The World Bank Health System Performance Strengthening Project (P172504) Concept Environmental and Social Review Summary Concept Stage (ESRS Concept Stage) Public Disclosure Date Prepared/Updated: 02/23/2021 | Report No: ESRSC01885 Feb 23, 2021 Page 1 of 10 The World Bank Health System Performance Strengthening Project (P172504) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Chad AFRICA WEST P172504 Project Name Health System Performance Strengthening Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 2/25/2021 3/30/2021 Population Financing Borrower(s) Implementing Agency(ies) Ministre de l`Economie et Ministry of Health de la Planification du Developement Proposed Development Objective Public Disclosure The Project Development Objective is to improve the service delivery of essential health services in project-supported areas Financing (in USD Million) Amount Total Project Cost 65.00 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 proposed project will focus mainly on improving the health service delivery of essential health care, through institutional capacity building and the institutionalization of PBF, building on lessons learned from the Mother and Child Health Services Strengthening project (P148052) and from other world bank operations in Chad. The GFF Process in Chad, together with PBF and institutional capacity building will contribute to address above-mentioned challenges of the Chad s Health system. The project will support: a) a progressive scale-up of PBF while institutionalizing it. Feb 23, 2021 Page 2 of 10 The World Bank Health System Performance Strengthening Project (P172504) The number of provinces and health districts to be covered will depend on the costing of PBF which will be done during preparation. The project will cover the 37 districts of the five (5) Provinces previously covered by Mother and Child Health Services Strengthening project. New provinces and districts to be covered under the project based on criteria to be defined with the government during the preparation. Based on lessons learned from the Mother and Child Health Services Strengthening Project, the following new features will be added to the PBF design: (i) Building of verification system in the national institution; (ii) Establishment of PBF national Unit at the Ministry of health; (iii) Adding a quality/ investment bonus and community activities to the scheme; (iv) Improving the targeting of the poorest for free health care in PBF health facilities; b) the institutional Capacity building at different level of the health system as well as the investments in high-impact RMNCAH-N interventions identified in the Global Financing Facility (GFF) Investment case. The capacity building program will include: (i) Reinforcement of Humane Resource through training in technical and managerial skills, regular supervision and coaching of health personnel and community health workers, ; (ii) Improvement of leadership and governance through Development of norms, policy documents and guideline, training in management skills, separation of functions, regular coordination meetings between different levels of the health system, evaluation of different level of the health system including financial management evaluation, Performance contracting of directorates of the ministry of health ; (iii) Improvement of health information system by supporting implementation and effective utilization of DHIS2 and IT for management of health information system, regular production of annual health statistic report and national health Account, contribution to national surveys like DHS; (iv) Support to health Care delivery by Procuring equipment and others input that cannot be procured directly by health facilities in the country and financing any other activity of the GFF investment case not yet cover in above-interventions, including Public Disclosure nutrition and Civil Registration and Vital Statistics systems (CRVS). (v) This component will also support activities related to Gender-Based Violence and citizen engagement. The capacity building activities will be implemented with the technical support of development partners, especially the UN Agencies (WHO, UNICEF, UNFPA). The partnership with UN Agencies to provide Technical Assistance (TA) to conduct some training and capacity building of health personnel and community workers in Emergency Obstetric Care (EmoC) and Immunization during the implementation of Mother and Child Health Services Strengthening Project was satisfactory. Their performance in procurement of equipment for health facilities was moderately satisfactory due to the long delivery period. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Chad is a large landlocked Central African country with an estimated population of 16 million. Population density is low and the majority of the population is very young with more than 50 percent under 15 years of age. Sixty percent of females and 44 percent of males aged 6 and up have no formal education (DHS-MICS 2014-2015). The median age of marriage is 16.1 years for women against 22.8 years for men. Nearly half of the population lives in poverty and most of the poor are in rural areas where access to basic services including health and education is very limited. The country is highly vulnerable to climate change, particularly rainfall modifications, increased desertification of arable land, droughts, and other phenomena related to extreme weather conditions. This operation is being prepared as a new stand-alone project that addresses critical country-level needs for healthcare. It will be implemented nationally per the planned scale up of PBF as outlined in the PCN. It is expected to Feb 23, 2021 Page 3 of 10 The World Bank Health System Performance Strengthening Project (P172504) be very challenging given the high rural population, extreme distances between health centers, minimal levels of existing service provision and many areas of high insecurity and armed conflict. The project will focus mainly on improving the delivery of essential health care through institutional capacity building and the institutionalization of Performance Based Financing (PBF). It will build on lessons learned from the Mother and Child Health Services Strengthening project (P148052) and other World Bank health operations in Chad. The specific subproject locations have not yet been identified. However, no major civil works will be financed as all potential works (such as upgrading and rehabilitation) will take place in existing health facilities and laboratories. The project is not expected to affect natural habitats or cultural sites or require any land acquisition or economic displacement. D. 2. Borrower’s Institutional Capacity The project will be implemented by the Ministry of Health using the existing PIU for the World Bank-funded Regional Disease Surveillance Systems Enhancement (REDISSE IV, P167817), COVID-19 Response Project (P173894) and Mother and Child Health Services Strengthening project (PRSSMI - P148052). The PIU has good experience managing World Bank financed projects and in particular worked to improve the implementation rate and disbursements significantly for the Mother and Child Health project over the last 18 months. However, the environmental specialist and social specialist have just been recruited and neither has any previous experience with the ESF. While the environmental and social risks are generally considered manageable, the lack of experience with the ESF does mean that the capacity to address and manage these risks is weak and limited. The ESCP includes plans for capacity building including training on the ESF and compliance monitoring, recruitment of specialized staff and support from third party entities to assist with monitoring and evaluation. Public Disclosure 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 is deemed moderate. The funding under the project is geared towards capacity building and institutional strengthening including: (i) hiring of external consultancy support; (ii) minor civil works; (iii) purchase of goods and equipment; (iv) training of human resources; and (v) purchase of medicines. The main environmental risk identified at concept stage is related to health care waste management and potential environmental negative impacts are linked to the handling and disposal of medical and health waste in health facilities covered by the project area. Indeed, with the improved utilization of health services through the project, the quantity of bio-medical waste will increase. The indirect potential negative environmental and social impacts of the project are expected to be site- specific, small to moderate and easily mitigated. Under the PRSSMI, a national Medical Waste Management Plan was prepared and an assessment of this plan based on the environmental and social audit the PRSSMI conducted in May 2020 will be undertaken to inform the preparation of the ESMF for this project. Social Risk Rating Moderate The social risk rating is also considered moderate. The project will finance capacity building and institutional strengthening to improve access to basic health services especially for those in rural areas. No land acquisition, physical or economic displacement will be required. While insecurity is likely to influence the flow of implementation, there are no large scale works that will be financed that would further increase this risk nor are there significant changes in healthcare policy anticipated. In addition to these risks, there are risks related to the environment and the Feb 23, 2021 Page 4 of 10 The World Bank Health System Performance Strengthening Project (P172504) health of the community as well as the occupational safety of workers in the context of Coronavirus pandemic (COVID-19). Although the Ministry of Public Health authorities are working to contain the COVID-19 pandemic, their efforts may not succeed unless the project regularly incorporates the latest guidance from WHO and the Government as it evolves and learns from its experience with COVID-19 worldwide. Security risks may have a negative effect on the implementation of the project and the achievement of project objectives and results. Indeed, security risks are noted in northern, northeastern, eastern and central Chad, which continues to be volatile and unpredictable. In the project implementation area, the intensity of the conflict varies greatly. Thus, the North, Northeast and East of the country are the most affected areas. The nature of the insecurity in this part of the country is reflected in: insurgencies by armed groups for many years, violent crimes such as armed robberies, carjackings, etc., as well as the lack of security in the region. These assaults have been reported in this area and are generally believed to be associated with poverty and social exclusion. The Center has not experienced any armed conflicts. However, inter- community conflicts related to the scarcity of natural resources such as water and plant cover have been recorded on a recurring basis. The security crisis observed in this part of the country has had serious social and humanitarian consequences on local communities. Inter-community/farmers' conflicts in their current form are continually spreading to the south of the country, which could increase the risk of project activities being disrupted by insecurity. As such, security risk assessment and management will be critical to the achievement of the project's development outcomes. Mitigation: Potential security risks – including damage to project assets or threats to the physical security of beneficiaries and government staff – will be examined through an assessment prepared by the Borrower. This can take the form of either (i) separate security risk assessment (SRA); (ii) a detailed chapter on security risks as part of other ESF instruments. This assessment will then inform a Security Management Plan (SMP). The SMP describes how Public Disclosure and by whom security will be managed and delivered, the resources required, and the behavior that is expected of security personnel if armed forces, police, or gendarmerie are involved in any project-related activities Second, the project will maximize flexibility in design and implementation, including the selection of intervention areas and types of investments correlated with levels of insecurity and potential negative impacts for the project. Third, the project will also use geospatial data and other Information and Communication Technology (ICT) tools for supervision, monitoring and evaluation, which will help ensure successful project implementation. Regular and consistent dialogue with partners involved in security-related activities based on a set of questions in Annex (X). However, it is likely that despite mitigation measures security risks will remain residual. As such, the SMP will stipulate clear emergency procedures to be followed by PIU staff in case of incidents. 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. The Project is expected to have overall positive environmental and social impacts as it will contribute to improving the health service delivery of essential health care, institutional capacity building and the institutionalization of PBF especially in rural areas where current services are quite limited. It builds on lessons learned from the Mother and Child Health Services Strengthening project (PRSSMI - P148052). However, there are environmental and social risks and impacts that will need to be assessed and managed through a risk-based approach during preparation and implementation. The primary risks identified during identification include: (i) environmental Feb 23, 2021 Page 5 of 10 The World Bank Health System Performance Strengthening Project (P172504) and community health related risks from inadequate storage, transportation and disposal of medical waste; (ii) occupational health and safety issues related to the availability and supply of personal protective equipment (PPE) for healthcare workers; (iii) possible social exclusion from health facilities and services, especially for the poorest and most marginalized who have a limited ability to pay, and for the elderly or those with underlying medical conditions who would be most at risk in the event of a disease or pandemic outbreak; (iv) socio-political risks specifically related to insecurity especially in the North and Center regions of the country; and (v) low trust in the government that could lead to the rejection of public health interventions. As the exact scope of the project activities and the specific sites have not yet been defined, an Environmental and Social Management Framework (ESMF) will be prepared to provide guidance regarding the instruments that may need to be prepared after approval, such as Environmental and Social Impact Assessments/ Environmental and Social Management Plans (ESIAs/ESMPs). The ESMF will inlcude a biomedical waste management plan that is consistent with international good practice and WHO standards and specific COVID-19 related measures. The PIU will also develop codes of conduct and training materials and develop communication strategies as part of the SEP to raise awareness around SEA/SH. An Environmental and Social Commitment Plan (ESCP) will be prepared by the client and will include a timeline for preparing or finalizing required instruments such as the ESMF, SEP, site-specific ESIAs and ESMPs (if necessary), Labor Management Procedures (LMP), Grievance Redress Mechanism (GRM), etc. Areas where “Use of Borrower Framework” is being considered: Public Disclosure Use of Borrower framework for environmental and social assessments is not currently being considered for this project. ESS10 Stakeholder Engagement and Information Disclosure The main stakeholders of the project include a broad range of actors including health care workers, local government stakeholders, civil society, NGOs, media, local/neighborhood associations/clubs, religious organizations and leaders, youth groups/associations, medical doctors’ association, private health institutions, pharmacists’ association, etc. The PIU will prepare a Stakeholder Engagement Plan (SEP) that will be disclosed prior to appraisal. It will contain further details regarding the direct and indirect beneficiaries and other stakeholders as well as guidance regarding COVID 19 adaptations such as social/physical distancing. Given the current restrictions on public gatherings, it should be noted that most of the consultation will be conducted virtually using the WHO principles for consultation during a global pandemic. An accessible and functional Grievance Redress Mechanism (GRM) will be established to receive complaints and feedback from all stakeholders and beneficiaries in a transparent and timely manner. A specific GRM to receive complaints and concerns from workers will also be outlined in the SEP and the LMP. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. Feb 23, 2021 Page 6 of 10 The World Bank Health System Performance Strengthening Project (P172504) ESS2 Labor and Working Conditions This standard is relevant. The project will have direct workers (staff of the department of health, the institutes, hospitals, healthcare facilities and education/training institutes who will be working at the PIU) and contract workers (people hired on a contractual basis ). The project will finance minor repair and renovation work in a number of health facilities but labor requirements are expected to be minimal and mostly supplied by local labor from the communities near the project sites. Construction material required for the limited repair and refurbishment work will be sourced from local legal business entities with up to date permits and no primary supplier will be required. A Labor Management Procedure (LMP) will be prepared to provide details regarding the working conditions and terms of employment for all project related workers. It will specify that the use of forced or child labor will be prohibited and any hazardous work situation including handling and transportation of bio-medical waste will be prohibited for any person under the age of 18. The LMP will include measures to ensure equality of opportunity, address SEA/SH risks, allow for workers’ associations and include OHS measures. Finally, the LMP will set out the functioning of the GRM for labor-related issues. Standard contracts for the limited civil works will be required to include key requirements from the LMP, including codes of conduct, labor procedures and occupational health and safety measures. ESS3 Resource Efficiency and Pollution Prevention and Management This standard is relevant. Potential impacts may arise due to improper waste management including medical waste, Public Disclosure infectious waste, human waste, etc. Use of plastic-based materials in health facilities may lead to generation of high volumes of plastic waste of various types and add to land pollution. Furthermore, disposal of wastewater generated in the facilities may act as hazard for transmission of infectious disease and chemical toxicity due to dissolved chemicals such as laboratory re-agents, disinfectants, corrosives etc. At the same time, health facilities that are major water consumers may allow for potential opportunities for water conservation. These and other resource efficiency opportunities shall be assessed during sub-project level ESIA once the exact sites have been identified. The ESMF will assess the potential pollution impact and provide recommendations for systematic improvement of medical waste management – at both facility level and state level. A MWMP was developed in July 2012 and updated in 2018 under the PRSSMI. However, according to the Environmental and Social Audit conducted in May 2020 at the end of the PRSSMI’s implementation period, medical waste is still of significant concern. The ESMF will provide recommendations to effectively and efficiently manage the bio-medical waste (both solid and liquid waste) and solid waste. Liquid waste will be required to be treated before being discharged into any stream or natural water bodies. ESS4 Community Health and Safety This standard is relevant. Project activities include some health care service provision and these services may generate medical waste that could endanger local communities if this waste is not properly managed and treated. Also, the small repair and refurbishment activities may generate minor noise, air pollution and potential SEA/SH risks. Key community health and safety measures to be adopted and implemented will be included in the ESMF and Feb 23, 2021 Page 7 of 10 The World Bank Health System Performance Strengthening Project (P172504) other relevant project E&S instruments in order to manage specific risks and impacts to the community arising from project activities, including behavior of project workers, response to emergency situations etc. The World Bank’s EHS guidelines will also guide the preparation of the ESMF and all relevant plans. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This standard is not currently relevant. The project is not expected to require any land acquisition, or cause any physical or economic displacement. However, as the project may involve minor repair and/or refurbishment of existing structures, site-specific screening will be carried out before such works. If the project requires any land acquisition leading to involuntary economic or physical displacement, Resettlement Action Plans (RAPs) will be prepared, consulted and disclosed and fully implemented prior to the start of works. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard is not currently relevant. However, the specific locations of project activities are not yet known so the ESMF will contain guidance for managing potential biodiversity issues and high sensitivity biodiversity areas will be excluded. This will include: requirements for detailed mapping and, where appropriate, identification of protected species and instructions for the preparation of the necessary sections of any site-specific ESIA / ESMP and provisions for the protection of biodiversity. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities Public Disclosure This standard is not currently relevant as the project is not being implemented in areas where Indigenous Peoples/Sub-Saharan Historically Underserved Traditional Local Communities (IP/SSAHUTLCs) are present or in areas to which they have a collective attachment. ESS8 Cultural Heritage This Standard is not currently relevant. However, a Chance Find procedure will be included in the ESMF as a precaution. ESS9 Financial Intermediaries This Standard is not currently relevant. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No Feb 23, 2021 Page 8 of 10 The World Bank Health System Performance Strengthening Project (P172504) III. WORLD BANK ENVIRONMENTAL AND SOCIAL DUE DILIGENCE A. Is a common approach being considered? No Financing Partners N/A B. Proposed Measures, Actions and Timing (Borrower’s commitments) Actions to be completed prior to Bank Board Approval: - An Environmental and Social Management Framework (ESMF) - A Labor Management Procedure (LMP) - A Stakeholder Engagement Plan (SEP) - Updated Biomedical Waste Management Plan (MWMP) Possible issues to be addressed in the Borrower Environmental and Social Commitment Plan (ESCP): The ESCP will include timelines and provisional budgets for the implementation (and preparation in some cases) of the various instruments and a capacity-building plan for the PIU. It will also identify the key staff/consultants that will need to be hired during project implementation. Public Disclosure C. Timing Tentative target date for preparing the Appraisal Stage ESRS 28-Feb-2021 IV. CONTACT POINTS World Bank Contact: Jean Claude Taptue Fotso Title: Senior Health Specialist Telephone No: 5351+2233 / - -53512233 Email: jtaptuefotso@worldbank.org Contact: Andy Chi Tembon Title: Senior Health Specialist Telephone No: +1-202-458-4879 Email: atembon@worldbank.org Borrower/Client/Recipient Borrower: Ministre de l`Economie et de la Planification du Developement Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT Feb 23, 2021 Page 9 of 10 The World Bank Health System Performance Strengthening Project (P172504) 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): Jean Claude Taptue Fotso, Andy Chi Tembon Practice Manager (ENR/Social) Maria Sarraf Recommended on 23-Feb-2021 at 07:22:51 GMT-05:00 Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Cleared on 23-Feb-2021 at 08:07:0 GMT-05:00 Public Disclosure Feb 23, 2021 Page 10 of 10