INTEGRATED SAFEGUARDS DATA SHEET APPRAISAL STAGE Report No.: ISDSA578 Public Disclosure Copy Date ISDS Prepared/Updated: 04-Mar-2013 Date ISDS Approved/Disclosed: 14-Mar-2013 I. BASIC INFORMATION 1. Basic Project Data Country: Pakistan Project ID: P123394 Project Name: Punjab Health Sector Reform Project (P123394) Task Team Inaam Ul Haq Leader: Estimated 14-Mar-2013 Estimated 28-May-2013 Appraisal Date: Board Date: Managing Unit: SASHN Lending Specific Investment Loan Instrument: Sector: Health (100%) Theme: Health system performance (50%), Nutrition and food security (20%), Population and reproductive health (20%), Child health (10%) Financing (In USD Million) Total Project Cost: 1116.50 Total Bank Financing: 100.00 Total Cofinancing: Financing Gap: 0.00 Public Disclosure Copy Financing Source Amount BORROWER/RECIPIENT 830.00 International Development Association (IDA) 100.00 UK British Department for International Development 165.00 (DFID) Health Results-based Financing 21.50 Total 1116.50 Environmental B - Partial Assessment Category: Is this a No Repeater project? 2. Project Objectives The development objective of the proposed project is to (a) enhance coverage, quality and access to essential health care especially for the poor and the vulnerable in under developed districts; and b) improve DoH capacity and systems for enhanced accountability and stewardship functions. Page 1 of 7 3. Project Description The proposed project with an investment of US$100 million will use a results-based approach. It will support the implementation of the GOPb’s medium-term health program 2013-2018. The project will Public Disclosure Copy be supported by US$21.5 million from the Health Results InnovationTrust Fund (HRITF) with an in- built impact evaluation to implement the results-based financing (RBF) and health care financing (HCF) pilots. The project comprises four components. The first three components are results-based components and will be financed by disbursing funds against the achievement of a specific set of results using Disbursement Link Indicators (DLIs). The fourth component will not use the DLI approach but will finance inputs for piloting and technical assistance. The project components are as follows. COMPONENT 1 – IMPROVING HEALTH SERVICE DELIVERY The objective of Component 1 is to enhance coverage, quality, and access to an essential package of health care services (EPHS) which has been developed, including outreach and community level interventions for primary health care (PHC). In addition, EPHS for secondary and tertiary care will be developed as part of the program. The Bank’s technical engagement and monitoring will focus on the following thematic areas. i) Integrated management of MNCH and Community Based Workers (LHWs) programs; ii) Introduction of Nutrition Services; ii)Expanded Coverage of HIV/AIDS Preventive Services. The component will support expanding coverage of preventive, treatment, and care services for population subgroups vulnerable to HIV infection (IDUs and MSM) in targeted cities with support for provincial integrated behavioral and sero-surveillance COMPONENT 2 – ENHANCING EFFICIENCY AND EFFECTIVENESS OF THE HEALTH SYSTEM The objective of the component is to enhance efficiency and effectiveness of the health system by strengthening ongoing initiatives with a focus on management and accountability and improving quality of care through regulations and standardization of services both in the public and private sectors. The Bank’s technical engagement and monitoring will focus on the following thematic areas: i) Strengthening PHC contracting out; ii) Results based District Management Public Disclosure Copy Contracting iii) Enhancing Governance and Accountability Mechanisms through regulatory and social accountability reforms COMPONENT 3: STRENGTHENING PROVINCIAL DEPARTMENT OF HEALTH MANAGEMENT CAPACITY The objective is to strengthen and reorganize the current DoH management system for improved performance in stewardship functions in the post 18th Amendment scenario. The component will support the following thematic areas: i)To strengthen stewardship functions in the post-18th Amendment, the component will support a functional/capability review of the DoH and organizational restructuring of provincial DOH offices; iii)Building fiduciary functions in the DoH by establishing financial management and procurement structures to improve internal control for greater accountability and management effectiveness; iv) Environmental and medical waste management the project will support roll out of the medical waste management in the pilot districts to ensure zero infectious waste going out of medical facilities. By applying lessons learned from the pilot, the project will support initiation of the expansion of successful practices across the province by the end of the project. COMPONENT 4: IMPROVING THE CAPACITIES IN TECHNICAL AREAS FOR EQUITABLE HEALTH SERVICES TO ALL: It will finance innovative pilots to guide policy development in results-based financing and alternate financing approaches, besides strengthening existing analytical Page 2 of 7 capacities in technical areas. The project will finance specific inputs for the component using tradition investment lending. Component 4 will disburse a c umulative value of US$15 million IDA credit and US$10 million HRITF funds over the project period. The component will specifically Public Disclosure Copy support the following areas: i) Results-based financing pilots in two districts; ii) Piloting of alternative financing models and iii)Technical assistance. The health care reform plan envisages development of a secondary care and tertiary care package, in addition to the development of an essential package of primary health care services. The project will support selected needs-based analytical work and research to provide evidence for policy decision making. The analytical work will include use and quality of secondary care services, urban health care, and a performance review of tertiary care hospitals. The analytical studies will be discussed and finalized during appraisal. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project will be implemented across the province over a four year period. The focus of the program is on the public sector with health facilities located within both urban and rural areas. Sixty percent of the population of the country lives in the province ofPunjab (land of five rivers), which has geographical variation from green mountains in the upper part to the rugged and barren hills towards its west. Predominantly the plains of the Punjab are irrigated and are considered to be the food basket of the country. The province also has two large tracts of deserts, Cholistan and Thal. The province also has five large cities with population over one million each. Dense population, more urban population and more industrialization in comparison to the rest of the country has resulted in typical environmental pollution issues including poor air and water quality and land degradation. Disposal of medical waste and its management is the prime focus from environmental safeguards perspective, which has implications both from geographical variation and population density. 5. Environmental and Social Safeguards Specialists Javaid Afzal (SASDI) Samina Mussarat Islam (SASDS) Public Disclosure Copy 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes The proposed project interventions are BP 4.01 environmentally benign, however, considering the project is being processed as sectoral program, safe disposal of medical waste is integrated into the project design. Currently, DLIs are being formulated in a way that the bank finances will not be used in any new construction, however rehabilitation or renovation of existing physical infrastructure is a possibility. Safe disposal of medical waste both in the urban and rural areas has remained a major issue and borrowers’ attention will be focused towards adequate and safe management by integrating it into the project design. There will be no negative impact of this project in terms of land acquisition, involuntary resettlement or indigenous people. In addition, there will be no construction of health Page 3 of 7 facilities associated with the project and it will not cause any damages to private and public assets, therefore, social safeguard policies will Public Disclosure Copy not trigger. No indirect or long term negative impacts are expected associated with the proposed interventions, other than those related to the disposal of safe medical wastes from the health facilities for which OP4.01 is triggered. Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources OP/ No BP 4.11 Indigenous Peoples OP/BP 4.10 No Involuntary Resettlement OP/BP No 4.12 Safety of Dams OP/BP 4.37 No Projects on International No Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP No 7.60 Public Disclosure Copy II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the Restructured project. Identify and describe any potential large scale, significant and/or irreversible impacts: The proposed project is designated as "Category B" and triggers OP/BP 4.01 (Environmental Assessment). The proposed project interventions are environmentally benign. The project is processed as a sectoral support to implement using a results-based approach. DLIs as formulated ensure that the bank finances will not be used in any new construction. However, under the Bank finances may be used for rehabilitation and renovation of existing physical infrastructure to enhance the quality of health care service delivery, which may have low to medium adverse environmental impacts. Therefore, the project has been categorized as ‘B’. Other than the Bank’s safeguards policy OP 4.01, no other policy is triggered by this project. Safe disposal and recycling of medical waste both in the urban and rural areas is a major issue for the health sector. Apart from some major hospitals in the province, none of the medical facilities have any incineration or other suitable facility. The Borrower has developed an Environmental and Medical Waste Management (EMWMP) with the objective to mitigate and manage identified issues, which have an overarching impact on health service delivery. EMWMP also presents an analysis of current situation in terms of medical waste collection and its disposal in the province Page 4 of 7 based on surveys and field visits. The plan developed by the borrower will help in reducing the risk of infection, safety and health hazards, and also providing a safe and hygienic health care infrastructure. EMWMP also presents arrangements for the internal and external monitoring, Public Disclosure Copy capacity building needs, and budgetary arrangements for implementation. The proposed project is also not expected to cause significant long term adverse environmental and social impacts. There will be no negative impact of this project in terms of land acquisition, involuntary resettlement or indigenous people. In addition, there will be no new construction of health facilities associated with the project and it will not cause any damages to private and public assets, therefore, social safeguard policies will not trigger. No indirect or long term negative impacts are expected associated with the proposed interventions, other than those related to the disposal of safe medical wastes from the health facilities for which OP4.01 is triggered. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: The proposed project is not anticipated to cause significant indirect or adverse social or environmental impacts. Environmental pollution control in the province is relatively weak and environmental pollution control indicators in the coming years will remain as such and not improve particularly when the pollution causing factors will increase manifold due to large scale infrastructural development, fast urbanization and industrialization process. One major element to determine the quality of health service is the adequate and safe disposal of medical waste, which as stated earlier, is at elementary stages. The combined effect of all these factors on the environmental indicators in the long run is therefore negative.pacts . 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. Since the project is designed to provide support to GoPb’s health sector reform project, the only option for the project is ‘no project’. The project provides an opportunity to the GoPb to consider and integrate environmental issues into the project design and upscale the results to the program level. Public Disclosure Copy 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. The overall responsibility of implementing the environmental and health care waste management issues, particularly the present EMWMP, will rest with the Program Director, Punjab Health Sector Reforms Program (PHSRP). PHSRP, will hire a full time senior level officer to help implement EMWMP and will be designated as the Environment and Waste Management Focal Point (EWMFP). The EWMFP will maintain vertical and horizontal coordination to ensure effective implementation of the present plan, and will be responsible for province-level documentation and reporting. At the district level, the Executive District Officer – Health (EDO- Health) of each district will be the focal point for performing/supervising the environment and health care waste management functions, and particularly for implementing the present EMWMP in the respective district. At the facility level, the Medical officer in smaller facilities and the AMS in larger facilities will be designated as the focal point for EMWMP implementation. During the environmental assessment, it has been indicated in the report that many hospitals, particularly at the district levels and above, have medical waste management plans developed and committees set up for their implementation. However, these are effective in terms of getting rid of medical waste out of their medical wards and in many cases waste ends up outside the medical facility. The project has therefore proposed an institutional arrangement for the waste management which Page 5 of 7 involves responsible officer at each tier of government and adequate financial resources have been earmarked for the implementation. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure Public Disclosure Copy on safeguard policies, with an emphasis on potentially affected people. The key stakeholders are the Department of Health, Planning and Development Department, Department of Finance, Provincial Environmental Protection Agency (PEPA) and the relevant provincial units of the department of health including PHSRP and Director General Health Services, and the contracted NGOs and especially the local communities. The EMWMP will be widely disseminated to all relevant stakeholder groups across medical facilities in the format and languages that suit the stakeholders. The EMWWP will be disclosed in all the relevant locations and DOH website in English and Urdu as well as in WB Infoshop. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 01-Mar-2013 Date of submission to InfoShop 13-Mar-2013 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure Pakistan 11-Mar-2013 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: Public Disclosure Copy C. Compliance Monitoring Indicators at the Corporate Level OP/BP/GP 4.01 - Environment Assessment 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? Page 6 of 7 Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] include the monitoring of safeguard impacts and measures Public Disclosure Copy related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] with the borrower and the same been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader: Inaam Ul Haq Approved By Regional Safeguards Name: Sanjay Srivastava (RSA) Date: 14-Mar-2013 Coordinator: Sector Manager: Name: Julie McLaughlin (SM) Date: 13-Mar-2013 Public Disclosure Copy Page 7 of 7