiliation strategy (among which the automatic inclusion of indigenous communities in the household targeting system SISFOH and the usage of live-birth certificate instead of DNI to register the newborns). It is expected that the target of 15,000 newborns could be reached by Overall Data on Financial Performance 10/10/2015 Page 7 of 9

8 Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P IBRD Effective USD % Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P IBRD Effective 08-Mar Jul Jan Mar Mar-2016 Cumulative Disbursements Restructuring History Level 2 Approved on 10-Jul-2013,Level 2 Approved on 26-Feb-2014,Level 2 Approved on 26-Nov-2014 Related Project(s) 10/10/2015 Page 8 of 9

9 There are no related projects. 10/10/2015 Page 9 of 9