The World Bank Honduras Improving Access and Governance in Health (P176532) Concept Environmental and Social Review Summary Concept Stage (ESRS Concept Stage) Public Disclosure Date Prepared/Updated: 06/28/2021 | Report No: ESRSC02148 Jun 28, 2021 Page 1 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Honduras LATIN AMERICA AND P176532 CARIBBEAN Project Name Honduras Improving Access and Governance in Health Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 9/3/2021 10/28/2021 Population Financing Borrower(s) Implementing Agency(ies) Republic of Honduras Ministry of Health (Secretaria de Salud Honduras) Public Disclosure Proposed Development Objective To improve the delivery of primary health care services in selected geographical areas and strengthen public health systems for emergency preparedness. Financing (in USD Million) Amount Total Project Cost 55.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The project will support the delivery of essential health and nutrition services and health sector governance in Honduras through improved: (i) access to, quality, and utilization of maternal and child health services, including through investments in integrated service delivery networks and infrastructure, equipment, and capacity of health staff to deliver essential services; (ii) surveillance and response capacity for health emergencies, such as those created by the COVID-19 pandemic and the recent Eta and Iota hurricanes; (iii) governance in the health sector through Jun 28, 2021 Page 2 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) support to maximize efficiency of spending through strategic purchasing and management of commodities, public financial management and planning that enables higher health budget execution for frontline services and Regional Health Directorates, and investments in information systems and their interoperability, among others. The project also includes a Contingent Emergency Response Component (CERC). D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The proposed project will finance activities to help strengthen essential adolescent, maternal, and child health services and to strengthen public health preparedness and response capacity. The provision of health services will be geographically targeted to prioritize regions with the highest burden and inequity in adolescent, maternal, and health indicators. The specific regions will be selected during project preparation in collaboration with the Ministry of Health and key partners. Honduras is the third poorest country in the Western Hemisphere, and faces various existing health sector challenges which have been exacerbated with by the COVID-19 pandemic. The effects of the COVID-19 pandemic have had a significant impact on national health response and services, which has been augmented with difficulties in deploying and establishing the national vaccination program. This critical health scenario is accentuated by the country’s accumulated vulnerabilities. Indigenous Peoples and Afro descendants, in particular, fare the worst both in terms of poverty and access to services and opportunities, including health. The 2013 Population Census shows that out of 8,303,773 habitants in Honduras, 717,620 people (8.64 percent) self-identify as indigenous and/or afro descendent populations. The nine Indigenous peoples are highly rural, with 82.9 percent of them (538,952 people) living in rural areas while 17.91 percent in urban settings (117,517). For those living in urban areas, Lenca Public Disclosure people are the most represented with 44,901 people; followed by Miskito population with 27,244, Garífuna with 22,144, and Maya Chortí with 10,891. While progress has been achieved in the reduction of maternal and child health mortality and morbidity, the epidemiological burden has now shifted towards non-communicable diseases such as cardiovascular disease, diabetes, cancer and pulmonary disease. The public health sector in Honduras has been investing in expanding coverage and services for primary health care, but coverage access varies across geographic regions and population groups, with age, income and education disparities in access to and quality of services. Density of human resources for healthcare was significantly lower than the regional LAC average in 2016: 3.1 doctors and 8.8 nurses per 10,000 population versus 21.7 doctors and 47.2 nurses per 10,000 population (World Development Indicators 2020). Hospital bed density is also low, with 7 beds per 10,000 population in 2014. Health and social challenges have accentuated as health services have experienced overburdened capacity, posing an immediate challenge to the sustainability and effective functioning of the health system. Regarding environmental characteristics, Honduras is exposed to extreme climatic events such as the two back to back tropical cyclones Eta and Iota at November of 2020, extensive droughts particularly in the region called the Dry Corridor (Corredor Seco), and periodic outbreaks of diseases such as dengue and chikungunya. Inhabitants in Honduras experience difficulty in accessing public services, such as health and education, partly due to the limited budgetary capacity of national institutions, which is more evident in rural regions. These threats occur in a social context with volatile indicators related to crime and violence (including GBV), uneven access to health services (particularly for the vulnerable) and the accumulated social pressures which have been exacerbated after more than Jun 28, 2021 Page 3 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) a year of pandemic-related restrictions. Project activities will be further refined during project preparation and thus the project location(s) and salient physical characteristics relevant to the E&S assessment. D. 2. Borrower’s Institutional Capacity The project will be implemented by the Ministry of Health (SESAL) of Honduras. SESAL is the leading institution in regard to health services and provision, and has a strong track-record of coordinating and implementing health programs with support from multiple actors. SESAL has been strained due to the effects of the COVID-19 pandemic, which remains an ongoing response challenge. Health coverage is limited and there are multiple challenges due to inequitable access to health, limited mobility and other factors augmented by the pandemic. Over the past year, SESAL’s teams have progressively adapted to manage the pandemic and the ongoing vaccination campaign together with the day-to-day management of its regular health services under difficult circumstances. This has included training its staff in multiple aspects of pandemic response, from using PPE to the use of specialized equipment. In addition to this, SESAL is the national coordinator of all vaccination-related activities in the country, led by the Expanded Program for Immunizations (EPI), which has a long track record of partnerships and engagements with international organizations such as the Pan American Health Organization (PAHO) and UNICEF and leads a successful immunization effort with internationally recognized results. Through the EPI program SESAL has subcontracted and partnered with a number of UN agencies and/or recognized nongovernmental organizations (NGOs) to implement project activities. Between 2020 and 2021, SESAL’s technical teams have strengthened their knowledge of environmental and social risk management and have become familiarized with the World Bank’s ESF and the ESF standards and its instruments. This knowledge has been developed through the update and preparation of instruments related to the WB Honduras Public Disclosure COVID-19 Emergency Response Project (P173861) and its Additional Financing (P176015) which have been already approved by the World Bank. In addition, during the past year SESAL has prepared other risk management instruments for projects with other organizations including the IDB and UNICEF. It is expected that, during preparation, SESAL will task the development of instruments to the same technical teams that have worked with the Bank in recent projects, which will remain the counterparts until all instruments are finalized. For the Project’s implementation SESAL will set up a Project Implementation Unit (PIU) that will be responsible for coordinating the implementation and enforcement of the environmental and social risk management instruments for the Projects. The PIU will coordinate the update, management and enforcement of the ESF instruments with key units within SESAL and external actors, including the GAVI Alliance and PAHO, who are expected to provide assessments and coordination support during project preparation and implementation. All relevant institutional and organizational assessments will be described in the E&S instruments. To implement these instruments, the PIU will include at least one environmental and one social specialist. The number of E&S specialists in the PIU as well as specific additional services of environmental, social, and Occupational Health and Safety consultant(s) will be determined before project appraisal, once the activates and project locations are defined. Training, capacity building, and additional support activities for SESAL technical teams will be provided during project preparation so that SESAL has a clear understanding of, and are capable of implementing, the various E&S risk management plans and instruments. In particular, strong capacity to carry out continuous stakeholder engagement will be key to managing perceptions, as well as to oversee implementation of measures for managing labor, community health and safety, and inclusion of IPs and ADs, and other vulnerable groups. SESAL will assign dedicated technical staff to prepare the draft ESF instruments with support from the Bank’s specialists. Jun 28, 2021 Page 4 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) II. SCREENING OF POTENTIAL ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate Environmental Risk Rating Moderate The environmental risk rating of the Project is Moderate, at this stage. The proposed activities to be carried out are aimed at strengthening the primary health care system, improving the quality of health services, increasing capacities and expanding coverage for children, adolescents and women in reproductive age. The proposed project will finance the delivery of quality essential health and nutrition services for adolescents, women and children amidst the COVID-19 pandemic; communication and social mobilization, including home visits by community representatives to increase the demand for vaccination service; development of training materials on Sexual and Reproductive Health and Rights (SRHR); training of non-health sector cadres to deliver messaging and education on SRHR; technical assistance and laboratories equipment; surveillance information systems; training for technical staff in epidemiology, and other related fields), and equipment, and office supplies. The proposed project will not finance major civil works or other activities that could affect the quality of the air, bodies of water, soils, vegetation or its associated fauna, in a relevant way, directly or indirectly. If minor civil works occur, these would be restricted to existing footprints and will be limited to minor renovations or adaptation of spaces to accommodate special equipment or other installations. The operation of health care centers, provision of medical services and provision of vector control awareness campaigns (such as prevention of zika and chikungunya) have environmental and occupational health risks derived from increased generation of medical care waste which may have biological risk Public Disclosure characteristics. These risks will be in situ and managed through the application and enforcement of existing specific OHS protocols for medical waste management and final disposal, and specific control measures, such as use of personal protective equipment (PPE) and training for the application of said protocols. In addition, the project might finance replacement of electronic equipment and acquisition of new equipment which will require specific mitigation measures to help manage e-waste and adoption of energy efficient equipment. SESAL will draft prior to project appraisal an Environmental and Social Management Framework (ESMF) which will reflect the specific applicable legislation and the required measures for the efficient management of risks and impacts in accordance with ESS1 and the mitigation hierarchy and in a manner appropriate to the scale and nature of activities. Given the current global situation caused by the COVID-19 pandemic, project activities associated with service delivery will include SESAL COVID19 prevention measures and protocols for health service delivery already in place. Social Risk Rating Moderate The Project’s social risk rating is Moderate at this stage and will be reviewed by Appraisal. The Project components will not involve resettlement or land acquisition and the project objectives benefit the Honduran society in general by strengthening and supporting vital health services and institutional capacity. Identified social risks for this project include: (i) potential discrimination and difficulties in access to services and vaccination programs by marginalized and vulnerable social groups, which are disproportionately represented by Afro-Hondurans and Indigenous Peoples, migrants, the elderly, LGBTI people and persons with disabilities; (ii) patient-centric risks for those receiving medical attention, including GBV or sexual exploitation and abuse (SEA) of patients or health staff; (iii) limited reach of the Project’s communication strategies to inform the population of the Project’s benefits if these are not adequately tailored or culturally adapted, and ; and (iv) insufficient measures to prevent misinformation which may contribute to propagate false expectations or generate mistrust about the benefits of health campaigns or programs. Difficult access to health in rural and remote areas of the country can also pose a challenge for service and vaccination Jun 28, 2021 Page 5 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) delivery, particularly for single mothers with children with need of vaccination. Some of these risks will be mitigated by the Project’s driving objectives, which focus on reducing health service gaps among some of the most vulnerable groups, and enhancing the impact of SESAL’s activities in communities living with high poverty and social disadvantages. Activities across the Project’s three components will be largely a continuation of existing health programs which are in need of support or expansion, as well as supporting different communication strategies. A successful, comprehensive support of these health programs will require the inclusion of multiple disadvantaged and vulnerable groups, particularly people living in rural communities with difficult access to the national health system. Indigenous People and Afro Descendants must be closely engaged, as there is evidence of service discrimination and a historical mistrust of traditional health approaches. Inclusive approaches should be tailored to consider other discriminated minorities such as LGBTI people and persons with disabilities, particularly those living in poverty. In Honduras, the contextual risk of crime and violence may pose a threat to local populations and potential project beneficiaries; SESAL, however, has extensive experience of working and delivering health services in challenging territories, where health staff is often trusted by communities and granted access without restrictions or fear of retaliation. Despite this contextual advantage, once site-specific Project activities are determined during preparation, the risk of crime and violence should be assessed to evaluate if additional risk mitigation strategies should be in place to ensure the safe implementation of project objectives. Migratory trends and waves should also be accounted for as an ongoing regional phenomenon that can affect project activities. The E&S instruments will evaluate these risks and determine the corresponding mitigating strategies to ensure social inclusion. The social risk rating may be revised at the appraisal stage, after having a greater definition of the project activities; additional information about how the contextual risks are related to the project, will be supported by the preparation of a social assessment, which will also be informed by the consultation process. Public Disclosure B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: This Standard is relevant. Based on available information at concept stage, the project is expected to have moderate environmental and social risks and impacts. The project aims to improve mechanisms and capacities in Honduras to strengthen SESAL ‘s health provision structure. Component 1 will focus on strengthening and maintaining the delivery of essential health services for adolescents, women, and children, including surveillance and response to emergencies. Activities under C1 will finance and support government efforts to continue the delivery of essential health and nutrition services for women and children in the context of the COVID-19 pandemic. Likewise, it is expected that this component will increase childhood vaccination coverage by increasing the number of vaccinated individuals and the geographic scope of vaccination efforts. Occupational Health and Safety risks can be exacerbated if activities are carried without the necessary training or personal protective equipment. This implies a risk to the health and safety of the participating health personnel and the target population, which may occur due to inadequate handling of the medical waste generated during the vaccination process, especially in those places where there is no previous experience. The ESMF will define specific mitigation measures to reduce OHS risks. Improving health care facilities might incur in purchasing and installing laboratory and field surveillance equipment, which could involve some minor civil works or adaptations Jun 28, 2021 Page 6 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) to existing facilities, with probable generation of construction and demolition debris and electronic waste. Provisions will be needed for managing C&D debris, e-waste, universal access, and energy efficiency equipment. In terms of social risks, C1 will require a characterization of beneficiaries and determine the risk of exclusion or discrimination from access to Project benefits. Similarly, once territorial aspects are more clearly defined, the risk and impact analysis will determine which contextual factors should be integrated into the E&S management. Component 2 focuses on financing activities seeking to address systemic and longstanding deficiencies in the health sector that affect the efficiency and quality with which health services are delivered in Honduras, including strategic purchasing and management of commodities to improve the efficiency of health service delivery, as well as strengthening communication and information programs. C2 will enhance the preparedness and response capacity of the country to face health emergencies, including pandemics and infectious disease outbreaks, such as dengue, malaria, and COVID-19. The project will finance technical assistance and equipment of regional laboratories, the development of information management solutions in national and regional surveillance hubs, training for technical staff, equipment, supplies, and development of communication activities to prevent and respond to infectious disease outbreaks. No environmental risk and adverse impacts are expected. This component will also finance communication activities to prevent and respond to infectious disease outbreaks, as well as designing risk communication strategies related to preparedness and resilience in health. Component 3, focused on Project management, will finance project management and coordination activities for the project, as such no environmental and social risks and impacts are expected from these activities. Public Disclosure Based on the scope of the proposed activities at concept note stage, SESAL will be asked to prepare, consult with main stakeholders, and disclose a project level Environmental and Social Management Framework (ESMF). By appraisal, a draft ESMF will outline the main risks and impacts and mitigation strategies and will include a legal gap analysis in relation to the ESSs, as well as feedback obtained from initial consultations. The final version will include a full analysis of risks and impacts, detailed budget and clear institutional arrangements among others. The ESMF will be proportionate to the E&S risks and impacts and in line with the Bank’s Environmental and Social Standards and the World Bank Group Environment, Health and Safety (EHS) Guidelines. The ESMF will provide guidance on E&S screening checklists and classification of site-specific project activities, the development of site-specific Environmental and Social Management Plans (ESMP)s to be prepared as deemed necessary during implementation, and provisions for environmental and social screening of activities to be financed under a Contingency Emergency Recovery Component (CERC) should this component be added to the proposed project. The ESMF will include a CERC- specific section including a positive list, institutional arrangements in case of activation and any other relevant information or requirements in accordance with the Bank Guidance Note on Contingent Emergency Response Components (2017). The criteria to determine whether an ESMP is considered necessary will be agreed upon between SESAL and the World Bank team and described in the ESMF. The ESMF will also analyze the positive and negative, direct and indirect impacts of the project and will define appropriate mitigation and management measures in accordance to the mitigation hierarchy. The ESMF will include OHS and COVID-19 transmission prevention measures and will include a description of implementation arrangements (including monitoring, supervision, and reporting) at the site-specific level. If specific or unforeseen risks and impacts emerge during preparation, the team will work closely with SESAL to ensure these risks are being adequately contextualized before appraisal. This would include referring to any relevant national and local assessments (if available) or preparing supporting assessments as part of the ESFM. Any significant gaps in knowledge or data will be strengthened and included in the corresponding Jun 28, 2021 Page 7 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) ESMF sections. To support a deeper understanding of potential social risks, SESAL will prepare before appraisal a social assessment that will directly inform the ESMF. In addition, the project will develop before appraisal a draft Stakeholder Engagement Plan (SEP) with its Grievance Redress Mechanism, a Labor Management Procedure (LMP) with its grievance redress mechanism for workers, and an Indigenous Peoples Planning Framework (IPPF), and will establish an organizational structure, described in the ESMF and the POM, with qualified staff to support the management of E&S risks. All these instruments will be proportional to the project’s E&S risks, and will be prepared as standalone instruments. Due to the physical restrictions imposed on stakeholder consultations after the COVID19 pandemic, it is necessary to put in place efficient virtual mechanisms for consultations, especially with socially excluded and vulnerable groups. If possible, physical but socially distanced gatherings for stakeholder engagement will be organized. A draft Environmental and Social Commitment Plan (ESCP) for SESAL will also be developed prior to appraisal. The Project Operations Manual (POM) to be prepared for the project will also include detailed information related to the E&S instruments prepared for the project, and clear instructions on how to apply these during project implementation. Areas where “Use of Borrower Framework” is being considered: None. ESS10 Stakeholder Engagement and Information Disclosure ESS10 is relevant for the project. The project includes communication and information related activities as part of Components 1 and 2 that will require close stakeholder engagement to support the objectives of capacity building Public Disclosure and awareness raising related to health services. Subcomponent 1.1 would support communication and social mobilization in targeted regions to be determined, including the use of reminders, incentives, and home visits by community-nominated “ambassadors” to increase the demand for vaccination services. Component 2 would support health preparedness and resilience by, among others, strengthening communication activities to prevent and respond to infectious disease outbreaks. The potential stakeholders for these activities will be identified before appraisal, and will include relevant civil society organizations, local communities, and their representative organizations and networks. It is also expected that external actors, such as the GAVI Alliance and PAHO are clearly characterized in the SEP, as well as their potential role as coordinators and partners in certain project activities. All public gatherings will be designed taking into account relevant local public health requirements in the context of the COVID-19 pandemic, including the WB Technical Note on “Public Consultations and Stakeholder Engagement in WB- Supported Operations when there are Constraints on Conducting Public Meetings (March 20, 2020)”. A draft standalone Stakeholder Engagement Plan (SEP), including a project-wide Grievance Redress Mechanism, will be prepared, consulted, and disclosed prior to Appraisal. The draft version should outline the proposed stakeholder engagement strategy, an identification of affected and interested groups, as well as feedback obtained from initial consultations. The final version will include a thorough description of consultations and their validation, detailed budget and commitments, clear institutional responsibilities for engagement and a full description of the Project’s GRM. The final version of the SEP will be consulted, disclosed and adopted within 30 days of the Effective Date. The SEP will describe engagement principles and measures and reference supporting instruments, such as guidance notes, to ensure adherence to ESS10 requirements. All relevant stakeholders will have equal opportunities to engage with the project through transparent participatory mechanisms. The SEP will outline a) who the key stakeholders are; b) the specific types of engagement with them, especially regarding Indigenous Peoples’ representatives, members of Jun 28, 2021 Page 8 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) the afro descendant communities, women of all ethnicities, and other vulnerable groups, including persons with disabilities and LGBTI people; c) how often the engagement will occur throughout the project; d) how feedback will be solicited, recorded and monitored; e) who will be responsible with this engagement; f) timeline for this engagement; g) budget and human resources, among other details. Significant consultations with groups or organizations representing those most vulnerable to exclusion of benefits will be planned and undertaken during preparation. Given the recent preparation of other health projects, SESAL has engaged with several vulnerable groups, which should ease the initiation of dialogue; in addition, the Social Assessment would identify if any potential unidentified group or a known vulnerable group which might require additional engagement or a differentiated approach. To avoid or minimize the risk of leaving identified vulnerable groups behind, the SEP will describe the measures that will be used to remove obstacles to participation in the benefits of the project activities, and how the views of differently affected groups will be captured. Where applicable, the SEP will include differentiated measures, some of which might be country-specific, to allow the effective participation of those identified as disadvantaged or vulnerable. Dedicated approaches and an increased level of resources may be needed for communication with such differently affected groups such as remote and dispersed populations so that they can obtain the information they need regarding the issues that will potentially affect them (positively or negatively). The SEP will also highlight if there are any risks or specific considerations around stakeholder engagement, grievance redress, and information disclosure/informed decision-making, particularly in the context of health service provision and the potential engagement limitations with some local communities. Additionally, a Beneficiary Feedback indicator will be included in the Project’s results framework, mentioned in the PAD and the SEP, in order to ensure a systematic measure of stakeholder engagement during implementation. The Public Disclosure appraisal ESRS will describe this indicator. Based on WHO guidance, a central purpose of the stakeholder engagement and consultation process is to build trust in the prevention and response of misinformation that may interfere with decision-making in the population to receive and adhere to public health advice. This will include scientifically sound information on relevant programs and health initiatives. Where relevant, this work would be based on WHO guidance (WHO Guidance - Risk Communication and Community Engagement) and would seek to provide proper awareness raising and timely information dissemination to (i) avoid conflicts resulting from false rumors; (ii) ensure equitable access to services for all who need it; and (iii) address issues resulting from the ongoing conditions due to the pandemic. Documentary evidence of the stakeholder engagement activities will be included in the SEP as well, taking into account privacy and anonymity criteria. The Project team will provide close guidance to the client on stakeholder mapping and sequencing of engagement in a way that is practical and takes into account the iterative nature of SEPs. The project's GRM will be available to all project stakeholders, will be accessible and culturally appropriate, and designed to guarantee confidentiality, accessibility, and translations to indigenous languages where necessary. The timeline for the GRM, including when it is expected to be operational, will be determined during project preparation once SESAL’s capacity to implement it is assessed and determined. SESAL has had previous experience managing grievance services as part of their implementing role with other WB Projects; the E&S team will ensure that the GRM designed for this project meets ESS10 requirements. The description of the GRM will cover its operational principles, processing responsibilities, internal administration, its budgeting, and the frequency of periodic monitoring reports. While the timeline for the GRM is still to be determined the team will work with SESAL to make it available as soon as Jun 28, 2021 Page 9 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) reasonably possible. The disclosed SEP will describe the commitments to monitoring the functionality of the GRM, its uptake channels, and will include information on reporting frequency, methods, and organizational responsibilities. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions ESS2 is relevant. The type of project workers, labor provisions and requirements will be described in standalone Labor Management Procedures (LMP) to be consulted, disclosed and adopted within 30 days of the Effective Date. A draft LMP will be prepared, consulted and disclosed by Appraisal, which should outline, among others, the main legal and institutional context, local labor gap analysis, a clear identification of different types of workers, and a robust outline of the workers’ GRM. The final version will include a comprehensive description of types of workers, a full description of the GRM and its operation, necessary budget, and will annex all relevant guidelines, protocols and codes of conduct. Most activities supported by the Project will be conducted by publicly employed health and laboratory workers. Additional potential project workers will include officials from PAHO and GAVI, contracted suppliers (including those involved in transport, handling and delivery of procured goods), as well as potentially some private consultants and other contract staff to support specific activities. A key risk remains the contamination with COVID- 19 (or other contagious illnesses as patients taken seriously ill with COVID-19 are likely to suffer from illnesses which compromise the immune system, which can lead to illness and death of workers). Emerging risks related to declining mental health and fatigue may impact project workers’ capacity to carry out core functions. Staff of health facilities, workers involved in vaccination activities, as well as all other workers involved in the procurement, delivery, training, Public Disclosure use, supervision/monitoring, and/or handling and disposal of medical supplies, equipment, or waste products within the scope of the project will receive necessary training on protecting themselves and others from COVID-19 infection, as well as other relevant occupational health and safety (OHS) and mental health risks and management measures. The Project will ensure the application of OHS measures is consistent and aligned with national regulations, World Bank and WHO guidelines, which will be referred to in the ESMF. SESAL has already published in its website two guidelines following WHO criteria for health providers outlining measures specific for COVID-19 treatment and protection. The website also includes additional guidelines for measures unrelated to COVID-19. These include procedures for entry into health care facilities; procedures for protection of workers in relation to infection control precautions; provision of immediate and ongoing training on the procedures to all categories of workers, and mandating hand hygiene and personal protective equipment (PPE); ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General EHSGs and industry specific EHSGs and following evolving international best practices. Staff of health facilities and those involved in Project activities will receive appropriate training under the Project on how to use the medical equipment, supplies and vaccines financed through the Project in a way that protects their health and safety. The LMP will identify and assess the new OHS risks to workers involved in vaccination activities, including risks such as declining mental health and fatigue, and ensure that mitigation measures are in place. In cases where there is risk of PPE shortage for health workers, the LMP will lay out measures to ensure that health staff involved in project activities is not forced to work without all necessary safety measures. Project activities would only be implemented if there are assurances that PPE will be available to health staff. Jun 28, 2021 Page 10 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) Although labor considerations will focus on the standard aspects considering worker wellbeing and health and safety, the LMP will include a code of conduct acceptable to the World Bank to mitigate the risk of sexual exploitation and abuse (SEA)/sexual harassment (SH) or misconduct in the workplace and in contact with communities. The LMP will also describe gender-specific measures that could be relevant to ensure participation by women to facilitate equal opportunity and access to project benefits, as well as measures to prevent discrimination in the workplace and during recruitment processes, and the use of inclusive language to proactively encourage social inclusion OHS considerations to ensure health and safety of workers. If during project preparation it is identified that construction activities will be carried out, OHS measures for workers will refer to the WB’s ESF/Safeguards Interim Note “COVID-19 Considerations in Construction/Civil Works Project”. The LMP will also ensure that the corresponding national labor-related laws are upheld related to public service and related human resource policies, labor law, and institutional roles related to enforcement of the laws, including recruitment, discipline, appraisals, and dismissals. Grievances will include the necessary considerations for confidentiality and whistle-blower protection. The worker- specific GRM will be described in the LMP, including information on reporting frequency, methods, and organizational responsibilities. The necessary training to project workers, including on workers' codes of conduct, will be included in the ESCP. During preparation SESAL’s labor systems as compared to ESS2 will be assessed; the ESMF will incorporate substantial measures (including budgetary) in capacity-building and oversight as needed to ensure that activities that underlay the Project outcomes manage the risks and impacts appropriately. The use of child or forced labor will be forbidden in accordance with ESS2. ESS3 Resource Efficiency and Pollution Prevention and Management Public Disclosure ESS3 is relevant due to the possible increase in the generation of medical waste, from the expansion of health service coverage; and by the possible generation of construction and demolition debris generated in the small works for the installation of equipment, which in case of improper handling, can imply contamination in different ways. Medical waste and general waste from health centers, and vaccination sites, laboratories, quarantine, and isolation centers have a high potential of being contaminated with micro-organisms that can infect the community at large if they are not properly disposed of. There is a possibility for these infectious microorganisms to be transmitted to members of the public if not well contained within laboratories or appropriately isolated areas of hospitals and medical centers, or due to accidents or emergencies. )These risks are in situ and no significant impact is expected. Any medical waste and/or C&D debris generated by project activities will be disposed according to national regulations, this ESS, and WBG EHS Guidelines. Additionally, the team will evaluate if e-waste management measures are required in the ESMF due to project activities. Appropriate mitigation measures will be developed as part of the ESMF following the mitigation hierarchy. Specific ESMPs if needed will include mitigation measures with more specificity as applicable. If it is determined during project preparation that electronic equipment will be procured, the ESMF will include electronic waste (e-waste) management considerations. ESS4 Community Health and Safety ESS4 is relevant. The project will ensure the safety of communities from risk of infection with different diseases, including COVID-19. Medical wastes and general waste from health centers, and vaccination sites, laboratories, quarantine and isolation centers have a high potential of being contaminated with micro-organisms that can infect the community at large if they are not properly disposed of. Measures for medical waste management will be Jun 28, 2021 Page 11 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) included in the ESMF, focusing on: i) how Project activities involving medical waste will be carried out in a safe manner in line with Good International Industry Practice (such as WHO guidelines); ii) measures to prevent or minimize the spread of infectious diseases; and iii) emergency preparedness measures. Information on preventive health measures to communities surrounding health facilities will be provided periodically through continuous stakeholder engagement. Before appraisal, the draft ESMF will contextualize relevant information regarding crime and violence and GBV risks in potential intervention areas and assess if additional security support and safety measures are necessary to protect project workers, beneficiaries, and communities. The ESMF will also develop the necessary guidelines to screen specific project activities and programs to determine the need for the Borrower to include additional security measures or criteria during implementation. Project activities will ensure that workers wear personal protective equipment (PPE) and receive appropriate training to prevent the spread of COVID-19 and other diseases to the community. Sexual Exploitation and Abuse (SEA)/ Sexual Harassment (SH) risks are Moderate at this stage and will be reviewed before appraisal. During implementation, the corresponding measures to prevent and mitigate the SEA/SH risks will be described in the ESMF including any relevant screening tools. The Project will promote the avoidance of SEA by relying on the WHO Code of Ethics and Professional Conduct for all workers related to the Project who will work as part of project activities. Military forces are not expected to have a role in any of the proposed components; this will be confirmed before appraisal to determine if the ESMF should identify and assess the risks associated with engaging security personnel, define the standards and code of conduct to be adopted by such personnel, including training Public Disclosure requirements on such standards and code of conduct, in line with the guidance provided in the WB’s Technical Note “ESF Good Practice Note (GPN) on Assessing and Managing the Risks and Impacts of the Use of Security Personnel”. Any allegations of unlawful or abusive acts of any military/security personnel in connection with the project will be processed through the project GRM and will be reviewed, acted (or request appropriate parties to take action) to prevent recurrence and, where necessary, report unlawful and abusive acts to the relevant authorities. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS5 is not relevant at this stage. The project does not expect to require land acquisition or resettlement and no potential risks and/or impacts relevant to ESS5 have been identified. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources ESS6 is not relevant at this stage. The activities that will be financed by this Project do not imply the direct use of ecosystem services, and will be developed in urban or rural environments already modified where it is not considered that they may represent any impact on biodiversity or natural resources. The proper management of waste that could be generated and that could represent some degree of adverse impact on the natural environment, is addressed in ESS1 and ESS3. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities Jun 28, 2021 Page 12 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) ESS7 is relevant. Due to the national scale of intervention, Indigenous People (IPs) and Afro descendants (ADs) who meet the criteria of ESS7 to be identified as IPs, are expected to be present in the Project’s area of influence. During preparation and before Appraisal, the Bank will carry out a Social Evaluation, which will include, among other aspects, an evaluation to determine which specific groups affected by the Project meet ESS7. Afro descendants that do not fit the criteria described in ESS7 will be considered as part of ESS1 in the ESMF and any additional mitigation measures in relevant documents including ESMPs, the SEP, and the LMP. The Borrower will prepare a standalone Indigenous Peoples Planning Framework (IPPF) to be consulted, disclosed and adopted within 30 days of the Effective Date. A draft IPPF will be prepared, consulted and disclosed by Appraisal, which should outline the main commitments and strategies tailored for IPADs, as well as feedback obtained from initial consultations. The final version will include a full analysis of risks and impacts, detailed budget and commitments with relevant communities, and clear institutional responsibilities for engagement. The IPPF will outline general principles consistent with ESS7, including the need to respect IPs traditions, health approaches and livelihood practices while at the same time allowing them to access the benefits provided through this project. The IPPF will set out the common principles, objectives and inclusion strategies for the Project, existing legal frameworks and historical background of engagement. The IPPF will also specify the circumstances in which Free, Prior, and Informed Consent would be needed, if relevant. A draft IPPF will be prepared, consulted, and disclosed prior to appraisal. Risks to be assessed and, as necessary, mitigated, include exclusion from consultation processes, lack of culturally appropriate communication, potential misinformation, discrimination in labor, discrimination and exclusion from accessing project benefits, susceptibility to SEA/SH risks, and others. During project preparation IP/ADs’ degree of involvement as beneficiaries of program incentives and supporting activities will be assessed, and also as influenced Public Disclosure stakeholders through the implementation of activities. Site-specific Indigenous Peoples Plans will be prepared as necessary. In Honduras, an estimated 656,000 people are IPs (8 percent of the national population); however, a census undertaken by Indigenous Peoples federations considers that the IP population might be closer to 18 percent (1.5 million people). Indigenous peoples and Afro-Hondurans (AHs) exhibit higher rates of poverty and extreme poverty relative to the non-IPAH population, as well as poorer access to basic services: 72 percent of indigenous households, compared to 41.6 percent of households nationally, cannot afford a basic food basket, which puts them on the extreme poverty line. The average monthly income of IPs amounts to 36.8 percent of the national average, and much less in the case of the Tolupán, Chortí, Pech and Lenca. IPs also face discrimination, which makes them vulnerable in general to unfair and precarious working conditions, as well as access to health services. During project preparation, the draft IPPF will outline and inform how to: (i) improve targeting of indigenous peoples, particularly those in areas of difficult access, (ii) support communication and outreach challenges due to geography, culture, and at times, language, (iii) ensure that access to health services is provided in a culturally adapted manner and that necessary institutional strengthening of the PIU at the various levels is done, and (iv) strengthen grievance redress mechanisms tailored to indigenous people’s customs. The project presents opportunities for inclusion of IPs and other vulnerable groups and all opportunities to design culturally appropriate activities in ways that are deliberately inclusive should be highlighted. The Project’s ESF instruments will be consulted with representative IP groups and communities, in a culturally- sensitive manner, taking into account potential COVID-19 health protections, with IP communities and/or their Jun 28, 2021 Page 13 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) representatives, as appropriate, to ensure communities´ broad support to the Project. Feedback will be integrated into the instruments. The instruments will be disclosed, online and through other channels accessible to potentially affected communities. ESS8 Cultural Heritage ESS8 is not relevant at this stage. Project activities will not have adverse impact on tangible or intangible cultural heritage. However, some of the project beneficiaries will be IPs and Afro-Hondurans who might maintain distinct cultural health practices. Health providers should recognize these traditional methods when working with IPs and Afro-Honduran communities in health-related matters, which includes recognition of their own traditional governance structures and traditional medicine agents. The project will ensure these customs are taken into consideration when communicating with and treating these communities and will be considered in the SEP, ESMF and IPPF as relevant. ESS9 Financial Intermediaries ESS9 is not relevant. B.3 Other Relevant Project Risks None at this stage. Public Disclosure C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No III. WORLD BANK ENVIRONMENTAL AND SOCIAL DUE DILIGENCE A. Is a common approach being considered? No Financing Partners None. B. Proposed Measures, Actions and Timing (Borrower’s commitments) Actions to be completed prior to Bank Board Approval: The Borrower will prepare and disclose prior to Appraisal standalone: (i) Draft Environmental and Social Commitment Plan (ESCP); Jun 28, 2021 Page 14 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) (ii) Draft Environmental and Social Management Framework (ESMF); (iii) Draft Stakeholder Engagement Plan (SEP), which will include the Project’s Grievance Redress Mechanism (GRM); (iv) Draft Labor Management Procedures (LMP) with a worker-specific GRM; (v) Draft Indigenous Peoples Planning Framework (IPPF); (vi) Social Assessment. Final versions of the project instruments will be expected no later than 30 days after Project Effectiveness. Possible issues to be addressed in the Borrower Environmental and Social Commitment Plan (ESCP): (i) Organization structure and personnel to manage the E&S risks of the project (ii) Incidents and accidents notifications (iii) Monitoring and reporting (iv) Preparation, finalization and implementation of required E&S instruments including the ESMF, LMP, SEP, IPPF and site specific instruments such as ESMPs and IPPs (v) Operationalization of the project GRM and the labor specific GRM (vi) Capacity building to project workers and stakeholders on E&S and OHS aspects of the project (Training for the management of waste with biological risk is relevant, which is mainly identified as an occupational risk with potential impacts on the health of workers). C. Timing Tentative target date for preparing the Appraisal Stage ESRS 30-Aug-2021 Public Disclosure IV. CONTACT POINTS World Bank Contact: Nicolas Antoine Robert Collin Dit De Title: Senior Economist Montesson Telephone No: +1-202-458-2120 Email: ncollin@worldbank.org Contact: Roberto F. Iunes Title: Senior Economist, Health Telephone No: +1-202-473-3427 Email: riunes@worldbank.org Borrower/Client/Recipient Borrower: Republic of Honduras Implementing Agency(ies) Implementing Agency: Ministry of Health (Secretaria de Salud Honduras) V. FOR MORE INFORMATION CONTACT Jun 28, 2021 Page 15 of 16 The World Bank Honduras Improving Access and Governance in Health (P176532) The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Roberto F. Iunes, Nicolas Antoine Robert Collin Dit De Montesson Practice Manager (ENR/Social) Tatiana Tassoni Recommended on 26-Jun-2021 at 08:25:22 GMT-04:00 Safeguards Advisor ESSA Angela Nyawira Khaminwa (SAESSA) Cleared on 28-Jun-2021 at 13:28:10 GMT-04:00 Public Disclosure Jun 28, 2021 Page 16 of 16