Public Disclosure Copy COMBINED PROJECT INFORMATION DOCUMENTS / INTEGRATED SAFEGUARDS DATA SHEET (PID/ISDS) APPRAISAL STAGE Report No.: PIDISDSA16082 Date Prepared/Updated: 16-Mar-2016 I. BASIC INFORMATION A. Basic Project Data Country: Africa Project ID: P155658 Parent Project ID (if any): Project Name: AFCC2/RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) Region: AFRICA Estimated 15-Feb-2016 Estimated 26-May-2016 Appraisal Date: Board Date: Practice Area Health, Nutrition & Population Lending Investment Project Financing (Lead): Instrument: Borrower(s): Republic of Mozambique, Kingdom of Lesotho, Republic of Zambia, Republic of Malawi, Ministry of Finance, Ministry of Finance Implementing Ministry of Health, Ministry of Health, Ministry of Health, Ministry of Health Agency: Financing (in USD Million) Public Disclosure Copy Financing Source Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 60.00 IDA Grant 62.00 Total Project Cost 122.00 Environmental B - Partial Assessment Category: Appraisal Review Decision (from Decision Note): Other Decision: Is this a No Repeater project? Page 1 of 11 Public Disclosure Copy B. Introduction and Context Country Context Despite steady economic growth over the past decade, the Southern Africa subregion continues to grapple with high levels of poverty combined with some of the worst income inequality in the world. Annual gross domestic product (GDP) growth in the subregion has generally hovered above 4 percent since 2005. Rising income inequality, however, has dampened the effect of growth on poverty and constrained human development outcomes. This inequality and low levels of human development create a fertile ground for the spread of communicable diseases, such as tuberculosis (TB) and HIV/AIDS. The Southern Africa subregion has some of the highest TB rates on the continent and has been at the epicenter of the global HIV/AIDS epidemic with elevated TB/HIV coinfection rates. High levels of intraregional economic activity in Southern Africa have also created a fertile ground for the transmission of diseases across porous borders, underscoring the regional nature of the problem and the need for coordinated action. Informal cross-border trade in the subregion, while an important source of livelihood for populations residing in these areas, has contributed to the spread of infectious diseases (e.g. cholera, hemorrhagic fevers). Likewise, the historical patterns of migration in the subregion, from labor-sending countries to South Africa have generated important economic opportunities but have exacerbated communicable disease control efforts in the subregion. With a rapidly growing regional economic integration agenda and policies to reduce trade barriers, and facilitate the movement of goods ad people across the subregion these issues will take on a greater importance, requiring countries to put in place appropriate public health measures. The mining sector is a prominent example of how labor mobility can contribute to disease transmission. The vibrant mining sector in South Africa has traditionally attracted large numbers of workers from neighboring countries. While there are currently about 500,000 miners in South Public Disclosure Copy Africa’s mines, there are an estimated 3 million ex-miners in South Africa, Lesotho, Mozambique, Malawi, and Swaziland. The skyrocketing rates of TB in the gold mines in South Africa (3,000-7,000 per 100,000) place miners among the highest risk groups in the region. Many migrant miners live in dwellings with severe overcrowding and poor ventilation and work under difficult conditions, placing them at greater risk of developing TB and other occupational health diseases. As a result of high levels of mobility, mining communities and labor-sending zones in neighboring countries are also disproportionately affected by TB and related occupational diseases. For example, close to 40 percent of adult male TB patients in three of Lesotho’s main hospitals had worked in South African mines, highlighting the continual risk of disease transmission across borders. Sectoral and institutional Context The year 2015 marked a crucial crossroads in the fight against TB—now officially the leading global cause of deaths from an infectious disease, ahead of HIV/AIDS. TB is a highly preventable and curable condition. Although the Millennium Development Goal for TB has been met, the world still confronted 9.6 million new cases and 1.5 million deaths from TB in 2015 (WHO Global Tuberculosis Report 2015). Most (99 percent) cases are in poorer nations and inflict a tremendous burden on poorer households. A 2015 survey of diagnostic and treatment practices by Médecins Sans Frontières (MSF) and the Stop TB Partnership in 24 countries, including Mozambique, found huge gaps between current TB control policies and best practices that are critical to meet a global target of 90 percent reduction in TB incidence and 95 percent reduction in Page 2 of 11 Public Disclosure Copy TB mortality by 2035. To meet the recently endorsed Sustainable Development Goals by 2030, countries need to scale up adoption and implementation of best practices in TB control. Sub-Saharan Africa has the highest rates of TB and the worst treatment outcomes in the world. The continent accounts for 13 percent of the world’s population but a disproportionate 28 percent of the world’s burden of TB and 34 percent of deaths. Sub-Saharan Africa has about 281 incident cases per 100,000 population, more than double the global average of 133. Although TB incidence decreased globally by 45 percent between 1990 and 2014, rates in the Africa region continued to rise. Southern Africa contributes substantially to the global TB burden. Around a third of the world’s 22 high-burden TB countries are in Southern Africa, and most countries in the subregion are above the WHO threshold for a TB emergency (250 cases per 100,000). Eight of the 14 countries in the world with the highest TB incidence (at least 400 cases per 100,000) are in Southern Africa. While the unprecedented rise in TB cases in Southern Africa has been largely driven by the HIV epidemic, mining has been historically associated with some of the highest TB incidence rates. In South Africa, the incidence of TB is four to seven times higher among miners and ex-miners than among the general population. In Zambia, a recent population-based national TB prevalence survey found that TB prevalence in mining areas such as Ndola, Kitwe, and Solwezi is three to five times higher than the national TB average. Regionally, 33 percent of new TB cases in Sub-Saharan Africa are attributed to mining. The burden of TB is also high along the region’s transport corridors, in cross-border areas, and in labor-sending communities. MDR-TB is becoming an increasing threat to health and development gains. Inadequate treatment of TB creates resistance to first-line drugs, and leads to MDR-TB. Inadequate treatment of MDR- TB can lead to a highly lethal form of extensively drug-resistant TB (XDR-TB). Resistant forms of TB require the use of much more expensive drugs, which also have higher levels of toxicity and higher case fatality and treatment failure rates. Individuals who are treated inappropriately continue to transmit TB, but countries are ill equipped to identify and respond efficiently to such outbreaks. With growth in regional migration, global travel, and the emergence of lethal forms of the disease, TB poses a major regional and global public health threat. Putting in place systems Public Disclosure Copy for early detection, diagnosis, and surveillance of MDR-TB will have multiple benefits for tackling the growing problem of antimicrobial drug resistance (AMR) for whic h the global community is galvanizing support. The capacity of health systems in Southern Africa to monitor, track, and share information on the scope and scale of AMR is limited. Detection, monitoring, and responding to AMR will rely on strengthened and coordinated laboratory and surveillance capacities. In mining operations and communities, several factors combine to create a “perfect storm” for TB infection and transmission. Working conditions inside mines constitute a high-risk environment for TB transmission, resulting from poor ventilation and exposure to silica dust, which is inadequately controlled and regulated. Prolonged exposure to silica dust damages the lungs and creates susceptibility to silicosis, a high-risk factor for TB. Emerging research indicates that even when silicosis does not develop, silica dust remains a risk factor for contracting pulmonary TB. A growing, small-scale mining sector, with a significant number of women, has recently documented high rates of safety and disease risks, which are largely unmonitored. Compounding the difficult work environments, health-seeking behavior of miners is not conducive to early diagnosis and treatment as a result of the high opportunity cost of accessing care and continued high levels of stigma. Families of mine workers with TB (especially women as primary caregivers) are at risk and may have limited access to information and health care. Moreover, antiquated laws in some countries prevent miners from seeking care, given fears over losing their Page 3 of 11 Public Disclosure Copy jobs. C. Proposed Development Objective(s) Development Objective(s) A. Proposed Development Objective(s) The overall objectives of the project are to: (i) improve coverage and quality of TB control and occupational lung disease services in targeted geographic areas of the participating countries; and (ii) strengthen regional capacity to manage the burden of TB and occupational diseases. Key Results To monitor progress toward the project development objective, a core set of indicators has been agreed upon: • TB case notification in target geographical areas (number) • TB treatment success rate in target geographical areas: (i) new and(ii) relapse TB cases (percentage) • Number of TB cases among vulnerable populations in target geographical areas screened for TB and occupation lung diseases • Number of project-supported laboratories compliant with regionally harmonized standard operating procedures for surveillance of MDR-TB (national and subnational laboratories conducting Xpert, Culture, and drug susceptibility tests) • Number of beneficiaries (direct/indirect) (of whom xx% are female)—(all diseases within health facilities, including TB) D. Project Description The project includes three mutually reinforcing components that will assist Lesotho, Malawi, Public Disclosure Copy Mozambique, and Zambia to mount an effective regional response to the burden of TB, and other occupational lung diseases. The project is expected to play a key role in enabling the subregion to build capacity and strengthen cooperation in TB control and other related health issues and, most importantly, implement common protocols and clinical quality standards in the management of TB and other occupational lung diseases. The primary beneficiaries will be TB-affected individuals and households. More generally, the project will target mining communities, high TB burden regions, high HIV/AIDS burden regions, transport corridors, and cross-border areas of the four target countries. Mine workers, ex-mine workers, their families, labor-sending areas, and health workers will be direct beneficiaries. The project will directly benefit women, particularly in the small-scale mining sector. Beneficiaries will: (i) access newer and more reliable technology to test TB and other occupational lung diseases; (ii) improved quality of TB control services and improved access to surveillance; and (iii) TB control services in targeted areas including cross border areas. While the project design has a focus on TB in the mining sector, the design has been refined to: (i) tailor investments to the epidemiologic context; and (ii) promote a health systems approach to maximize the impact of investments and reap potential synergies. The project is designed to respond to key constraints in TB control cited in the regional and sectoral contexts, and thus will support countries to implement international best practices in TB Page 4 of 11 Public Disclosure Copy control and to identify and scale up promising TB interventions supported under the innovative TB Reach program, and other promising national programs. The project will support a paradigm shift in how the subregion prevents and treats TB, such as building a multisectoral platform for regionally coordinated actions led by ministries of health but closely coordinated with selected and strategic public, private and civil society stakeholders. These stakeholders will encompass ministries of labor and mines, community-based health organizations, research organizations and private sector mining organizations. The project will prioritize two aspects: full implementation of the latest WHO TB Strategy, including the 90-90-90 targets in strengthening demand and supply sides of public health systems for effective management of TB and other communicable diseases; and improved use of the latest diagnostic methods for TB and occupational lung diseases. Component Name Component 1: Innovative Prevention, Detection and Treatment of TB Comments (optional) Component 1 will support interventions to strengthen case detection and treatment success rates in different geographic areas and among vulnerable population groups. The overarching thrust of the component is to improve the demand and availability of high quality TB, TB-HIV/AIDS and occupational lung disease prevention and treatment services in targeted geographic areas of the four participating countries. It will support: (i) roll-out of a harmonized package of TB services— with a focus on active screening of TB suspects, miners, ex-miners, and mining communities, active contact tracing and strengthened capacity for diagnosis of TB; (ii) strengthening of occupational health services; and (iii) strengthening of national TB programs to manage MDR- TB. Component Name Component 2: Regional Capacity for Disease Surveillance, and Diagnostics and Management of TB and Occupational Lung Diseases Public Disclosure Copy Comments (optional) Component 2 will strengthen basic health systems to position the subregion to better manage TB and other infectious diseases. It will prioritize: (i) improving quality and availability of skilled human resources for disease surveillance, management of MDR-TB, and occupational health services; (ii) strengthening diagnostic capacity; and (iii) strengthening mine health regulation. Component Name Component 3: Regional Learning and Innovation, and Project Management Comments (optional) Component 3 will support learning and knowledge sharing and focus on innovative evidence generation to inform national and regional health policies and practices. Knowledge activities and products generated will be in the form of: (i) regional baseline assessment reports that bring evidence to better define the context, and inform policy and project interventions; (ii) in-depth case studies capturing the mechanism and outputs of innovations funded by the project; (iii) joint operational research; (iv) South–South learning exchanges between policy makers and practitioners from the four countries and other parts of the developing world with successes in TB; and (v) rigorous evaluations of interventions. E. Project location and salient physical characteristics relevant to the safeguard analysis (if known) Page 5 of 11 Public Disclosure Copy The proposed regional project will initially focus four of the countries in the SADC bloc - Lesotho, Malawi, Mozambique, and Zambia. These countries have been selected based on the burden of disease as measured by the high incidence of TB, which are above the World Health Organization (WHO) threshold for TB Emergency; high levels of TB/HIV coinfection; and increased risk of multidrug-resistant TB (MDR-TB); (ii) a large-scale or growing mining sector, associated with domestic and/or regional migration; and (iii) strong government commitment to work collaboratively at the regional level. The project directly strengthens overall regional and national TB control efforts, though it places added focus on TB in mines and occupational health and safety services and compensation services—which are intricately linked to the burden of TB in the sub-region. Primary beneficiaries will be TB-affected individuals and households, mining communities and high TB– burden regions of the four participating countries. Mine workers, ex-miners, their families, labor sending areas and health workers will be direct beneficiaries. The project will directly benefit women, particularly in the small-scale mining sector. F. Environmental and Social Safeguards Specialists Paula F. Lytle (GSU07) Ruma Tavorath (GEN07) II. Implementation Institutional and Implementation Arrangements At the regional level, implementation arrangements include: (i) ECSA-HC will serve as the Regional Coordinating Organization (RCO) and will coordinate project activities at the regional level and provide project implementation support to participating countries and specialized technical assistance on health systems strengthening; and (ii) a Regional Advisory Committee (RAC), which will provide strategic guidance and governance functions. Public Disclosure Copy At the national level, the project will promote multisectoral collaboration between the key implementing sectors (ministries of health, mines, and labor). In each country, the National TB Program—with the support of the Policy and Planning Department of MOH— will coordinate project implementation. The MOH as the lead implementing agency will coordinate multisectoral activities implemented by the ministries of mines and labor as well as competitively selected NGOs and private sector stakeholders. At country level, an interministerial national technical committee (NTC) will be established to oversee the project. It will review and approve consolidated annual work plans and budgets submitted by the technical departments and provide technical guidance to implementing agencies. Project Implementing Units (PIUs) and other MOH structures will provide overall support for project implementation and day-to-day coordination of the project, including fiduciary aspects and preparation of quarterly and annual consolidated technical and financial reports. III.Safeguard Policies that might apply Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment Yes Key environmental issues are related to (1) infection OP/BP 4.01 control measures for patients; (2) clinical and infectious waste materials (primarily sharps including needles and slides and sputum cups) Page 6 of 11 Public Disclosure Copy generated from service delivery and treatment centers; (3) biosafety and occupational safety of health care staff and workers and laboratory technicians; and (4) construction management of laboratories, including siting, solid and liquid waste treatment infrastructure and construction waste. Mitigation measures include good practices and occupational safety measures by staff within healthcare facilities when dealing with infectious patients and during testing and surveillance. Good practices during construction and waste management will be defined to address environmental issues related to construction and civil works. No new land is expected to be acquired since the project does not foresee construction of new labs. Natural Habitats OP/BP 4.04 No The project is not expected to affect natural habitats. Forests OP/BP 4.36 No The project does not foresee construction of new labs, but will finance upgrading and enhancement. It is not expected to impact forest lands Pest Management OP 4.09 No There will not be any pesticide usage or procurement in the project. Physical Cultural Resources No The project does not foresee construction of new OP/BP 4.11 labs. It is not expected to impact any physical cultural resources. Indigenous Peoples OP/BP No There are no San peoples resident in the districts to 4.10 be targeted. Involuntary Resettlement OP/ No The project does not foresee any construction or Public Disclosure Copy BP 4.12 activities which would require land acquisition. Safety of Dams OP/BP 4.37 No The project activities will not construct or rely on dams. Projects on International No The project activities will not have any impacts on Waterways OP/BP 7.50 international waterways. Projects in Disputed Areas OP/ No Project activities are not located in disputed areas. BP 7.60 IV. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: There are no large scale, significant and/or irreversible impacts associated with the proposed project. Key environmental issues are related to (1) infection control measures for patients; (2) clinical and infectious waste materials (primarily sharps including needles and slides and sputum cups) generated from service delivery and treatment centers; (3) biosafety and occupational safety of health care staff and workers and laboratory technicians; and (4) construction management of laboratories, including siting, solid and liquid waste treatment infrastructure and construction Page 7 of 11 Public Disclosure Copy waste. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Project activities are not expected to have long-term or significant impacts, both in terms of public health risks and in terms of its environmental footprint, if adequate mitigation measures are undertaken. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. There are no specific alternatives considered by the project, since the activities will mostly be on existing sites and within defined boundaries of provision of healthcare services. 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. All four of the countries have prepared/are preparing Environmental and Social Management Frameworks (ESMFs), which define key issues and mitigation measures required to manage construction related issues. The projects are also preparing Infection Control and Waste Management Plans (ICWMPs) which detail occupational safety measures and good practices required for dealing with infections waste. All the 4 countries have ongoing health sector projects funded by the World Bank, under which they are implementing Healthcare waste management plans. The respective Ministries of Health are therefore familiar with and have experience in implementing World Bank projects and Operational Safeguards Policies. Mozambique’s capacity to plan for safeguard measures under the project has demonstrated certain capacity issues in terms of the development of broader frameworks and the supervision of safeguards consultants; the project will focus on building capacity to manage safeguards issues and reporting during implementation. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Primary stakeholders will be the beneficiaries which are TB-affected individuals and households, Public Disclosure Copy mining communities, mine workers, ex-mine workers, their families, labor-sending areas, and health workers. Additional stakeholders are Ministries of Health, Labor and Mines of the respective countries, research organizations and private sector mining organizations and selected and strategic public, private and civil society stakeholders. The ESMFs and the ICWMPs define the mechanism for consultation and disclosure prior to and/or during implementation of project activities. All 4 countries will undertake consultations and disclosure of both documents with key stakeholders prior to Appraisal. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 20-Dec-2015 Date of submission to InfoShop 14-Mar-2016 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure Lesotho 09-Mar-2016 Comments: Lesotho: ESMF and ICWMP received on 1/18/16. Reviewed on 2/3/16. Page 8 of 11 Public Disclosure Copy Malawi 14-Mar-2016 Comments: Malawi: ESMF and ICWMP received on 12/20/15. Reviewed on 12/27/15. Mozambique 16-Mar-2016 Comments: Mozambique: Received on 3/13/2016 Reviewed on 3/14/2016. Zambia 16-Mar-2016 Comments: Zambia: Received on 3/15/2016 Reviewed on 3/15/2016. 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: C. Compliance Monitoring Indicators at the Corporate Level OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) Yes [ ] No [ ] NA [ ] report? 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 [ ] Public Disclosure Copy responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included Yes [ ] No [ ] NA [ ] in the project cost? Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] with the borrower and the same been adequately reflected in the project legal documents? V. Contact point World Bank Contact: Ronald Upenyu Mutasa Title: Senior Health Specialist Borrower/Client/Recipient Name: Republic of Mozambique Contact: Sua Excelencia Adriano Maleiane Title: Minister Page 9 of 11 Public Disclosure Copy Email: roda,muianga@mf.gov.mz Name: Kingdom of Lesotho Contact: Hon. Mokoto Hloaele Title: Minister of Development Planning Email: rnl.lephs@hotmail.com Name: Republic of Zambia Contact: Dr. Ronald Simwinga Title: Permanent Secretary - EMF Email: kamphasa@zambia.co.zm Name: Republic of Malawi Contact: Hon Goodall E. Gondwe Title: Minister Email: secmof@finance.gov.mw Name: Ministry of Finance Contact: Honorable Alexander Bwalya Chikwanda Title: Minister Email: ALL_MOFNP@mofnp.gov.zm Name: Ministry of Finance Contact: Hon. Dr Mamphono Khaketla Title: Minister Email: kpmoleleki@yahoo.com Implementing Agencies Name: Ministry of Health Contact: Sua Excelencia Nazira Abdula Title: Minister Email: fsouto@misau.gov.mz Public Disclosure Copy Name: Ministry of Health Contact: Dr. Peter Mwaba Title: Permanent Secretary Email: dps@moh.gov.zm Name: Ministry of Health Contact: Mamoruti Tiheli Title: Acting PS Health Email: mtiheli@hotmail.com Name: Ministry of Health Contact: Dr. Peter Kumpalume Title: Minister Email: pkumpalume@gmail.com VI. 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 Page 10 of 11 Public Disclosure Copy VII. Approval Task Team Leader(s): Name: Ronald Upenyu Mutasa Approved By Safeguards Advisor: Name: Johanna van Tilburg (SA) Date: 21-Mar-2016 Practice Manager/ Name: Magnus Lindelow (PMGR) Date: 21-Mar-2016 Manager: Country Director: Name: Yisgedullish Amde (CD) Date: 28-Jul-2016 Public Disclosure Copy Page 11 of 11