INTEGRATED SAFEGUARDS DATA SHEET APPRAISAL STAGE Report No.: ISDSA5984 Public Disclosure Copy Date ISDS Prepared/Updated: 01-Nov-2013 Date ISDS Approved/Disclosed: 16-Jan-2014 I. BASIC INFORMATION 1. Basic Project Data Country: Serbia Project ID: P129539 Project Name: Second Serbia Health Project (P129539) Task Team Timothy A. Johnston Leader: Estimated 29-Oct-2013 Estimated 27-Feb-2014 Appraisal Date: Board Date: Managing Unit: ECSH1 Lending Investment Project Financing Instrument: Sector(s): Health (91%), Public administration- Health (9%) Theme(s): Health system performance (100%) Is this project processed under OP 8.50 (Emergency Recovery) or OP No 8.00 (Rapid Response to Crises and Emergencies)? Financing (In USD Million) Total Project Cost: 40.00 Total Bank Financing: 40.00 Public Disclosure Copy Financing Gap: 0.00 Financing Source Amount Borrower 0.00 International Bank for Reconstruction and Development 40.00 Total 40.00 Environmental B - Partial Assessment Category: Is this a No Repeater project? 2. Project Development Objective(s) The PDO is to contribute to improving the efficiency and quality of the public health system of the Republic of Serbia through the strengthening of: (i) health financing, purchasing, and maintenance systems; and (ii) quality improvement systems and management of selected priority non- communicable diseases. 3. Project Description Page 1 of 7 Component 1: Improving Health Financing. This component will support reforms to improve the quality, efficiency, and transparency of financing for primary care and hospitals. The component will finance technical assistance, training, goods and equipment to support the design and implementation Public Disclosure Copy of incentives and oversee results; finance initial piloting of a quality improvement grants scheme to primary care facilities; and support upgrades of information technology capacity to improve financial reporting and performance monitoring at central, hospital, and primary levels. This component will also support TA to enable the necessary modifications to by-laws and regulations needed for the implementation of finance reforms; to make recommendations on governance arrangements to strengthen management autonomy and accountability at hospital and primary care levels; and to address cross-cutting issues, such as strengthening the referral system between primary and hospital care. Component 2: Efficient Purchasing of Pharmaceuticals and Medical Products. Activities under this component will be organized around the following main areas: support for centralized procurement of drugs and supplies through framework contracts; strengthening of Health Technology Assessment (HTA); and improving systems for medical equipment maintenance. Activities in this area will support TA, training and equipment, including a piloting of a multi-vender medical equipment maintenance contact. Component 3: Strengthening Quality of Service Delivery. This component aims to improve standards of quality and efficiency of care in the Serbian health sector through two main approaches: (i) Strengthening quality improvement systems, and (ii) Modernizing cancer treatment at selected tertiary facilities. This component will strengthen cross-cutting systems of performance management and information technology that are pertinent across both sub-components, and will finance goods, technical assistance, training and equipment. Component 4: Monitoring, Evaluation, and Project Management. This component will support routine Project management, including fiduciary tasks, monitoring and evaluation, audits of Project Public Disclosure Copy financial statements. It will finance Project operating costs, including translation, interpretation, equipment, supervision costs (transportation and per diem), staffing costs of the PCU, M&E, studies and surveys, and incremental costs at the MoH. Monitoring the implementation of the proposed reforms, including potential unintended consequences, will be supported under this component. Financing for the five-yearly National Health Survey is also planned for 2017/18. Study tours in countries where similar reforms are at a well advanced stage of implementation and where significant results have been achieved may be envisaged, particularly in the areas of hospital rationalization and primary health care financing. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The Project will be implemented in health centers and hospitals throughout Serbia. Linear accelerators for treatment of cancer generate low level radio radioactivity. They use electricity to generate either high-energy x-rays or accelerated electrons that can be precisely targeted on cancerous tissue. When not in operation, no harmful radiation is generated, although the treatment room itself requires shielding of the walls, doors, and ceiling to prevent escape of scattered radiation during the radiotherapy treatment. The solution is similar to the arrangements used to protect staff using diagnostic x-ray equipment, although the higher energy of therapy beams requires a radiation vault (bunker) with thick concrete walls (2.5 m) to provide adequate radiation shielding. Fourteen high-energy linear accelerators are currently installed in Serbia, with age ranging from 4 to 10 years. The typical life time for this kind of technology in Western Europe can exceed 12 years, but Page 2 of 7 reliability of equipment is compromised by poor maintenance, resulting in frequent disruption of therapeutic activity and relevant increase of waiting lists. Final information on the sites where these equipment would be replaced or upgraded with new equipment is not yet confirmed. Preliminary Public Disclosure Copy information indicates that existing bunkers are mostly adequate, although they will require upgrading, without change of the building footprint. In case of construction of new facilities, these will be executed within the existing hospital buildings, or their yards. So the two likely scenarios under the Project are: (i) replacement of old accelerator(s) on existing site(s), with only minor civil works for installation; and (ii) construction of new bunker(s) to house a new or larger accelerator. 5. Environmental and Social Safeguards Specialists Nikola Ille (ECSEN) 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes The Project is rated environmental category B. BP 4.01 Most of the Project Components are environmentally neutral; however Component 3 will include installation of the medical equipment into already existing, purpose-built facilities (bunkers) that will be modified, to suit specifications of the new equipment. Environmental Management Framework (EMF) is being prepared for the Project. The related civil works activities will be undertaken within existing hospitals and medical centers throughout Serbia, and are not expected to have any significant negative environmental impact. The issues related to this type of activities include noise, dust, vibrations, and management of construction waste during civil engineering Public Disclosure Copy activities - which could be successfully managed and mitigated by application of good engineering practices. Specific issues that will also be taken care of relate to management of the site (as hospitals must continue operating during the execution of works), and health and safety of population. In some cases, the presence of asbestos, lead or other medical or possibly hazardous waste (if found during rehabilitation works), may require specific handling procedures, which will be defined in site-specific EMPs that are to be prepared for each facility when the locations become known. This includes the extremely small potential risk of residual radioactivity adhering to walls of existing bunkers, which will assessed before any civil works relating to existing bunkers. The potential for negative impact will exist during operation of the accelerator equipment, in case that Serbian Page 3 of 7 standard for ionizing radiation and nuclear safety is not adequately applied. The Project will, as a part of the design and permitting process, ensure Public Disclosure Copy for each piece of equipment that relevant standards are applied and design is certified by the Institute of Occupational Health of Serbia. Additionally, the Word Bank EHS Guidelines and ILO Code of Practice “Radiation Protection of Workers (Ionizing Radiation”)” will apply to all sites under Project Component 3. As a rule, whenever the Serbian and World Bank standards and guidance documents differ on environment, health and safety issues, the more stringent ones will be applied. As required by the EMF, the implementing groups in the Ministry of Health will ensure that construction contracts will include clauses that will require contractors to comply with the construction safety rules in Serbia, health regulations and safeguards standards of Serbia, as well as of the Bank. The Project may fund construction of new facilities (bunkers) to house linear accelerators. These facilities will be constructed within the existing hospital buildings (without change of footprint), or in adjacent buildings – within the existing hospital compounds. Natural Habitats OP/BP 4.04 No No works within or near protected habitats are Public Disclosure Copy anticipated. Forests OP/BP 4.36 No No works within or near protected forests are anticipated. Pest Management OP 4.09 No Not relevant. Physical Cultural Resources OP/ No During project preparation it will be confirmed BP 4.11 whether any of the buildings chosen for rehabilitation are designated cultural property. As provided for in the EMF, in these cases the site- specific EMPs will include clauses related to heritage protection and conservation. The civil engineering works will have to be reviewed and approved by competent national cultural heritage institutions. Indigenous Peoples OP/BP 4.10 No Not relevant. Involuntary Resettlement OP/BP No The measures implemented at the project sites 4.12 include rehabilitation of the existing structures Page 4 of 7 and equipment and do not require land acquisition nor resettlement, nor will it lead to loss of access or income. Accordingly, no social safeguards Public Disclosure Copy issues related to land acquisition or resettlement issues are foreseen. Safety of Dams OP/BP 4.37 No Not relevant. Projects on International No Not relevant. Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP No Not relevant. 7.60 II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: Implementation of the project-funded activities is not expected to have any significant negative environmental impact. The issues related to this type of activities include noise, dust, vibrations, and management of construction waste during civil engineering activities - which could be successfully managed and mitigated by application of good engineering practices. Specific issues that will also be taken care of relate to management of the site (as hospitals must continue operating during the execution of works), and health and safety of population. In some cases, the presence of asbestos, lead or other medical or possibly hazardous waste (if found during rehabilitation works), may require specific handling procedures, which will be defined in site- specific EMPs that are to be prepared for each facility when the locations become known. This includes the extremely small potential risk of residual radioactivity adhering to walls of existing Public Disclosure Copy bunkers, which will assessed before any civil works relating to existing bunkers. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: There will be no long-term negative environmental impacts if project activities are executed as designed. The minor temporary negative effects (noise, vibrations, dust, construction-related waste) are of limited duration and can be successfully mitigated by application of good engineering practices and application of site-specific EMPs, which will be based on Environmental Framework Document and tailored for each specific site. The potential for negative impact will exist during operation of the accelerator equipment, in case that Serbian standard for ionizing radiation and nuclear safety is not adequately applied. The Project will, as a part of the design and permitting process, ensure for each piece of equipment that relevant standards are applied and design is certified by the Institute of Occupational Health of Serbia. Additionally, the Word Bank EHS Guidelines and ILO Code of Practice “Radiation Protection of Workers (Ionizing Radiation”)” will apply to all sites under Project Component 3. As a rule, whenever the Serbian and World Bank standards and guidance documents differ on environment, health and safety issues, the more stringent ones will be applied. Comparison between WB and national legislation shows that standards are compliant, as they both incorporate international best practice. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. Page 5 of 7 Not relevant. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. Public Disclosure Copy An Environmental Management Framework (EMF) including a sample Environmental Management Plan (EMP)/Checklist was prepared for the Project. Site specific EMPs/Checklists will be prepared during the subsequent phases, when the locations of investments are finalized. EMPs will become part of the bidding documents and resulting contracts. Monitoring and reporting on contractor’s compliance with site-specific EMPs on the existing Project will be undertaken on a monthly basis by the supervising engineer/environmental specialist and reports sent to the Project Implementation Team. Reporting from PIT to the Bank will be undertaken at least twice per year, and more frequently in case of particular issues or problems. Review of the environmental compliance monthly reports and reality check on sample sub- projects will be undertaken by the Bank’s safeguards specialist at least once per year, during the regular implementation support missions. While implementing the currently ongoing DILS Project, the Project’s implementation team has developed an understanding and capacity to successfully deal with the environmentally-related activities, which was documented during Bank’s regular implementation support missions. The same team is expected to continue work on this Project. The requirements for the environmentally-related activities under the Project will include: (i) preparation of draft site-specific EMPs by the Project Implementation Team; (ii) review and approval of site-specific EMPs by the Bank’s team; (iii) inclusion of site-specific EMP as a part of the Bidding Document, and subsequent contract; (iv) execution of EMP-related measures by the respective contractor(s); (v) monitoring and reporting of compliance with EMP- related measures by supervising engineer/environmental specialist (to the Project Implementation Team); (vi) reporting on compliance with EMP to the Bank (by the Project Implementation Team). 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Key stakeholders are: Ministry of Health; Ministry of Energy and Environmental Protection; Public Disclosure Copy Institute for Occupational Health of Serbia; Medical centers throughout Serbia. Potentially affected people are medical staff and patients in hospitals where the equipment is being replaced. The preparation of an EMF and its public disclosure in-country has been completed, and is fully compliant with OP/BP 4.01. According to national legislation there are no additional requirements for the preparation of EMPs and/or their disclosure. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 31-Oct-2013 Date of submission to InfoShop 31-Oct-2013 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure Comments: If the project triggers the Pest Management and/or Physical Cultural Resources policies, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/ Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: Page 6 of 7 C. Compliance Monitoring Indicators at the Corporate Level Public Disclosure Copy OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) Yes [ ] No [ ] NA [ ] report? If yes, then did the Regional Environment Unit or Sector Yes [ ] No [ ] NA [ ] Manager (SM) review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated Yes [ ] No [ ] NA [ ] in the credit/loan? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the Yes [ ] No [ ] NA [ ] World Bank's Infoshop? Have relevant documents been disclosed in-country in a public Yes [ ] No [ ] NA [ ] place in a form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional Yes [ ] No [ ] NA [ ] responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included Yes [ ] No [ ] NA [ ] in the project cost? Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] Public Disclosure Copy with the borrower and the same been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader: Name: Timothy A. Johnston Approved By Regional Safeguards Name: Agnes I. Kiss (RSA) Date: 31-Oct-2013 Advisor: Sector Manager: Name: Daniel Dulitzky (SM) Date: 16-Jan-2014 Page 7 of 7