INTEGRATED SAFEGUARDS DATA SHEET CONCEPT STAGE Public Disclosure Copy Report No.: ISDSC8331 Date ISDS Prepared/Updated: 08-May-2014 Date ISDS Approved/Disclosed: 08-May-2014 I. BASIC INFORMATION A. Basic Project Data Country: Myanmar Project ID: P149960 Project Name: Myanmar Towards Universal Health Coverage (P149960) Task Team Hnin Hnin Pyne Leader: Estimated Estimated 10-Sep-2014 Appraisal Date: Board Date: Managing Unit: EASHH Lending Investment Project Financing Instrument: Sector(s): Health (85%), Other social services (15%) Theme(s): Health system performance (85%), Other social protection and risk management (15%) Financing (In USD Million) Total Project Cost: 115.00 Total Bank Financing: 100.00 Public Disclosure Copy Financing Gap: 0.00 Financing Source Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 100.00 Health Results-based Financing 15.00 Total 115.00 Environmental B - Partial Assessment Category: Is this a No Repeater project? B. Project Objectives The objective of the proposed operation is to increase access to essential health services, with a focus on progress towards MDGs related to maternal, newborn and child health (MNCH). The proposed project is the first phase in the program of support that aims to advance Myanmar towards UHC goals of equitable access to quality essential health services and enhanced financial protection. C. Project Description Public Disclosure Copy A. Project Concept To advance towards the UHC goals of equitable access to quality essential health services and enhanced financial protection, Myanmar would need a program of support that delivers: (i) service delivery readiness, quality, and performance; (ii) sustainable and equitable health financing; and (iii) strong governance and stewardship of the health sector. The proposed operation is the first phase of this program of support, which would focus on service delivery readiness, quality and performance at the Primary Health Care (PHC) level and also provide capacity-building and program support and lay the ground-work for Phase II. To facilitate smooth and timely implementation, the proposed operation, to be financed by IDA credit and Health Results Innovation Trust Fund Grant, would be complemented by a coherent and well aligned program of technical assistance (TA) – finances for which would be mobilized from other development partners with shared interests. Component 1: Strengthening Primary Health Care Delivery and Utilization. A priority for achieving UHC is making the delivery of a basic package of services of good quality available to the entire population. In order to achieve this, the Government would need to make sure that medical supplies including pharmaceuticals and other consumables, are regularly supplied to primary care facilities to prevent any stock-outs, that staff in the facilities are well trained, be present in sufficient numbers and treat patients in a friendly and respectable manner. The facilities would need to be well maintained. These efforts would need to take into account existing service delivery models in the country, such as social franchised networks of General Practitioners, NGOs, and faith-based organizations in the ethnic and border areas. Public Disclosure Copy While long-term sustainable financing mechanisms are being developed, in parallel, urgent measures are needed to empower local level health care managers to ensure the smooth operation of health services. In order to achieve the MDGs 4 and 5, in the immediate-term, the supply of MNCH services at the PHC level need to be of acceptable quality, with adequate coverage and utilization. Enhanced service utilization will also need effective communication efforts to inform and empower communities – both to improve health-care seeking behaviors and to be able to demand services from the providers and provide feedback. To assist Myanmar in realizing the above short-term strategy, World Bank financing would support: • Channeling funds through MOH to Township levels and below for operational costs, medical consumables and minor maintenance. Grants would be provided to TMOs, for onward disbursement to RHC and SC levels based on Standard Operating Procedures, for eligible expenditures • Strengthening FM capacity at Township and Central levels, which could encourage other development partners to channel funds through Government systems • Health Care Waste Management and social safeguard compliance activities • Community empowerment: Building on existing mechanisms, such as Village Health Committees, communities will be informed and empowered to demand services, provide feedback and community oversight. • Results-Based Financing: Phase I will be used for sensitization of policy-makers, planners and implementers to the concepts of RBF, and for designing and developing the pilot interventions. Component 2: Program support, capacity building and Phase-II ground-work. The component Public Disclosure Copy would provide management support to the program, and finance the development of strategies, guidelines and operational manuals (e.g., Health Financing Strategy, Definition of Essential Package of Health Services, Quality Assurance and Accreditation Systems, Health Care Waste Management Guidelines, Social Assessment, Standard Operating Procedures for fund-flow). It would strengthen fiduciary systems so as improve efficiency in the sector and create more transparency, accountability and a smooth flow to frontline services. The Bank funds would support consultation workshops, training programs, South-South exchanges, and independent verification of Disbursement Linked Indicators achievements through third party monitoring and make funds available for training. Progress in this focus area would be further bolstered by leveraging USAID technical support program on supply chain management, and service availability and readiness assessments funded by GAVI Health systems strengthening project and 3MDG Fund. Proposed Instrument The proposed operation would use Investment Project Financing with Disbursement Linked Indicators. DLI progress will be reviewed annually and will be subject to independent verification. The arrangements for the review, its financing as well as its timing will be decided with Government during project appraisal, so that IDA disbursements can be made at a proper time in the Government’s budget cycle. World Bank plans to mobilize additional financial support in the form of international and national technical assistance to be focused on monitoring and evaluation of the programs and capacity building to enhance program implementation towards achievement of DLI targets. The project is conceived as the first phase of a larger program of support to the sector, which would Public Disclosure Copy include health financing and broader sector reforms. Such program will be prepared in the coming year and may run contemporaneously with this first phase. D. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project is nation-wide in scope, exact scope and roll-out will depend on minimum capacity criteria being met, in particular financial management and data. The support to frontline service delivery is expected to increase the utilization of health services by target populations and may generate incremental health care waste, such as sharps or contaminated waste, which needs to be handled properly. Eligible expenditure items may include minor renovations and repairs of existing facilities. Specific environmental safeguard mitigation measures would be applied under the project. It will be important that these basic services are available in an equitable manner to the entire population including remote populations and ethnic minorities. The implication of fee-exemption schemes and other possible financial protection measures also need to make sure equitable application across different social groups. Specific social safeguard measures would be applied under the project. E. Borrowers Institutional Capacity for Safeguard Policies No past experience with World Bank funded operations or relevant safeguard policies. There is a lack of legal requirements and limited institutional capacity for ensuring effective safeguard Public Disclosure Copy preparation and implementation. The institutional capacity to address safeguard policies will be further assessed during project preparation, and measures will be identified to build capacity and support the Ministry of Health in the implementation of the safeguard instruments (Environmental Management Plan and Community Engagement Planning Framework). Specific training on project relevant activities such as medical waste management including medical waste tracking and treatment recording as well as safe work practices in medical facilities will be proposed and costs estimated in the Health Care Waste Management Plan developed as part of the EMP and followed during project implementation. F. Environmental and Social Safeguards Specialists on the Team Svend Jensby (EASDE) Pamornrat Tansanguanwong (EASTS) Ruxandra Maria Floroiu (EASER) Satoshi Ishihara (EASTS) II. SAFEGUARD POLICIES THAT MIGHT APPLY Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes The project is expected to provide direct BP 4.01 financing to existing operational budget linked primarily to operation and maintenance of health care facilities; No new construction or expansion of existing health facilities will be financed. However, the project may include financing for small-scale rehabilitation of Public Disclosure Copy existing health care facilities within the same foot print (if budget permits) or financial support for new health care equipment for primary care use (e.g., syringes). Such support might generate minor temporary site-specific environment impacts (e.g., dust, noise) and/or contribute indirectly to increased health waste, which needs proper management and disposal. Consequently, the project has been proposed as category B since all physical works will take place within footprint of existing facilities with minor impacts. In order to address the OP 4.01 requirements, the client will prepare before project appraisal implement an Environmental Management Plan (EMP) adapted to the project that will include: (i) specific ECoPs to address impacts linked to planned minor refurbishment works (e.g., wall painting, window repairs) and (ii) anHealth Care Waste Management Plan (HCWMP) adapted to the project that will ensure addressing properly health care waste management impacts, as well Public Disclosure Copy as those linked to minor refurbishment works. The HCWMP will include, among other aspects, info on: characteristics and hazards profile of health care waste (solid, liquid, infectious, pathological, sharps, pharmaceutical, radioactive and mixed); medical waste containment and storage requirements and locations; treatment, disposal and transportation, including options; emergency actions; responsibilities for health care waste management, and training. The EMP including the ECoPs and the Health Waste Management Plan will be annexed to the Project Operational Manual, and will be disclosed in country and Infoshop before project appraisal as the instrument to implement the OP 4.01 provisions for this operation. One public consultation will be held on the draft EMP before project appraisal. During project implementation, the project also intends to support the development of national health care waste management guidelines (which will represent one of the DLI targets). A social assessment will be undertaken during project preparation to assess potential social impacts and risks as per OP 4.01 and OP Public Disclosure Copy 4.10, and measures to address such impacts during project implementation will be addressed in the Community Engagement Planning Framework as well as Community Engagement Plans. Natural Habitats OP/BP 4.04 No The project will not finance construction of new, or expansion of existing, health facilities and will not impact natural habitats. Forests OP/BP 4.36 No The project will not finance activities that will affect forest, forest health and forest-dependent communities. Pest Management OP 4.09 No The project activities will not support or finance the use of pesticides, such as for control of vector-borne diseases such as malaria and dengue. Physical Cultural Resources OP/ No There are no known important cultural BP 4.11 resources in health facilities which could be affected by the project. As such, the project will not adversely affect sites with archeological, paleontological, historical, religious, or unique natural values. Public Disclosure Copy Indigenous Peoples OP/BP 4.10 Yes Specific project areas have not been identified and will not be identified prior to project appraisal. However, the project is national and will include areas with ethnic minorities that are covered under OP 4.10. Myanmar is made up of 135 officially recognized ethnic groups, grouped into 8 “ethnic races” including the majority Bamar. In the absence of exact census figures, it is estimated that Ethnic minorities account for one third or more about 30% of the total population, and live mainly in the 7 Ethnic States (Kayah, Kayin, Kachin, Chin, Mon, Rakhine, and Shan) in the border areas. The provision of health services supported by the project is not expected to have adverse impacts on ethnic minorities. However, the project presents issues related to equity in access and culturally appropriate delivery of services and their quality in areas with ethnic minorities as well as other vulnerable population groups. A social assessment (SA) will be undertaken during project preparation, and will include consultations with organizations representing and working with ethnic minorities. The SA and consultations will Public Disclosure Copy inform the preparation of an implementation framework that will go beyond OP 4.10 and address social issues and potential impacts for all communities for engaging local communities while addressing particular issues concerning ethnic minorities and other vulnerable groups. The Framework will include an Indigenous Peoples Planning Framework as required under OP 4.10. It will contain namely procedures for practical and site-specific social assessments, consultations and culturally appropriate measures that will be contained in Community Engagement Plans (equivalent of Ethnic Minority Plans) to be developed during project implementation. The Community Engagement Plans may go beyond OP 4.10 and address social issues and potential impacts for all communities, however, with clear provisions for addressing particular issues in cases where ethnic minorities are present. Involuntary Resettlement OP/BP No The project will not finance construction of Public Disclosure Copy 4.12 new, or expansion of existing, health facilities and will therefore not involve any land acquisition. Safety of Dams OP/BP 4.37 No The Project will not finance any activities related to the construction of dams nor affect operations of existing dams or affiliated reservoirs. Projects on International No The project will not affect international Waterways OP/BP 7.50 waterways. Projects in Disputed Areas OP/BP No No activities are planned in any disputed areas. 7.60 III. SAFEGUARD PREPARATION PLAN A. Tentative target date for preparing the PAD Stage ISDS: 02-Jun-2014 B. Time frame for launching and completing the safeguard-related studies that may be needed. The specific studies and their timing1 should be specified in the PAD-stage ISDS: During project preparation, the Task Team (TT) will work with the Ministry of Health (MoH) in assessing potential environmental impacts and issues related to the project and existing policies and mechanism for addressing such issues, particularly concerning management of health care waste. Relevant ECoPs and a simple Health Waste Management Plan will be prepared prior to appraisal for project specific activities that may have environmental impacts, such as rehabilitation of health facilities and generation of health-care related waste. Public Disclosure Copy The TT will work with the MoH in the undertaken of the social assessment and consultations during project preparation. The TT will also support the preparation, prior to appraisal, of the implementation framework for engaging local communities and addressing particular issues concerning ethnic minorities and other vulnerable groups, including the required elements of an IPPF. To be specified at PAD stage. Public disclosure and consultations will be undertaken concerning the EMP, SA and the Community Engagement Planning Framework prior to project appraisal. IV. APPROVALS Task Team Leader: Name: Hnin Hnin Pyne Approved By: Regional Safeguards Name: Peter Leonard (RSA) Date: 08-May-2014 Coordinator: Sector Manager: Name: Toomas Palu (SM) Date: 08-May-2014 1 Reminder: The Bank's Disclosure Policy requires that safeguard-related documents be disclosed before appraisal (i) at the InfoShop and (ii) in country, at publicly accessible locations and in a form and language that are accessible to potentially affected persons.