The World Bank Kiribati Health Systems Strengthening Project (P176306) Project Information Document (PID) Concept Stage | Date Prepared/Updated: 24-Jul-2021 | Report No: PIDC31523 Jun 25, 2021 Page 1 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) BASIC INFORMATION A. Basic Project Data OPS TABLE Country Project ID Parent Project ID (if any) Project Name Kiribati P176306 Kiribati Health Systems Strengthening Project (P176306) Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) EAST ASIA AND PACIFIC Oct 15, 2021 Mar 15, 2022 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Republic of Kiribati Ministry of Health and Medical Services Proposed Development Objective(s) The Project Development Objective (PDO) is to improve equity and quality of health care in Kiribati and to provide immediate and effective response in case of an eligible crisis or emergency. PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 Total Project Cost 9.00 Total Financing 9.00 of which IBRD/IDA 9.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 9.00 IDA Grant 9.00 Environmental and Social Risk Classification Concept Review Decision Substantial Track II-The review did authorize the preparation to continue Jun 25, 2021 Page 2 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) Other Decision (as needed) B. Introduction and Context Country Context 1. Kiribati, one of the smallest and most remote countries in the world1, is a lower middle-income country with an estimated population of 117,606 spread over 21 of the country’s 33 atolls and islands in the Pacific.2 Only around 20% of the country’s population is formally employed in the cash economy, with 80% of the jobs provided by the public sector; food security relies largely on fisheries and subsistence agriculture. It has a limited economic base, dominated by (a) investment income from its sovereign wealth fund, the Revenue Equalization Reserve Fund; (b) the sale of fishing license fees; (c) remittances; and (d) aid flow. The total land area is only 811 sq km, but its exclusive economic zone covers approximately 3.5 million sq km.3 Around 50% of the population lives in villages across the islands, the rest lives on the main island of South Tarawa, where the capital Tarawa is located, one of the most densely populated areas in the Pacific. With its low-lying atolls on average rising barely 3 meters above sea level, Kiribati is one of the countries most exposed to climate change. The fishing license fees have seen a steady rise over the years, although this level of income may not continue due to changing climate and tuna migration patterns.4 2. The additional public revenues5, in recent years, have led to a strong growth in GNI per capita, but the human development outcomes are relatively low.6 Kiribati’s latest assessed Human Capital Index (HCI)7 remains low; a child born in Kiribati today will be 49% as productive when s/he grows up as s/he could be if s/he enjoyed complete education and full health. Kiribati has done well in lifting most of its population over the US$1.90 extreme poverty line; as measured by international living standards, it has very low levels of extreme poverty, with only 1.5% of the population living below the extreme poverty line and most of these live outside of South Tarawa. There are major geographic differences in the extent of poverty across Kiribati, measured in the basic needs poverty rate8, detailed in Table 1. The largest number (almost one-third) of people in the Southern division live in poverty, while only 10% of the population in the Central division are poor. Although the poverty rate is only slightly lower in South Tarawa compared to the Northern and Line Islands divisions, there is a substantially lower poverty gap. This means that on average the poor in South Tarawa have a level of consumption much closer to the poverty line than the poor in the Northern and Line Islands divisions. 1 It is more than 4,000 kilometers (km) from the nearest major economies (Australia and New Zealand). 2 Annex 1 Figure 1 presents the location of Kiribati in the South Pacific and Figure 2 presents the five administrative divisions in Kiribati: Northern, South Tarawa, Central, Southern and Line Islands. 3 Kiribati Household Income and Expenditure Survey (HIES) for 2019-20. 4 World Bank Regional Partnership Framework FY2017-2021. 5 The Government has experienced a fourfold increase in public revenues from the fishing sector in the past decade, receiving fishing license revenues worth 66% of gross domestic product on average per year. 6 Kiribati ranked 132 out of 189 countries in the 2019 Human Development Index, the Human Capital Index (measuring the amount of human capital that a child born today can expect to attain by age 18, given the risks of poor health and poor education that prevail in the country where he/she lives) is 0.49 in 2020, similar to other Pacific Island countries; HIES for 2019-2020. 7 https://www.worldbank.org/en/publication/human-capital & https://openknowledge.worldbank.org/handle/10986/34432 8 A “cost of basic needs� poverty line is a way of measuring poverty by calculating the threshold of consumption required to me et the minimum food and non-food needs. Jun 25, 2021 Page 3 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) Table 1: Kiribati Population Spread, Regional Poverty Rates and Distribution of the Poor Share of total population (%) Poverty Rate (%) Distribution of the Poor (%) South Tarawa 53.3 19.5 47 Northern 18.0 25.8 21 Central 7.4 9.6 3 Southern 13.8 31.5 20 Line Islands 7.5 24.6 8 Source: Kiribati Household Income and Expenditure Survey (HIES) for 2019-20 3. Kiribati remained COVID-19 free until mid-May 2021, when two seafarers on a cargo ship tested positive on board a fishing vessel returning from a foreign fishing port. The government had been taking proactive preparedness and response measures, and on May 25 received its 20% allocation of AstraZeneca vaccines from COVAX. Vaccinations started in the country on May 28, targeting first the frontline and essential workers, as well as the vulnerable and older citizens. In early April, Kiribati had been allocated 24,000 doses of the AstraZeneca vaccine through COVAX, with an expiration shelf life at the end of May 2021. The government requested for another batch to be sent with a longer shelf life and is now awaiting the shipment of vaccines to arrive before August 2021. For vaccination beyond the initial 20%, the government is also in discussion with the Governments of Australia and China. The COVID-19 response effort is supported by the development partners, including the Australian Department of Foreign Affairs and Trade (DFAT) and New Zealand’s Ministry of Foreign Affairs and Trade (MFAT), World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Asian Development Bank (ADB), and the World Bank. Sectoral and Institutional Context 4. The Ministry of Health and Medical Services (MHMS) is responsible for delivering health care services, health human resource training and development, statutory function and responsibilities, as well as contributing to national cross-cutting agendas, such as aged/elderly, disabilities, climate change and gender-based violence (GBV). The draft National Health Strategic Plan 2020-2023 (NHSP) aims to operationalize both the Government’s health objectives as outlined in the Kiribati Vision20 plan, and the National Development Plan 2016-2019, as well as its commitments to regional and global initiatives and undertakings for the population’s health. The NHSP is aligned with Goal 7 of the National Development Plan 2016-2020 to “improve health and promote healthy lifestyles� and gives priority to mortality and morbidity related to non-communicable diseases (NCDs), maternal and child health, as well as health system issues. The standard functions, priority interventions and new development activities of the Ministry have been grouped under six Key Priority Areas (KPAs-see Annex 2 for a listing). The Plan, which includes MHMS’ relationship to laws, regulations and policies, provides a snapshot of the country’s health status (see Annex 3). 5. Despite notable improvements in recent decades, most of the population’s health outcomes do not compare well with other small countries in the Pacific; and is now focused on the universal health coverage (UHC) targets under the Sustainable Development Goals. In many respects, this reflects the very difficult geographic, environmental, and social determinants of health that the country faces. Strong collaboration across sectors was recognized as essential to implement the “health in all Government policies� under the Kiribati Ambo Declaration in 2017, but there is no reporting available on progress for this important initiative. As reflected in the World Bank’s work with the Government under the ongoing program of advisory services and analytics (PASA), the MHMS has taken steps to improve its oversight of health sector performance. While MHMS had made good progress reviewing the health sector’s performance on a quarterly basis with development partners up to 2019, it has not been sustained. Jun 25, 2021 Page 4 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) 6. The leading communicable diseases reported include tuberculosis (TB), leprosy, trachoma, diarrhea, dysentery, and sexually transmitted infections; notwithstanding a steady decline over the years, the TB incidence remains one of the highest in the region.9 Kiribati is one of three countries in the Pacific where leprosy remains a public health problem, and neglected tropical diseases (i.e., trachoma, and soil-transmitted helminthiases) are common. Poor water quality, poor sanitary conditions and unhygienic behaviors, among other things, contribute to the most reported and prevalent health issues (diarrhea and dysentery); these diseases are highly contagious and a major contributor to under-five morbidity and mortality. While maternal, neonatal, infant, and under-five mortalities have declined since the early 1990s, the rates are among the highest in the region10; child mortality rates are slightly higher for girls than boys and in remote outer islands among poorer households and among mothers with lower levels of education. There were three maternal deaths in 2020 (similar to previous years). While immunization rates are relatively high, following a major measles and rubella supplementary vaccination program in 2019, coverage reportedly dropped in 2020, with the childhood measles immunization rate (at least one dose) dropping from 85% in 2019 to 81% in 2020. 7. Non-communicable diseases (NCDs) are estimated to account for 54 deaths per 10,000 population aged 30 to 69 years in Kiribati, based on 2019 data, and the probability of dying from any cardiovascular, cancer, diabetes, and chronic respiratory diseases between the ages of 30 and 70 is 28.4%. The major risk factors in the adult population are tobacco use, unhealthy eating, alcohol consumption and physical inactivity. Additionally, mental illness, suicides, domestic violence and injuries are growing health concerns and challenges to be addressed. 8. While some form of a health facility is usually accessible, the quality of these varies considerably across the islands due to restricted communication and related support systems adding to the many challenges faced by service providers and the people they serve. Kiribati generally reports much higher health seeking behavior compared with most other lower-middle income Pacific countries, with outpatient consultations between 2015-2020 averaging around 4.7 per person per year (in 2020 it dropped to 3.7 per person per year which may reflect COVID-19 pandemic related changes to health seeking behavior across the country). While in principle the population of Kiribati has free access to some form of basic health care, delivered primarily by the MHMS through a network of public facilities consisting of 4 hospitals, 22 health centers, and 87 village clinics (there are 3 non-governmental organization health clinics) , there are significant inequities and quality of service. As of 2019, there were 62 doctors and 409 nurses on the Employment Register which equates to 0.5 physicians, and 3.5 nurses per 1,000 population. 9. Recent improvements in the evolving telecommunication services across the country provide an opportunity to reinvigorate previous efforts by MHMS to strengthen service performance at all health facilities. This could include: (a) better patient monitoring and care closer to home, with telehealth support to local health workers for more effective case management; (b) more supportive supervision of health workers as a result of ongoing learning and professional development; (c) more timely monitoring of health service data; and (d) more efficient stock management of pharmaceuticals and medical supplies. The number of facilities and staff varies significantly across geographic locations and island groups, with nearly two-thirds of the clinical staff deployed in South Tarawa. Current connectivity between many outer island facilities rely on the use of mobile phones – but with limited service coverage and usually at considerable expense to the individual health worker. 10. The MHMS is finalizing its Role Delineation Policy (RDP) which sets out what services are expected to be provided at each level of the health system; implementation of the RDP includes plans to strengthen supportive supervision of health workers across facilities, particularly for those working in more remote and isolated locations. As 9 In 2019, 419 case notifications per 100,000 population, United Nations Development Program/Global Fund Multi-Country Western Pacific Integrated HIV/TB Program 10 World Bank Regional Partnership Framework FY2017-FY2021, February 28, 2017. Jun 25, 2021 Page 5 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) part of the World Bank-supported Kiribati COVID-19 Emergency Response Project (P174219)11, and informed by the RDP work, the MHMS has completed a user requirement analysis on information communication technology (ICT) for health facilities, to improve connectivity across facilities. The Ministry of Information, Communication, Transport and Tourism Development is part of this ongoing work given the need to have a more integrated approach to this across the Government of Kiribati (GOK). 11. The GOK’s 20-year vision 2016-36, recognizes that a healthy population is a productive population and good health is a pre-requisite to economic growth and poverty reduction. While the GOK is implementing measures to build a healthy society, the high prevalence of both communicable and NCDs remain significant threats to the lives, wellbeing, and productivity of its people. The COVID-19 pandemic has reinforced that safe water and sanitation services remain inadequate for many. There is a lack of working hand-basins and taps for basic infection prevention and control (IPC) in most health facilities, despite recent efforts to address some of the immediate needs.12 In addition to general poor nutrition, respiratory health is compromised by the ongoing high levels of cigarette smoking, and high rates of TB. When combined with the often-crowded living arrangements, particularly in urban Tarawa and in the islet of Betio (the country’s main port and large township with a population density equal to Hong Kong), disease outbreaks of any major nature will likely overwhelm the health system and further exacerbate the many other health, social and economic challenges the country faces. Relationship to CPF 12. When the World Bank Group Regional Partnership Framework FY17-FY21 (RPF)13 was developed, International Development Association (IDA) support to this region had been rising, with further increases expected for those on the harmonized list of fragile and/or conflict-affected situations (which included Kiribati); the situation is now exacerbated by the global COVID-19 pandemic. Like many of its neighbors, Kiribati having a widely dispersed population across a huge archipelago, translates into high costs of public administration delivery, limiting the quantity and quality of services available. 13. The proposed project is designed to strengthen health systems, improve access and equity to respond to communicable diseases and NCDs, as well as preparedness and resilience to natural disasters and climate change, and contribute to addressing the gender gap, in particular GBV. Of the four Focus Areas identified in the RFP, the proposed project will contribute to two aspects as follows: (a) Focus Area 314 by strengthening the health system, including addressing NCDs, communicable disease preparedness and response to include aspects of preparedness and resilience to natural disasters and climate change (under aspects of proposed components 1 and 2); and (b) Focus Area 2 by identifying entry points to address GBV in the training (proposed under components 1 and 2) and strengthen healthy family clinics to provide services for survivors. 14. In December of 2020, the Vice President and Minister of Finance and Economic Development wrote to the World Bank, indicating the Government’s priority list for its IDA 19 allocation, which included a Health Sector 11https://wbdocs.worldbank.org/wbdocs/component/drl?objectId=090224b087ae1f9a&Reload=1624905980365&__dmfClientId=1624905980 365&__dmfTzoff=240 12 Kiribati started, in 2020, to produce a local hand sanitizer in line with WHO guidance given the global supply chain constraints. 13 Pacific Islands - Regional partnership framework: FY17-FY21 (English). Washington, D.C.: World Bank Group. Report No. 120479. January 1, 2017. http://documents.worldbank.org/curated/en/137341508303097110/Pacific-Islands-Regional-partnership-framework-FY17-FY21. It covers Kiribati, Republic of Nauru, Republic of The Marshall Islands, Federated States of Micronesia, Republic of Palau, Independent State of Samoa, Kingdom of Tonga, Tuvalu, and Vanuatu. 14 Focus Area 3: Protecting incomes and livelihoods. A key focus will be on strengthened preparedness and resilience to natural disasters and climate change. Interventions will also help strengthen health systems and address NCDs. Jun 25, 2021 Page 6 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) Systems Strengthening project in an amount of US$9.0 million. This project will complement the ongoing COVID-19 project and fill critical gaps to strengthen the country’s health systems, such as the management of pharmaceuticals and medical supplies, improvement of laboratory and radiology diagnostic services, ICT connectivity, and telehealth services, among others. C. Proposed Development Objective(s) 15. The project development objective is to improve equity and quality of health care in Kiribati and to provide immediate and effective response in case of an eligible crisis or emergency. 16. Project areas. The project is national in scope but with a focus on strengthening health systems and improving services in the outer islands. 17. Project target group. The primary beneficiary of the project is the general population who seek health care services in public health facilities, particularly the vulnerable groups, including maternal, newborn, infant, and adolescents. Key Results (From PCN) 18. The proposed project’s contribution to the country’s overall health systems strengthening goals will be monitored primarily through PDO and intermediate indicators that focus on integrated health services to outer islands, nutritional status of children, in-service training to health care workers, upgrade and expand selected hospitals and lower level health facilities15, infection prevention control and health care waste management. 19. Achievement of the PDO will be measured by the indicators listed in Table 2. The list of indicators is a long list to select from based on the activities that will be agreed to during project appraisal. Table 2. PDO level indicators PDO Elements PDO Indicators Equitable • Number or percent of health facilities adequately equipped in outer islands. access to • Number or percent of health care workers in outer islands who received integrated in- primary service training. health • Number of Under-5 children in outer islands with monitored BMI (>75% of BMI monitored). services Quality of • Number or percent of health facilities that have 90% or more availability of essential health medicines and supplies. services • Number of health facilities that meet the minimum equipment standards set out in the MHMS Role Delineation Policy. • Enhanced Betio and Kiritimati hospital infrastructure capacity to provide critical services. Preparedness • Number of staff trained and assessed as competent in infection prevention and control per and response MHMS protocols. • Proportion of healthcare facilities with a basic functional healthcare waste management facility (100% health care facilities with functional health care waste management facility by 2023). 15 Health facilities at different levels predominantly provide primary health care services. Hospitals in most countries in the Pacific are primarily large primary health care centres. Jun 25, 2021 Page 7 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) D. Concept Description 20. The draft Kiribati National Health Strategic Plan for 2020-2023 (NHSP) provides a point of departure to identify priority interventions, new development activities, and programs for the MHMS. The NHSP has grouped broad goals and specific activities under six Key Priority Areas, shaping the discussions, content, and components of the proposed World Bank project. Development of the project and its implementation will be aligned, coordinated, and planned in conjunction with engaged bilateral partners such as New Zealand and Australia, international entities such as ADB, and MHMS technical partners, including WHO and UNICEF. 21. The proposed project will support MHMS to implement elements of the NHSP. It will have four components, namely: (a) Improving equitable access to health services in outer islands; (b) Strengthening quality and range of services provided through hospitals; (c) Project management enhancement, and (e) a contingent emergency response component (CERC). These components, and the activities which are described below are preliminary, and will be refined as project preparation proceeds. Project financing for all goods and services will take into consideration existing, current, and planned investments by other external partners; any health infrastructure development will be carried out taking into account environmental and social risks assessments, as well as climate change considerations. 22. Component 1: Improving equitable access to health services in outer islands. The scattered geographical distribution of Kiribati poses major challenges to accessing health services and distribution of medical supplies to outer islands. The physical layout of the country, and its current health service provision, often results in a need to conduct medevac missions (dispatched from Tungaru Central Hospital (TCH) located on Tarawa Island), which are affected due to unreliable air and sea transport. This often leads to delays in access to timely emergency and essential life-saving services which result in poor health outcomes. An identified need is for better, more regular, and timely health support to address known communicable diseases and NCDs prevalent on the outer islands, and expand prevention efforts, both of which are almost entirely dependent on the public sector. Financing under this component would be aimed at (a) improving referral services through provision of two sea ambulances with appropriate critical medical and communications equipment to provide integrated medical outreach programs to outer islands; (b) expanding outer island focused preventive programs designed to improve the nutritional status of mothers, newborns, children during the first 1,000 days, and for children under 5 years of age, building on existing government and external partner programs, including supplies of key micronutrients and expanding information education and communications; (c) improving outer island health providers skills through in-service training, particularly for the nurses and midwives in a range of MNCH high priority issues; and (d) conducting operational research to inform policies towards innovative outreach and referral systems that fit Kiribati’s geographical and infrastructure context. 23. Component 2: Strengthening quality and range of services provided through hospitals. The MHMS recognizes that, to provide satisfactory health care for all of Kiribati, it requires more effective public sector health facilities, in particular hospitals and allied services capabilities, and other elements in their health pyramid. MHMS identified the following core needs for support under the proposed project: (a) enhancement of health infrastructure, including (i) rebuilding and equipping the Kiritimati district hospital with climate resilient design; (ii) equipping the new District Betio Hospital; equipping, improving and modernizing pharmaceutical, laboratory and radiology diagnostic services; (iii) providing essential equipment for health centers and health clinics and refurbishing, based on a survey of their needs; (iv) supporting improved and well equipped hazardous waste management, along with bolstering MHMS’ efforts related to IPC implementation; (v) emergency ambulance; and (vi) establishing a mobile blood donor unit; (b) enhancement of the health information system (i.e., collection, storage and connectivity) building on ongoing efforts; (c) provision of training to technical specialists (i.e., laboratory, radiology, biomedical, pharmacy and information technology), and allied health workers to better utilize aspects supported under the proposed project, based on a Jun 25, 2021 Page 8 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) training needs assessment; (d) introduction of Geographical Information System to map out and support a syndromic surveillance system for early detection of outbreaks and early public health response which will assist in strengthening core elements of MHMS (i.e., human resource management as well as monitoring). 24. Component 3: Project management enhancement. This component will, on the basis of an assessment of MHMS’ list of priorities, provide support to project management. It will finance additional requirements (i.e., in aspects of safeguards, monitoring and evaluation-M&E, operational costs and others based on the activities which will ultimately be supported) for the World Bank supported COVID-19 project management unit (PMU) in MHMS, which will support this project’s management. 25. Component 4: Contingent emergency response component (CERC). The objective of this component is to improve the GOK’s response capacity in the event of an emergency, following the procedures governed by OP/BP 8.00 (rapid response to crisis and emergencies). The component would support a rapid response to a request for urgent assistance in respect of an event that has caused, or is likely to imminently cause, a major adverse economic and/or social impact to Kiribati associated with a natural or man-made crisis or disaster. In the event of an emergency, financial support could be mobilized by reallocation of funds from other Components to support expenditures on a positive list of goods and/or specific works and services required for emergency recovery. A CERC operational manual, governing implementation arrangements for this component, will be prepared with support under the project. Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Summary of Screening of Environmental and Social Risks and Impacts . Whilst the project aims to deliver significant environmental benefits through the financing of healthcare waste management infrastructure and capacity building the Environmental Risk Rating is considered 'Substantial' due to the complexity of managing risks and impacts such as healthcare waste in remote atoll island environments with limited natural resources, infrastructure and capacity. Potential environmental risks an impacts include: i) the consumption of finite natural resources (construction materials, aggregates, water and energy) during both construction and operational phases, particularly for the Kiritimati hospital; ii) the generation of healthcare waste such as liquid contaminated waste (e.g. blood, other body fluids and contaminated fluid), infected materials (water used; lab solutions and reagents, syringes, bed sheets etc.) and expired vaccines and other drugs; iii) increased dust and noise, sedimentation, minor hydrocarbon spills and waste disposal (potentially including hazardous materials such as asbestos and e-waste) from construction activities; and iv) other operational risks such as the ongoing storage and disposal of laboratory chemical, e-waste and sewage. Construction works are expected to be completed on brownfield sites minimizing any impacts to biodiversity. Potential occupational health and safety risks and impacts relate to the completion of construction activities, infection prevention and control, use of project financed equipment including the two sea ambulances (and more generally travel to outer islands) and the handling of medical or other hazardous waste such as asbestos or laboratory chemicals. Social risks for the project are considered Substantial given risks and impacts are of moderate significance but manageable. Most physical works are located within existing brownfield sites and therefore are not considered to be sensitive areas. Project activities are of medium complexity and impacts are expected to be site specific and primarily Jun 25, 2021 Page 9 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) temporary and/or reversible. Activities have a generally low potential for harming people or the environment, with any expected risks expected to be temporary, predictable, and readily managed through project design features and mitigation measures. Key social risks and potential impacts for Kiritimati hospital construction and road upgrade include land access, potential land acquisition, community health and safety risks due to interactions with construction workers and equipment, social disruption due to labor influx, risks to vulnerable groups and gender-based violence as a result of construction activities and the movement of people, GBV, Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) risks which are associated with construction; and increased traffic incidents and reduction in road safety due to road construction activities or improved road conditions which encourage faster travel times. Social inclusion risks include social tensions arising from perceived inequalities to vaccine roll out, risks to unequal distribution of benefits to vulnerable groups. SEA/SH risks have been assessed as low given the project involves moderate scale civil works, with a low to moderate influx workforce which are not expected to significantly increase the risk of GBV and SEA/SH risk within the community. There are some (low) risks SEA/SH risks of health workers operating in remote areas. E&S risks have been assessed for similar projects in Kiribati and are therefore generally well understood. Project risks and impacts will be managed through the inclusion of activities such as the financing of healthcare waste management infrastructure and capacity building in project design and the development and implementation of an environmental and social management framework (including an infection prevention and control and waste management plan and a code of environmental and social practice for construction activities), a labor management plan, a stakeholder engagement plan, and a resettlement framework and abbreviated resettlement action plan. Component 5 CERC activities are unknown as are based on emergency events, a CERC ESMF will be prepared to screen environment and social risks for CERC activities and will include a positive activities list. . CONTACT POINT World Bank Netsanet Walelign Workie Senior Economist, Health Borrower/Client/Recipient Republic of Kiribati Teuea Toatu Dr. hon.vicepresident@mfep.gov.ki Implementing Agencies Jun 25, 2021 Page 10 of 11 The World Bank Kiribati Health Systems Strengthening Project (P176306) Ministry of Health and Medical Services Tinte Itinteang Dr. tinte@mhms.gov.ki FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Task Team Leader(s): Netsanet Walelign Workie Approved By APPROVALTBL Country Director: Stephen N. Ndegwa 30-Jul-2021 Jun 25, 2021 Page 11 of 11