The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) Concept Environmental and Social Review Summary Concept Stage (ESRS Concept Stage) Public Disclosure Date Prepared/Updated: 10/25/2021 | Report No: ESRSC02387 Oct 25, 2021 Page 1 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Central African Republic AFRICA WEST P177003 Project Name CAR Health Service Delivery & System Strengthening Project (SENI-plus) Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 12/20/2021 3/17/2022 Population Financing Borrower(s) Implementing Agency(ies) Central African Republic Ministry of Health and Population, Central African Republic Proposed Development Objective Public Disclosure To increase utilization of quality essential health services for women and chidren in targeted areas in the Central African Republic. Financing (in USD Million) Amount Total Project Cost 55.00 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 project supports the government’s effort to improve the delivery of essential health services and strengthen the country’s health system by: (i) providing continued support to the implementation of the government’s targeted free health care policy, through continued use of PBF as a health system strengthening strategy; (ii) strengthening community level service delivery through support to implementation of the National Community Health Strategy. The project will further strengthen the various pillars of the health system, particularly on: (iii) developing and establishing a functional supply chain system for the country; (iv) strengthening the health system to provide holistic support to GBV survivors; (v) strengthen governance and health financing; (vi) provide support to human resources for health Oct 25, 2021 Page 2 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) through enhanced capacity building of frontline health workers; and (vii) strengthening the health information systems through introduction of a new DHIS2-based national health information system. Additionally, the project will continue to support expansion of the holistic GBV strategy for GBV survivors with medical, psychosocial response and wide-scale community prevention and behavior change activities. Component 1 seeks to (i) continue and expand the delivery of targeted free health care through continued use of PBF as a delivery model but with an adapted approach; (ii) support the implementation of the Community Health Strategy by financing a basic service packages including exploring different approaches to incentivizing the community health workers, as well as development of tools and materials to facilitate coordination. Component 2 will address critical bottlenecks to a functioning health system in CAR. Activities to be supported under this component will comprise: (i) reconstruction of a national supply chain; (ii) strengthening the health system to provide holistic support to GBV survivors, (iii) implementation support to key reforms that address system bottlenecks, including in the areas of health financing, human resources for health and health information systems. Component 3 will help ensure an effective and efficient technical and fiduciary management and implementation of the project. The component will support the project implementation through the financing of (i) operating costs, training, and equipment; (ii) paying salaries of international and national consultants; (iii) audits and communications, and (iv) implementation and monitoring of environmental and social standards as well as project results indicators. Component 4 will be a Contingency Emergency Response Component (CERC) in accordance with World Bank IPF Public Disclosure Policy paragraphs 12 and 13, for projects in Situations of Urgent Need of Assistance or Capacity Constraints. This will allow for rapid reallocation of project proceeds in the event of a natural or man-made disaster or crisis that has caused, or is likely to imminently cause, a major adverse economic and/or social impact. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The project will cover the same regions as SENI (2, 3, 4, 5, and 6 with respectively 143, 64, 122, 22 and 60 health facilities) and will include 22 districts (15 SENI districts and 7 new districts) with approximately 643 health facilities (increased from 400 covered by SENI). The 15 SENI districts are: Baboua-Abba, Bouar-Baoro, Berberati, Carnot-Gadzi, Sangha-Mbaere, Bozoum-Bossemptele, Paoua, Kemo, Nana Grebizi (Kaga), Bambari, Kouango-Grimari, Bamingui Bangoran, Bangassou, Alindao-Mingala, Kembe-Satema, Mobaye-Zangba. The seven (7) additional districts are: Batangafo, Bouca, Nangha-Boguila, Bocaranga, Ngaoundaye in Region 3, Haut Mbomou in Region 6, Mbaïki in Region 1. These health regions cover the whole country. CAR has approximately 4.66 million inhabitants with an average density of 7.5 inhabitants/km2 The Country has suffered from decades of repeated conflicts and political instability. For a decade now, CAR has been struggling with violence and insecurity countrywide. CAR seemed to be gradually recovering in recent years when the political turmoil of December 2020 brought a sudden violence and increased insecurity throughout the country. Instability and violence in CAR have resulted in substantial deterioration of social services, including health. It also Oct 25, 2021 Page 3 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) exacerbated GBV/Sexual Exploitation Abuse/Sexual Harrasment (SEA/SH). The proposed GBV risk is substantial and to be confirmed with screening during the preparation phase. There is risk of the project having negative impacts on vulnerable groups like indigenous peoples and GBV survivors. Equal access to free healthcare including GBV services will be provided by hospitals and health facilities in the intervention zones. Negative impacts could occur given that these identified groups are unable to readily access these services given that they live in remote rural areas. Project districts are already known at this stage of the Project. Some of these districts have indigenous people among their communities, namely the three prefectures of Nana-Mambere, Mambere-Kadei and Sangha Mbaere. Negative impacts on vulnerable groups, indigenous people, poor households and GBV survivors will be taken into consideration by integrating gender equality and a non-discriminatory approach into project design and activities. D. 2. Borrower’s Institutional Capacity The Government of CAR has experience in managing the E&S risks and impacts of WB-financed projects implemented under the Safeguard Policies. The country can also rely on an established legal framework and institutions for E&S management. However, there is limited experience in implementing projects under the ESF and experience from other Bank-financed projects highlight that the management of E&S risks and impacts still require considerable improvement, particularly in the areas of supervision, monitoring and reporting. Public Disclosure The Ministry of Health and Population (MHP) will lead Project implementation through the PIU that currently oversees the implementation of three Bank-financed projects: SENI-CAR Health System Strengthening Project (P164953), CAR COVID-19 Response Project (P173832) and REDISSE IV CAR Regional Diseases Surveillance System Enhancement Project (P167817). However, other ministries (Ministry for the Promotion of Women, the Family and Child Protection and Ministry of Social Action and Gender Promotion) will be involved in the implementation of Component 1. These ministries will also be involved in the GBV component as was the case with the SENI project. The Project will work with some service providers, including UNOPS and various NGOs, who have some experience in the implementation and monitoring of safeguard instruments but limited experience with the ESF. . The PIU’s current E&S team includes: 1 Environmental specialist, 1 Social specialist and 2 GBV/SEA/SH specialists (1 international & 1 national). This team will be strengthened by adding 2 E&S assistants and 1 GBV specialist to manage the E&S risks and impacts of Project activities. In addition, the PIU’s E&S team will receive regular training throughout the implementation of the project, in the form of clinics on specific issues. Based on the arrangement put in place under SENI-REDISSE IV, the National Steering Committee of the Project will be hosted by the MHP and chaired by the Cabinet Director at the MHP. Given that SENI is implemented under the safeguards policies, while the COVID-19 and REDISSE IV projects are under ESF, the MHP has not yet fully mastered the application of the ESF instruments. Thus, the E&S capacity of the MHP, as well as that of other relevant institutions (Ministries, Agencies) involved in the Project, will need to be strengthened at all levels to ensure their participation, especially given their limited knowledge of, and experience with, WB ESF requirements. Oct 25, 2021 Page 4 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) At the national level, the Director General for Environment (DGE) is the main institution in the Ministry of Environment (MEDD) that is responsible for conducting and coordinating the E&S assessment process in CAR (e.g., validation of ESIAs, ESMPs, field reports, inspection and E&S audits). At the departmental level, the DGE collaborates with local branches/ offices of the MEDD. However, DGE implementing capacity is low as it lacks the needed financial and technical resources. In the particular case of infrastructure construction and health waste management, arrangements will be put in place to ensure that appropriate OHS measures are monitored at the district/ local level, as well as community empowerment processes. This will be done through (i) training sessions for construction companies on the application of occupational health and safety measures, as well as their codes of conduct; and (ii) sensitization and training of members of district/local management committees to ensure the implementation of safeguards, access to the various GRM channels, mitigation measures for the various risks related to vulnerable and accidents, but above all to ensure the sustainability of these measures. II. SCREENING OF POTENTIAL ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The environmental risk rating is substantial. The implementation of project activities will generate risks and Public Disclosure potentially reversible impacts on the environment. The improvement in the provision of essential services in health facilities and communities through PBF under component 1 will lead some beneficiary hospitals and health facilities to carry out small-scale rehabilitation of delivery rooms, laboratories, and treatment rooms, in addition to enabling a safe space for GBV survivors to access services without being exposed. The improvement in the provision of services in health facilities will also lead to an increase in the amount of biomedical waste, as well as an increase in the health and safety risks for staff and, to a lesser extent, to communities, especially if the waste is not properly managed. Under component 2, some activities will involve civil works, notably the construction of a national and regional supply warehouses under the subcomponent 2.1. The civil works will generate negative impacts such as: construction waste, noise pollution, space conversion, destruction of vegetation cover, increase in aerosols and engine fumes, risks of transmission of STIs/HIV/AIDS due to the arrival of working personnel, and community and occupational health and safety risks(OHS) (including the risk of spreading COVID-19). All of these potential risks and impacts will be assessed in detail in the ESMF that will be prepared along with other instruments prior to project appraisal. Social Risk Rating Substantial The social risk rating is Substantial at this stage of project preparation. Under Component 1, Improving essential service delivery at health facilities and in communities, activities to be developed include the PBF interventions support targeted free healthcare for maternal and child primary healthcare, preventative interventions, and survivors of GBV, and for the marginalized and poor households, TA and improvements of health service quality within health facilities and communities. All these activities will target beneficiaries such as vulnerable groups (women, GBV survivors, IPs) and poor households. They will need to ensure that any risks of discrimination and exclusion are addressed. Moreover, the criteria for providing free healthcare services should be clearly designed, Oct 25, 2021 Page 5 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) fixed and publicly disclosed in a transparent process of selection of beneficiaries. An inappropriate or flawed selection process could create social tension among communities. The same attention should be paid under Component 2 concerning the recruitment of community workers (Indigenous people, young people) in the construction of warehouses. In addition, measures need to be taken to mitigate risks related to the expansion of transmissible diseases (STI, HIV/AIDS, COVID-19) given that through these activities, the project will be able to reach a wide range of people, and disseminate training and information. However, while the overall social benefits are expected to be positive, the anticipated social risks and impacts include security risks. The project is intending to be implemented in urban, peri-urban or rural areas in the country. Unfortunately, there may be the presence of non- state armed groups in these areas. Thus, the risk of attacks on project workers, beneficiaries, as well as their personnel should be considered. A project security assessment and management plan should be developed to define mitigation measures. The new wave of COVID-19 risks include COVID-19 related risks of dissemination, uncertainties from new waves, and awareness campaign activities. Measures set by CAR government in its press release of March 2020, and in line with those of WHO and WBG health and safety guidance, should be adapted and implemented in all mass meetings (training sessions, events, information campaign, consultations, etc.) to avoid the spread of COVID-19 among project stakeholders. Risks to increase HIV/AIDS transmission: in addition to community health workers, moderate labor influx in different communities may lead to the spread of communicable diseases and a number of other safety and health risks to (communities and workers themselves), especially risk of transmission of STI and HIV/AIDS cases. The client should incorporate awareness raising sessions and preventive materials into the workers' health and safety plan and the ESMP. Risks of exclusion of households led by women and other vulnerable individuals: as this project involves the selection of beneficiaries, strategic approaches need to be developed in the SEP to ensure that there is no exclusion of, discrimination against, vulnerable groups and Public Disclosure individuals, especially (GBV survivors, poor households, households with children under five years, , young girls and other vulnerable people) for different services (essential health and nutrition service for maternal-child mortality and malnutrition, medical, psychosocial, and socioeconomic assistance, distribution of PEP Kit, etc.). The project will mitigate these risks mainly by applying the relevant ESF standards. 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: The Environmental and Social Standards (ESS) relevant to this project are, ESS1, ESS2, ESS3, ESS4, ESS5, ESS7, ESS8, and ESS10. Assessment and management of environmental and social risks and impacts (health, hygien and safety problems at work); proliferation of biomedical waste (healthcare services) as a potential source of groundwater and soil pollution; denaturation of the biological nature of the soil, noise pollution from machinery, nauseating odors from paints, pollution of the soil and air by dust and gas from engines; risk of transmission of STI/HIV/AIDS) will be required and are mainly associated with Component 1 (Improving essential service delivery at health facilities and in communities), and Component 2 (health system strengthening for improved essential service delivery). They will support alleviating critical bottlenecks for the well-functioning of the health system. Potential impacts are expected to be site-specific. Measures will be put in place to manage impacts related to the eventual implementation of downstream activities to repair or improve health facilities. Impacts should be adequately managed during project implementation, in accordance with the Environmental and Social Management Framework (ESMF) that will be Oct 25, 2021 Page 6 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) prepared. This ESMF will need to provide clear guidance for the management of construction impacts and biomedical waste management that shall be compliant with WHO “Safe management of wastes from health-care activities” guidelines. Regarding the CERC component of the project, the activities under this component are not yet known at this stage. The project’s institutional arrangements for environmental and social due diligence and monitoring under this component will be included in the ESMF. The Bank’s review considered the project’s capacity to manage its environmental and social performance as a challenge. It can therefore be concluded that the project’s environmental and social management system and procedures will need to be complemented/enhanced to comply with ESS1 requirements. The Project will address the gaps through the preparation and implementation of the Environmental and Social Commitment Plan (ESCP) to be prepared by the Borrower prior to project appraisal, as well as targeted training and support to the environmental and social specialists to be recruited. However, other relevant instruments to be prepared and captured within the ESCP are: - a Security Risk Assessment (SRA) and Security Management Plan (SMP). - a SEA/SH risk assessment and Action Plan including code of conduct (to be updated from parent project) and accountability and response framework. - a Labor Management Procedures (LMP) including a GRM for workers; - a Resettlement Policy Framework (RPF); including approach to Livelihood Restoration Plan; - a RAP (including Livelihood Restoration Plan); - a Biomedical waste management plan (update from parent project) Public Disclosure - an Indigenous People Plan (IPP); - the site specific E&S instruments such as ESIA/ESMP as per ESMF screening and requirement. Areas where “Use of Borrower Framework” is being considered: Due to the weak existing E&S frameworks, reliance on Borrower E&S Framework will not be considered in this project. ESS10 Stakeholder Engagement and Information Disclosure In consultation with the Bank, the Borrower (under the technical guidance of the SENI safeguard unit which has already acquired some experience in the preparation and implementation of the SEP for the REDISSE IV Project) will prepare and disclose prior to appraisal a Stakeholder Engagement Plan (SEP) proportional to the nature and scale of the project and its associated risks and impacts, to be implemented and updated as needed throughout the project lifecycle. The objective of the SEP is to establish a systematic approach to stakeholder engagement, maintain a constructive relationship with stakeholders, consider stakeholders’ views, promote and provide means for effective and inclusive engagement with stakeholders throughout the project life cycle, and ensure that appropriate project information is disclosed to stakeholders in a timely, understandable, culturally accessible and appropriate manner, which is free of manipulation, interference, coercion, discrimination and intimidation. To ensure this, the Borrower would need, to engage in meaningful consultations with all stakeholders while paying attention to the inclusion of vulnerable and disadvantaged groups. Oct 25, 2021 Page 7 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) In relation to IPs, the approach to stakeholder engagement should be based on the principles of meaningful consultation and disclosure of appropriate information. The Borrower will undertake meaningful consultation in a manner that provides an opportunity for IPs to provide input on the risks, impacts and mitigation measures of the project, and for the Borrower to consider and respond to them in a culturally sensitive manner. These consultations will be carried out on an ongoing basis, as issues, impacts and opportunities evolve. If potential adverse effects on IPs are identified, those adverse effects are avoided, minimized, mitigated or compensated. Once project-specific sites and activities are determined, IPs’ Free, Prior and Informed Consent (FPIC) will be required if the project will : (a) have adverse impacts on land and natural resources subject to traditional ownership or under customary use or occupation; (b) cause relocation of IPs from land and natural resources subject to traditional ownership or under customary use or occupation; or (c) have significant impacts on IPs’ cultural heritage that is material to the identity and/or cultural, ceremonial, or spiritual aspects of the affected IPs’ lives. Given the COVID-19 crisis, measures will be put in place to prevent or minimize the spread of COVID-19 during household and technical support activities, and other various awareness or training sessions. These measures will include, among others, respecting social distancing measures as stated by the government in its press release of March 13, 2020. The concerns and needs of identified stakeholders would be related to their full participation in project activities and information sharing. The Borrower will maintain, and disclose, a documented record of stakeholder engagement, including a description of the stakeholders consulted, a summary of the feedback received, and a brief explanation of how the feedback was considered, or the reasons why it was not. Community consultations Public Disclosure with (women, young girls, and women and female heads of households) that are related to SEA/SH risk mitigation will be conducted in safe and enabling environments, such as in sex-segregated groups and with female facilitators. The project will need to identify and consult with relevant stakeholders who could promote increased adhesion and encourage retention of young girls, women leading households, and female workers within the activities. Such consultations will be focused on understanding women and girl’s risks and vulnerabilities, understand girl’s enrolment and engagement experience in healthcare, psychological, socioeconomic assistance and nutrition concerns in relation to the project. Furthermore, the consultations will need to include the disabled groups, disadvantaged groups and minorities within the project’s targeted communities, and be carried out in an accessible and appropriate manner, with information provided in accessible formats. The project will set up a project-specific Grievance Mechanism (GM), sensitive to SEA/SH issues, and the ethical treatment and resolution of such complaints that is proportionate of the potential risks and impacts of the project. Due to the considerable workforce involved in the project, and the potential for SEA/SH, the GM should refer to the Bank’s good practice note “Addressing Sexual Exploitation and Abuse and Sexual Harassment (SEA/SH) in Investment Project Financing involving Major Civil Works”, as well as the Bank’s technical note on SEA/SH in Grievance Mechanisms. In relation to healthcare, psychological, socioeconomic assistance and nutrition support—and to enrolment of IPs and other vulnerable groups with respect to measures to reduce various violence including exclusion and discrimination against IPs and especially on children, young girls and women—the establishment of a GBV-sensitive GM will also consider inclusion of IP counselor systems within the community, workers committee, and other community platforms. The GM will also serve as a platform for continuous feedback from project-affected communities, other Oct 25, 2021 Page 8 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) interested stakeholders and implementing partners. The project-specific GRM will be outlined in the SEP for people to report concerns or complaints. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This standard is relevant. The implementation of the CAR Health Service Delivery & System Strengthening Project (SENI-plus) is likely to involve various workers, ranging from the PIU and government to specialized personnel for consulting, service provision and construction firms as well as unskilled laborers and community workers. In sum, a considerable workforce will be required, and the project will face difficulties in promoting sound worker- management relations and guaranteeing safe and healthy working conditions. The Borrower will develop Labor Management Procedures (LMP) within 2 months of the Effectiveness Date, to manage labor related risks and impacts. The LMP will provide an overview of national labor law, types of personnel to be hired under the project, and measures to comply with ESS2, including: Working conditions and management of workers relationship: The Borrower shall describe how project workers will be managed in accordance with the requirements of this standard and national laws. It will ensure communication in clear language and understandable by each worker of the project, information and documents (such as code of Public Disclosure conduct and internal regulations) which describe their rights under national law (which will include the applicable collective agreements where applicable), including their rights to wages, overtime, remuneration and social benefits as well as any other rights mentioned in the requirements of ESS2. The Borrower shall base employment relationships on the principle of equality of opportunity and treatment. Protecting the work force: The Borrower emphasizes compliance with the minimum age for employment and recruitment of project workers, which shall be at least 14 years unless the Borrower's legislation determines a higher age. The Project will not hire people younger than 18 years old for hazardous work; those between the national legal minimum age and 18 could do non-hazardous work in line with ESS2 provisions and will comply with CAR labor law. To ensure the health and safety of workers during project implementation, the ESMF will address Occupational Health and Safety, in line with the WBG’s EHS Guidelines and Good International Industry Practice (GIIP), including WHO guidance, particularly for the COVID-19 virus. The measures will include requirements for the use of Personal Protective Equipment (PPE), planning of training activities, and investigation/reporting of accidents, a worker Code of Conduct, and other labor issues such as labor influx, non-discrimination, equal opportunity, and prevention of all forms of forced labor including child labor and SEA/SH including the workers’ code of conduct. The project also shall include a grievance mechanism for labor disputes of project workers and the roles and responsibilities for monitoring such workers. The establishment of a workers’ GM as developed in detail in the LMP shall allow workers to quickly inform management of labor issues, such as a lack of PPE and unreasonable overtime. Oct 25, 2021 Page 9 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) A set of Environment, Social, Health and Safety requirements, as detailed in the ESMF will be included in bidding documents for all activities, and serve as the basis for the development of Contractor-specific ESMPs that will be required for all site-specific subprojects. ESS3 Resource Efficiency and Pollution Prevention and Management The project's funding in component 1 will lead to an increase in waste in the project's beneficiary health facilities. The project will prepare a biomedical waste management plan, taking into account the existing biomedical waste management plan prepared under the SENI project including guidance related to transportation and disposal/destruction of expired chemical products including OHS, community health and safety, and pollution (air, water, etc.) issues. The project may undertake downstream works related to rehabilitation/enhancement of existing facilities, so other issues may need to be managed, such as pollution, noise and dust that are related to minor construction/rehabilitation works. Safeguards instruments (ESMF, site-specific ESMPs) will include mitigation measures to manage environmental impacts during project implementation. In case asbestos materials are found in existing buildings, handling and disposal of asbestos will be done in accordance with GIIP OHS and EHS practices. However the project will use resources efficiently and will not lead to any significant GHG emissions. ESS4 Community Health and Safety This standard is relevant. Specific measures to protect the health and safety of communities in project areas are Public Disclosure necessary, as healthcare and construction of infrastructure, and even socioeconomic and nutrition activities, are likely to have direct and indirect impacts on communities. As the likelihood of awareness raising and face-to-face training is quite high, COVID-19 precaution measures will be prepared and implemented by the project in case such activities take place, to minimize the risk of infection. Community health and safety: The project will conduct a risk and hazard assessment (RHA) during the preparation of the ESMF. The project includes activities to provide the necessary information for decision-making in terms of protection against the hazards of waste from medical products during or after treatment, if used improperly, may be hazardous to communities. As noted above, a good practice procedure for the transportation, distribution and use of medicinal products will be developed and incorporated into the ESMF to help protect communities and ecosystem services. Infrastructure construction works could lead to accidents at construction sites or on the roads serving these sites, particularly in areas where the road network is already limited and which are usually occupied by pedestrians. The ESMF will include measures to reduce accidents involving project vehicles during construction. The contractor's site- specific ESMPs will include traffic management measures to ensure pedestrian safety, as well as requirements for the adoption of safety signs and barriers in or near work areas and safe storage arrangements for machinery and equipment. Further, a SEA/SH Assessment will take place by appraisal to analyze the risk on harassment (especially of women beneficiaries) and recommend measures to address this risk. The project will provide services mostly to vulnerable Oct 25, 2021 Page 10 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) women who may encounter these problems. In addition, the ESMF will also provide an analysis of the current security situation, and the risks of SEA/SH for project staff and beneficiaries.The project will screen for, and where necessary, include specific measures to address SEA/SH risks. This will be captured in the SEA/SH assessment and associated action plan, to be prepared during project preparation. The project will be implemented in certain areas with security issues where armed groups continue to operate. A security risk assessment (SRA) will be carried out during project preparation and security management plan (SMP) with adequate security risks mitigation measures to project’s workers, beneficiaries and assets will be developed accordingly, in line with the “UN Voluntary Principles on Security and Human Rights” to ensure that the security measures taken to protect the projects equipment and personnel are appropriate. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS5 is considered as relevant to the Project: The project will finance the construction of infrastructure (warehouses) in the targeted areas. To date, site-specific locations of these expected warehouses are not known. They will only be known with certainty during project implementation. More specifically, the impacts of the anticipated civil works (warehouses, etc.) may require land acquisition that could lead to involuntary resettlement, and loss or disruption of income or livelihood activities for individuals or groups of people. Therefore, as the sites and type of investments are not known with precision, a RPF will be prepared, consulted upon, cleared by the Bank and publicly disclosed prior to appraisal. The RAPs shall be prepared before any request for proposals is issued for any projects that include in part Public Disclosure or in full civil works. Therefore, RAPs will be required to be implemented before the start of relevant works. This will be reflected in the ESCP. In addition, a screening tool will be developed as part of the ESMF, and there will be a requirement to screen all sites/facilities to ensure economic or physical displacement does not occur once the site-specific activities are identified; this will especially apply in cases where the decision is taken for infrastructure to be built. At this stage of project development, the land for the construction of some infrastructure (warehouses) will be made available by the municipalities. In principle, this will be unoccupied land. The risk of land being taken from indigenous populations is not envisaged; and the land acquisition through voluntary donation is not foreseen in the project. However, after the screening of specific project sites (if occupied), the possibilities for resettlement or compensation will be analyzed and determined. In all cases, the basic principle will always be to avoid resettlement. Nevertheless, in case land is handed over by municipalities, due diligence shall be conducted to ensure that no forced eviction took place. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The project will not include activities that will have impacts on biodiversity or natural resources according to the ESS6. Hence this standard is not considered relevant to this project. However, the ESMF will include measures for the protection of biodiversity and natural resources specifically for civils works related to the construction of a national and regional supply warehouses. Oct 25, 2021 Page 11 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is considered relevant to the project. Indigenous Peoples (Aka/Bayaka) communities are present in the CAR and are considered vulnerable and disadvantaged. The project will be implemented in 22 health districts. The IPs are present in some of those areas, in particular Indigenous People (Aka/ Bayaka), namely in Sangha-Mbaéré, Mambere- Kadei and Nana-Mambere prefectures. The Social Assessment will, among other things, examine potential risks, impacts, and benefits for the IPs. Using a consultative approach, the Social Assessment will identify measures to mitigate risks and to ensure culturally acceptable benefits to IPs. However, no activity under this project is expected to have an adverse effect on Indigenous Peoples (displacement, land, cultural heritage, habits & behaviors). The Stakeholder Engagement Plan will include outreach programs to ensure that indigenous communities, especially those living in remote areas, are aware of the availability of essential free healthcare and nutrition services for maternal-child mortality; and malnutrition, medical, psychosocial, and socioeconomic assistance activities as well as training sessions under the project. The potential social impacts can be adequately managed/ mitigated through the development, implementation and monitoring of appropriate measures. This means that the Borrower should proactively engage with the IPs to ensure their ownership and participation in project design, implementation, monitoring, and evaluation. In addition, some measures provided under the project to ensure that IPs and other groups will be able to share in project benefits are: the ability to enroll beneficiaries without distinction or discrimination in their participation in health committees, and employment of animators and/or community health workers, etc., in the most equitable way. Here, particular attention will need to be paid to the additional disadvantages that some specific Public Disclosure vulnerable groups—including IDPs, Peulhs Mbororos, etc.—may face in terms of impacts and/or exclusion from project benefits. The Social Assessment will also explore the appropriate consultation methods for these groups and examine culturally appropriate grievance mechanisms. These measures will be detailed in an Indigenous Peoples Plan (IPP) and will be incorporated into the project design including, but not limited to, the Stakeholder Engagement Plan and the grievance mechanism. It is also essential for all ethnic groups (IPs and others, including the Peulhs Mbororos where they live), without exception, to be able to access the grievance mechanism. Project activities will not cause relocation or impact resources or cultural heritage of IP groups. As project sites (districts) are already known and activities are determined, the PIU will prepare an Indigenous Peoples Plan (IPP), acceptable to the Bank that sets out measures through which the project will ensure that: (i) IPs affected by the project receive culturally appropriate social and economic benefits; and (ii) if potential adverse effects on IPs are identified, those adverse effects are avoided, minimized, mitigated or compensated. The IPP will be prepared, consulted upon, cleared by the Bank and disclosed prior to appraisal of any activities (not just civil works) in areas where IPs are present. At this stage of project development, the site-specific locations for civil works (construction of warehouses) are not yet known. No activity will have significant impact social norms/practices aspects of the affected Indigenous Peoples. The Free, Prior, and Informed Consent (FPIC) of IPs will not be required. However, IPs’ Free, Prior and Informed Consent (FPIC) will be required if the project will : Oct 25, 2021 Page 12 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) (a) have adverse impacts on land and natural resources subject to traditional ownership or under customary use or occupation; (b) cause relocation of IPs from land and natural resources subject to traditional ownership or under customary use or occupation; or (c) have significant impacts on IPs’ cultural heritage that is material to the identity and/or cultural, ceremonial, or spiritual aspects of the affected IPs’ lives. ESS8 Cultural Heritage This Standard is relevant since the construction of warehouses may involve soil excavation. The ESMF will include provisions for site-specific screening and assessment of any known sites of cultural or historic importance which may be impacted locally, as well as identification of any sites of cultural/social importance for local communities. The ESMF will include a generic Chance Finds Procedure for all construction or works contracts, requiring civil contractors to take proper protective measures in case cultural heritage sites are discovered, including to stop construction activities if cultural property sites are encountered during construction. ESS9 Financial Intermediaries This standard is not relevant, as the project is not an FI operation. Public Disclosure C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No 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: Documents and actions prepared and completed prior to Appraisal: - Preparation, consultation and disclosure of the Stakeholder Engagement Plan (SEP) including a GBV-sensitive GM and an IP-specific approach; - Preparation and disclosure of Environmental and Social Commitment Plan (ESCP). Oct 25, 2021 Page 13 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) - Preparation and disclosure of a Security Risk Assessment (SRA) and Security Management Plan (SMP). - Preparation and disclosure of a SEA/SH risk assessment and Action Plan including code of conduct (to be updated from parent project) and accountability and response framework. - Preparation, consultation and disclosure of an Indigenous People Plan (IPP); - Preparation, consultation and disclosure of the Resettlement Policy Framework (RPF) including approach to Livelihood Restoration Plan; - Preparation, consultation and disclosure of the Environmental and Social Management Plan (ESMF) including a risk and hazard assessment (RHA), Occupational Health and Safety and biomedical waste management plan. Possible issues to be addressed in the Borrower Environmental and Social Commitment Plan (ESCP): Documents and actions prepared and completed by two months after project effectiveness: - Preparation and disclosure of Labor Management Procedures (LMP) including GRM for workers; - Strengthening of the PIU’s current E&S capacity by recruiting 2 E&S assistants and 1 GBV specialist Documents and actions prepared and completed prior to start of activities in site specific areas: - Preparation, consultation and disclosure of RAP (including Livelihood Restoration Plan); - Preparation, consultation and disclosure of site specific E&S instruments such as ESIA/ESMP as per ESMF screening and requirement. Public Disclosure C. Timing Tentative target date for preparing the Appraisal Stage ESRS 09-Dec-2021 IV. CONTACT POINTS World Bank Contact: Tomo Morimoto Title: Senior Health Specialist Telephone No: 5274+3044 / 95-1-9255030 Email: tmorimoto@worldbank.org Contact: Mahoko Kamatsuchi Title: Senior Health Specialist Telephone No: +1-202-473-9370 Email: mkamatsuchi@worldbank.org Borrower/Client/Recipient Borrower: Central African Republic Implementing Agency(ies) Oct 25, 2021 Page 14 of 15 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) Implementing Agency: Ministry of Health and Population, Central African Republic V. 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 VI. APPROVAL Task Team Leader(s): Mahoko Kamatsuchi, Tomo Morimoto Practice Manager (ENR/Social) Senait Nigiru Assefa Recommended on 20-Oct-2021 at 10:27:36 GMT-04:00 Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Cleared on 25-Oct-2021 at 08:03:41 GMT-04:00 Public Disclosure Oct 25, 2021 Page 15 of 15