Environmental and Social Management Framework for India COVID-19 Emergency Response and Health Systems Preparedness Project Ministry of Health and Family Welfare Government of India August 2020 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Table of Contents Section Heading Page No. No. Abbreviations and Acronyms 4 Executive Summary 5 1. Background 7 2. Project Description 9 3. Policy, Legal and Regulatory Framework 14 4. Environmental and Social Baselines 21 5. Potential Environmental and Social Risks and Mitigation 26 6. Environment and Social Management Plan 31 7. Procedures to Address Environmental and Social Issues 46 8. Public Consultation and Disclosure 48 9. Stakeholder Engagement 51 10. Institutional Arrangements, Responsibilities and Capacity Building 53 Annex I: Environmental and Social Management Plan (ESMP) Template 56 Annex II: Biomedical Waste Management Plan (BMWMP) Template 68 Annex III: Screening Form for Potential Environmental and Social Issues 73 Annex IV: India COVID-19 Project – Clauses for Inclusion in Civil Works Contracts 76 Annex V: Institutional Capacity Assessment Tool for Biomedical Waste Management 78 and Infection Control at Healthcare Facility Annex VI: Biosafety Laboratories and required Mitigation Actions 81 Annex VII: Labor Management Procedures 83 Annex VIII: Resource List: COVID-19 Guidance 92 List of Tables and Figures Table 1: Environmental and Social Laws, Regulations and Policies that are relevant to the 14 proposed program Table 2: World Bank Environment and Social Standards and their Relevance to the Project 18 Table 3: Environmental and Social Baseline 24 Table 4: Environmental and Social Risk categorization of Planned Activities and Suggested 26 Mitigation Approach Table 5: Environmental and Social Management Plan 31 Table 6: Procedures to Address Environmental and Social Issues 46 Table 7: Summary of Feedback Received during Stakeholder Consultation 48 Table 8: Preliminary Strategy for Information Disclosure for the Project 49 Table 9: Indicative Budget for Implementing the ESMF 55 Table AI.1- Environmental and Social Risks and Mitigation Measures during Planning and 57 Designing Stage Table AI.2 - Environmental and Social Risks and Mitigation Measures during Construction 60 Stage Table AI.3- Environmental and Social Risks and Mitigation Measures during Operational Stage 63 Table AI.4- Environmental and Social Risks and Mitigation Measures during Decommissioning 67 Table AII.1: BMWMP 71 Figure 1: Procedure for Biomedical Waste Management at Healthcare Facility (non-COVID-19) 44 Figure 2: Procedure for COVID-19 related Biomedical Waste Management at Healthcare 45 Facility Figure 3: Flowchart depicting Process Chain with Responsibility to be followed in addressing 47 the Environmental and Social Issues 2 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Abbreviations and Acronyms BMW Bio Medical Waste BMWM Bio Medical Waste Management BSC Biological Safety Cabinets BSL Biosafety Level CDC Centre for Disease Control and Prevention CERC Contingent Emergency Response Component COVID-19 Corona virus Disease 2019 CTF Common Treatment Facility DGHS Director General of Health Services E&S Environment and Social EHS Environmental, Health and Safety EIDs Emerging Infectious Diseases EOC Emergency Operating Centre ERP Emergency Response Plan ESCP Environment and Social Commitment Plan ESF Environmental and Social Framework ESHS Environmental, Social, Health and Safety ESIA Environmental and Social Impact Assessment ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan ETP Effluent Treatment Plant GBV Gender Based Violence GIIP Good International Industry Practice GOI Government of India GRM Grievance Redress Mechanism HCF Healthcare Facility HCW Healthcare Waste HEPA High Efficiency Particulate Air filter HIV Human Immunodeficiency Virus HVAC Heating, Ventilation and Air Conditioning HWMS Healthcare Waste Management System ICMR Indian Council of Medical Research ICT Information Communication Technology ICU Intensive Care Unit ICWMP Infection Control and Waste Management Plan IDSP Integrated Disease Surveillance Program INR Indian Rupees IPC Infection and Prevention Control IPF Investment Project Financing LMP Labor Management Procedure MHA Ministry of Home Affairs MNREGA Mahatma Gandhi Rural Employment Guarantee Authority MOEFCC Ministry of Environment, Forests and Climate Change MOF Ministry of Finance MOHFW Ministry of Health and Family Welfare MOR Ministry of Railway 3 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 MOWCD Ministry of Women and Child Development MPA Multi Phase Approach NCDC National Center for Disease Control NGOs Non Governmental Organizations NHM National Health Mission NPMU National Project Management Unit NPPA National Pharmaceutical Pricing Authority OHS Occupational Health and Safety OPD Out Patient Department PAD Project Appraisal Document PDO Project Development Objective PMGKP Pradhan Mantri Garib Kalyan Package POE Point of Entry PPE Personal Protective Equipment PPSD Project Procurement Strategy for Development RAP Resettlement Action Plan RPF Resettlement Policy Framework RPF Railway Protection Force SBCC Social and Behavior Change Communication SC Schedule Caste SDRF State Disaster Response Fund SEA Sexual Exploitation and Abuse SEP Stakeholder Engagement Plan SH Sexual Harassment SOP Standard Operating Procedures ST Schedule Tribe STP Sewage Treatment Plant TA Technical Assistance TB Tuberculosis TSU Technical Support Unit WB World Bank WBG World Bank Group WHO World Health Organization WWTP Wastewater Treatment Plant 4 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 INDIA: COVID-19 EMERGENCY RESPONSE PROJECT ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK Executive Summary The World Bank is providing support to Government of India (GOI) for addressing the immediate and medium-term requirement in addressing COVID-19. This support is for ensuring optimal medical care, maintain essential health services and to minimize risks for patients and health personnel (including training health facilities staff and front-line workers on risk mitigation measures and providing them with the appropriate protective equipment and hygiene materials). The key implementing entities for the Emergency COVID-19 project are the Ministry of Health & Family Welfare (MOHFW), National Center for Disease Control (NCDC), Indian Council of Medical Research (ICMR) and the Ministry of Railways (MOR). The project development objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national health systems for preparedness in India. The project has following the components Component 1: Emergency COVID-19 Response (Indicative Amount: US$500 million): The aim of this component is to slow and limit as much as possible the spread of COVID-19 in India. Component 2: Strengthening National and State health Systems to support Prevention and Preparedness (Indicative Amount: US$ 270 million): The aim of this component is to support building resilient health systems to provide core public health, prevention, and patient management functions to manage COVID- 19 and future disease outbreaks. Component 3: Strengthening Pandemic Research and Multi-sector, National Institutions and Platforms for One Health (Indicative Amount: US$ 100 million): The aim of this component is to support research on COVID-19 by Indian and other global institutions working in collaboration with the ICMR, including biomedical research to generate evidence to inform the short- and medium-term response to the COVID- 19 pandemic. Component 4: Community Engagement and Risk Communication (Indicative Amount: US$70 million): The aim of this component is to address significant negative externalities expected in the event of a widespread COVID-19 outbreak and include comprehensive communication strategies. A critical objective of this sub-component will be to improve the commitment of all participants of the “epidemiological surveillance networks� and health security as a public good. Component 5: Implementation Management, Capacity Building, Monitoring and Evaluation (Indicative Amount US$60 million): The main aim of this component is strengthening of public structures for the coordination and management of the project, including MOHFW and state (decentralized) arrangements for coordination of activities, financial management, procurement, and monitoring and evaluation. Component 6: Contingent Emergency Response Component (CERC) (US$0 million): Provision of immediate response to an Eligible Crisis or Health Emergency. The project will finance a range of activities. From civil works including construction, upgrading, expansion or rehabilitation of existing healthcare facilities and/or waste management facilities to procurement of goods such as medical equipment, PPE, chemical/biological reagent, and other medical supplies or materials. Investments will be made in general hospitals, medical laboratories (BSL 2 & 3), screening posts, quarantine and isolation centers, infection treatment centers, intensive care units (ICUs) etc. The project involves employing or engaging direct and contracted workers. Given the extraordinary 5 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 nature of the pandemic, use of security or military forces cannot be ruled out. Investments will be made for building capacities in managing healthcare waste, to reduce production, enable segregated collection, storage, transportation and disposal, including COVID-19 wastes. The project does not involve land acquisition and/or restrictions on land use connected to construction of healthcare facilities or waste management facilities. Since the project responds to an emerging pandemic situation and in absence of specific locations and detailed information about the subprojects, an Environmental and Social Management Framework (ESMF) has been prepared for managing the identified risks and impacts. Prior to project negotiations, an Environment and Social Commitment Plan (ESCP) and a Stakeholder Engagement Plan (SEP) was agreed and disclosed nationally and on the Bank’s external website. Given country-wide lockdown and travel restrictions, limited consultations were carried, most of which were virtual. Consultations covered aspects of COVID-19 related biomedical waste management (BMWM) practices, aspects related to One Health approach and use of technology in monitoring the pandemic within India. Based on the identified potential environmental and social risks and impacts, the project’s E&S risks are rated as ‘Substantial’. Potential adverse environmental impacts and risks identified include Occupational Health and Safety (OHS) for the healthcare providers, laboratory and other workers in the COVID-19 situation, environmental pollution and community health and safety issues related to the handling, transportation and disposal of bio-medical wastes from hospitals, laboratories, COVID-19 screening posts and quarantine centers, management of construction debris and wastes and risks of access to services for the poor, vulnerable and marginalized social groups. The key risks and impacts on the social side identified are inclusion and access to medical services (COVID-19 testing and treatment) to marginalized and vulnerable social groups (women, the elderly, the differently abled, scheduled tribes [ST], scheduled castes [SC], communities in remote and hilly locations, women headed households, especially single mothers with underage children, unemployed youth, patients with chronic diseases, informal sector workers including domestic workers, laborers, and construction workers) in accessing the benefits and services of the project. The sexual exploitation and abuse (SEA)/ sexual harassment (SH) rating based on the World Bank risk rating tool is moderate for the project. Six out of ten World Bank Environment and Social Standards (ESSs) are considered ‘relevant’. These are ESS1: Assessment and Management of Environmental and Social Risks and Impacts, ESS2: Labor and Working Conditions, ESS3: Resource Efficiency and Pollution Prevention and Management, ESS4: Community Health and Safety, ESS7: Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities and ESS10: Stakeholder Engagement and Information Disclosure. The ESMF is exhaustive and covers all the critical aspects for managing the potential environmental and social risks of the project. The ESMF includes an analysis of the national/subnational legal and policy framework, an environmental and social baseline, screening check lists for risk categorization of subprojects, negative list of investments, due diligence procedures and processes, mitigation actions with responsible agencies against each action and provides procedures relevant to the development of the subprojects, a generic Environmental and Social Management Plans (ESMP), and further guidance for developing the Bio-Medical Waste Management Plan (BMWMP) in accordance with the World Bank’s Environmental and Social Framework (ESF). It includes a summarized SEP and details out the institutional arrangements required for E&S risk management, including the requirements for qualified experts and a capacity building plan. The EMSF includes a Grievance Redress Mechanism and refers to a range of COVID-19 related national, international best practices and WHO guidelines. 6 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 INDIA: COVID-19 EMERGENCY RESPONSE PROJECT ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK 1. Background 1. The World Bank is providing support to Government of India (GOI) for addressing the immediate and medium-term requirement in addressing COVID-19. This support is for ensuring optimal medical care, maintain essential health services and to minimize risks for patients and health personnel (including training health facilities staff and front-line workers on risk mitigation measures and providing them with the appropriate protective equipment and hygiene materials). As COVID-19 places a substantial burden on inpatient and outpatient health care services, support will be provided for several different activities, all aimed at strengthening national and sub-national health care systems. 2. This Environmental and Social Management Framework (ESMF) is prepared for the India: COVID-19 Emergency Response Project to mitigate any potential adverse impact and/or risk. The project will involve the construction, expansion, rehabilitation and/or operation of healthcare facilities in response to COVID-19 amongst other activities, such as, procurement of hospital equipment, personal protection equipment (PPE), testing of patients etc. (also refer Para #9 for details on proposed activities)Potential adverse impacts and risks identified include Occupational Health and Safety (OHS) for the healthcare providers, laboratory and other workers in the COVID-19 situation, environmental pollution and community health and safety issues related to the handling, transportation and disposal of bio-medical wastes from hospitals, laboratories, COVID-19 screening posts and quarantine centers, management of construction debris and wastes and risks of access to services for the poor, vulnerable and marginalized social groups.The ESMF provides procedures relevant to the development of the subprojects, includes a generic Environmental and Social Management Plans (ESMP) and further guidance fordeveloping specific sub=project level ESMPs, when required, in accordance with the World Bank’s Environmental and Social Framework (ESF). 3. This ESMF includes templates for the ESMP (Annex I) and the Bio-Medical Waste Management Plan (BMWMP) (Annex II). The ESMP template identifies potential environmental, social, health and safety issues associated with the construction and operation of healthcare facilities in response to COVID-19. The BMWMP template focuses on infection control and healthcare waste management practices during the operation of healthcare facilities. The ESMP and BMWMP should set out appropriate measures for infection control and waste management during operation of the relevant healthcare facility. 4. An Environmental and Social Commitment Plan (ESCP) has been agreed with key implementing agencies. The Ministry of Health and Family Welfare (MOHFW), Indian Council of Medical Research (ICMR) and National Center for Disease Control (NCDC) are the three key implementing agencies of this project. A preliminary Stakeholder Engagement Plan (SEP), was also developed and both the ESCP and SEP were disclosed publicly in the country and at the World Bank external site. 5. The proposed project development objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national health systems for preparedness in India.The PDO will be monitored through the following PDO level outcome indicators: 7 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 a. Percentage of district hospitals with isolation capacity {Global Multi Phase Approach (MPA)1}; b. Percentages of district health centers/district hospitals with personal protective equipment and infection control products and supplies, without stock-outs in preceding two weeks; c. Proportion of specimens submitted for COVID-19 laboratory testing confirmed within WHO- stipulated standard time; d. Proportion of population able to identify three key symptoms of COVID-19 and/or seasonal influenza and three personal prevention measures (as assessed by a representative population survey); and e. The Government has activated their one health coordination mechanism for COVID-19 and other Emerging Infectious Diseases at Union level 6. The project aims to support the acceleration and scale up of the GOI response to COVID-19, while serving the dual purpose of building systems to respond to future disease outbreaks. This is a new Investment Project Financing (IPF) and includes several activities as described below (refer Section 2; para #7 to #). For a detailed project description, including components, please refer to the Project Appraisal Document (PAD) at http://documents.worldbank.org/curated/en/466861585949433867/pdf/India-COVID-19-Emergency- Response-and-Health-Systems-Preparedness-Project.pdfand www.mohfw.gov/. 7. The rationale for preparing an ESMF over project-specific environmental and social assessment and management plans is as follows: • The project responds to an emerging pandemic situation and therefore, specific locations and detailed information about the subprojects can only be known during implementation; and • Purpose of a framework is to guide the National Project Management Unit (NPMU) and the Subproject Proponents on the E&S screening and assessments of subprojects during implementation, including subproject specific ESMPs in accordance with the ESF. The ESMF will help identify mitigation measures, as part of subproject-specific assessment and plans. 1 District hospitals are being used as the proxy to measure coverage of acute health care capacity in line with the Global MPA guidance. The indicator is defined in the Results Framework. 8 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 2. Project Description 2.1 Project Components and Indicative Activities 8. The project has the following components. Component description provides a fairly good idea of the kinds of activities to be supported. a) Component 1: Emergency COVID-19 Response (Indicative Amount: US$500million): The aim of this component is to slow and limit as much as possible the spread of COVID-19 in India. This will be achieved through: • Support to enhance disease detection capacities, increasing surveillance, reporting and contact tracing, health screening, technical expertise, for case finding and local containment; • Strengthening laboratory and diagnostic systems capacity for human and animal diseases at national and state level by procuring reagents and kits, upgrading virus repository, standardizing sample collection, channeling, and transportation; determining sites most in need of introduction of point-of-care diagnostics; and engaging private laboratories to expand capacity to test and manage COVID-19; • Scaling up procurement of personal protective equipment (PPE), oxygen delivery systems, medicines, and financing service delivery costs to sustain the deployment of current (skilled health workers) and new health and other personnel through extra payments (such as hazard pay and death benefits in line with GOI norms for compensation); • Constructing/establishing new isolation wards (including single occupancy negative-pressure isolation rooms in select facilities), implementing infection prevention and control activitiesin public health facilities (district hospitals, medical colleges, other civil/general hospitals, and designated infectious disease hospitals). This will involve civil works including construction, upgrading, expansion or rehabilitation of existing healthcare facilities with biomedical waste management facilities; • Training healthcare workers and rolling out protocols and guidelines on COVID-19 management, transportation, and referrals. The project will support the establishment of dedicated help lines and engage NGOs to strengthen community engagement, grievance redressal, and education on COVID-19; and • With a project restructuring in May 2020, Ministry of Railway’s (MoR) has been included as an implementing agency for (i) conversion of passenger coaches as isolation coaches; (ii) procurement of medicine, consumables, and paramedics for railway trains and premises for COVID-19 activities; (iii) sanitization of railway premises and trains; and (iv) isolation wards in railway healthcare facilities. It is expected that about 5000 coaches in 134 railway yards of the 16 railway zones will be converted, which may be stationed across 200+ locations. Sixteen zonal railway hospitals and 68 divisional railway hospitals may be upgraded to expand their capacity for establishing isolation wards and procuring PPE, ventilators, oxygen cylinders etc. Also, the sanitization of railway stations and trains are likely to be undertaken throughout the country but specifically where isolation coaches would be stationed. b) Component 2: Strengthening National and State health Systems to support Prevention and Preparedness (Indicative Amount: US$ 270 million):The aim of this component is to support building resilient health systems to provide core public health, prevention, and patient management functions to manage COVID-19 and future disease outbreaks. Key activities include: 9 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 • Building a network of Biosafety Level (BSL) 2 &3, high containment laboratories, including support for the ICMR to upgrade Viral Research and Diagnostic Laboratories in government institutions to meet the requirements of testing for pandemics and research; • Expanding point-of-care molecular testing for viral disease in sub-district and district laboratories and sample transport mechanisms; • Improving disease surveillance systems in humans and animals and health information systems across the country by strengthening the Integrated Disease Surveillance Program (IDSP) and integration of all health information; • Bolstering community-based disease surveillance capacity through increased personnel and the use of Information Communication Technology (ICT) systems to track and monitor infectious outbreaks; • Developing human resource competencies in integrated disease surveillance across different states and at the central level to track and monitor current and new disease-outbreaks; • Creating institutional mechanisms and capacities for epidemic response at district level by providing dedicated resources on the lines of existing mechanisms for disaster management, including strengthening referral transport systems and linkages; and • Develop and update national guidelines to strengthen the emergency management of COVID- 19 and early detection of diseases and response mechanisms. These include: (i) Guidelines on infection prevention and control in healthcare facilities; (ii) Guidelines on quarantine, including home quarantine; (iii) Guidelines for notifying COVID affected persons by private institutions; and (iv) Guidelines on dead body management. c) Component 3: Strengthening Pandemic Research and Multi-sector, National Institutions and Platforms for One Health (Indicative Amount: US$ 100 million):The aim of this component is to support research on COVID-19 by Indian and other global institutions working in collaboration with the ICMR, including biomedical research to generate evidence to inform the short- and medium-term response to the COVID-19 pandemic. Investments are planned to: • Developing core capacity to deliver the One Health approach to prevent, detect (priority existing and emerging zoonoses) at the animal-human interface, and respond to infectious disease outbreaks in animals and humans. Undertake an assessment of national protocols for detection, surveillance, and response systems for animal and human health infections; • Strengthening surveillance systems for prioritized zoonotic diseases or pathogens of high national public health concern; • Improving biosafety and biosecurity management, including staff training and proper specimen transportation; • Strengthening national and state-level One-Health capacity of the animal health workforce (e.g., veterinarians, veterinary paraprofessionals, the public sector and community-based extension workers) to respond to Emerging Infectious Diseases (EIDs); • Establishment of a center of excellence in One-Health, as well other disease outbreak and control research centers; • Expansion of the data collection and surveillance platforms in the dairy sector, including data on small ruminants and other livestock species with significant zoonotic risk; and • Preparing a communication strategy to address community outreach and dissemination of information around risk to the human population of zoonotic diseases. d) Component 4: Community Engagement and Risk Communication (Indicative Amount: US$70 million): The aim of this component is to address significant negative externalities expected in the event of a widespread COVID-19 outbreak and include comprehensive communication strategies. A critical objective of this sub-component will be to improve the commitment of all participants of 10 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 the “epidemiological surveillance networks� and health security as a public good. Key activities that may be supported (and defined clearly) from time to time may include: • Mitigate against (when required) the possible negative impacts on children’s learning and wellbeing due to extended closing of schools, including, a campaign for schools and parents; • Prepare plans (when required) to ensure the continuity of learning, including remote learning options such as radio broadcast and other means of distance delivery of academic content. For tertiary education, a pilot for teaching remotely and for maintaining operation continuity will be financed to facilitate engagement of students; • Support to additional actions to complement social distancing. These include personal hygiene promotion, such as, promoting proper hand washing and cooking standards and distribution and use of masks, along with increased awareness and promotion of community participation in slowing the spread of the pandemic; • Provision of mental health and psychosocial services for vulnerable communities; • Support systems for community-based disease surveillance and multi-stakeholder engagement for social inclusion and healthcare worker safety, among others. Rebuilding community and citizen trust that can be eroded during crises; and • Support community-based animal disease surveillance and early warning networks and systems for robust emergency reporting and feedback against notifiable diseases. Also support training for animal health workers, and treatment of infected animals and reporting procedures. Farmers, herders, extension professionals, and paraprofessionals would receive hands-on training in detection of clinical signs. Participatory methodologies involving farmers, para- veterinarians, and community workers would be used extensively, given that the major control targets are the small-scale and semi- commercial livestock production systems. e) Component 5: Implementation Management, Capacity Building, Monitoring and Evaluation (Indicative Amount US$60 million):The main aim of this component is strengthening of public structures for the coordination and management of the project, including MOHFW and state (decentralized) arrangements for coordination of activities, financial management, procurement, and monitoring and evaluation. Key activities include: • Strengthening NCDC capacity for health emergency and disease outbreak management; • Upgrading information systems for program management; and • Expand staffing with core competencies for disease surveillance, epidemiology, labs, and One Health service delivery. f) Component 6: Contingent Emergency Response Component (CERC) (US$0 million): Provision of immediate response to an Eligible Crisis or Health Emergency. 9. The project will finance a range of activities. Based on the project description, it is confirmed that the project involves civil works including construction, upgrading, expansion or rehabilitation of existing healthcare facilities and/or waste management facilities. It will finance various types of healthcare facilities, such as, general hospital, medical laboratories (BSL 2& 3), screening posts, quarantine and isolation centers, infection treatment centers, intensive care units (ICUs), and assisted living facilities. Project will finance procurement of goods such as medical equipment, PPE, chemical/biological reagent, and other medical supplies or materials. The project will involve employing or engaging direct and contracted workers. Given the extraordinary nature of the pandemic, use of security or military forces cannot be ruled out. Investments will be made for building capacities in managing healthcare waste, to reduce production, enable segregated collection, storage, transportation and disposal, including COVID-19 wastes. Third-party managed Common Treatment Facilities (CTF) with 11 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 incinerators will be involved. The project does not involve land acquisition and/or restrictions on land use connected to construction of healthcare facilities or waste management facilities. 2.2 Project Environmental and Social Risks 10. Given the nature and potential of spread of the COVID-19 pathogen, the environmental risks are rated Substantial. However, the project is expected to have mostly positive environmental impacts, insofar as it should improve COVID-19 surveillance, monitoring, case management and containment, thereby preventing a wider spread of the disease. The main environmental risks identified are: a. The occupational health and safety issues related to shortage of PPE for health care and other workers in the COVID-19-related logistical supply chains; b. PPE are not appropriately used by the laboratory technicians and medical staff; and c. Environmental pollution and community health and safety issues related to the handling, transportation, and disposal of health care waste, including solid and liquid wastes from hospitals, public and private laboratories, COVID-19 screening posts and quarantine centers, and any construction waste generated during upgrading and/or building new healthcare facilities. The associated risks are unusually higher and require higher awareness, behavior modification, and special handling. This is critical to reduce accidental contact with liquid wastes (blood, other body fluids, reagents, and water used during testing) and solid wastes and consumables (bed sheets, utensils, etc. of infected patients and waste generated during testing and treatment). 11. The social risks are also considered Substantial. India has geographic, socio-cultural, and economic diversity and varied capacity of local governments for handling health service delivery, including quality of facilities for isolation and quarantine across states. These variations carry Substantial risks to marginalized and vulnerable social groups who may be disproportionately impacted or further disadvantaged by the project(s) as compared to others (and will include women, the elderly, the differently abled, scheduled tribes [ST], scheduled castes [SC], communities in remote and hilly locations, women headed households, especially single mothers with underage children, unemployed youth, patients with chronic diseases, informal sector workers including domestic workers, laborers, and construction workers) in accessing the benefits and services of the project. These risks are further accentuated by the large population working in the informal sector as daily wage earners whose livelihoods are at stake in the short term, and who therefore may flout state- or national-level recommendations. And hence, requires additional social protection and livelihood enhancement measures by various other Ministries and departments of state and national government dealing with production systems and livelihood generations at different levels along with additional guidance on preventive measures to be taken post lockdown situation for functioning of institutional, commercial and agricultural operations. In fact, there is a potential risk of social tension and conflict within communities due to the adverse impacts of containment strategies on people’s livelihoods, particularly when it comes to marginalized and vulnerable groups. The sexual exploitation and abuse (SEA)/ sexual harassment (SH) rating based on the World Bank risk rating tool is ‘moderate’ for the project, and requires mitigation measures including sensitization and capacity building of the health care staffs and others associated with COVID19 operations following MOHFW’s guidance on the same, setting up gender-sensitive infrastructure such as segregated toilets and well-lit quarantine and isolation centers, along with building linkages to Ministry of women and Child Development’s (MoWCD) initiative of establishing One-stop center in each district for addressing violence against women in districts where it is operational. Hence, handling medical isolation of individuals with quarantine interventions (including dignified treatment of patients; attention to specific, culturally determined concerns of vulnerable groups; prevention of sexual exploitation and abuse (SEA) and sexual harassment (SH); as well as minimum accommodation and servicing requirements) are issues that will require close 12 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 attention while managing the project’s social risks. While the project will support the establishment of isolation units, quarantine facilities and laboratories, the associated civil works are expected to be minor and limited to existing facilities and their footprints (e.g., hospitals or other existing spaces). And hence, the project is not expected to involve in any land acquisition nor involuntary resettlement. 12. Given that project locations and investment activities are still evolving, an ESMF has been prepared, which has procedures in place for E&S risk classification and mitigation. Based on the project design and existing capacity, the overall E&S risk of the project is categorized as ‘Substantial’. All sub- projects will be screened based on the Screening Form for Potential Environmental and Social Issues (Annex III), which sets out a list of questions on the screening of E&S risks and impacts, identifies the relevant ESSs and the type of assessments and management tools that can be developed. The ESMF has pre-screened several project activities, listed their risk category (refer Table 4; page #26) and provided guidance on addressing the potential risks and impacts. All sub-projects identified as high risk will constitute the negative list and will not be financed under the project. 1.3 Objectives of the ESMF 13. Projects financed under the World Bank’s Investment Policy Financing (IPF) need to comply with the Environmental and Social Standards (ESSs) of the World Bank’s Environmental and Social Framework (ESF). Therefore, all investment packages eligible for funding under the India COVID-19 Emergency Response and Health Systems Preparedness Project (P173836) are required to satisfy the World Bank’s ESF in addition to conformity with environmental and social legislation of the Government of India (GoI) and that of the States where implemented. The ESMF will serve as the basis in the preparation of recommended sub-project specific instruments, such as, Environmental and Social Impact Assessments (ESIA) and/or Environmental and Social Management Plans (ESMPs) etc. as may be required. 14. The objectives of this ESMF are: a. To establish clear procedures and methodologies for environmental planning, assessment, review, approval and monitoring of subprojects to be financed under the Project; b. To specify appropriate roles and responsibilities, and outline the necessary reporting procedures, for managing and monitoring environmental concerns related to subprojects; c. To determine training, capacity building and technical assistance needed to successfully implement the provisions of the ESMF; and d. To provide for resources necessary for implementing the ESMF. 13 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 3. Policy, Legal and Regulatory Framework 3.1 National Policy and Legislations 15. India has specific policy, legal and regulatory provisions directly relevant to the activities being carried out in the project. Table 1 lists legal instruments that manage the biomedical and other wastes, pollution prevention, labor related aspects relevant to the project. To deal with the emerging shortages of required medical supplies, including PPE, medicines etc., GOI has recently waived certain regulatory requirements under the Environment (Protection Act) to encourage private sector set up manufacturing units for producing these. These may have some impacts on the environment however, these fall outside the purview of the project investments. Table 2 outlines World Bank Environmental and Social Standards (ESSs) relevant to the project. It also lists other relevant international and regional conventions to which India is a signatory. 16. The provisions of the existing environmental legal and regulatory framework are adequate but require enabling institutional and technical capacity to comply with. While the provisions of the Biomedical Waste Management & Handling) Rules, 1998 – as amended up to March 2018 are being implemented, provisions of other relevant environmental Acts, such as, hazardous, solid, plastic and E- waste Rules 2016 require additional capacity building efforts. Efforts are required to improve the monitoring of the management of different kinds of wastes. 17. The existing legislative framework is adequate to ensure social sustainability of the protection of interest of marginalized and vulnerable population including women, the elderly, the differently abled, ST, SC, women headed households, patients with chronic diseases informal sector workers (including domestic workers, laborers, and construction workers). It ensures (a) protection of the interest of all the vulnerable population as mentioned above, (b) non-discrimination based on religion, race, caste, and gender, and (c) transparency with right to information. Table1: Environmental and Social Laws, Regulations and Policies that are relevant to the proposed program S. Applicable Act/ Objective and Provisions Relevance to the Project and key No. Regulation/ Policy Findings 1 The Constitution of The Indian Constitution (Article 15) prohibits any Relevant to the overall Program India (especially, discrimination based on religion, race, caste, sex, and Articles 15,16 place of birth. Article 16 refers to the equality of and 46) opportunity in matters of public employment. Article 46 directs the state to promote with special care the educational and economic interests of the weaker sections of the people, particularly of the Scheduled Castes and the Scheduled Tribes and also directs the state to protect them from social injustice and all forms of exploitation. 2 Bio-medical Waste Schedule 1: Categorization and Management Highly relevant Management Schedule 2: Standards for treatment and disposal of -As per Accreditation requirements, (Amendment) BMW healthcare facilities are required to Rules,2018 Schedule 3: Prescribed Authority and duties develop Standard Operating Procedures Schedule 4: Label of containers, bags and (SOPs) in the handling of medical transportation of Bio-Medical waste solid, liquid and radioactive wastes. The provisions under the rules provide for both solid On solid BMW there is good overall and liquid medical wastes. capacity and compliance. On liquid Liquid waste should be treated with 1% hypochlorite BMW, there are significant gaps in solution before discharge into sewers. 14 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 S. Applicable Act/ Objective and Provisions Relevance to the Project and key No. Regulation/ Policy Findings Hospitals not connected to municipal Waste Water treatment and disposal of wastewater Treatment Plants (WWTPs) should install compact from hospitals. on-site sewage treatments (i.e. primary and -The requirements in MOEFCC secondary treatment, disinfection) to ensure that Notification- G.S.R.234 (E), dated 28th wastewater discharges meet applicable thresholds March, 2016 are found to be equivalent to the WBG EHS Guidelines for Healthcare Facilities as they cover good international industry practice (GIIP) such as labeling and symbols for hazardous materials and waste, waste reduction, segregation, storage, transportation (manifest), treatment and handling (with autoclave, incineration), health workers occupational health and safety and public health and safety. The effluent standards are also equivalent or better than the World Bank Group (WBG) EHS Guidelines for Health Care Facilities (Performance Monitoring); for example, 100mg/L for COD (India) and 250 mg/L(WBG Guidelines). 3 Construction and Waste comprising of building materials, debris and Relevant as there will be construction Demolition Waste rubble resulting from construction, re-modeling, waste generated. CPCB guidelines on Management Rules, repair and demolition of any civil structure Environmental Management of C&D 2016 Waste Management in India (2017) will be applicable. 4 E-Waste To address leakage of e-waste to informal sector at Relevant as it is applicable for (Management all the stages of channelization. consumers or bulk consumer. The and Handling) Rules The 2016 Amendment brought health care facilities disposal of E-wastes to be done at the 2011as Amendment (with turnover over INR 20 crores or more than 20 specified collection centers and up to 2018 employees). reported annually. 5 Plastic Waste All institutional generators of plastic waste, shall Relevant as hospitals are generators of Management Rules segregate and store the waste generated by them in large quantity of plastics, including 2016 accordance with the Solid Waste Management Rules, non-reusable types. and handover segregated wastes to authorized waste processing or disposal facilities or deposition centers, either on its own or through the authorized waste collection agency 6 Water (Prevention Provisions are largely to prevent air and water Relevant and largely complied with; and Control of pollution by not releasing untreated effluents and gaps exist in disposal of liquid wastes Pollution) Act 1974 harmful emissions. Most provisions are already from healthcare facilities Air (Prevention and discussed under the Bio-Medical Waste Rules Control of Pollution) Act 1981 Environment Protection Act (and Rules), 1986 & 1996 7 Environment Impact The schedule of the Act lists investment activities Applicable if project finances: a) Assessment 2006 under two categories ‘A’ and ‘B’, including Common Hazardous Waste Treatment expansion of existing ones and sets up State EIA facility having landfill with incineration Authority. All investment activities listed under or incineration alone; b) Common ‘A’ require approval from the Expert Appraisal Effluent Treatment Plant; and c) 15 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 S. Applicable Act/ Objective and Provisions Relevance to the Project and key No. Regulation/ Policy Findings Committee of the Ministry of Environment, building with built up area > 20,000 Forests and Climate Change. sq.m. and < 1,50,000 sq.m. 8 Indian Penal Code Section 278 (making atmosphere noxious to health) Relevant (IPC) and Section 269 (negligent act likely to spread Although individuals would require infection or disease dangerous to life, unlawfully or providing evidence negligently 9 The Indian Medical Provisions are applicable to practicing doctors and Relevant Council Act 1956 medical professionals to provide quality service to The Indian Medical the patients or healthcare seekers. Council Professional Conduct, Etiquette and Ethics Regulations 2002) 10 Right to Information Provides a practical regime of right to information Relevant as all documents pertaining to Act, 2005 for citizens to secure access to information under the the Program requires be disclosed to control of Public Authorities. public. The act sets out (a) obligations of public authorities with respect to provision of information; (b) requires designating of a Public Information Officer; (c) process for any citizen to obtain information/disposal of request, etc. (d) provides for institutions such as Central Information Commission/State Information Commission 11 The Sexual An act that aims at providing a sense of security at Relevant and applicable to all health Harassment of the workplace that improves women’s participation directorates and most of the health care Women at Workplace in work and results in their economic empowerment. facilities (Prevention, It requires an employer to set up an “Internal Prohibition Complaints Committee� (ICC) and the Government and Redressal) to set up a ‘Local Complaints Committee’ (LCC) at Act, 2013 the district level to investigate complaints regarding sexual harassment at workplace and for inquiring into the complaint in a time bound manner. The ICC need to set up by ever organization and its branches with more than 10 employees. 12 Criminal Law The Act recognizes the broad range of sexual crimes Relevant and applicable to deal with (Amendment) Act, to which women may fall victim, and a number of GBV including SEA/ SH issues. 2013: Sexual ways in which gender based discrimination manifests Offences itself.It also acknowledges that lesser crimes of bodily integrity often escalate to graver ones and offences such as acid attack, sexual harassment, voyeurism, stalking has been incorporated into the Indian Penal Code (IPC). It seeks to treat cases as “rarest of the rare� for which courts can award capital punishment if they decide so. The Act clarifies and extends the offense of sexual assaults or rape as a result of abuse of position of trust. As per the Act, the police will also be penalized for failing to register FIRs – this will make it easier for rape victims to report their cases. 13 The Street Vendors The act aims at providing social security and Relevant as it becomes applicable if the (Protection of livelihood rights to street vendors. It provides squatters to be removed comes under Livelihood and protection of legitimate street vendors from the preview of this act harassment by police and civic authorities, and 16 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 S. Applicable Act/ Objective and Provisions Relevance to the Project and key No. Regulation/ Policy Findings Regulation of Street demarcation of "vending zones" on the basis of Vending) Act, 2014 "traditional natural markets", proper representation of vendors and women in decision making bodies, and establishment of effective grievance redressal and dispute resolution mechanism. 14 Fifth and Sixth The scheduled areas under the Constitution has Relevant to the overall Program for Schedule Areas in the special provisions for the administration of the tribal enhancing access to services in tribal Constitution of India dominated areas and autonomous regions with areas and participation of tribal certain legislative and judicial powers. In the population in the program Scheduled Areas, involvement of tribal councils and communities, incorporating their views and culture specific needs will enhance their participation in the Program. 15 The Panchayat The Act mandates for the Fifth Schedule areas to Relevant to the Program – All Tribal (Extension to the make legislative provisions in order to give wide- Sub Plan (TSP) districts as 'High Scheduled Areas) ranging powers to the tribes on matters relating to Priority Districts' under National Rural Act, 1996 decision-making and development of their Health Mission. Also, the Gram Sabha communities. The PESA Act empowers the Gram have control over local institutions and Sabha (the council of village adults) and the Gram functionaries including the Health Sub- Panchayat to take charge of village administration. centres and Anganwadi centres. Gram Under the Act, Government of India stipulates to Panchayat is also implementing many conduct consultations and obtain consent for the development schemes of government development Program from the tribal advisory including for livelihood and council (TAC), Gram Sabha and the Gram Panchayat employment generation. under the Fifth Schedule Areas. 16 The Building and This is a social welfare legislation that aims to Relevant to the program and applicable Other Constructions benefit workers engaged in building and for sub-projects involving any Workers (Regulation construction activities across the country and construction. of Employment and regulates the employment and conditions of Conditions of service of building and other construction workers Service) Act, 1996 and to provide for their safety, health and welfare and the associated measures and for other matters connected Central Rules, 1998 therewith or incidental thereto. 18. India has also issued several national policies and guidelines specific to COVID-19 pandemic.Since the outbreak of COVID19, India has proactively taken several measures for containing the disease which are in line with guidance form WHO, CDC and other international best practices guidance and learning. While many of these policies are evolving based on the COVID19 pandemic situation in India, some of the guidance relevant to environmental and social measures are as below: i. Advisory on Social Distancing – March 2020 – MOHFW ii. Advisory on Mass Gatherings – March 2020 – MOHFW iii. Guidelines for home quarantine – March 2020 – MOHFW iv. Guidelines for handling, treatment and disposal of waste generated during treatment, diagnostics and quarantine of COVID19 patients – March 2020 and April 2020 – Central Pollution Control Board v. Strategy of COVID19 Testing in India – March 17, 2020, from Indian Council of Medical Research vi. Standard Operating Procedures for Passenger Movement Post Disembarkation (including SOP for Quarantine) – March 2020 – MOHFW vii. Guidelines for Notifying COVID19 Affected Persons by Private Institutions – March 2020 – MOHFW 17 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 viii. Gazette Notification – Essential Commodities Order 2020 – with regards to masks and hand sanitizers ix. National Pharmaceutical Pricing Authority (NPPA) Order regarding Masks, Hand Sanitizers and Gloves x. COVID19 Guidelines on Dead Body Management – March 15, 2020 – Director General of Health Services (DGHS), MOHFW (EMR Divisions) xi. Office Memorandum on Preventive Measures to be taken to contain the spread of Novel Coronavirus (COVID19) – March 16, 2020 – Department of Personnel and Training), Ministry of Personnel, Public Grievances and Pensions xii. Guidance document on appropriate management of suspect/confirmed cases of COVID-19 - Types of Covid-19 dedicated facilities xiii. Guidelines for Quarantine facilities COVID-19 xiv. Guidance for COVID-19 & Pregnancy &Labour Management xv. Guidance document on appropriate management of suspect/confirmed cases of COVID-19 - Types of Covid-19 dedicated facilities xvi. Advisory issued by Ministry of Rural Development to the State Rural Livelihoods Missions on actions to be taken to address the COVID 19 outbreak xvii. Norms of assistance from State Disaster Response Fund (SDRF) in wake of COVID-19 outbreak xviii. Containment Plan for Large Outbreaks of COVID-19 xix. Model Micro plan for containment of local transmission of COVID19 xx. Advisory for quarantine of migrant workers xxi. Various mass awareness generation activities and guidance xxii. Various audiovisuals and print material on Psycho-Social support along with setting up toll free helpline-08046110007 xxiii. Ordinance to protect healthcare workers form abuse and assault xxiv. Guidelines on preventive measures to contain spread of COVID-19 in workplace settings xxv. Advisory for managing Health care workers working in COVID and Non-COVID areas of the Hospital xxvi. Guidance note for Immunization services during and post COVID outbreak 3.2 World Bank Environmental and Social Framework (ESF) 19. The World Bank Environmental and Social Framework (ESF) sets out the World Bank’s commitment to sustainable development, through a Bank Policy and a set of ten Environmental and Social Standards (ESS) that are designed to support projects in a sustainable manner for the benefit of the environment and their citizens. Depending on the project implementation, the relevance of these Standards could vary. Based on the environmental and social risks assessed at this stage, the relevance of ESS are given in Table 2below: Table 2: World Bank Environment and Social Standards and their Relevance to the Project Environment and Social Standard Relevance Justification ESS1: Assessment and Management of Relevant Given ‘substantial’ risk rating for environment and Environmental and Social Risks and social impacts, the project needs to undertake an Impacts assessment and prepare an ESMF with adequate mitigation actions. ESS2: Labor and Working Conditions Relevant Even though most activities under the project will be carried out by the healthcare, laboratory workers and public servants, there will be involvement of hired/contractual/daily wager in the form of labor and consultants. 18 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Environment and Social Standard Relevance Justification ESS3: Resource Efficiency and Pollution Relevant It will be critical to prevent spread of infection Prevention and Management through pollution management in the form of better handling and disposal of biomedical wastes. ESS4: Community Health and Safety Relevant Chances of infection caused due to project supported activities cannot be ruled out, especially while creating facilities, testing for COVID-19. ESS5: Land Acquisition, Restrictions on Not Currently Project will not support any sub projects involving Land Use and Involuntary Resettlement Relevant land requirement or involuntary resettlement. ESS6: Biodiversity Conservation and Not Currently Planned activities are unlikely to have any impact Sustainable Management of Living Natural Relevant on natural resources and/or biodiversity. Resources ESS7: Indigenous Peoples Relevant Indigenous people are present in several project locations and are an important stakeholder in terms of accessing medical facilities for COVID-19. ESS8: Cultural Heritage Not Currently The project will unlikely support activities that Relevant require large-scale earthwork or cause damage to existing cultural heritage. ESS9: Financial Intermediaries Not Currently FIs are not involved. Relevant ESS10: Stakeholder Engagement and Relevant Consultations and public outreach is critical in Information Disclosure designing interventions that are well-informed through feedback from a diverse set of stakeholders for addressing the pandemic. Ensuring transparency and disclosure will be key to better manage the emerging situation. 3.3 World Health Organization (WHO) Guidelines 20. Several WHO resources are available for reference and adoption during project implementation. To help countries navigate through the challenges of COVID-19, WHO has updated operational planning guidelines in balancing the demands of responding directly to COVID-19 while maintaining essential health service delivery and mitigating the risk of system collapse. This includes a set of targeted immediate actions that countries should consider at national, regional, and local level to reorganize and maintain access to high-quality essential health services for all.In response to COVID-19 India has also updated several national guidelines that are aligned with those of the WHO. The WHO is maintaining a website specific to the COVID-19 pandemic with up-to-date country and technical guidance. Some of the technical guidance available are: (i) laboratory biosafety, (ii) infection prevention and control, (iii) rights, roles and responsibilities of health workers, including key considerations for occupational safety and health, (iv) water, sanitation, hygiene and waste management, (v) quarantine of individuals, (vi) rational use of PPE, (vii) oxygen sources and distribution for COVID-19 treatment centers.A list of all relevant guidelines is presented in Annex- VIII.As the situation remains fluid it is critical that those managing both the national response as well as specific health care facilities and programs keep abreast of guidance provided by the WHO. The dedicated WHO website can be accessed at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance. 3.4 World Bank Group Environment, Health and Safety Guidelines (EHSG) 21. The EHSG are technical reference documents with general and industry-specific examples of Good International Industry Practice (GIIP) and are referred to in the ESF. The EHSG contain the performance levels and measures that are normally acceptable to the World Bank Group (WBG), and that are generally considered to be achievable in new facilities at reasonable costs by existing 19 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 technology. The WBG requires borrowers to apply the relevant levels or measures of the EHSG. When host country regulations differ from the levels and measures presented in the EHSG, projects will be required to achieve whichever is more stringent. In the case of the present Project the General EHSG will apply. The Implementing Agency (IA) will pay particular attention to EHS 1.5 Hazardous Materials Management; EHS 2.5 Biological Hazards; EHS 2.7 Personal Protective Equipment (PPE); EHS 2.8 Special Hazard Environments; EHS 3.5 Transportation of Hazardous Materials; and EHS 3.6 Disease Prevention. A separate EHSG on Health Care Facilities will also apply to this Project intervention. It illustrates waste management, air quality and wastewater disposal guidelines related to HCFs. 20 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 4. Environmental and Social Baseline 22. The risk of spread of COVID-19 in India is substantial, given its population density, socio-economic structure. While no particular environmental parameters are associated with the spread of COVID-19, India is varied in terms of its biogeographical as well as seasonal variations. India is the second most populated country in the world with 1.38 billion people. The scheduled tribe (ST) population is about 104.2 million (8.6 percent). In addition to the North eastern states with about 25%ST population, Madhya Pradesh, Maharashtra, Orissa, Gujarat, Rajasthan, Jharkhand, Chhattisgarh, Andhra Pradesh, West Bengal, and Karnataka are the states with large ST populations. The overall areas inhabited by the tribal population constitute a significant part of the underdeveloped, mostly rural and forested, areas of the country. About 75 tribes are known as Particularly Vulnerable Tribal Groups (PVTGs), who are characterized by (a) pre-agriculture level of technology; (b) stagnant or declining population; (c) extremely low literacy; and (d) subsistence level of economy. 23. India has made substantial improvements in health outcomes since 1990, yet, challenges in health care access, quality, and utilization remain. Between 1990 and 2016, infant mortality rates fell by half, deliveries in health facilities tripled, and maternal mortality ratios fell by more than 60 percent. Quality of care is a significant and complex challenge varying across states. India’s demographic and epidemiological transition calls for an aggressive response to persisting communicable diseases and a burgeoning burden of non-communicable diseases (NCDs). The private sector plays an important role in providing services in both rural and urban areas and can play a key role in responding to disease outbreaks and pandemics. India has recently faced disease outbreaks, such as, NIPAH and SARS and has started putting in place a coordination mechanism for strengthening the One Health approach (also supported under this project).The National Centre for Disease Control (NCDC) has a center for arboviral and zoonotic diseases responsible for the Inter-Sectoral Coordination for Prevention and Control of Zoonotic Diseases. 24. Government health spending in India is just over 1 percent of GDP, less than the average among comparable middle-income countries. Over 60 percent of total health spending is paid out-of-pocket by households. Over the past decade or more, major health financing reforms have been initiated with a focus on government-sponsored health insurance schemes for the poor, including the Pradhan Mantri Jan Arogya Yojana (PM-JAY) launched in September 2018. Considering that 70% of the out of pocket expenditure in India is on account of drugs and diagnostics, the Government under the NHM has been providing the states support for free drugs and diagnostics in the health facilities. The PM-JAY insurance scheme provides more than 500 million people (i.e., the bottom 40 percent of the population) with free secondary and tertiary hospital care at over 20,000 empaneled hospitals nationwide, of which about half are in the private sector. Government has further decided to make the testing and treatment for COVID-19 available under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PM JAY) free in the public facilities leading to more than 500 million citizens, eligible under the Government of India’s health assurance scheme will be able to avail free testing through private labs and treatment for COVID-19 in empaneled hospitals. 25. The overall health care delivery services are categorized as primary, secondary and tertiary care services and at state level being managed by different Directorates of the State Health Department. While the primary health care services by Sub-Centre (SC), and Primary Health Centre (PHC) are largely preventive and promotive, the Community Health Centre (CHC) works as the first referral unit for curative services. The District hospitals, sub-divisional hospitals form the core of the secondary services, which the Medical college hospitals and super specialty hospitals forms part of the tertiary health services. The table below further details out the key functions of district hospital, CHC, PHC and SC. For the treatment of COVID cases it will be largely the secondary and tertiary health care institutions and associated laboratories. 21 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Type of Health Typology and Geographic Numbers and Human Resources Facility Distribution Compliance District One in each district. District DH is manned by 11-23 Every district has at least Hospital (DH) Hospital serves as secondary Medical Officers based one District Hospital and referral unit and provides on number of beds along there are more than 1,000 comprehensive secondary with minimum of DH in the country. health care services to the Medicine, Surgery, people in the district at Obstetric & Gynae, All DHs are mandated to an acceptable level of quality. Paediatrics, Anaesthesia, comply with the BMW Ophthalmology, Rules (2018); most DHs Based on population size Orthopaedics, are having tie-up with district are graded and varies Radiology, Pathology, Common Treatment from 100 bedded to 500 ENT, and Dental Facilities (CTF) for bedded hospitals]services specialists along with 45 collection and disposal of include OPD, indoor and to 225 Staff Nurses and BMW; while solid BMW Emergency Services and will other support staffs is being managed, there have OT and ICUs. based on number of are gaps in treating liquid beds. wastes from DHs. Community CHCs are being established CHC is manned by four As on 31stMarch, 2019, Health Centres and maintained by the State medical specialists i.e. there are5,335 CHCs in (CHCs) or Sun- government. It also works as a surgeon, physician, the country and 1,255 Divisional First Referral Unit (FRU). gynaecologist and Sub-Divisional Hospitals. Hospitals paediatrician supported The standard norm for a CHC by 21 paramedical and Compliance with BMW is at every 120,000 population other staffs. Rules 2018 is generally in plain areas and every satisfactory with respect 80,000 population in hilly It has 30 in-door beds to segregation of wastes, areas. In urban areas it is at with one OT, X-ray, collection in colored bins 250,000 population. labour room and and final disposal. Liquid laboratory facilities. It wastes are generally serves as a referral centre untreated. Staff trainings for 4 PHCs and also on BMWM is provided provides facilities for bur often refresher obstetric care and trainings are missing. specialist consultations. Primary Health PHC is the first contact point PHC is manned by a As on 31stMarch, 2019, Centres (PHCs) between village community medical officer there are 24,855 PHCs and the medical officer. The supported by about 14 (i.e 16,613 PHCs and PHCs were envisaged to paramedical and other 8,242 PHCs upgraded to provide an integrated curative staff (1- Pharmacist, 3 Health Wellness Centre and preventive health care to Staff Nurse including HWC-PHCs) functioning the rural population with from NRHM, 1 ANM, 1 in the country. emphasis on preventive and Laboratory Technician, promotive aspects of health and other staffs). Volumes of BMW are care. generally low and It acts as a referral unit disposal is done through The standard norm for a for 6 Sub Centres and deep burial pits located on PHCis at every 30,000 has 4-6 beds for patients. site. BMW segregation is population in plain areas and The activities of PHC practiced but better every 20,000 population in involve curative, training and monitoring is hilly areas. preventive, promotive required at PHCs. and family welfare services. 22 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Type of Health Typology and Geographic Numbers and Human Resources Facility Distribution Compliance Sub – Centre The Sub Centre (SC) is the Each Sub-centre is As on 31stMarch, 2019, (SC) most peripheral and first manned by at least one there are 157,411 contact point between the auxiliary nurse midwife numbers of rural SCs primary health care system (ANM)/ female health functional in the country. and the community. worker and one male health worker. Generation of BMW is The standard norm is one SC meager and disposal is at every 5,000 population in done on site; disinfection plain areas and every 3,000 is carried out subject to population in hilly areas. availability of disinfectants. Source: MOHFW, 2019 26. The biomedical waste management (BMW) has steadily improved in the country, though some gaps remain. Overall, compliance with the BMWM Rules 2018 is good. Most medium to large-sized hospitals have elaborate systems to address BMW, including waste segregation, collection in colored bins, on site storage, sharps management and tie-up with CTFs. While many states have outsourced CTFs to private operators, there remain some gaps in terms of the number of CTFs, frequency of BMW collections etc. The NHM provides financing for managing BMW and the budget allocation has been increasing over the years. This allocation also covers providing training on BMWM to all levels of healthcare workers across all levels of healthcare facilities. There is good awareness (and often knowledge) on procedures and practices on BMWM across all levels of healthcare staff and facilities, though refresher training are required more frequently. Almost all states have good communication materials, posters and required materials (colored bins, disposable bags, deep-burial pits, sharp kits etc.) In general, solid BMW is managed satisfactorily, including when on-site disposal is practices in deep burial puts. One gap in BMW is the treatment and disposal of the liquid wastes from hospitals and other healthcare facilities, where substantial investments and efforts are required. 27. As on 08 June 2020, a total of 2,49,410 COVID positive cases reported of which 1,24,981 cases are active, 1,24,429 cured/discharged and 7200 deaths reported across the country. Top five state with active/treated cases reported are Maharashtra 43601 active/39314 treated), Delhi (17125 active/10999 treated), Tamil Nadu (14399 active/16999 treated), Gujarat (5186 active/13635 treated) and Uttar Pradesh (4076 active/6185 discharged). 23 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Time Series of Cumulative Cases in India Source: https://app.powerbi.com/view 28. A number of relevant parameters are identified for developing the environmental and social baseline for the project, which is given in Table 3 below. The COVID-19 response project is nation-wide and include project-supported activities involving Point of Entry (POE) and border areas2,transport hubs, quarantine centers and healthcare facilities. Some of these interventions will be implemented in remote, rural, vulnerable or fragile situations, for example, in predominantly tribal districts in heavily forested areas where connectivity is poor and access to healthcare services limited. The data however for these parameters is not currently available, nor the MoHFW is in a position to collate these details given current ‘expanding emergencies throughout the country.’ The MoHFW, however, will attempt to collect and furnish these details earliest possible, during early stages of project implementation, and will be evaluated at the end of project to verify the achievements during the project implementation. Table 3: Environmental and Social Baseline S. Baseline Parameter Unit As on Increased No. Jan 01, 2020 during Project Implementation Environmental 1. Dedicated COVID-19 healthcare facilities Number 00 2. Budget under NHM allocated for COVID-19 BMWM INR 00 Million 3. Persons trained on handling COVID-19 waste Number 00 4. Aggregate volume of COVID-19 biomedical waste Tons/Year 00 generated 5. BSL3 laboratories Number 04 6. No. of passenger coaches converted to isolation Number 00 coaches Social 7. People tested for COVID-19 (all India) Number 00 2 The activities at point of entry and border areas are limited to health screening and some emergency support. In case of detection of symptoms, the person is sent for quarantine to the facilities available in that city/town.The screening at entry points usually involve contact-less procedures. However, masks and gloves etc. and/or any additional medical waste needs to be treated as per BMW Rules 2018. 24 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 S. Baseline Parameter Unit As on Increased No. Jan 01, 2020 during Project Implementation Women Number 00 In Urban area Number 00 In Rural area Number 00 29. Testing for COVID-19: The initial shortage of testing kits has been overcome and indigenously developed test kits authorized by ICMR are also available now. Health being the State subject, and for uniformity of multifaceted response to COVID19 emergency which required response from various other Ministries and Departments both at national level and at state and district level, the GOI invoked the powers of National Disaster Management Act for the first time in the country to take effective measures to prevent the spread of COVID19 across the country. As on 15th April 2020, in order strengthen government's efforts to contain the novel corona virus, districts were classified into three categories – hotspot districts which report a large number of positive cases (classified as red zone), non- hotspot districts which record a few corona virus cases and classified as orange zone and green zones which have not reported fresh cases for some time. The ministry has identified 170 districts as hotspots (red zone), and 207 districts as non-hotspots (orange zone). 25 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 5. Potential Environmental and Social Risks and Mitigation 30. Based on the assessment of the potential environmental and social risks posed due to planned investments, the E&S risk rating for the project is considered as ‘Substantial’. The potential E&S risks and impacts could be due to planned investments on testing, construction of new hospitals, wards and laboratories, occupational and community health hazards etc. The ESMF has pre-categorized investments into different risk categories (low, moderate, substantial and high) and have suggested appropriate mitigation approach against each of the risk category (see Table 4). All activities listed under ‘Negative List category are ineligible under the project. The purpose of Table 4 is to provide guidance on overall mitigation approach to facilitate quick decision-making during implementation for addressing the emergency situation. Specific mitigation measures and actions are provided in Table 6 in the next chapter. Table 4: Environmental and Social Risk categorization of Planned Activities and Suggested Mitigation Approach S. Proposed Sub-Project Activities Risk Suggested Mitigation Approach No Category 1 ▪ Training(s) including on Low ▪ No specific mitigation biomedical waste handling, requirement COVID-19 testing, ▪ General supervision by the communications agency responsible for activities ▪ Printing of awareness, ▪ Waste papers etc. to be disposed information, communication as municipal waste and knowledge materials, ▪ IEC measures to be used for training manuals, posters, awareness building among the guidance note on preventive poor and vulnerable of the risk measures etc. of infection along with potential ▪ Procurement of medicines, measures and mechanisms that linen and mattresses, pillows are put in place for accessing etc. for hospitals, especially health services for use in COVID-19 wards/facilities and for quarantine facilities 2 ▪ Procurement of medical Moderate ▪ All COVID-19 equipment to be equipment, hospital beds, properly labelled COVID-19 testing kits, PPE, ▪ Precautions not to mix COVID- ventilators etc. 19 materials with other medical ▪ Procurement of tents for supplies establishing new isolation ▪ Disposal of COVID-19 and areas other Biomedical Waste as per relevant Rules (refer Figure 2) ▪ Procurement management of equipment, chemicals, PPE kits, medicines and Biomedical waste management. ▪ Occupational hazards and risk of infection to HCWs when handling and using reusable material such as linen etc. and PPEs during HCF operations. 26 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 S. Proposed Sub-Project Activities Risk Suggested Mitigation Approach No Category 3 ▪ All new construction works Substantial ▪ Environmental impacts such as (civil works) dust, noise, occupational health ▪ All temporary set up for and safety associated with civil isolation and quarantine areas works. Ensuring no child labor (tented and/or pre-fabricated) is involved as per government ▪ All reconstruction or norms. And ensuring community expansion within existing health and safety measures are in hospitals for establishing place and followed. wards, isolation areas, ▪ Construction waste and other pathological laboratories general waste management as ▪ All new and upgrading of per available guidelines existing laboratories, ▪ Biomedical waste management especially upgrading to BSL3 as per BMW guidelines ▪ Ensuring access to services to ▪ Suitable PPEs to healthcare poor and vulnerable including workers women, the elderly, the ▪ Additional clauses for bid differently abled, scheduled documents for construction tribes [ST], scheduled castes contracts (Annex IV) [SC], and communities in ▪ Health and hygiene training and remote and hilly locations, orientation for all women headed households, ▪ E&S screening for identifying especially single mothers with and avoiding/minimizing social underage children, and environmental issues unemployed youth, patients ▪ Ensuring adequate health care with chronic diseases, services in each of the districts, informal sector workers and in municipal areas based on including domestic workers, its risk profile with specifically laborers, and construction targeting poor and vulnerable workers. population including migrants ▪ Site selection for the facilities and urban poor population (risk can be substantial if groups. meaningful consultation is not ▪ Health care providers including held) doctors, nurses, midwives, ▪ Conversion of passenger multipurpose health workers and coaches for use as isolation other staff at the health facilities coaches to be sensitizedby HCF ▪ Sanitization of coaches and management/ CMO under the railway premises guidance of State nodal E&S (platforms/stations etc.) specialist towards services to poor and vulnerable including providing psychosocial support where needed ▪ Ensuring safety of vulnerable population especially women in quarantine and isolation centers from any sexual exploitation and abuse (SEA) and sexual harassment (SH) with sensitization of health care staff 27 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 S. Proposed Sub-Project Activities Risk Suggested Mitigation Approach No Category on SEA/SH along with adequate security measures and setting up gender-sensitive infrastructure such as segregated toilets and well-lit quarantine and isolation centers, and mechanism to access redressal services including linkages to services provided by One Stop Centre3 (OSC) where available (see Annex-IX). ▪ Addressing social tension and conflicts associated with handling medical isolation of individuals with quarantine interventions and using dignified quality treatment of patients and building awareness about these services ▪ Refer to ESMF (Table 5) for mitigating potential risks/impacts of rail isolation coaches and sanitization of railway premises. 4 ▪ Upgradation of existing BSL2 High ▪ This will require undertaking an and/or construction of new environmental assessment and BSL3 laboratories preparation of an environmental management plan for construction phase and for the operational phase. 5 ▪ Activities requiring diversion Negative List ▪ Ineligible for financing under of forestland to non-forestry the project purposes(or infringement in eco-sensitive areas) ▪ Activities requiring land acquisition and involuntary resettlements 31. Most of the activities supported by the project will be conducted by health professionals and associated health staff and laboratory workers who are employed/ contracted by the government (Center/ State) or by Ministry of Railways using their own staff and/or hiring of additional staff. The activities by these staff encompass surveillance, sample collection and testing as well as treatment of patients at the hospitals/ health care facilities and quarantine facilities. In addition, any expansion of services will also involve contracted labor. Both the health service providers and contracted labor are at enhanced risk of 3 Ministry of Women and Child Development (WCD), Government of India had initiated setting up One Stop Center (OSC) to deal with women facing sexual harassment and till June 2019, there were 462 OSC were functional against the planned 728 OSC at least one for each district. One Stop Centers (OSCs) are intended to support women affected by violence, in private and public spaces, within the family, community and at the workplace. 28 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 exposure to the outbreak of COVID-19. The Labor Management Procedure (LMP) (Annex VII)for the project illustrates the provision for both direct and contract labor associated with the project. 32. The Ministry of Health and Family Welfare (MOHFW) recognizes the issue of sexual exploitation and abuse (SEA)/ sexual harassment (SH) in the society at large and in COVID19 emergency situation, and recognizes the critical role to be played by the health professionals and health systems in preventing and caring for survivors/victims of sexual violence.MoHFW had come out with ‘Guidelines and Protocols for Medico-legal care for survivors/victims of sexual violence’to provide guidance to health sector services in this regard(https://main.mohfw.gov.in/sites/default/files/953522324.pdf) and at the same time recognizes the need for multisectoral approach in dealing with SEA/ SH issues. In addition, ‘The Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013’ which replaced the erstwhileVishaka Guidelines, provides for measures such as Internal complaint committees (ICC) to be constituted at the workplace and has been a mandatory measures for all public and private sector institutions. Also, Ministry of Women and Child Development (WCD), Government of India had initiated setting up One Stop Center (OSC) to deal with women facing sexual harassment and are intended to support women affected by violence, in private and public spaces, within the family, community and at the workplace. Women facing physical, sexual, emotional, psychological and economic abuse, irrespective of age, class, caste, education status, marital status, race and culture will be facilitated with support and redressal.Annex-IX provides the details mitigation measures with SEA/SH issues. 33. The project does not intend to finance any land acquisition and/or restrictions on land use connected to construction of healthcare facilities or waste management facilities. Also, the project does not support any involuntary resettlements and/or any informal/illegal occupants in case of land being encroached and is needed for any expansion and/or new construction of HCF/ laboratory. To ensure this screening of subprojects will be conducted to ensure that any infrastructure expansion or construction will be supported only on HCF’s/ laboratory’s own land or on government land free from any encumbrances. The screening done at the sub project level, will be verified and certified by the state level Environmental and Social nodal officers. This will also be checked by the PMU/nodal officer at MoHFW level and the Bank will also monitor and cross verify the screening exercise on sample basis. 34. Government of India has also taken several measures to reduce the risk and vulnerability of people in general and especially for the vulnerable groups of the population. In order to ensure that all aspects of emergency are being adequately addressed with synchronized efforts cutting across various Ministries/ Departments, GoI through Ministry of Home Affairs (MHA) setup eleven (11) Empowered Groups under the Disaster Management Act 2005 keeping in view for comprehensive response in an integrated manner. These groups were empowered to identify problem areas and effective solutions, including delineate policy, formulate plans, strategize operations, and take all necessary steps of effective and time bound implementation of these plans/ policies/ strategies/ decisions. These Empowered Groups were for: i. Medical Emergency Management Plan ii. Availability of Hospitals, Isolation & quarantine facilities, Disease surveillance &Testing and Critical care Training iii. Ensuring availability of essential medical equipment such as PPE, Masks, Gloves, Ventilators; Production, procurement, import and distribution iv. Augmenting Human Resource and Capacity Building v. Facilitating Supply Chain & Logistic Management for availability of necessary items such as Food and Medicines 29 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 vi. Coordinating with Private Sector, NGOs, and International Organizations for response related activities vii. Economic and Welfare Measures viii. Information, Communication and Public Awareness ix. Technology and Data Management x. Public Grievance and Suggestions xi. Strategic Issues Related to Lockdown 35. Component 6 of the project is a Contingent Emergency Response Component (CERC). The project ESMF will be updated as soon as the scope of contingency component becomes better defined during project implementation. In addition, a CERC operations Manuel will be prepared during project implementation to govern the operation of the component, this document will be aligned with the ESMF at the time of preparation and include provisions to ensure environmental and social due diligence in line with the requirements of the ESF. A list of typical positive and negative activities associated with CERC implementation will also be developed and included in the updated ESMF and the CERC manual. 30 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 6. Environment and Social Management Plan (ESMP) 36. The project will involve various stages of planning and design, construction, implementation and/or operational stages and finally decommissioning stage in certain cases. The ESMP(Table5) discusses the risks and impacts and required mitigation measures as well as provides the responsibilities and timelines for applying the mitigation suggested measures. Table 5: Environmental and Social Management Plan Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts Planning and Design Stage Location of ▪ Damage to natural environment due ▪ For construction of new hospitals, conduct an Design Agency Before start of healthcare facilities to construction debris disposal, Environmental and Social Impact Assessment (architect), construction (HCF) discharge of untreated sewage and (ESIA) and prepare a standalone ESMP ESIA Agency effluents etc. ▪ For new healthcare facilities, site selection should and HCF ▪ Risk of infection to nearby not impact natural habitats, such as, wetlands, Management residential areas and schools in ponds etc. proximity if visitor circulation is not ▪ Plan new hospitals away from schools and controlled residential areas ▪ Chose sites where access to municipal services (public water supply, sewage and waste collection) are easy Scale up healthcare ▪ A large hospital with multi-bed ▪ Proper design and functional layout of healthcare Design Agency Before start of and other facilities capacity will generate biomedical facilities, which may involve several aspects: i) (architect), construction (including isolation wastes. structural and equipment safety, universal access4; ESIA Agency wards at Railway ▪ Dedicated COVID-19 facility or ii) nosocomial infection5 control and HCF Hospitals) housed within an existing hospital ▪ Consider the waste, including biomedical, Management will generate infections waste with segregation, storage, processing and transportation MOR high risk of exposure to others arrangements, operational procedures and working E&S Nodal ▪ Temporary isolation practices, and the required capacity of the type of Officer of MOR wards/quarantine facilities (tented disposal facility needed for the volume of the or in rented buildings) will also pose wastes generated high risk of infection spread ▪ Ensure universal access to the building and its ▪ Accessibility to built infrastructure various sections (cafeteria/OPD etc.) ▪ Constructing a new BSL3 ▪ The design, set up and management of will take laboratory into account the advice provided by WHO 4 Refer to ESS 4 Community Health and Safety 5 Nosocomial infection can be described as an infection acquired in hospital by a patient who was admitted for a reason other than that infection. Also called “hospital acquired infection�. 31 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts ▪ Require any informal/illegal guidance forSevere Acute Respiratory Infections occupants’ removal in case of land Treatment Center being encroached and is needed for ▪ Isolation rooms should be designed for single any expansion and/or new occupancy with attached toilet/bath and as far as construction of HCF/ laboratory possible should be negative pressure rooms ▪ Design to include negative pressure rooms and disinfecting of air conditioning ducts and vents; entry/exits to be properly controlled and all visitors to be routinely screened ▪ Requirements on food, water, fuel, hygiene, infection prevention and control, and monitoring the health of quarantined persons should be considered in temporary facilities ▪ The project does not support any resettlement including removal of informal/illegal occupants. And hence, an alternate site or design to be explored without disturbing the existing occupants. ▪ Screening to be conducted for finding any informal/illegal occupants on the land available for expansion/ new construction (as per Annex-III) Ensuring Free and ▪ Since being the national project, ▪ Prior information about intervention planned ESIA Agency Before start of Prior Informed Indigenous Peoples (IPs), in the form shall be provided to tribal community and their and HCF construction Consent (FPIC) of Scheduled Tribes (ST), are institutions (on going IEC measures can also be Management provisions if the present in various states including in used for this) construction is the areas designated under Schedule ▪ Site specific consultations with respective being undertaken V and Schedule VI areas as per the community groups to be conducted illustrating in tribal areas. Constitution. detailed scope of the intervention (virtual method ▪ As some of these areas are governed of consultations will be used) by tribal institutions with special ▪ Incorporating tribal community’s feedback and provisions and rights to the ST suggestions and taking their consent on going population. The provisions of FPIC ahead with intervention as agreed upon (virtual will help enhance acceptance and method of consultations and agreement can be participation of ST population to the used) program. Hiring of existing ▪ Hiring of an existing asset such as a ▪ Ensure that access to the hired facility is restricted Design Agency Before start of assets such as hotel or stadium for quarantine, ▪ Ensure that the facility is connected to municipal (architect), construction hiring of buildings isolation or treatment purposes could disposal network works contractor, 32 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts as temporary pose risk to local habitation, other ▪ Complete and regular disinfection of the hired material measures visitors, expose staff to infection risk facility, especially before vacating and allowing supplier and the facility to remain in lock for at least one week HCF after vacating Management ▪ Training and orientation of staff of the hired NPMU facility Healthcare staff ▪ Risk of COVID-19 infection ▪ Estimate numbers and type of project workers Design Agency Throughout and other workers / ▪ Altercation with resident ▪ Assess whether temporary accommodation and/or (architect), project labors, including communities labor camp will be required ESIA Agency implementation healthcare staff at ▪ Risk of workplace and/or sexual ▪ Select suitable location for labor camp and HCF COVID designated harassment ▪ Prepare gender sensitive work plans Management Railway hospitals ▪ Ensure parity with respect to usage of PPE among and and isolation/ all workers irrespective of being regular or MOHFW quarantine coaches contracted MOR and other ▪ Ensure early payout of INR 50 Lakh per health ES& Nodal associated staffs/ worker fighting COVID-19 under Insurance Officer of MOR workers engaged Scheme announced by the Government Station Master ▪ No child labor, forced or conscripted labor used ▪ Ensure proper site-specific grievance redress management plan ▪ Setting up gender-sensitive infrastructure such as segregated toilets and well-lit quarantine and isolation centers and other mitigation measures addressing SEA/ SH issues (see Annex-IX). ▪ Labor Management Plan (LMP) for the project to be referred for further details. Use of materials ▪ Risk of high resource consumption ▪ Plan for installation of solar water heating, LED Design Agency Before start of and resource (energy and water) lighting and use natural elements in design of the (architect), construction efficiency building (large windows for natural light, proper ESIA Agency air ventilation and circulation, landscaping with and HCF canopy trees) Management Waste ▪ Inadequate biomedical waste ▪ Waste disposal, including biomedical waste, Design Agency Before start of management, management capacity facilities to be part of design of the healthcare (architect), construction including ▪ Risk of mixing of Covid-19 facility, including temporary storage. ESIA Agency biomedical wastes biomedical waste with other ▪ Plan waste transport routes within and outside and HCF medical and general waste facility as part of design Management MOR 33 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts ▪ Setting up a waste disposal/treatment unit within healthcare facility should be subject to local laws (for example incinerator) Other Risks ▪ Inadequate entry and exit route may ▪ Ensure road safety in and around healthcare Design Agency Before start of including clog traffic posing accident hazard facility through a traffic circulation plan while (architect), construction Occupational for nearby residential/commercial designing entry/exit points ESIA Agency, Health & Safety areas ▪ Provide ample parking space within healthcare NPMU and (OHS) and ▪ Risk of fire, earthquake, facility HCF Community Health waterlogging etc. ▪ Ensure that building design comply with Management & Safety ▪ Lack of or inadequate mortuary earthquake specifications, fire escapes and other capacity fire prevention requirements, have proper drainage etc. ▪ Include adequate mortuary arrangements in the design (refer to WHO Infection Prevention and Control for the safe management of a dead body in the context of COVID-19) Access to services ▪ Risk of inadequate access to ▪ Wide media campaign for informing about the MOHFW in Throughout for the poor, healthcare services for people below services made available across healthcare coordination project vulnerable and poverty and in remote locations facilities, including dedicated COVID-19 facilities with MOR and implementation marginalized social ▪ Limited testing due to lack of ▪ Set up help lines for vulnerable groups other groups availability of kits and trained ▪ Ensuring adequate health care services in each of departments personnel at remote locations the districts, and in municipal areas based on its ▪ Lack of accessibility for persons risk profile with specifically targeting poor and with special needs in existing vulnerable population including migrants and healthcare facilities urban poor population groups. ▪ Health care providers sensitized towards services to poor and vulnerable including providing psychosocial support where needed ▪ All healthcare facilities to be compliant with universal access provisions through retrofitting ▪ Mechanism for provision of health services in an inclusive manner that addresses the differential needs of the vulnerable population including risk of receiving a disparity on the basis of financial or social characteristics such as age, race, gender, ethnicity, sexual orientation, spirituality, disability, or socioeconomic or insurance status. Also, wherever possible linkages with other government 34 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts departments and schemes to be done to address the differential needs of the vulnerable groups. ▪ Ensuring safety of vulnerable population especially women in quarantine and isolation centers from any sexual exploitation and abuse (SEA) and sexual harassment (SH) and mechanism to access redressal services including services provided by One Stop Centre (OSC) along with other measures as mentioned in Annex-IX. ▪ Addressing social tension and conflicts associated with handling medical isolation of individuals with quarantine interventions and using dignified quality treatment of patients and building awareness about these services. ▪ This will be part of Stakeholder Engagement Plan (SEP) and will also be guided by the GOI Empowered Group on Information, Communication and Public Awareness. Addressing ▪ Informal sector and daily wage ▪ In addition to using all administrative mechanism MOHFW Throughout behavioral risks earners whose livelihoods are at to ensure prescribed norms of maintaining social project induced by stake in the short and medium term distancing, using masks, washing hands at frequent implementation livelihood related may tend to flout the health intervals etc. among others, Government of India issues advisories posing higher risk of also tried providing interim financial and food being infected and/ or infecting support during lockdown/ containment to the others. informal sector workers, daily wage laborers, ▪ potential risk of social tension and migrants and their family members,and also issued conflict within communities due to additional packagessuch as by the Ministry of the adverse impacts of containment Finance (MOF) for INR1.7 Lakh crore and strategies on people’s livelihoods Pradhan Mantri Garib Kalyan Package (PMGK) and health seeking behavior for the poor and vulnerable section of the society, particularly when it comes to and furthermore packages to support employment marginalized and vulnerable groups generation in agriculture, manufacturing and other sectors to address the challenges of livelihood for informal sector workers. Though these initiatives are outside the MOHFW’s domain it indirectly helps in reducing the adverse behavioral risks of getting infected. . 35 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts ▪ To support GOI’s initiative in enhancing livelihood and social protection measures, another World Bank program “Accelerating India’s COVID-19 Social Protection Response Program (PMGKY) (P173943)� has been planned and being implemented. ▪ The Social and Behavioral Change Communication (SBCC) to take cognizance of this situation and associated behavioral risks in design of appropriate communication plans and activities. ▪ Communication activities targeting behavioral health along with psychosocial support addressing social stigma associated with COVID19 Construction Stage Clearing of ▪ Risk to natural environment due to ▪ Minimize disturbance to natural environment by Contractor During vegetation and construction activities near managing debris, noise dust and encroachment on E&S Specialist construction trees ecologically sensitive areas/spots natural habitat HCF ▪ Ensure tree plantation at designated spaces and Management parks within healthcare facility and outside where possible Waste ▪ Hazardous wastes and materials ▪ Use Good International Industry Practices for Contractor During Management management managing construction waste, including reuse at Construction construction ▪ Provisioning for biomedical wastes site to the extent possible Supervision inside rooms/wards and within ▪ Ensure good housekeeping and clean operations Consultant(s) facility always/immediately removing rubble strewn E&S Specialist outside construction areas HCF ▪ Build biomedical waste holding area near separate Management service exit MOR Hospitals ▪ Use of Asbestos is prohibited ▪ Fine earth materials (sand, murram) should be covered during haulage to facilities under renovation to prevent spillage Pollution ▪ Risk of pollution from construction ▪ Use screens or nets to avoid flying debris and dust Contractor During management solid waste, dust, wastewater, noise, and use of regular water sprays to suppress dust E&S Specialist construction during construction lubricants and oils, air emissions ▪ Hazardous waste separated from nonhazardous HCF from heavy equipment and diesel waste on site and disposed off to designated sites Management generators ▪ Measure and report noise (decibel) levels regularly MOR Hospitals ▪ Manage oil leaks/spills from heavy machinery 36 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts Material use and ▪ Risks and impacts associated with ▪ Adopt installation of solar panels and LED lighting Contractor During resource efficiency resource efficiency and material wherever possible for ensuring energy efficiency E&S Specialist construction supply ▪ Use adequate insulation for ambient temperature HCF control and reducing the energy requirement for Management heating and cooling MOR Hospitals Labor employment ▪ Workers coming from infected areas ▪ Include additional clauses for contractors in bid Contractor During ▪ Co-workers becoming infected document (refer Annex IV) for all construction E&S Specialist construction ▪ Workers introducing infection into contracts which also prohibits employment of HCF community/general public child labor and/or forced labor in construction in Management ▪ Social issues, including in relation to line with government norms. MOR Hospitals labor influx, GBV/Sexual ▪ Labour influx is not foreseen given widespread Exploitation and Abuse/Sexual small size construction activities. However, in case Harassment (SEA/SH) risks, gender any such occurances, will be addressed and or disability monitored through ESIA/ESMP measures ▪ Arrangements for employment and (Annexure III). accommodation of workers to be ▪ Refer to COVID-19 LMP engaged in project activities, and ▪ Adequate hand washing and sanitization facilities issues relating to working conditions provided during construction (including in relation to periods of ▪ Consider ways to minimize/control movement in sickness and quarantine), and out of construction areas/site. particularly if these are impacted by ▪ If workers are accommodated on site, require them emergency legislation to minimize contact with people outside the ▪ Involvement of child labor and/or construction area/site or prohibit them from leaving forced labor the area/site for the duration of their contract ▪ Labour influx ▪ Implement procedures to confirm workers are fit for work before they start work, paying special to workers with underlying health issues or who may be otherwise at risk ▪ Check and record temperatures of workers and other people entering the construction area/site or require self-reporting prior to or on entering ▪ Provide daily briefings to workers prior to commencing work, focusing on COVID-19 specific considerations including cough etiquette, hand hygiene and distancing measures. ▪ Require workers to self-monitor for possible symptoms (fever, cough) and to report to their 37 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts supervisorif they have symptoms or are feeling unwell ▪ Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days ▪ Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days ▪ The process of screening, investigation, resolution of grievances, documentation, and reporting of grievances to follow existing MOHFW mechanism. The respective State Health and Family Welfare department will also address the grievances through their existing channels including the COVID-19 helplines and nominate a key official for COVID-19 related grievances ▪ Sensitization construction workers and health care staffs involved ▪ Setting up gender-sensitive infrastructure such as segregated toilets and well-lit living areas/ camps (if any). ▪ Ensuring safety of women from any sexual exploitation and abuse (SEA) and sexual harassment (SH), sensitizing health care staffs on SEA/ SH, and mechanism to access redressal services including building linkages to Ministry of women and Child Development’s (MoWCD) initiative of One-stop center for addressing violence against women in districts where it is operational (see Annex-IX). ▪ services provided by One Stop Centre (OSC) etc. Occupational ▪ Health and safety risks to ▪ The contractor (in cases of civil works) shall Contractor During Health & Safety construction workers and others prepare a site specific COVID19 Action Plan. E&S Specialist construction (OHS) and Sanitary related problem ▪ Provide relevant PPE to all workers with onsite HCF Community Health ▪ Traffic and road safety due to toilet and washing facilities Management & Safety increase in number of heavy ▪ Cordon off areas under construction and provide Staff/workers/ vehicles signage to warn of ongoing construction works drivers 38 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts ▪ Risk of traffic related accidents and ▪ Ensure drivers respect speed limits through built MOR incidents on and off site areas and urban centers ▪ Employ safe traffic control measures, including road signs and flag persons to warn of dangerous conditions and children crossings ▪ Road safety awareness training for staff, workers and nearby communities ▪ Create water trough for disinfecting vehicle tyres as they exit Operational Stage Biomedical, ▪ Delivery and storage of goods, ▪ Prepare a facility specific Biomedical Waste Health & Throughout including, COVID- including samples, pharmaceuticals, Management Plan for healthcare facilities (refer Community implementation 19 waste reagents and other hazardous Figure 1) Safety Expert generation from materials ▪ Prepare a COVID-19 Biomedical Waste Social testing and ▪ Healthcare treatment practices, Management Plan for healthcare facilities (refer Development treatment of including provision and use of PPE, Figure 2) Specialist COVID-19 patients appropriate cleaning procedures, ▪ Strict segregation of COVID-19 biomedical waste HCF (including in testing for COVID-19, and from other biomedical and general solid wastes Management Railway hospitals) transportation of samples to testing ▪ Have dedicated equipment (for example blood E&S Nodal facilities pressure machine, peak flow meter and Officers ▪ Generation of biomedical waste, stethoscope for COVID-19 treatment areas (including of specifically COVID-19 infectious ▪ Ensure an anteroom for staff to put on and take off MOR) waste PPE and to wash/decontaminate before and after MOR Hospitals ▪ Chance of infection to other wards providing treatment from COVID-19 treatment areas ▪ Designate separate areas for holding biomedical wastes ▪ Use onsite disinfection when possible, such as through an autoclave ▪ Adopt waste minimization, reuse and recycling best practices ▪ Develop capacity of onsite disinfection and waste handling equipment such as autoclave ▪ Onsite treatment facilities may include small-scale incinerator and wastewater treatment works, should comply with local laws and necessary statutory approvals to be obtained 39 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts ▪ Proper capacity assessment of the Common Treatment Facility (CTF) disposal facilities, where healthcare wastes will be transported and disposed ▪ The adequacy and compliance with transport and disposal regulations and licensing for the transport vehicles and the offsite disposal facilities should be assessed and verified ▪ Driver training on responding to accidents ▪ Waste bags and containers should be labeled with the date, type of waste and point of generation to allow them to be tracked through to disposal (bar coding if possible) Hazardous waste, ▪ Risk of mixing of hazardous and ▪ Ensure segregation, transportation and disposal of Health & Throughout chemicals, nonhazardous waste (also with hazardous wastes separately Community implementation biological samples COVID-19 waste) ▪ Regularly monitor ambient air and water quality Safety Expert etc., including including testing of sewage samples for presence Social Radioactive of Corona virus Development material used in ▪ Prepare and make workers/staff aware of an Specialist labs emergency response protocol HCF Management E&S Nodal Officers Healthcare facility ▪ Inadequate capacity may increase ▪ Regularly assess capacity of the healthcare facility All Throughout capacity for spread of COVID-19 and expose using Checklist 1 and Checklist 2 given in Implementing implementation biomedical waste healthcare staff to risk of infection AnnexV. Agencies at management and HCF level infection control Biosafety Level 3 ▪ Risk of accidental escape of ▪ Follow proper SOPs for constructing BSL3 MOHFW Throughout laboratory hazardous pathogens and exposure laboratories with proper access and exit procedures ICMR implementation of laboratory personnel and public ▪ Refer to Annex VI for additional guidance on NCDC minimum required mitigation measures NPMU Conversion of ▪ Spread of infection from COVID-19 ▪ Building mechanism for segregating biomedical MOHFW Throughout coaches into related waste waste at source MOR project isolation coaches ▪ Untreated disposal of biomedical ▪ Apply MOHFW guidelines for isolation coaches Station Master implementation waste ▪ Biomedical waste, particularly COVID-19 waste SPCB ▪ Exposure to COVID-19 pathogen to be properly segregated and disinfected before CTF operator for service providers final disposal 40 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts ▪ Spread of COVID-19 within ▪ Tie-up with CTF for picking up biomedical waste coaches between suspect and wherever coaches are stationed confirmed patients ▪ Ensure access to coaches only for the authorized ▪ Risk of other vector-borne diseases personnel from mosquitos when coaches are ▪ Proper PPE for all staff/paramedics/ service stationed areas prone to mosquito providers/cleaning workers in relation to isolation breeding coaches ▪ Unhygienic conditions with ▪ Ensure social distancing – not more than 2 per overused bedding cabin in an isolation coach ▪ Ensure general cleanliness and remove water logging near caches ▪ Provide mosquito nets on coach windows and other mosquito repellants ▪ Ensure regular washing and cleaning of beddings, linens and towels ▪ Regular disinfection and deep-sanitization of coaches ▪ Coaches to have separate duty room for paramedic staff and separate store for medicines and other supplies ▪ Adequate fire extinguishers in each coach ▪ Follow Labor Management Procedure (LMP) for the project (Annex VII of the main ESMF) Procurement of ▪ Exposure of paramedic staff to ▪ Proper PPE for all paramedics working in isolation MOHFW Throughout medicine, COVID-19 infection coaches MOR implementation consumables, and ▪ Accidental use of expired medicines ▪ Dispose expired medicines as per Biomedical paramedics for ▪ Exposure of passengers with Waste Rules railway trains and asymptomatic staff ▪ Ensure minimum exposure of railway staff and premises for paramedics with passengers COVID-19 activities Sanitization of ▪ Chance contact of people with ▪ Proper PPE for all staff/service providers/cleaning MOR Throughout Railway Premises chemical sprays workers in relation to isolation coaches Station Master implementation and Trains ▪ Risk of food material contamination ▪ Ensuring traffic flow during sanitization of outside RPF at station canteens/stalls/restaurants areas (parking, driveway, entry/exit gates etc.) and train pantry cars ▪ Manage people with social distancing norms ▪ Traffic and people management during sanitizing station platforms, waiting rooms etc. 41 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts ▪ Use of Railway Protection Force ▪ Ensuring that all food materials and utensils etc. (RPF) are adequately covered and protected from chemical sprays during sanitization ▪ Sensitization and training of security forces (RPF) on code of conduct in managing COVID-19 patients Workers/staff and ▪ Risk of infection for staff in ▪ Best practice in avoiding or minimizing the spread Health & Throughout visitors pathological laboratory testing for of infectious diseases, specifically about cross- Community implementation COVID-19 infection between healthcare facilities and the Safety Expert ▪ Social issues such as labor influx, community Social GBV/Sexual Exploitation and ▪ Adequate PPE for professionals responsible for Development Abuse/Sexual Harassment testing to be provided Specialist (SEA/SH) risks, gender or disability ▪ Labor Management Plan (LMP) to include OHS HCF and labor and working conditions Management ▪ Ensuring establishing Internal Complaints E&S Nodal Committee (ICC) at the facility level and the Officers ‘Local Complaints Committee’ (LCC) at the (including of district level to investigate complaints regarding MOR) sexual harassment at workplace and for inquiring MOR Hospitals into the complaint in a time bound manner as perceived under the ‘The Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013’. ▪ Sensitization of health care providers on SEA/ SH along with other mitigation measures as mentioned in Annex-IX. ▪ Sensitization and capacity building of the health care staffs and others associate with COVID19 operations. ▪ Setting up gender-sensitive infrastructure such as segregated toilets and well-lit quarantine and isolation centers. ▪ Building linkages to Ministry of women and Child Development’s (MoWCD) initiative of One-stop center for addressing violence against women in districts where it is operational. 42 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Risks and Impacts Cleaning and ▪ Risk of exposure to COVID-19 for ▪ Provide cleaning staff with adequate cleaning Health & Throughout maintenance of cleaning staff and workers equipment, materials and disinfectant Community implementation healthcare facility ▪ Review general cleaning systems, training Safety Expert cleaning staff on appropriate cleaning procedures Social and appropriate frequency in high use or high-risk Development areas Specialist ▪ Training of cleaners in proper hygiene (including HCF handwashing) prior to, during and after conducting Management cleaning activities; how to safely use PPE (where E&S Nodal required); in waste control (including for used PPE Officers and cleaning materials) (including of ▪ Test cleaning staff for COVID-19 when symptoms MOR) appear MOR Hospitals Indigenous people ▪ Risk of indecent behavior and ▪ Prepared guidance and provide orientation/training MOHFW with inadequate attention towards tribal towards sensitization of health care providers on Ministry of providing services with respect to the dignity, Tribal Affairs aspirations, identity, culture of the ST and other vulnerable population Decommissioning Stage Decommissioning ▪ Risk of spread of infection from non- ▪ Prepare a decommissioning plan accounting for all Health & After facility is of temporary disinfected materials, PPE, bed linen disposable items to be sent to respective disposable Community no longer in use facilities (isolation, and other fabrics and clothing sites – municipal landfill, biomedical waste Safety Expert quarantine, ▪ Generation of plastic and disposable disposal facility, and/or as required Social screening and wastes, expired medicines, ▪ All reusable items to be thoroughly disinfected and Development treatment etc.) disposable kits and food articles etc. left unused for up to a week after Specialist decommissioning the facility Local ▪ Expired equipment and/or PPE to be Administration decommissioned and disposed properly E&S Nodal Officers 43 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Figure 1: Procedure for Biomedical Waste Management at Healthcare Facility (non-COVID-19) Color Coded Waste Segregation at Heath Care Facility Sharp Waste Body Parts / Medicines / Translucent Cardboard Boxes General Waste Infectious Waste Pharmaceutical Waste (puncture, temper & with Blue Color leak proof) Food waste, paper, Infected Gown, apron, Human Pharmaceuticals Discarded Used or unused sharps Glassware disposable cups, Mineral gloves, shoe cover, mask, tissues, that are expired linen, ( needles; auto-disable Infected broken glass water bottles, plates, dressing, Urine bags, I.V. organs or no longer Nappies , syringes; syringes with bottles, broken and spoons, Uninfected tubes /BT sets, central or needed; items mattresses, attached needle; infusion unbroken glassware and disposable towel, gowns, line, PICC line Catheters, fluids; contaminated beddings sets; scalpels; pipettes; vials, Ampoules (except shoe covers, cap, masks, normal saline, Ostomy body by or containing contaminated knives; blades), Suture cytotoxic waste) covers of sterile items bags, DNS, Ringer lactate parts; pharmaceuticals with blood or needles, Cannula and such as syringes, plastic bottled, All plastic fetuses; body fluid, biopsy needle stilette Sterillium used bottle etc and rubber infected waste unused Bandages generated from blood laboratories products 1. Collect in black bag 1. Collect in small 1. Collect in autoclavable bio hazard bags 1. Autoclave Disinfection (by soaking 2. Close and tie when Autoclavable bio hazard 2. Close and tie lose when 2/3rd full 2. Put in white bag and tie the washed glass waste 2/3rd full bags 3. Label (Name of the facility, date and 3. Label (Name of the after cleaning with 3. Label (Name of the 2. Close and tie lose time) facility, Date and time) detergent and Sodium facility, Date and time) when 2/3rd full 4. Autoclave 4. Label as“TREATED hypochlorite treatment) 4. Incinerate OR burn 3. Label (Name of the 5. Plasma pyrolysis or deep burial SHARP WASTE� or through autoclaving or (away from households HCF, Date and time) 5. Put in yellow bag and tie properly 5. Transfer out for microwaving or and HCF 4. Autoclave 6. Transport out for incineration to Incinerating or hydroclaving and then 5. Put in black bag common treatment facility (CTF) burning to Common sent for recycling. and tie properly treatment facility (CTF) 6. Transport out to common treatment facility (CTF) 44 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Figure 2: Procedure for COVID-19 related Biomedical Waste Management at Healthcare Facility Color Coded Waste Segregation at Heath Care Facility during Diagnosis/Treatment/Quarantine for COVID-19 Sharp Waste Translucent Cardboard Body Parts / Medicines / Pharmaceutical General Waste Infectious Waste (puncture, temper Boxes with Blue Waste & Color leak proof) All health care Infected PPE kits, goggles, Human Pharmaceuticals Discarded linen, Used or unused Glassware waste of COVID-19 Gown, apron, gloves, shoe tissues, that are expired Nappies mattresses, sharps ( needles; Infected broken glass patients must be cover, dressing, Urine bags, organs or no longer beddings contaminated auto-disable syringes; bottles, broken and considered as I.V. tubes /BT sets, central or fluids; needed; items with blood or body syringes with unbroken glassware infectious and line, PICC line Catheters, body contaminated fluid, Bandages, used attached needle; and vials, Ampoules should be collected normal saline, Ostomy bags, parts; by or containing masks (including triple infusion sets; (except cytotoxic safely in designated DNS, Ringer lactate plastic fetuses; pharmaceuticals layer, N95), head scalpels; pipettes; waste) containers and bags, bottled, All plastic and unused waste cover/cap, shoe-cover, knives; blades), treated and then rubber infected waste blood disposable linen Gown, Suture needles, safely disposed generated from laboratories products non-plastic or semi- Cannula and biopsy (WHO) plastic cover needle stilette 1. Collect in double 1. Collect in small 1. Collect in autoclavable bio hazard bags (double 1. Autoclave Disinfection (by black bag autoclavable biohazard bags layered) to prevent leakage 2. Put in white double soaking the washed 2. Close and tie (double layer) 2. Close and tie lose when 2/3rd full layered bag and tie glass waste after when 2/3rd full and 2. Close and tie lose when 3. Label as COVID 19 waste (Name of the facility, 3. Label as (Name of cleaning with shift by dedicated 2/3rd full date and time) the facility, Date and detergent and Sodium trolley to collection 3. Label COVID 19 waste 4. Autoclave time) hypochlorite Van or storage area (Name of the HCF, Date, 5. Plasma pyrolysis or deep burial 4. Label treatment) or through 3. Label as time) 5. Put in yellow bag and tie properly as“TREATED autoclaving or “Covid19� waste 4. Autoclave 6. Transport out for incineration to common treatment SHARP WASTE� microwaving or (Name of the 5. Put in Red bag and tie facility (CTF) 5. Transfer out for hydroclaving and facility, date, time) properly Incinerating or then sent for 4. Incinerate /burn. 6. Transport out to common burning to Common recycling. 5. Transport out to treatment facility (CTF) treatment facility CTF (CTF) 45 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 7. Procedures to Address Environmental and Social Issues 37. Given that the project is implemented throughout India with varying degree of sub-projects to be taken up by the relevant State Health Departments, Medical colleges and other sub-national agencies, it is important to streamline the procedures for addressing environmental and social issues. The ESMF provides the responsible agencies for ensuring specific mitigation actions and Section 10 on Institutional Arrangements, Responsibilities and Capacity Building lists out specific tasks of the E&S related personnel across agencies. 38. The following procedures given in Table 6are to be followed in identifying, preparing and implementing the subprojects. In combination with Figure 3 it describes the step-by-step procedure for apply environmental and social due diligence and approval steps. Table 6: Procedures to Address Environmental and Social Issues Identified Activity Procedure Responsibility All pre-screened and risk Follow mitigation guidance and apply Health & Safety Expert, NPMU, categorized activities mitigation actions as per ESMF Social Development Specialist E&S Nodal Officers MOR Nodal Officers for E&S Any new activity/sub-project Screen for potential E&S risks and impacts Chief Medical Officer, NPMU, (not yet identified) and classifying each subproject according TSU, Health & Safety Expert, NHM to risk (Annex 3, Screening Form) Social Development Specialist, MOR Nodal Officers for E&S All new construction related These are categorized as ‘Substantial’ and Project Director sub-projects, including in case of BSL3 it is categorized as ‘High’, Health & Safety Expert, NHM upgrading existing will be subject to a standalone ESIA and an Social Development Specialist infrastructure ESMP will be prepared as per Annex I Contracted ESIA Agency MOR Nodal Officers for E&S Consultation and Disclosure All E&S plans and instruments will be Project Director consulted with relevant stakeholders Health & Safety Expert, NHM periodically and disclosed whenever a new Social Development Specialist update is available. All consultation will MOR Nodal Officers for E&S follow the Stakeholder Engagement Plan (SEP) for the project. Management of Staffs and All E&S plans involving management of NMPU, TSU, workers health care facility staffs and/ or Chief Medical Officer, NHM Social construction workers will follow the Labor Development Specialist, Management Plan (LMP) for the project. Contracted ESIA Agency MOR Nodal Officers for E&S Review and approval of E&S All E&S plans and instruments for Project Director plans and instruments ‘Substantial’ risk sub-projects will be Health & Safety Expert, NHM approved by the Bank prior to disclosure Social Development Specialist MOR Nodal Officers for E&S, The World Bank Implementation and All mitigation action will be monitored, Project Director monitoring of mitigation documented and reported to the Bank Health & Safety Expert, NHM measures in ESMF and World Bank to monitor during regular Social Development Specialist specific E&S plans and Implementation Support Missions and MOR Nodal Officers for E&S. The instruments for ‘Substantial’ using remote approaches World Bank risk sub-projects 46 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Figure 3: Flowchart depicting Process Chain with Responsibility to be followed in addressing the Environmental and Social Issues Process Chain Responsibility NPMU/ State/ MoR New Activity/ Subproject E&S Nodal Officer at State with support from Screening using Annex-III DPM/ CMHO at District E&S Officer at NPMU to verify screening results If Low Risk If Moderate If Substantial/ High E&S Nodal Officer at State/ NPMU E&S Risk Risk Officials No specific Consultation on E&S Nodal Officer at State with support from mitigation to be preparation of ESIA DPM/ CMHO at District followed and ESMP ESIA and ESMP Healthcare level staff/E&S Nodal Officer at Follow mitigation approach prepared as per State/ NPMU E&S Officials and specific actions as per Table 4 & 5; COVID-19 Annex-I waste to be treated as per Figure 2; EHS provisions Review of ESIA/ESMP will apply by the World Bank World Bank E&S Specialists/ TTL Disclosure of E&S Plan E&S Nodal Officer at State/ NPMU E&S and Instruments Officials Implementation of Mitigation measures including E&S Nodal Officer at State with support from Labor Management Plan as in Annex-VII DPM/ CMHO at District Monitoring and E&S Nodal Officer at State/ NPMU E&S Reporting Officials 47 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 8. Public Consultation and Disclosure 39. Public consultation and disclosure will be consistent with the requirements for stakeholder engagement. It will take into account COVID-19 related quarantine and lockdown measures and will follow the guidance provided in the Technical Note: Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints on conducting public meetings. All ESF related documents (ESCP, SEP, ESMF) will be disclosed publicly on the website of the implementing agencies and will be made available at select healthcare facilities. Following the SEP, stakeholders will be kept informed. 40. As part of the COVID19 emergency operation, Government of India, through MOHFW, ICMR and other departments and agencies have been engaging with various stakeholders and public at large. The engagement has been on almost at daily basis during the lockdown period to build awareness and sensitize communities on the risks of COVID-19 and measures that are being taken by the national and state government to mitigate emerging risks and dealing with COVID19 spread. This has been taken at the highest level whereby the Prime Minister at national level and some of the Chief Minister’s at the state level have also made attempts to engage and communicate with various stakeholders and public at large. 41. Given the COVID19 situation and related travel restrictions, to the extent possible most of the consultations during preparation of ESMF were conducted in a virtual manner. The public consultation during the preparation of sub-projects followed the stakeholder engagement plan (SEP) for the project. The feedback received contributed to the drafting of the ESMF. Apart from consulting with key officials of all implementing agencies including MOHFW, ICMR, NCDC and MoR at national level, consultations were also held with select group of healthcare workers and representatives of some civil society organizations. These consultations covered aspects of handling the pandemic, use of technology, nature and scale of emergency response, One Health aspects and testing for COVID- 19.Note that face-to-face consultations will be held when situation normalizes, and travel restrictions are eased and the outputs of those consultations will be documented and presented separately . Table 7 gives a summary of the consultations held so far. Table 7: Summary of Feedback Received during Stakeholder Consultation Date of Nature of Participating Summary of Feedback Received Consultation Consultation Stakeholders April 17, Integration of Nature Conservation • Better coordination for research on 2020 Wildlife Issues in Foundation, Institute novel viruses and Animal Husbandry the One Health of Public Health, Department. Approach in India Ashoka Trust for • Need to shift focus from disease Research on management to on One Health Environment surveillance with investments on &Ecology pathogen discovery; also need to (Karnataka), broaden coverage from around Wildlife Trust of protected areas to other areas India (Delhi), Dept. • Having a One Health Agency and/or of Animal Platform is needed but decentralized Husbandry (Kerala), working models will be essential for Michigan State implementation University (USA) • Need to boost training on One Health approaches • Need better monitoring of wet markets and illegal trade 48 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 Date of Nature of Participating Summary of Feedback Received Consultation Consultation Stakeholders June 12, 2020 One Heath and International • Livestock hygiene and reducing Livestock Livestock Research interaction with wildlife is critical Institute (ILRI) • Need to increase livestock vaccination coverage July 17, 2020 One Health FAO (Rome/India), • Need to build on the existing Strategy and Indian Council of committee on One Health mandated Approach Agriculture under NCDC Research (ICAR) • Good to use existing resources – One Health Metrics and Tripartite Zoonoses Guide • FAO could be a good technical partner 42. Consultations will continue during implementation, including face-to-face when COVID-19 situation normalize. With support from MOHFW/NCDC/ICMR, a series of consultations are planned during implementation covering a range of stakeholders. These will especially focus on indigenous and vulnerable community groups, including women, healthcare staff, community members residing near hospitals and laboratories proposed as BSL3.The feedback received will help subproject design and implementation and ensure its post-project sustainability. 43. Disclosure of environmental and social related risks and mitigation is paramount. NPMU will ensure that the different activities for stakeholder engagement, including information disclosure, are inclusive and culturally sensitive. All communications directed to public at large and to various stakeholders are being disclosed at the MOHFW website and through mass media channels including Newspaper, TV, FM/AM radio and through social media channels. The practice will continue to ensure that information on disclosures also reaches to various states and local communities through regional media channels. 44. Measures will also be taken to ensure that the vulnerable groups as outlined earlier will have the chance to participate and take benefits of the project. This will include, among other things, household outreach through various channels including social media and through SMS, telephone calls, etc., depending on the social distancing requirements, the use of different languages (Hindi, English and other regional languages to target local areas), the use of verbal communication, audio visuals or pictures instead of text, etc. will be used. The country-wide awareness campaigns will be conducted as being done so far since the beginning of COVID19 pandemic in India. Travel (intra-state, interstate, and international), geography, and local context specific communication as well as information about availability of COVID19 treatment specific hospitals, laboratories and quarantine centres will be timed according to need and be adjusted to the specific local circumstance. 45. A preliminary strategy for information disclosure is given in Table 7 below: Table 8: Preliminary Strategy for Information Disclosure for the Project List of information Project stage Target stakeholders Methods and timing proposed to be disclosed Preparation of ESMF Government entities; local Project documents, Dissemination MOHFW websites communities; vulnerable ESMF, SEP, other and World Bank website groups; NGOs and relevant E&S academics; health workers; documents, GRM 49 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 List of information Project stage Target stakeholders Methods and timing proposed to be disclosed media representatives; health procedure, regular agencies; others updates on Project development Preparation of social Government entities; local Project documents, Dissemination MOHFW and State distancing and Social communities; vulnerable SBCC Strategy health department websites; hard and Behavior Change groups; school children and document copies at designated public Communication(SBCC) their parents, NGOs and locations; Information leaflets and strategy academics; health workers; brochures media representatives; health agencies; others Implementation of Affected parties, public at Update on project Public notices – at MOHFW public awareness large, vulnerable groups, development; the website, Electronic publications and campaigns public health workers, social distancing and press releases; Press releases in the government entities, other SBCC strategy local media; Information leaflets public authorities and brochures; audio-visual materials, social media and other direct communication channels such as mobile/ telephone calls, SMS, etc. Site selection for local People under COVID-19 Project documents, Public notices; Electronic isolation units and quarantine, including workers technical designs of publications and press releases on quarantine facilities in the facilities; Relatives of the isolation units the MOHFW website; Press patients/affected people; and quarantine releases in the local media; Help neighboring communities; facilities, SEP, desk mechanism public health workers; other relevant E&S public authorities; island documents, GRM councils; civil society procedure, regular organizations updates on Project development During project COVID-affected persons and SEP, relevant E&S Public notices; Electronic implementation their families, neighboring documents; LMP, publications and press releases on communities to laboratories, GRM procedure; the MOHFW website; Press quarantine centers, resorts and regular updates on releases in the local media; workers, workers at Project development Consultation with vulnerable groups construction sites of using mobile/ telephone calls, SMS, quarantine centers and etc.; Help desk mechanism screening posts, public health workers, MoH, airline and border control staff, government entities, island councils 50 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 9. Stakeholder Engagement 46. The Stakeholder Engagement Plan (SEP) prepared for the project is to ensure consultations under the project to be carried out mainly on two fronts.: First, consultations with stakeholders throughout the entire project cycle to inform them about the project, including their concerns, feedback and complaints about the project and any activities related to the project; and second, building awareness and sensitizing communities on the risks of COVID-19 as per the Component 4 of the project. The SEP has been disclosed at the MOHFW website and once updated the revised SEP will also be disclosed on the MOHFW website. 47. Design of the project’s communication strategy is innovative. The SEP outlines the need to conduct rapid behavior assessment to understand key target audience, perceptions, concerns, influencers and preferred communication channels, and based on that prepare a comprehensive Social and Behavior Change Communication (SBCC) strategy for COVID-19, including details of anticipated public health measures. Based on SBCC strategy, communication messages are prepared in local languages and pre- test through participatory process, especially targeting key stakeholders, vulnerable groups and at-risk populations. Also, identifying trusted community groups (e.g., celebrities, elected representatives, community leaders, religious leaders, health workers, community volunteers) and local networks to support the communication strategy. 48. Given health is a state subject, states will establish a nodal communication cell to anchor the SBCC implementation. Developed materials will be translated in local language for timely dissemination of messages by the State level communication cell. This will involve engaging with existing health and community-based networks, media, local NGOs, self-help groups, schools, local governments and other sectors such healthcare service providers, education sector, business, travel and food/agriculture sectors using a consistent mechanism of communication. National and State specific help desks will be used for utilizing the two-way “channels� for community and public information sharing. Also, the responsive social media, TV and radio shows, with systems will be used to detect and rapidly respond to and counter misinformation. 49. A large-scale community engagement strategy for social and behavior change approaches will be undertaken as defined in the SBCC. This is to ensure preventive community and individual health and hygiene practices in line with the national public health containment recommendations. Given the need to also consider social distancing, the strategy would focus on using IT-based technology, telecommunications, mobile technology, social media platforms, print and broadcast media, etc. 50. The NMPU along with State level E&S nodal officer will systematically establish community information mechanisms for learning and feedback. The mechanism will be using national and state specific help desks and through social media monitoring, community perceptions, knowledge, attitude, and practice surveys, and direct dialogues and consultations. In the current context, these will be carried out virtually to prevent COVID-19 transmission. PMU will also ensure changes to community engagement approaches are based on evidence and needs, and ensure all engagement is culturally appropriate and empathetic and document lessons learned to inform future preparedness and response activities. 51 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 51. For stakeholder engagement relating to the specifics of the project and project activities, different modes of communication will be utilized. Policymakers and influencers will be reached through small engagement or virtual meetings with religious, administrative, youth, and women’s groups. Individual communities might be reached through theatre performance meetings with women and youth groups. For public at large, identified and trusted media channels including, television and radio, print media (newspapers, magazines), trusted organizations’ websites, social media (Facebook, Twitter ) etc. will be used. Text messages for mobile phones, hand-outs and brochures in community and health centers, municipal forums, community health boards, billboards plan, will also be utilized. 52. The main objective of a Grievance Redress Mechanism (GRM) is to assist to resolve complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Specifically, it provides a transparent and credible process for fair, effective and lasting outcomes. It also builds trust and cooperation as an integral component of broader community consultation that facilitates corrective actions. Specifically, the GRM: • Provides affected people with avenues for making a complaint or resolving any dispute that may arise during the course of the implementation of projects; • Ensures that appropriate and mutually acceptable redress actions are identified and implemented to the satisfaction of complainants; and • Avoids the need to resort to judicial proceedings (at least at first). 53. The Grievances will be handled at the MOHFW and State level by the concerned official designated for the GRM and using the Centralized Public Grievance Redress and Monitoring System at the MOHFW. Once all possible redress has been proposed and if the complainant is still not satisfied then they should be advised of their right to legal recourse. The numbers and contacts of the GRM will be detailed in the final SEP. The construction site-specific GRM is presented in LMP. The GRM includes the following steps: Step 0: Raising and registering the grievances using various mechanism including through Help desk, online using internet, email, Walk-ins and registering a complaint on grievance logbook at healthcare facility or suggestion box at clinic/ hospitals Step 1: Grievance raised is screened and forwarded to respective administrative/ facility level for redressing Step 2: Grievance discussed at the respective administrative/ facility level, and addressed Step 3: If not addressed in stipulated period it is escalated to next level and finally the MoHFW level Step 4: Once addressed, feedback sent to the complainant Step 5: If not satisfied, appeal to the other public authorities 52 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 10. Institutional Arrangements, Responsibilities and Capacity Building 10.1 Institutional Arrangements and Responsibilities of Key Personnel 54. The institutional arrangements for preparation and consultation in relation to the assessment and identification of mitigation measures for subprojects, review, clearance and disclosure of documentation and instruments, and monitoring the implementation of the ESMF, ESMP, RAP, etc.,including the screening of subprojects for environmental and social risks and impacts, follow the procedure described in Table 6.Adequate and qualified staff are proposed covering the key roles for infection control and waste management. A clear delineation of responsibilities is spelled out below in para(s). 55. The National Project Management Unit (NPMU) will ensure that the project is implemented in accordance with the provisions of the ESMF. This would include, but not limited to: a. Providing technical and operational support to states on implementing the mitigation measures included in the ESMF; b. Documenting and reporting the progress on the implementation of the ESMF, including monitoring the civil construction contracts, environment and social indicators and any grievances raised during implementation; c. Assessing the requirements and monitoring the biomedical waste management systems, particularly related to waste generated through COVID19 treatment; d. Supporting the training and capacity building actions included in the ESMF; and e. Ensuring close coordination within NPMU and with the States on budget, technical resources etc. for implementing the ESMF requirements. 56. Health and Safety Expert (Environment Specialist) in NPMUwill support the implementation of the provisions of the ESMF and provide oversight to civil construction sub-projects for ensuring compliance with clauses for safeguarding environment and social risks and impacts. In addition, S/he will help prepare monitoring reports and document the implementation of ESMF performance. S/he will also support training and capacity building of relevant stakeholders on environmental issues, including bio-medical waste management. 57. Social Specialist in NPMU will support in planning, implementation and monitoring of social safeguard measures including implementing the SEP and LMP. S/he will undertake Situation Analysis of social issues and impacts associated with the project and support development and implementation of strategies addressing social safeguard concerns, including collection, collation and reporting of social safeguard measures. 58. Technical Specialist (One Health) in NPMU will support the wildlife dimension of the One Health approach, including supporting better surveillance and response against potential zoonotic diseases, and collaboration amongst various agencies for strengthening the One Health approach. 59. Technical Specialist Biomedical Waste Management in TSU (NHM) will support the States in assessing the current status of biomedical waste management in states, prepare and support the implementation of a comprehensive biomedical waste management plan, including liquid waste management and monitor the relevant mitigation measures included in the ESMF. 60. Technical Specialist Laboratory Strengthening in TSU (ICMR) will provide specific guidance on disinfection and disposal of COVID-19 related waste generated during testing and treatment and will 53 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 also conduct bio safety risk assessment in all laboratories and build systems. S/he will help develop a comprehensive bio-risk management system. 61. E&S Nodal officer at State level will be designated within state NHM Directorate in each of the state and UTs in India to support implementation of the provisions of the ESMF with support from NHM District Program Manager (DPM) and/or Chief Medical and Health Officer (CMHO) at district level and provide oversight to ESMF implementation along with civil construction sub-projects for ensuring compliance with clauses for safeguarding environment and social risks and impacts. In addition, S/he will help prepare monitoring reports and document the implementation of ESMF performance in the state. S/he will also support training and capacity building of relevant stakeholders on environmental issues, including bio-medical waste management in the state. 62. Health & Safety officer in MOR will support the implementation of the provisions of the ESMF and provide oversight to coach conversion and civil construction sub-projects for ensuring compliance with clauses for safeguarding environment risks and impacts. In addition, S/he will help prepare monitoring reports and document the implementation of ESMF performance of facilities under MOR COVID19 emergency operations. S/he will also support training and capacity building of relevant stakeholders on environmental issues, including bio-medical waste management. 63. Social Development Specialist in MOR will support in planning and implementation of social safeguard measures including implementing the ESMF and associated SEP and LMP where relevant. S/he will undertake Situation Analysis of social issues and impacts associated with the project and support development and implementation of strategies addressing social safeguard concerns, including collection, collation and reporting of social safeguard measures. In addition, S/he will help prepare monitoring reports and document the implementation of ESMF performance of facilities under MOR COVID19 emergency operations. S/he will also support training and capacity building of relevant stakeholders on environmental issues, including bio-medical waste management. 64. In addition to the above specific roles and responsibilities, the ESMF also assigns specific responsible agencies/individuals for the operational stage in implementing the procedures and mitigation measures that have been adopted to avoid or minimize the spread of COVID-19. The Chief Medical Officer (CMO) of healthcare facilities will be responsible for ‘cradle-to-grave’ infection control and for biomedical waste management. As the implementation progresses, the need for additional staff with what qualifications and training will be assessed and the required expertise will be contracted/deputed. 10.2 Training and Capacity Building 65. The project will provide a range of training and capacity building support on managing environmental and social risks associated with the project. Several training and capacity building programs/modules would be provided to medical workers, waste management workers and cleaners, as well as third-party waste management service providers, including those involved in transporting the biomedical wastes on specific requirements for handling the COVID-19 wastes. Given that the project is being implemented nation-wide, the project will work with the existing training and capacity building provisions of the central and state governments to mainstream training and capacity building opportunities. The training provided under NHM on biomedical waste management will continue and a training calendar will be developed for each healthcare facilities covering all the States and provision for refresher training will be made. Awareness and orientation on World Bank’s ESF may be provided separately. A list of potential training and capacity building efforts are given below. 54 India: COVID-19 Emergency Response Project – ESMF / August 20, 2020 a. BMWM arising out of COVID19 testing, treatment, quarantine, COVID-19 Infection Prevention and Control for the safety of healthcare workers across all healthcare facilities. This will done primarily by including a module in the ongoing national and state managed training programs. b. Laboratory biosafety guidance related to the COVID-19, including specimen collection and shipment c. Preventing GBV, SEA and SH trainings to healthcare workers d. Orientation training on implementing the various provisions of ESMF, including an introduction to the World Bank’s ESF e. Training on OHS/Community Health and Safety, use of PPE etc. including for contractors and the labors/workers engaged with civil works f. Training of trainers for the environment and social specialists at the central and state level implementing entities and project management units, on monitoring of compliances with ESMF 10.2 Monitoring Indicators 66. The ESMF will track few important parameters as monitoring indicators. Based on the baseline (refer Table 3), important parameters, such as, COVID-19 related biomedical waste generated, budget allocated to handle it, persons trained in handling such waste, persons tested, including number of women in urban and rural areas etc. will be monitored. 10.3 Indicative Budget 67. An indicative budget is prepared for implementing the ESMF. Given the emergency nature and extremely short timeline for preparing the project in responding to the emerging COVID-19 situation, only an indicative budget is developed that covers the cost of human resources and capacity building and training requirements (refer Table 9 below). Mitigation actions to be deployed during construction of buildings etc. will be part of the detailed project reports and their specific ESMPs. Table 9: Indicative Budget for Implementing the ESMF S. No. Implementation Requirements as per ESMF Indicative Budget (US$ Million) 1. Human Resources across all Implementing Agencies 1.0 MOHFW/ICMR/NCDC/MOR) 2. Capacity building and training(s)6 1.0 For BMWM, Social inclusion, SEA/SH etc. 68. The project’s GRM process will be supported both by a traditional and technology-based approach, for early resolution of complaints. Other social accountability measures such as social audit or citizen scorecard, and report card will be used for acquiring feedback on performance and recording citizens’ recommendations. A simple mobile-based feedback system will be used to capture and feed data into the MIS of the Project Management Unit (PMU). Additionally, nongovernmental organizations (NGOs) or community-based organizations (CBOs) will facilitate the beneficiaries’ access to the GRMs. 6 This budget is in addition to the financial resources already being deployed by the Government of India through its various implementing agencies and existing institutional and financing mechanisms, such as, the National Health Mission (NHM) 55 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Annex I: Environmental and Social Management Plan (ESMP) Template Introduction The Borrower will need to develop an Environmental and Social Management Plan (ESMP), setting out how the environmental and social risks and impacts will be managed through the project lifecycle. This ESMP template includes several matrices identifying key risks and setting out suggested E&S mitigation measures. The Borrower can use the matrices to assist in identifying risks and possible mitigations. The ESMP should also include other key elements relevant to delivery of the project, such as institutional arrangements, plans for capacity building and training plan, and background information. The Borrower may incorporate relevant sections of the ESMF into the ESMP, with necessary updates. The matrices illustrate the importance of considering lifecycle management of E&S risks, including during the different phases of the project identified in the ESMF: planning and design, construction, operations and decommissioning. The issues and risks identified in the matrix are based on current COVID-19 responses and experience of other Bank financed healthcare sector projects. The Borrower should review and add to them during the environmental and social assessment of a subproject. The WBG EHS Guidelines, WHO technical guidance documents and other GIIPs set out in detail many mitigation measures and good practices and can be used by the Borrower to develop the ESMP. Proper stakeholder engagement should be conducted in determining the mitigation measures, including close involvement of medical and healthcare waste management professionals. The Infection Control and Waste Management Plan forms part of the ESMP. The ESMP should identify other specific E&S management tools/instruments, such as the Stakeholder Engagement Plan (SEP), labor management procedures (LMP), and/or Medical Waste Management Plan. 56 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Table AI.1- Environmental and Social Risks and Mitigation Measures during Planning and Designing Stage Key Activities Potential E&S Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Risks and Impacts Monitoring Measures Identify the type, location and scale of healthcare facilities (HCF) Identify the need for new construction, expansion, upgrading and/or rehabilitation Identify the needs for ancillary works and associated facilities, such as access roads, construction materials, supplies of water and power, sewage system Identify onsite and offsite Inadequate facilities and ➢ Estimate potential waste streams waste management processes for treatment ➢ Consider the capacity of existing facilities, facilities, and waste of waste and plan to increase capacity, if necessary, transportation routes and through construction, expansion etc. service providers ➢ Specify that the design of the facility considers the collection, segregation, transport and treatment of the anticipated volumes and types of healthcare wastes ➢ Require that receptacles for waste should be sized appropriately for the waste volumes generated, and color coded and labeled according to the types of waste to be deposited. Develop appropriate protocols for the collection of waste and transportation to storage/disposal areas in accordance with WHO guidance Design training for staff in the segregation of wastes at the time of use Identify needs for transboundary movement of samples, specimen, reagent, and other hazardous materials 57 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Key Activities Potential E&S Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Risks and Impacts Monitoring Measures Identify needs for ➢ Identify numbers andtypes of workers workforce and type of ➢ Consider accommodation and measures project workers to minimize cross infection ➢ Use the COVID-19 LMP template to identify possible mitigation measures Identify needs for using security personnel during construction and/or operation of HCF HCF design – general - Structural safety risk; - Functional layout and engineering control for nosocomial infection HCF design - Some groups may have considerations for difficulty accessing differentiated treatment for health facilities groups of higher sensitivity or vulnerable (the elderly, those with preexisting conditions, or the very young) and those with disabilities Design of facility should ➢ The design, set up and management of reflect specific treatment will take into account the advice provided requirements, including by WHO guidance for Severe Acute triage, isolation or Respiratory Infections Treatment Center. quarantine ➢ Hand washing facilities should be provided at the entrances to health care facilities in line with WHO Recommendations to Member States to Improve Hygiene Practices. ➢ Isolation rooms should be provided and used at medical facilities for patients with possible or confirmed COVID-19. ➢ Isolation rooms should: 58 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Key Activities Potential E&S Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Risks and Impacts Monitoring Measures ✓ be single rooms with attached bathrooms (or with a dedicated commode); ✓ ideally be under negative pressure (neutral pressure may be used, but positive pressure rooms should be avoided) ✓ be sited away from busy areas or close to vulnerable or high-risk patients, to minimize chances of infection spread; ✓ have dedicated equipment (for example blood pressure machine, peak flow meter and stethoscope ✓ have signs on doors to control entry to the room, with the door kept closed; ✓ have an ante-room for staff to put on and take off PPE and to wash/decontaminate before and after providing treatment. Design to consider Insufficient capacity ➢ Include adequate mortuary arrangements mortuary arrangements Spread of infection in the design ➢ See WHO Infection Prevention and Control for the safe management of a dead body in the context of COVID-19) 59 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Table AI.2 - Environmental and Social Risks and Mitigation Measures during Construction Stage Activities Potential E&S Risks and Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Impacts Monitoring Measures Clearing of vegetation - Impacts on natural and trees; Construction habitats, ecological activities near resources and ecologically sensitive biodiversity areas/spots General construction - Impacts on soils and activities Foundation groundwater; excavation; borehole - Geological risks digging General construction - Resource efficiency activities issues, including raw materials, water and energy use; - Materials supply General construction - Construction solid waste; activities – general - Construction wastewater; pollution management - Nosie; - Vibration; - Dust; - Air emissions from construction equipment General construction - Fuel, oils, lubricant activities – hazardous waste management General construction - Workers coming from - Refer to COVID-19 LMP activities – Labor issues infected areas - Consider ways to minimize/control - Co-workers becoming movement in and out of infected construction areas/site. - Workers introducing - If workers are accommodated on infection into site require them to minimize community/general contact with people outside the public construction area/site or prohibit them from leaving the area/site for the duration of their contract - Implement procedures to confirm workers are fit for work before they start work, paying special to 60 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Activities Potential E&S Risks and Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Impacts Monitoring Measures workers with underlying health issues or who may be otherwise at risk - Check and record temperatures of workers and other people entering the construction area/site or require self-reporting prior to or on entering - Provide daily briefings to workers prior to commencing work, focusing on COVID-19 specific considerations including cough etiquette, hand hygiene and distancing measures. - Require workers to self-monitor for possible symptoms (fever, cough) and to report to their supervisorif they have symptoms or are feeling unwell - Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days - Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days General construction activities – Occupational Health and Safety (OHS) General construction activities – traffic and road safety 61 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Activities Potential E&S Risks and Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Impacts Monitoring Measures General construction activities – security personnel General construction Acquisition of land and assets The project will not finance any land activities – land and acquisition and/or resettlement asset including squatter removals. In case there are informal/ illegal settlers/ squatters being there on the land, alternate site or design to be explored in order not to disturb or remove them. General construction GBV/SEA issues Refer Annex-IX activities General construction Cultural heritage Chance-finds procedure activities – cultural heritage General construction activities – emergency preparedness and response Construction activities related to onsite waste management facilities, including temporary storage, incinerator, sewerage system and wastewater treatment works Construction activities related to demolition of existing structures or facilities (if needed) To be expanded 62 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Table AI.3- Environmental and Social Risks and Mitigation Measures during Operational Stage Activities Potential E&S Risks and Impacts Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Monitoring Measures General HCF operation General wastes, wastewater and air – Environment emissions General HCF operation - Physical hazards; – OHS issues - Electrical and explosive hazards; - Fire; - Chemical use; - Ergonomic hazard; - Radioactive hazard HCF operation – Labor - Refer to COVID-19 LMP issue HCF operation - considerations for differentiated treatment for groups with different needs (e.g. the elderly, those with preexisting conditions, the very young, people with disabilities) HCF operation – • Provide cleaning staff with cleaning adequate cleaning equipment, materials and disinfectant. • Review general cleaning systems, training cleaning staff on appropriate cleaning procedures and appropriate frequency in high use or high-risk areas. • Where cleaners will be required to clean areas that have been or are suspected to have been contaminated with COVID-19, provide appropriate PPE: gowns or aprons, gloves, eye protection (masks, goggles or face screens) and boots or closed work shoes. If 63 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Activities Potential E&S Risks and Impacts Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Monitoring Measures appropriate PPE is not available, provide best available alternatives. • Train cleaners in proper hygiene (including handwashing) prior to, during and after conducting cleaning activities; how to safely use PPE (where required); in waste control (including for used PPE and cleaning materials). HCF operation - Infection control and waste management plan Waste minimization, Use of incinerators results in ➢ Where possible avoid the use of reuse and recycling emission of dioxins, furans and incinerators particulate matter ➢ If small-scale incineration is the only option, this should be done using best practices, and plans should be in place to transition to alternative treatment as soon as practicable(such as steam treatment prior to disposal with sterile/non-infectious shredded waste and disposed of in suitable waste facilities) ➢ Do not use single-chamber, drum and brick incinerators ➢ If small-scale incinerators are used, adopt best practices to minimize operational impacts. Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies Storage and handling of specimen, samples, reagents, and infectious materials 64 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Activities Potential E&S Risks and Impacts Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Monitoring Measures Waste segregation, packaging, color coding and labeling Onsite collection and transport Waste storage Onsite waste treatment and disposal Waste transportation to and disposal in offsite treatment and disposal facilities Transportation and disposal at offsite waste management facilities HCF operation – transboundary movement of specimen, samples, reagents, medical equipment, and infectious materials Operation of acquired assets for holding potential COVID-19 patients Emergency events - Spillage; ➢ Emergency Response Plan - Occupational exposure to infectious disease; - Exposure to radiation; - Accidental releases of infectious or hazardous substances to the environment; - Medical equipment failure; - Failure of solid waste and wastewater treatment facilities - Fire; - Other emergent events Mortuary arrangements - Arrangements are insufficient ➢ Implement good infection control - Processes are insufficient practices (see WHO Infection 65 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Activities Potential E&S Risks and Impacts Proposed Mitigation Measures Proposed Responsibilities Timeline Budget Monitoring Measures Prevention and Control for the safe management of a dead body in the context of COVID-19) ➢ Use mortuaries and body bags, together with appropriate safeguards during funerals (see WHO Practical considerations and recommendations for religious leaders and faith-based communities in the context of COVID-19) 66 India: COVID-19 Emergency Response Project – ESMF May 21, 2020 Table AI.4- Environmental and Social Risks and Mitigation Measures during Decommissioning Key Activities Potential E&S Risks and Proposed Mitigation Proposed Responsibilitie Timeline Budget Impacts Measures Monitoring s Measures Decommissioning of interim HCF Decommissioning of medical equipment Regular decommissioning To be expanded 67 COVID-19 Response ESMF – ICWMP Annex II: Biomedical Waste Management Plan (BMWMP) Template 1. Introduction 1.1 Describe the project context and components 1.2 Describe the targeted healthcare facility (HCF): - Type: E.g. general hospital, clinics, inpatient/outpatient facility, medical laboratory, quarantine or isolation centers; - Special type of HCF in response to COVID-19: E.g. existing assets may be acquired to hold yet-to- confirm cases for medical observation or isolation; - Functions and requirement for the level infection control, e.g. biosafety levels; - Location and associated facilities, including access, water supply, power supply; - Capacity: beds 1.3 Describe the design requirements of the HCF, which may include specifications for general design and safety, separation of wards, heating, ventilation and air conditioning (HVAC), autoclave, and waste management facilities. 2. Infection Control and Waste Management 2.1 Overview of infection control and waste management in the HCF - Type, source and volume of biomedical waste generated in the HCF, including solid, liquid and air emissions (if significant) - Classify and quantify the HCW (infectious waste, pathological waste, sharps, liquid and non- hazardous) following WBGEHS Guidelines for Healthcare Facilities and pertaining GIIP. - Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non-hazardous may be considered hazardous. It’s likely the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak. Special attention should be given to the identification, classification and quantification of the healthcare wastes. - Describe the healthcare waste management system in the HCF, including material delivery, waste generation, handling, disinfection and sterilization, collection, storage, transport, and disposal and treatment works - Provide a flow chart of waste streams in the HCF if available - Describe applicable performance levels and/or standards - Describe institutional arrangement, roles and responsibilities in the HCF for infection control and waste management 2.2 Management Measures - Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations. - Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of hazardous medical goods. 68 COVID-19 Response ESMF – ICWMP - Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. - Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. - Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours. - Onsite waste treatment and disposal (e.g. an incinerator): Many HCFs have their own waste incineration facilities installed onsite. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended. For new HCF financed by the project, waste disposal facilities should be integrated into the overall design and ESIA developed. Good design, operational practices and internationally adopted emission standards for healthcare waste incinerators can be found in pertaining EHS Guidelines and GIIP. - Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well- performed incinerator onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government or the private sector is probably needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, processcapacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. - Wastewater treatment: HCF wastewater is related to hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP)is capable of handling the type of effluent discharged. In cases where municipal sewage system is not in place, HCF should build and properly operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There’re also cases where HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted. 3. Emergency Preparedness and Response Emergency incidents occurring in a HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, communities, the HCF’s operation and the environment. Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed. The key elements of an ERP are defined in ESS 4 Community Health and Safety (para. 21). 69 COVID-19 Response ESMF – ICWMP 4. Institutional Arrangement and Capacity Building A clearly defined institutional arrangement, roles and responsibilities should be included. A training plan with recurring training programs should be developed. The following aspects are recommended: - Define roles and responsibilities along each link of the chain along the cradle-to-crave infection control and waste management process; - Ensure adequate and qualified staffs are in place, including those in charge of infection control and biosafety and waste management facility operation. - Stress the chief of a HCF takes overall responsibility for infection control and waste management; - Involve all relevant departments in aHCF, and build an intra-departmental team to manage, coordinate and regularly review issues and performance; - Establish an information management system to track and record the waste streams in HCF; and - Capacity building and training should involve medical workers, waste management workers and cleaners. Third-party waste management service providers should be provided with relevant training as well. 5. Monitoring and Reporting Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams. HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. The HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow. As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing systems should be in place. Externally, reporting should be conducted per government and World Bank requirements. 70 COVID-19 Response ESMF – ICWMP Table AII.1: BMWMP Activities Potential E&S Issues and Risks Proposed Mitigation Proposed Responsibilities Timeline Budget Measures Monitoring Measures General HCF operation General wastes, wastewater and – Environment air emissions General HCF operation - Physical hazards; – OHS issues - Electrical and explosive hazards; - Fire; - Chemical use; - Ergonomic hazard; - Radioactive hazard. HCF operation - Infection control and waste management plan Waste minimization, reuse and recycling Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies Storage and handling of specimen, samples, reagents, and infectious materials Waste segregation, packaging, color coding and labeling Onsite collection and transport Waste storage Onsite waste treatment and disposal Waste transportation to and disposal in offsite treatment and disposal facilities HCF operation – transboundary movement of specimen, samples, reagents, 71 COVID-19 Response ESMF – ICWMP Activities Potential E&S Issues and Risks Proposed Mitigation Proposed Responsibilities Timeline Budget Measures Monitoring Measures medical equipment, and infectious materials Emergency events - Spillage; Emergency response plan - Occupational exposure to infectious; - Exposure to radiation; - Accidental releases of infectious or hazardous substances to the environment; - Medical equipment failure; - Failure of solid waste and wastewater treatment facilities; - Fire; - Other emergent events Operation of acquired assets for holding potential COVID-19 patients To be expanded 72 COVID-19 Response ESMF – ICWMP Annex III: Screening Form for Potential Environmental and Social Issues This form is to be used by the Project Implementation Unit (PIU) to screen for the potential environmental and social risks and impacts of a proposed subproject. It will help the PIU in identifying the relevant Environmental and Social Standards (ESS), establishing an appropriate E&S risk rating for these subprojects and specifying the type of environmental and social assessment required, including specific instruments/plans. Use of this form will allow the PIU to form an initial view of the potential risks and impacts of a subproject. It is not a substitute for project-specific E&S assessments or specific mitigation plans. A note on Considerations and Tools for E&S Screening and Risk Rating is included in this Annex to assist the process. Subproject Name Subproject Location Subproject Proponent Estimated Investment Start/Completion Date Questions Answer ESS relevance Due diligence* Yes no / Actions Does the subproject involve civil works ESS1 ESIA/ESMP including new construction, expansion, upgrading or rehabilitation of healthcare facilities and/or waste management facilities? Does the subproject involve additional land for ESS5 Not supported expansion and/ or new construction of HCF/ by the project. laboratory through land acquisition or direct Alternative purchase and/or restrictions on land use? options to be explored. Does the subproject involve additional land for ESS5 ESIA/ESMP, expansion and/ or new construction of HCF/ Follow laboratory through transfer from another government government department norms for transfer Does the subproject require any informal/illegal ESS5 Not supported occupants’removal in case of any expansion by the project; and/or new construction of HCF/ laboratory Alternative options to be explored Does the subproject involve hiring of assets for ESS1, ESS 10 ESIA/ ESMP quarantine, isolation or medical treatment purposes? 73 COVID-19 Response ESMF – ICWMP Questions Answer ESS relevance Due diligence* Yes no / Actions Does the subproject involve transportation of ESS3 ESMP potentially infected specimens from healthcare facilities to testing laboratories Does the subproject upgrade an existing BSL2 ESS1, ESS3, ESIA/ESMP laboratory to BSL3 level and/or establish a new ESS6, ESS10 BSL3 lab? Does the subproject use security personnel for ESS1, ESS2 ESIA/ guarding/protecting temporary or permamnent Stakeholder infrastructure assets and human resources Consultations Does the subproject set up a quarantine center ESS1, ESS3 ESIA/ESMP/ and/or a BSL2/3 laboratory close to human Stakeholder habitation Consultations Is the subproject associated with any external ESS3 ESIA/ESMP waste management facilities such as a sanitary landfill, incinerator, or wastewater treatment plant for healthcare waste disposal? Is there a sound regulatory framework and ESS1 ESIA/ESMP institutional capacity in place for healthcare facility infection control and healthcare waste management? Does the subproject have an adequate system in ESS3 ESIA/ESMP place (capacity, processes and management)to address waste? Does the subproject involve recruitment of ESS2 ESIA/ESMP; workers including direct, contracted, primary and follow LMP supply, and/or community workers? for labor management Does the sub projects involve any labour influx ESS2 ESIA/ESMP; 7 ? and follow LMP for labor management Does the subproject have appropriate OHS ESS2 ESIA/ESMP procedures in place, and an adequate supply of PPE (where necessary)? Does the subproject have a GRM in place, to ESS2, ESS10 ESIA/ESMP; which all workers have access, designed to and follow LMP respond quickly and effectively? Does the subproject involve transboundary ESS3 ESIA/ESMP transportation (including Potentially infected specimens may be transported from healthcare facilities to testing laboratories, and transboundary) of specimen, samples, infectious and hazardous materials? 7 Given the scale of operation in highly dispersed locations across the country to undertake any repair, renovation, upgradation and/or new construction, it does not attract any large labor influx. 74 COVID-19 Response ESMF – ICWMP Questions Answer ESS relevance Due diligence* Yes no / Actions Does the subproject involve use of security or ESS4 ESIA/ESMP military personnel during construction and/or operation of healthcare facilities and related activities? Is the subproject located within or in the vicinity ESS6 ESIA/ESMP of any ecologically sensitive areas? Are there any indigenous groups (meeting ESS7 ESIA/ESMP specified ESS7 criteria) present in the subproject area and are they likely to be affected by the proposed subproject negatively or positively? Is the subproject located within or in the vicinity ESS8 ESIA/ESMP, of any known cultural heritage sites? SEP Does the project area present considerable ESS4 ESIA/ESMP Gender-Based Violence (GBV) and Sexual Exploitation and Abuse (SEA) risk? Is there any territorial dispute between two or OP7.60 Projects Governments more countries in the subproject and its in Disputed concerned agree ancillary aspects and related activities? Areas Will the subproject and related activities involve OP7.50 Projects Notification the use or potential pollution of, or be located in on International (or exceptions) international waterways8? Waterways * Due Diligence Measures: Given the potentially dispersed location of the subprojects, it is expected that the NHM-DPM/ CMHO at district level will conduct the screening with guidance from State level E&S officer and ensure that activities that are part of negative list are not financed or supported by the project including land acquisition, direct land purchase or land donation and/or any involuntary resettlement or removal of illegal/ informal settlers on the land. Any infrastructure expansion or construction will be supported only on HCF’s/ laboratory’s own land or on government land free from any encumbrances.This is verified by the E&S officer at the state level and further verified by E&S officials at MOHFW and World Bank on random basis. Conclusions: Proposed Environmental and Social Risk Ratings (High, Substantial, Moderate or Low). Provide Justifications. 8 International waterways include any river, canal, lake or similar body of water that forms a boundary between, or any river or surface water that flows through two or more states. 75 COVID-19 Response ESMF – ICWMP Annex IV: India COVID-19 Project – Clauses for Inclusion in Civil Works Contracts ➢ Clauses already part of contract/bidding documents being used need not be duplicated. ➢ The primary/main contractor will be responsible for ensuring these, even if one or more sub- contractors are used for completing the civil works. ➢ The contractor to put in place measures to avoid or minimize the spread of the transmission of COVID-19 and/or any communicable diseases that may be associated with the influx of temporary or permanent contract-related labor. ➢ Any suspect case of COVID19 should be tested as per the national/state guidelines issued by the Health and Family Welfare Ministry/Departments and precautions/protocol to be followed for the infected worker and his/her co-workers. 1. General Obligations of the Contractor ▪ To take all necessary precautions to maintain the health and safety of the Contractor’s Personnel. ▪ To depute a health and safety officer at site, who will have the authority to issue directives for the purpose of maintaining the health and safety of all personnel authorized to enter and or work on the site and to take protective measures to prevent accidents, including spread of COVID19. ▪ To ensure, in collaboration with local health authorities, access to medical help, first aid and ambulance services are available for workers/labors, as and when needed. 2. Labor ▪ No child labor and/or forced labor at construction site for all works. ▪ Equal pay/wage for men and women labors. ▪ Provide health and safety training/orientation on COVID19 to all workers and staff and other employees of the sub-contractor (tips on cough etiquette, hand hygiene and social distancing). ▪ Prepare a detailed profile of the project work force, key work activities, schedule for carrying out such activities, different durations of contract and rotations, confirmed addresses of the labor and any underlying health conditions that increases the risk of severe infection, to facilitate tracking of workers in case of COVID-19 exposure. ▪ All laborers to be provided with photo ID cards for accessing the construction site. ▪ All laborers engaged at construction site to be provided with the required Personal Protection Equipment (PPE) – safety helmet and shoes, secured harness when working at heights, electrical gloves, eye protection for welding etc., without which entry to the construction site shall not be allowed. ▪ In relation to COVID19, masks, adequate hand washing/ sanitization, clean drinking water and sanitation facilities to be provided at construction site. ▪ All workers/labor to be regularly checked for symptoms before allowing entry to the work site. ▪ Paid leave to be mandatorily given if labor contacts COVID-19 and/or any other contagious disease while working at the construction site or in the labor camp. ▪ Steps necessary to prevent labor harassment, including sexual harassment, gender-based violence and any discrimination based on religious, political and/or sexual orientation. 3. Labor Camps (only when labor camps are established) ▪ Contractor to provide hygienic living conditions and safe drinking water. ▪ Separate toilets for male and females and adequate hand washing/sanitization facilities. ▪ Small creche and/or play areas for children with helper, when labor is away at work. ▪ Fireproof wiring and good quality electricals to be used inside the camp. ▪ Cooking gas and/or electric/induction plate to be provided for each labor household. ▪ Monthly/weekly health check up to be organized at the camp for all labors/family. ▪ Organize awareness campaign for social distancing and general health and hygiene. 4. Involuntary Resettlement Related (Only When Relevant) ▪ No forced eviction of any squatter and/or encroacher at the construction site. ▪ Such matter to be informed in writing to the concerned authorities and the World Bank for appropriate action as per the environment and social standard (ESS5). 5. Greenfield/New Constructions – Permits / Environment and Social Management Plan (ESMP) ▪ No use of Asbestos or components/fixtures having asbestos. 76 COVID-19 Response ESMF – ICWMP ▪ Comply with all applicable national/state permits. ▪ For greenfield projects involving construction of new buildings and/or adding new floors and/or constructing a new section/wing in an existing building (hospitals, laboratories, isolation wards and quarantine facilities), an ESMP to be prepared by the contractor,as per works specifications. 6. Construction Management in Upgrading of Existing Buildings ▪ For all contracts involving upgrading of existing buildings (adding rooms, wards, halls, treatment and isolation areas, medication rooms, operation theaters, intensive care units, laboratories etc.), follow the Construction Management Framework prepared for the India COVID-19 Project and included in the project’s Environmental and Social Management Framework (ESMF), along with following various guidelines issued by the Government of India, WHO best practices etc. ▪ Maintain a roster of workers/staff at work site indicating their health condition and symptoms and ensure screening procedures (non-physical temperature measurement) at work sites. ▪ Depute and assign monitoring and reporting responsibilities on environmental management, health and personnel safety. ▪ Preventing a worker from an affected area or who has been in contact with an infected person from returning to the site for 14 days or (if that is not possible) isolating such worker for 14 days. ▪ Place posters and signages at/around the site, with images and text in local languages relating to personal safety, hygiene and on COVID-19 symptoms and guidelines. ▪ Ensuring hand washing facilities supplied with soap, disposable paper towels and closed waste bins exist at key places throughout site, including at entrances/exits to work areas; where there is a toilet, canteen or food distribution, or provision of drinking water; in worker accommodation; at waste stations; at stores; and in common spaces. ▪ Segregate lunch hours at worksite of workers to maintain social distancing. ▪ Designated separate space for storing construction material. ▪ Securing the construction site with entry only for authorized personnel and disinfecting of the worksite to be undertaken at close of work every day or as may be required. ▪ Any medical waste produced during the care of ill workers should be collected safely in designated containers or bags and treated and disposed of following relevant requirements (e.g., Biomedical Waste Rules-2018, WHO). 7. Grievance Redress Mechanism (GRM) ▪ Contractor to establish and widely advertise (within labor camps and at construction site) a GRM. Workers to be informed of their rights for reporting a workplace condition that is not safe or healthy for them and poses imminent risk of contracting COVID-19 without any reprisal/penalty. ▪ GRM to have provisions for receiving, registering, following up and resolution system for any complaint/grievance received during the construction period. ▪ A complaints register will always be maintained at the site office and responsibilities allotted to a sufficiently senior official for complaint redress. ▪ Quarterly report on the grievances received at each of the subproject is submitted to the contracting authority ▪ 77 COVID-19 Response ESMF – ICWMP Annex V: Institutional Capacity Assessment Tool for Biomedical Waste Management and Infection Control at Healthcare Facility Checklist 1: Assessment of healthcare facility capacity to manage biomedical waste S.No Questions/Description Yes No 1 Does the occupier has authority to set up its own treatment facility or having any other Yes No alternative option 2 Is the segregation of waste being done at the point of generation Yes No 3 Is Biomedical waste mixed with other waste Yes No 4 Are waste collection containers available Yes No 5 Are containers color coded as per the rule Yes 6 Does the waste marked for incineration have plastic waste mixed in it Yes No 7 Does the institution has system for waste classification Yes No 8 Are the containers in good condition Yes No 9 Is institution taking steps for Biomedical waste management as per the recommended Yes No method of treatment and disposal for the particular category 10 Is the used COVID 19 test Kit or biomedical waste of COVID 19 patients managed and Yes No buried/ incineration properly and separately 11 Is spill treatment kit available Yes No 12 Is institution has standard operating procedure for mercury spill management Yes No 13 Is liquid waste being treated with 1% sodium hypochlorite solution before discharge into Yes No sewers 14 Are needle destroyers available in sufficient number Yes No 15 Are needle destroyers in Good working condition Yes No 16 Is there proper storage and internal and external transport facility available Yes No 17 Are these facilities as per BMWM rules 1998 Yes No 18 Do employees wear protective barrier(PPE) while on the job Yes No 19 Is there any incidence of occupational injury Yes No 20 Is the record of such injury with sufficient details available Yes No 21 Is daily record of generation of waste available as per the category Yes No 22 Is there any accessibility of unauthorized person to waste storage Yes No 23 Is separate facility for treated and untreated waste storage available Yes No 24 Is there any separate route for waste transport Yes No 25 Does the institution have recorded policy on the waste type, collection time and weighing Yes No of waste 26 Is medical record of waste handlers available Yes No 27 Is the vehicle which is carrying waste from institution to offsite authorized for such Yes No specialized work 28 Is the training manual for staff available Yes No 29 Is record of employees training available Yes No 30 Are colored plastic bags in good condition Yes No 31 Is waste generation aware of difference between soiled and unsoiled waste Yes No 32 Are Doctors, Nurses, Housekeeping staff and BMW handler and ambulance driver Yes No test/screen for COVID-19, if suspect any infection 33 Is any record of accidental transmission infection in Doctors & other staff during Yes No treatment of corona patients 34 Is record available of treatment for Doctor & other staff infected during the treatment of Yes No corona patients 78 COVID-19 Response ESMF – ICWMP Checklist 2: Assessment of Healthcare facility capacity to manage infection and prevention S.No Questions/ Description Yes No 1. Decontamination of instruments a. Is sterilizer available Yes No b. Is it in good working condition Yes No c. Are clean instruments stored in cupboards under lock Yes No d. Are instruments rust free Yes No 2. Handling of sharps a. Is puncture proof container available Yes No b. Are sharps pepping out of containers Yes No c. Are sharps lying outside containers Yes No d. Is there any recapping of needles/ syringes Yes No e. Is needle cutter available Yes No f. Is it in good working condition Yes No 3. Close of protective barrier a. Are protective barriers available Yes No b. Are they in good condition Yes No c. Are they of good quality Yes No d. Are they being used by staff having the risk of exposure Yes No 4 Availability of Personal Protective Equipment (PPE) a. availability of appropriate personal protective equipment (PPE) for all personnel at the Yes No point-of-care to apply standard, contact and droplet precautions b. Is surgical Mask available for the patients Yes No c. Is the patients wearing mask in the hospital Yes No d. Is surgical cap available for covering the head of staff Yes No e. Is surgical gloves available as per the standard quality Yes No f. Is the FFP2/FFP3 Respirators (N95/N99 mask) available for Doctors, Paramedical Yes No staff and Nursing staffs involve in treatment of Corona patients g. Is the COVID -19 protective suit/gown available for Doctors and Nursing staff Yes No involve in treatment of Corona patients h. Is the COVID -19 protective suit /gown available for Housekeeping staff and Yes No ambulance driver involve in Corona patients treatment and transportation i. Is COVID-19 protective suit/ gown, as per the standard quality to protect from Yes No infection /transmission of disease j. Are the Doctor, Nurse, Housekeeping staff and ambulance drivers wearing mask Yes No k. Is the goggles adapted for clinical assessment of suspected COVID-19 case by Doctor Yes No and Nurses l. Is the use of heavy-duty gloves and boots considered for the BMW handler Yes No 5. Hand washing practices a. Is liquid soap and clean water available Yes No b. Is paper towel/ clean towel available Yes No c. Is staff aware of hand washing practices Yes No d. Are staff members washing their hands properly (more than 20 second) Yes No e. Are list of universal precautions available Yes No f. Is the poster of hand washing instruction pasted near facility Yes No 6. Hand Sanitizing practices Yes No a. Is Hand sanitizers available Yes No b. Is the hand sanitizer with 60% Isopropyl alcohol based Yes No 79 COVID-19 Response ESMF – ICWMP c. Are the Doctor, staff, Nurses and Patients using hand sanitizer regularly Yes No d. Are staff and patient taking care as the sanitizer highly flammable Yes No e. Is BMW handler using sanitizer regularly before and after the work Yes No f. Is the Housekeeping staff using sanitizer regularly before and after the work Yes No g. Is the ambulance driver using sanitizer regularly Yes No 7. Social distancing a. Is dedicated separate ward and isolation centre for COVID 19 patients Yes no b. Is the healthcare workers performing the first assessment without direct contact Yes No c. Is the patients following social distance while consult Doctor Yes No d. Is the social distance following during the treatment Yes No e. Is the distance between the patients and staff (3 - 6 ft) Yes No f. Is the social distance marked with some sign/ color/shape/symbol Yes No g. Are suspected cases of COVID-19 isolated, or at least separated from other patients Yes No h. Is dedicated toilet facilities available for COVID-19 patient Yes No I Non-essential contacts between suspected cases and other persons minimized Yes No 8. Waste management a. Is waste being managed as per rule Yes No b. Is there any contaminated waste littered around Yes No c. Are the container in good condition Yes No d. Does staff handle the waste with bare hands Yes No e. Are containers color coded as per rules Yes No f. Is the COVID 19 patient waste managed separately as the infection spreads through Yes No any objects also g. Are the isolation ward, separate hospital ward of COVID 19 patients being sanitized Yes No regularly h. Are the waste storage area, containers and vehicles being sanitized regularly Yes No 80 COVID-19 Response ESMF – ICWMP Annex VI: Biosafety Laboratories and required Mitigation Actions As per the guidelines of the Ministry of Environment & Forests, India, various animal pathogens and plant pests are classified and defined in G.S.R. 1037(E) conferred by sections 6, 8 and 25 of the Environment (Protection) Act, 1986 (29 of 1986) with a view to protect the environment, nature and health, in connection with the application of gene-technology and microorganisms. Therefore, relevant environmental safety and mitigation measures are required while setting up a biosafety level laboratory, particularly BSL2 and above. Biosafety Indicative Activities Suggested Mitigation Measures Level BSL1 Teaching and research laboratory ▪ Work can be performed on open-bench with good involving biological agents not laboratory practices, aseptic techniques known to cause disease in ▪ Proper waste disposal is required immunocompetent adult humans and pose minimal potential hazard to laboratory personnel and environment BSL2 Involves working with agents that ▪ Restricted access and containment during certain pose moderate hazards to personnel processes (i.e. aerosols, large volumes, etc.) and the environment. Usually non- ▪ Use autoclaves and biological safety cabinets respiratory, non-lethal agents are ▪ Use of good laboratory practices, safe waste disposal handled in BSL-2 laboratory measures, and aseptic techniques are mandatory BSL3 Applicable to clinical, diagnostic, ▪ laboratory personnel receive specific training in teaching, research, or production handling pathogenic and potentially lethal agents facilities where work is performed ▪ Supervised by scientists competent in handling with agents that may cause serious infectious agents and associated procedures or potentially lethal disease through ▪ All work is performed in biocontained environments inhalation, to the personnel, and using appropriate engineering controls may contaminate the environment ▪ Laboratory protocols should be developed to identify the areas where biosafety can be breached or compromised using existing standard operating procedures (SOP), administrative and personal protective equipment (PPE) control, or engineering control of existing laboratory ▪ unidirectional air flow using room pressure gradients of negative pressure, exhaust air being HEPA (high efficiency particulate air) filtered (capable of filtering 0.3-micron air-borne particles with an efficiency of 99.97%) and proper procedures for disposal of biomedical waste ▪ Personal decontamination procedures and provisions, including soaps, hand washing, showers should be available ▪ Protective clothing should be provided to laboratory personnel ▪ Solid biomedical waste generated from laboratories which includes gloves, soiled gauze pads, cotton, etc. should be soaked in 2.5 per cent solution of sodium hypochlorite and 0.25N NaOH for 16 h or more. Also if the laboratory has an autoclave facility, the biohazardous laboratory waste should be autoclaved at 121°C at 15 psi pressure for 20 min for complete decontamination; it can then be disposed off in 81 COVID-19 Response ESMF – ICWMP Biosafety Indicative Activities Suggested Mitigation Measures Level accordance with the State/local pollution control bodies requirements ▪ Toxic liquid effluents generated from the BSL-3 laboratories should be decontaminated with a 1:1 (v/v) mixture of 2.5 per cent sodium hypochlorite and 0.25N NaOH, mixed well and kept for 8 h. Also, if the laboratory has an autoclave facility, the liquid effluent can be autoclaved at 121°C at 15 psi pressure for 20 min through a specific liquid cycle in the autoclave. This decontaminated effluent can then be disposed off in accordance with the State/local pollution control bodies requirements. ▪ Equipment/Work surfaces must be cleaned. For most toxins and chemicals, 0.5 per cent sodium hypochlorite solution is an effective decontaminant. Additionally, one should read carefully the Material Safety Data Sheet (MSDS) for the appropriate decontaminant for a particular toxin/chemical used ▪ All the contaminated glasswares should be soaked in a mixture of 2.5 per cent sodium hypochlorite and 0.25N NaOH solution for 8 h. Alternatively, glasswares can also be soaked in 5 per cent sodium hypochlorite solution for 8 h BSL4 Working with dangerous and exotic ▪ All BSL3 mitigation measures infectious agents that pose a high ▪ Laboratory personnel receive specific training in individual as well as environment handling pathogenic and potentially lethal agents risk of life-threatening disease, ▪ mandatorily work wearing positive pressure BSL-4 aerosol transmission, or a related suits agent with unknown risk of ▪ All laboratory wastes must follow strict disinfecting transmission procedures using autoclaves and bioseals For a detailed account of step-wise mitigation measures to be followed for BSL3 laboratory, refer to – Devendra T. Mourya, Pragya D. Yadav, Triparna Dutta Majumdar, Devendra S. Chauhan, and Vishwa Mohan Katoch. Establishment of Biosafety Level-3 (BSL-3) laboratory: Important criteria to consider while designing, constructing, commissioning & operating the facility in Indian setting. Indian J Med Res. 2014 Aug; 140(2): 171–183. 82 COVID-19 Response ESMF – ICWMP Annex VII: Labor Management Procedures OVERVIEW OF LABOR USE ON THE PROJECT Type of Workers 1. The ESS2 (Labor and Working Conditions) categorizes workers into direct workers, contracted workers, community workers, and primary supply workers. However, only the two categories of workers are expected for this project i.e. Direct Workers and Contracted Workers. 2. Direct Workers: The project will be implemented by the Ministry of Health and Family Welfare (MOHFW). The project will be managed by three entities within the MOHFW namely: The National Health Mission (NHM), the National Center for Disease Control (NCDC) and the Indian Council of Medical Research (ICMR). In addition, Ministry of Railway’s will be involved in developing and providing railway coaches for quarantine and isolation facilities. The National Project Management Unit (NPMU) set up for the project will have about 12-14 officials as the core team at MOHFW and about 6 officials each at the three Technical Support Units (TSUs) for NHM, NCDC and ICMR. 3. Direct workers will comprise project staff hired by MOHFW, civil servants and other government employees at various Ministries and Departments at National and at State level associated with COVID19 operations, health care workers (including Doctors, Nurses, Paramedics, Hygiene workers, Technicians, Auxiliary Nursing Midwifes (ANMs) etc) at the designated COVID19 facilities including at quarantine and isolation facilities across the country and those working in Railway Coaches which was converted as COVID Care Centres, State Government officials, Police personnel, and other officials/ workers associated with COVID19 operations including community health workers such as Multi-purpose health workers and Accredited Social Health Activist (ASHA) who also help support some of the contact tracing activities for COVID19. These employees are as per the employment norms set by the government and confirming to prevailing employment regulations and labor laws in India. 4. Contract Workers: Site specific contract workers will be employed as deemed appropriate by contractors, sub-contractors, and other intermediaries under the project that may involve construction, expansion, rehabilitation and/or operation of healthcare facilities in response to COVID-19 amongst other activities. The contract workers are of two types: (a) contract staffs at the health facility which may include Doctors, Nurses, Paramedics, Hygiene workers, Technicians etc., and (b) contract workers for civil work. 5. The contract worker for functioning of health care facility are generally a long term contract workers with periodic renewal of their employment terms and providing day-to-day services often because of increased patient load in particular hospital(s)/ health facility(ies) or to temporarily fill the vacant position till the time proper recruitment is conducted by the respective state government which may vary anywhere from one year to more than a decade in some cases. These workers also meet the necessary employment eligibility for the particular position that they are filling in absence of permanent employee. The civil work on the other hand is undertaken by the civil contractor/ sub-contractor for repair, refurbishing, upgrading and/or building new healthcare facilities and often employing small number of labor given the scale of operation expected under the project. The civil construction will be undertaken need based to enhance 83 COVID-19 Response ESMF – ICWMP services as necessary for COVID19 operation in particular area and will be dispersed at various locations across the country. ASSESSMENT OF KEY POTENTIAL LABOR RISKS 6. Labor Risk associated with Health Care Workers: The potential risk to the health care workers (both regular employee and contracted staff) is associated with treatment of COVID-19 patients. This risk to health care workers is largely related to risks of exposure to pathogen. The occupational health and safety issues related to shortage of PPE for health care and other workers in the COVID-19-related logistical supply chains, PPE not being appropriately used by the laboratory technicians and medical staff; and risk related to handling, transportation, and disposal of health care waste from hospitals and laboratories, COVID-19 screening posts and quarantine centers are the key risks. 7. Labor Risk associated with Contract workers for civil works: For civil construction workers risk are again the occupational health and safety risks in dealing with construction activities and risk of exposure to pathogen given working in health facilities designated for COVID operations. 8. Given the civil work related to repair, refurbishing, upgrading will require small number of labor employed locally, hence no labor influx is expected as the scale of civil work being small. However, in case of construction of new healthcare facilities which likely to be very few in numbers (if at all), and based on size of the facility, risk of labour influx does exist for such operations. The civil construction will be undertaken need based to enhance services as necessary for COVID19 operation in particular area and will be dispersed at various locations across the country. BRIEF OVERVIEW OF LABOR LEGISLATION: TERMS AND CONDITIONS 9. The terms and conditions of employment/ engagement for the direct and contract workers is presented below. Type of Worker Terms and Condition Direct Workers The direct workers are governed by the employment terms and condition as defined by the Central/ State government under the Department of Personnel and Training. A detailed rules and regulations governing the employment is available at https://dopt.gov.in/ais-rules. The state specific rules generally follow the central services rules with some state specific amendments. They are guided by the occupational health and safety norms set for all employees and further guidance by MOHFW in adhering to COVID situation. The employment code, wages, working hours, overtime, leave and benefits, disputes and grievances are all governed by the above rules. Contract staffs at The contract staffs are governed by the terms set out in their contractual appointment Health Facilities for their employment. These contracts are regulated by The Indian Contract Act 1872 (include Doctors, and its Amendments (last updated in December 2018) and provisions of Payment of Nurses, Paramedics, Wages Act, 1936; Minimum Wages Act, 2020; Employer’s Liability Act, 1938; the Hygiene workers, Workmen Compensation Act,1923 and The Employees' Compensation Technicians etc.) (Amendment) Act, 2017; Industrial Disputes Act, 1947; Maternity Benefit Act, 2017 and other relevant Acts. In case of contract staffs at the health facilities, employment code, wages, working hours, overtime, leave and benefits, disputes and grievances are all governed by the 84 COVID-19 Response ESMF – ICWMP contractual obligations as set out in the contracts. However, the contractual staffs at the health facilities are also guided by the same occupational health and safety norms as set for all employees and further guidance by MOHFW in adhering to COVID situation. Contract workers for Labour and employment laws are listed under the Concurrent List in the Constitution. civil work There are hundreds of legislations relating to labour and employment in India, including around 50 legislations enacted by the Union Parliament. Most of these legislations concern blue-collar employees or workmen, owing to the historical emphasis on improving working conditions for these employees. However, the key legislation governing the contract worker for civil work is ‘The Building and Other Constructions Workers (Regulation of Employment and Conditions of Service) Act, 1996’ and ‘The Building and Other Construction Workers (Regulation of Employment and Condition of Services) Central Rules, 1998’. This is a social welfare legislation that aims to benefit workers engaged in building and construction activities across the country and regulates the employment and conditions of service of building and other construction workers and to provide for their safety, health and welfare measures and for other matters connected therewith or incidental thereto. In addition, Annex IV of this document also mentions that clauses for inclusion in Civil Works Contracts. BRIEF OVERVIEW OF LABOR LEGISLATION: OCCUPATIONAL HEALTH AND SAFETY 10. As mentioned earlier in section 2 and further , the occupational health and safety risks is one of the main labor risks under the project. The key occupational health and safety guidelines specific to dealing with COVID19 pandemic issued by the MOHFW in line with guidance form WHO, CDC and other international best practices guidance and learning includes: i. Advisory on Social Distancing – March 2020 – MOHFW ii. Standard Operating Procedure (SOP) for transporting a suspect/confirmed case of COVID-19 iii. Revised National Clinical Management Guidelines for COVID-19 iv. Guidelines for handling, treatment and disposal of waste generated during treatment, diagnostics and quarantine of COVID19 patients – March 2020 and April 2020 – Central Pollution Control Board v. COVID19 Guidelines on Dead Body Management – March 15, 2020 – Director General of Health Services (DGHS), MOHFW (EMR Divisions) vi. Office Memorandum on Preventive Measures to be taken to contain the spread of Novel Coronavirus (COVID19) – March 16, 2020 – Department of Personnel and Training), Ministry of Personnel, Public Grievances and Pensions vii. Guidelines for Quarantine facilities COVID-19 viii. Ordinance to protect healthcare workers form abuse and assault ix. Guidelines on preventive measures to contain spread of COVID-19 in workplace settings x. Advisory for managing Health care workers working in COVID and Non-COVID areas of the Hospital xi. Guidelines for Dental Professionals in Covid-19 pandemic situation xii. Video on use of PPE in different areas of the hospital xiii. Guidelines on rational use of Personal Protective Equipment 85 COVID-19 Response ESMF – ICWMP xiv. Updated Additional guidelines on rational use of Personal Protective Equipment (setting approach for Health functionaries working in non-COVID areas) xv. SOP for allocation of Residents/PG Students and Nursing Students as part of hospital management of COVID-19 xvi. Advisory for Exemption to mark biometric attendance in AEBAS RESPONSIBLE STAFF 11. The overall responsibility of LMP implementation rests with the NPMU at MOHFW. The Social Development Specialist at the NPMU will oversee the LMP implementation including coordinating with the three TSUs, Department of Personnel and Training at national level and/or respective states for addressing any issues, and report to Team Leader for necessary guidance. At the State level the E&S Nodal Officers will oversee the LMP implementation and report to NPMU. 12. The Social Development Specialist at the NPMU and the E&S Nodal Officer at state level will be responsible for the following: • Implement this labor management procedure • Ensure that civil works contractors comply with these labor management procedures, and also adhere to occupational health and safety measures • Ensure the contracts with the contractors are developed in line with the provisions of this LMP and the project’s ESMF • Monitor to verify that contractors are meeting labour and OHS obligations toward contracted and subcontracted workers • Monitor contractors and subcontractors implementation of labor management procedures. • Monitor compliance with occupational health and safety standards at all health care facilities and all workplaces • Monitor and implement training on LMP and OHS for project workers. • Ensure that the grievance redress mechanism for the project is established and implemented and workers are informed of its purpose and how to use it. • Have a system for regular monitoring and reporting on labor and occupational health and safety performance • Monitor implementation of the Worker Code of Conduct 13. The Contractors will be responsible for the following: • To obey requirements of the national and state legislation and this labor management procedure; • Maintain records of recruitment and employment process of contracted workers; • Communicate clearly job description and employment conditions to contracted workers; • Have a system for regular review and reporting on labor, and occupational safety and health performance. 14. In addition, the Project Implementation Manual (PIM) and ESMF includes the standard clauses for inclusion in civil works contracts and includes LMP, OHS aspects, and the contractor’s role and obligations towards them. This includes (but not limited to): 86 COVID-19 Response ESMF – ICWMP • The general obligations of the contractor with respect to maintaining the health and safety of the workers • Ensuring no child labor and/or forced labor at the construction site for any works • Equal pay/wage for men and women labors • Providing health and safety training/orientation on COVID19 to all workers and staffs • All laborers engaged at construction site to be provided with the required Personal Protection Equipment (PPE) • In relation to COVID19, masks, adequate hand washing/ sanitization, clean drinking water and sanitation facilities to be provided at construction site • Adherence to MOHFW advisories and all workers/labor to be regularly checked for symptoms before allowing entry to the work site. Paid leave to be mandatorily given if labor contacts COVID-19 and/or any other contagious disease while working at the construction site or in the labor camp • Steps necessary to prevent labor harassment, including sexual harassment, gender-based violence and any discrimination based on religious, political and/or sexual orientation • Basic facilities at labor camps (in case any labor camp is setup) • Establishing Grievance Redress Mechanism (GRM) with GRM having provisions for receiving, registering, following up and resolution system for any complaint/grievance received during the construction period. And, ensuring workers awareness about GRM. POLICIES AND PROCEDURES Policy and Procedure for Direct Workers 15. For proper functioning of health facilities, MOHFW has issued various guidance and procedures to be followed across the country by the health care workers since March 2020 in line with WHO, CDC, and international best practices. These includes guidance on Social Distancing; SOP for transporting a suspect/confirmed case of COVID-19; Guidelines on Clinical Management for COVID-19; Guidelines for handling, treatment and disposal of waste generated during treatment, diagnostics and quarantine of COVID19 patients; Guidelines on Dead Body Management; Preventive Measures to contain the spread of Coronavirus; Ordinance to protect healthcare workers form abuse and assault; Guidelines on preventive measures to contain spread of COVID-19 in workplace settings; Advisory for managing Health care workers working in COVID and Non-COVID areas of the Hospital; and Guidelines on rational use of Personal Protective Equipment (PPE) etc. 16. In addition, some of the key procedure emphasized in this LMP is ensuring (a) Sufficient PPE kits for health facility staffs (b) Parity with respect to usage of PPE among all workers irrespective of being regular or contracted; (c) Early pay out of INR 50 Lakh per health worker (both regular and contractual) fighting COVID-19 under Insurance Scheme announced by the Government; (d) Health and hygiene training and orientation for all; (e) Safety of women from any sexual exploitation and abuse (SEA) and sexual harassment (SH) and mechanism to access redressal services such as services provided by One Stop Centre (OSC) among others (see Annex-IX). 87 COVID-19 Response ESMF – ICWMP Policy and Procedure for Contract Workers for Civil Work 17. The key procedure at the construction site includes as follows: (i) Equal pay/wage for men and women labors. (ii) No child labor and/or forced labor at construction site for all works (iii) Prepare a detailed profile of the project work force, key work activities, schedule for carrying out such activities, different durations of contract and rotations, confirmed addresses of the labor and any underlying health conditions that increases the risk of severe infection, to facilitate tracking of workers in case of COVID-19 exposure. (iv) Provide health and safety training/orientation on COVID19 to all workers and staff and other employees of the sub-contractor (tips on cough etiquette, hand hygiene and social distancing). (v) Place posters and signages at/around the site, with images and text in local languages relating to personal safety, hygiene and on COVID-19 symptoms and guidelines. (vi) All laborers to be provided with photo ID cards for accessing the construction site. (vii) All laborers engaged at construction site to be provided with the required Personal Protection Equipment (PPE) – safety helmet and shoes, secured harness when working at heights, electrical gloves, eye protection for welding etc., without which entry to the construction site shall not be allowed. (viii) In relation to COVID19, masks, adequate hand washing/ sanitization, clean drinking water and sanitation facilities to be provided at construction site. (ix) Limiting the number of workers on site at any one time (x) Adequate hand washing and sanitization facilities provided during construction (xi) Health and hygiene training and orientation for all; (xii) Consider ways to minimize/control movement in and out of construction areas/site (xiii) All workers/labor to be regularly checked for symptoms before allowing entry to the work site. (xiv) Maintain a roster of workers/staff at work site indicating their health condition and symptoms and ensure screening procedures (non-physical temperature measurement) at work sites. (xv) Implement procedures to confirm workers are fit for work before they start work, paying special to workers with underlying health issues or who may be otherwise at risk (xvi) Provide daily briefings to workers prior to commencing work, focusing on COVID-19specific considerations including cough etiquette, hand hygiene and distancing measures. (xvii) Segregate lunch hours at worksite of workers to maintain social distancing. (xviii) Securing the construction site with entry only for authorized personnel and disinfecting of the worksite to be undertaken at close of work every day or as may be required. (xix) Check and record temperatures of workers and other people entering the construction area/site or require self-reporting prior to or on entering (xx) Require workers to self-monitor for possible symptoms (fever, cough) and to report to their supervisor if they have symptoms or are feeling unwell (xxi) Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days (xxii) Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days (xxiii) Paid leave to be mandatorily given if labor contacts COVID-19 and/or any other contagious disease while working at the construction site or in the labor camp. 88 COVID-19 Response ESMF – ICWMP (xxiv) If workers are accommodated on site, require them to minimize contact with people outside the construction area/site or prohibit them from leaving the area/site for the duration of their contract (xxv) Steps necessary to prevent labor harassment, including sexual harassment, gender-based violence and any discrimination based on religious, political and/or sexual orientation. (xxvi) Depute and assign monitoring and reporting responsibilities on environmental management, health and personnel safety. 18. The key procedure to be followed at the labor camp (if setup): ▪ Contractor to provide hygienic living conditions and safe drinking water. ▪ Separate toilets for male and females and adequate hand washing/sanitization facilities. ▪ Small creche and/or play areas for children with helper, when labor is away at work. ▪ Fireproof wiring and good quality electricals to be used inside the camp. ▪ Cooking gas and/or electric/induction plate to be provided for each labor household. ▪ Monthly/weekly health check up to be organized at the camp for all labors/family. ▪ Organize awareness campaign for social distancing and general health and hygiene ▪ Limit labor dormitory occupancy to ensure social distancing norms ▪ Labor camps to be cleaned and disinfected on daily basis ▪ Adequate hand washing and sanitization facilities provided in common areas ▪ Social gathering to be restricted and recommended protocols for health hygiene to be maintained ▪ Place posters and signages at/around the site, with images and text in local languages relating to personal safety, hygiene and on COVID-19 symptoms and guidelines. ▪ Providing cleaning staff with adequate cleaning equipment, materials and disinfectant ▪ Contractor shall include security measures to be provided at the camps which may include fencing, locks, alarms, pass card systems, badge and pass system, access points, safe transport of personnel as appropriate. ▪ In addition, Health advisories of MOHFW and State Government to be followed AGE OF EMPLOYMENT 19. In accordance with the Constitution of India, no child below the age of fourteen years shall be employed to work in any factory or mine or engaged in any other hazardous employment. Employment of child under 14 years of age is strictly prohibited in any establishment. Adolescents between the age of 14 – 18 years cannot be employed in any hazardous occupation as per the Child Labour (Prohibition and Regulation) Amendment Act, 2016. Given the nature of occupation in health care settings and risk to infections, the minimum age of employment is 18 years. 20. Contractors will be required to verify and identify the age of all workers. This will require workers to provide official documentation, which could include a birth certificate, ratio card, Aadhar card and other national identification cards, passport, or medical or school record. If a minor under the minimum labour eligible age is discovered working on the project, measures will be taken to immediately terminate the employment or engagement of the minor in a responsible manner, taking into account the best interest of the minor. 89 COVID-19 Response ESMF – ICWMP TERMS AND CONDITIONS OF EMPLOYMENT 21. The terms of employment of the direct project workers of regular category is governed by the All India Service rules or the State specific service rules, the terms of employment of the contractual staffs at the health facilities is governed by their terms of contract as mentioned in Section 2 and in all cases the principles of non-discrimination and equal opportunity apply. 22. The terms of employment of the contract workers for civil work is also based on the terms of contract and governed by the larger policies laid down by the government specifically ‘The Building and Other Constructions Workers (Regulation of Employment and Conditions of Service) Act, 1996’ and ‘The Building and Other Construction Workers (Regulation of Employment and Condition of Services) Central Rules, 1998’. The act specifies that no worker employed in building or construction work shall be required or allowed to work for more than nine hours a day or forty-eight hours a week. Over that s/he shall, in respect of overtime work, be entitled to wages at double the ordinary rate of wages. GRIEVANCE MECHANISM FOR LABOR ENGAGED IN CONSTRUCTION WORK 23. The main objective of a Grievance Redress Mechanism (GRM) is to assist to resolve complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Construction Site Specific Grievance Mechanism to be setup by the contractor/ sub-contractor. It shall include site specific Grievance Focal Point (GFP) assigned by the Contractor who will file the grievances and appeals of contracted workers and will be responsible to facilitate addressing them. If the issue cannot be resolved at contractor’s level within 7 working days, then it will be escalated to HCF Management and then to CMO at district level and finally to the contract issuing authority. Worker can also register grievances using the GRM system setup by MOHFW and State Health Department. 24. The GEPGFP will register the grievances in a formal manner in register or in electronic format to be easily tracked for its resolution. The GRM will include the process of screening, investigation, resolution of grievances, documentation, and reporting of grievances as the steps mentioned below. Step 0: Raising and registering the grievances using various mechanism including through written or verbal complaints and registered in grievance logbook at the construction site at healthcare facility; or using the MOHFW mechanism as mentioned in Section 9. Step 1: Grievance raised is screened by the GFP and based on its severity/ jurisdiction forwarded to respective contractor/ sub-contractor for redressing Step 2: Grievance discussed at the GFP/ respective contractor/ sub-contractor level, and addressed Step 3: If not addressed in stipulated period it is escalated to next level at HCF Management, and then to CMO and finally to contract issuing authority Step 4: Once addressed, feedback is given/ sent to the complainant Step 5: If not satisfied, appeal to the other public authorities 25. Once all possible redress has been proposed and if the complainant is still not satisfied then they should be advised of their right to legal recourse. 26. Quarterly report on the grievances received at each of the subproject is submitted to the contracting authority at the state level and a compiled summary of the same by the State E&S Nodal Officer to NPMU on quarterly basis. 90 COVID-19 Response ESMF – ICWMP CONTRACTOR MANAGEMENT OF CIVIL WORKS 27. While the appropriate contact issuing authority will oversee the implementation of contract as per the terms and clauses mentioned in the contract. The E&S Nodal Officer at the state level in association with NHM District Program Manager (DPM)/ Chief Medical and Health Officer (CMO) at district level will manage and monitor the E&S performance of contractors in relation to contracted workers, focusing on compliance by contractors with their contractual agreements (obligations, representations, and warranties) and labor management procedures. This may include periodic audits, inspections, and/or spot checks of the sub-project locations and work sites as well as of labor management records and reports compiled by the contractors. 28. Contractors’ labor management records and reports that may be reviewed would include representative samples of employment contracts or arrangements between third parties and contracted workers, records relating to grievances received and their resolution, reports relating to safety inspections, including fatalities and incidents and implementation of corrective actions, records relating to incidents of non-compliance with national law and the labor management procedures, and records of training provided for contracted workers to explain occupational health and safety risks and preventive measures. 91 COVID-19 Response ESMF – ICWMP Annex VIII: Resource List: COVID-19 Guidance Given the COVID-19 situation is rapidly evolving, a version of this resource list will be regularly updated and made available on the World Bank COVID-19 operations intranet page (http://covidoperations/). WHO Guidance Advice for the public • WHO advice for the public, including on social distancing, respiratory hygiene, self-quarantine, and seeking medical advice, can be consulted on this WHO website: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public Technical guidance • Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, issued on March 19, 2020 • Recommendations to Member States to Improve Hygiene Practices, issued on April 1, 2020 • Severe Acute Respiratory Infections Treatment Center, issued on March 28, 2020 • Infection prevention and control at health care facilities (with a focus on settings with limited resources), issued in 2018 • Laboratory biosafety guidance related to coronavirus disease 2019 (COVID-19), issued on March 18, 2020 • Laboratory Biosafety Manual, 3rd edition, issued in 2014 • Laboratory testing for COVID-19, including specimen collection and shipment, issued on March 19, 2020 • Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios, issued on March 21, 2020 • Infection Prevention and Control for the safe management of a dead body in the context of COVID-19, issued on March 24, 2020 • Key considerations for repatriation and quarantine of travelers in relation to the outbreak COVID-19, issued on February 11, 2020 • Preparedness, prevention and control of COVID-19 for refugees and migrants in non-camp settings, issued on April 17, 2020 • Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health, issued on March 18, 2020 • Oxygen sources and distribution for COVID-19 treatment centers, issued on April 4, 2020 • Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response, issued on March 16, 2020 • Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19), issued on March 19, 2020 • Operational considerations for case management of COVID-19 in health facility and community, issued on March 19, 2020 • Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19), issued on February 27, 2020 • Getting your workplace ready for COVID-19, issued on March 19, 2020 • Water, sanitation, hygiene and waste management for COVID-19, issued on March 19, 2020 • Safe management of wastes from health-care activities, issued in 2014 • Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak, issued on March 19, 2020 92 COVID-19 Response ESMF – ICWMP • Disability Considerations during the COVID-19 outbreak, issued on March 26, 2020 WORLD BANK GROUP GUIDANCE • Technical Note: Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints on conducting public meetings, issued on March 20, 2020 • Technical Note: Use of Military Forces to Assist in COVID-19 Operations, issued on March 25, 2020 • ESF/Safeguards Interim Note: COVID-19 Considerations in Construction/Civil Works Projects, issued on April 7, 2020 • Technical Note on SEA/H for HNP COVID Response Operations, issued in March 2020 • Interim Advice for IFC Clients on Preventing and Managing Health Risks of COVID-19 in the Workplace, issued on April 6, 2020 • Interim Advice for IFC Clients on Supporting Workers in the Context of COVID-19, issued on April 6, 2020 • IFC Tip Sheet for Company Leadership on Crisis Response: Facing the COVID-19 Pandemic, issued on April 6, 2020 • WBG EHS Guidelines for Healthcare Facilities, issued on April 30, 2007 ILO GUIDANCE • ILO Standards and COVID-19 FAQ, issued on March 23, 2020 (provides a compilation of answers to most frequently asked questions related to international labor standards and COVID-19) MFI GUIDANCE • ADB Managing Infectious Medical Waste during the COVID-19 Pandemic • IDB InvestGuidance for Infrastructure Projects on COVID-19: A Rapid Risk Profile and Decision Framework • KfW DEG COVID-19 Guidance for employers, issued on March 31, 2020 • CDC Group COVID-19 Guidance for Employers, issued on March 23, 2020 MOHFEW, GoI’sGUIDANCE India has also issued several national policies and guidelines specific to COVID-19 pandemic.Since the outbreak of COVID19, India has proactively taken several measures for containing the disease which are in line with guidance form WHO, CDC and other international best practices guidance and learning. While many of these policies are evolving based on the COVID19 pandemic situation in India, some of the guidance relevant to environmental and social measures are as below: i. Advisory on Social Distancing – March 2020 – MOHFW ii. Advisory on Mass Gatherings – March 2020 – MOHFW iii. Guidelines for home quarantine – March 2020 – MOHFW 93 COVID-19 Response ESMF – ICWMP iv. Guidelines for handling, treatment and disposal of waste generated during treatment, diagnostics and quarantine of COVID19 patients – March 2020 and April 2020 – Central Pollution Control Board v. Strategy of COVID19 Testing in India – March 17, 2020, from Indian Council of Medical Research vi. Standard Operating Procedures for Passenger Movement Post Disembarkation (including SOP for Quarantine) – March 2020 – MOHFW vii. Guidelines for Notifying COVID19 Affected Persons by Private Institutions – March 2020 – MOHFW viii. Gazette Notification – Essential Commodities Order 2020 – with regards to masks and hand sanitizers ix. National Pharmaceutical Pricing Authority (NPPA) Order regarding Masks, Hand Sanitizers and Gloves x. COVID19 Guidelines on Dead Body Management – March 15, 2020 – Director General of Health Services (DGHS), MOHFW (EMR Divisions) xi. Office Memorandum on Preventive Measures to be taken to contain the spread of Novel Coronavirus (COVID19) – March 16, 2020 – Department of Personnel and Training), Ministry of Personnel, Public Grievances and Pensions xii. Guidance document on appropriate management of suspect/confirmed cases of COVID-19 - Types of Covid-19 dedicated facilities xiii. Guidelines for Quarantine facilities COVID-19 xiv. Guidance for COVID-19 & Pregnancy &Labour Management xv. Guidance document on appropriate management of suspect/confirmed cases of COVID-19 - Types of Covid-19 dedicated facilities xvi. Advisory issued by Ministry of Rural Development to the State Rural Livelihoods Missions on actions to be taken to address the COVID 19 outbreak xvii. Norms of assistance from State Disaster Response Fund (SDRF) in wake of COVID-19 outbreak xviii. Containment Plan for Large Outbreaks of COVID-19 xix. Model Micro plan for containment of local transmission of COVID19 xx. Advisory for quarantine of migrant workers xxi. Various mass awareness generation activities and guidance xxii. Various audiovisuals and print material on Psycho-Social support along with setting up toll free helpline-08046110007 xxiii. Ordinance to protect healthcare workers form abuse and assault xxiv. Guidelines on preventive measures to contain spread of COVID-19 in workplace settings xxv. Advisory for managing Health care workers working in COVID and Non-COVID areas of the Hospital xxvi. Guidance note for Immunization services during and post COVID outbreak 94 COVID-19 Response ESMF – ICWMP Annex IX: GBV, Sexual Exploitation and Abuse (SEA)/ Sexual Harassment (SH) Guidance Given the COVID19 situation where government has been setting up a large number of quarantine facilities for medical isolation of individuals along with isolation units. It poses the risk of gender based violence (GBV), sexual exploitation and abuse (SEA) and sexual harassment (SH), and hence the following mitigation measures to address SEA/ SH risks are put in place. Most of these mitigation measures are already mandated by the Government of India for application across the country and covering all states and UTs and all Ministries and Departments including MOHFW. The key measures include: 1. Sensitization of Health care staffs on preventing GBV, SEA/ SH. 2. Orienting health care staffs mainly doctors, nurses, and para medics and using ‘Guidelines and Protocols for Medico-legal care for survivors/victims of sexual violence’ by MOHFW (https://main.mohfw.gov.in/sites/default/files/953522324.pdf) illustrating the need to play the dual role of responding to the survivors of sexual assault, by providing required medical treatment and psychological support, and at the same time assist survivors in their medico-legal proceedings by collecting evidence and ensuring a good quality documentation. 3. Setting up gender-sensitive infrastructure such as segregated toilets for men and women; and well- lit quarantine and isolation centers, with adequate human resource deployment and security measures. 4. Implementation of measures as mandated by Government of India as provided under 'The Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013 (also known as POSH Act) by establishing ‘Internal Complaints Committee (ICC)’at health facility level (as applicable) and setting up of a ‘Local Complaints Committee (LCC)’ at the district level to investigate complaints regarding sexual harassment at workplace. 5. Building linkages to services addressing the larger need of the victim of GBV, SEA/SH such as One-stop center initiatives by Ministry of women and Child Development’s (MoWCD) for establishing integrated response services to victim of GBV in each district, where it is operational or National or State Commission for Women, or civil society organizations working on GBV. 6. Monitoring GBV, SEA/ SH cases in project facilities by the State E&S nodal officers and reporting to NPMU at MOHFW in a periodic manner i.e. six monthly/ annual. The key measures applicable at the facility level and at subprojects will include as below. Sl. No. Facilities/ Subproject sites Key Measures Applicable Responsibility 1 Designated Health Facility a. Ensuring establishment of ICC as State E&S Nodal officer including designated mandated by GoIunder POSH Act from NHM with the help of Railway hospitals for b. Sensitization of Health care staffs on DPM/ CMHO at districts; treatment of COVID GBV, SEA/ SH MoR E&S Nodal officer patients c. Orienting health care staffs on Protocols for Medico-legal care for survivors/victims of sexual violence by MOHFW d. Building linkages to services addressing the needs of the victim of GBV, SEA/SH 2 Designated quarantine/ a. Setting up gender-sensitive infrastructure State E&S Nodal officer Isolation centers including b. Sensitization of Health care staffs on from NHM with the help of isolation/ quarantine GBV, SEA/ SH DPM/ CMHO at districts; MoR E&S Nodal officer 95 COVID-19 Response ESMF – ICWMP Sl. No. Facilities/ Subproject sites Key Measures Applicable Responsibility coaches by MoRfor COVID c. Orienting health care staffs on Protocols patients for Medico-legal care for survivors/victims of sexual violence by MOHFW d. Building linkages to services addressing the needs of the victim of GBV, SEA/SH 3 Subprojects/ construction a. The contract clauses as mentioned in Contractor; with sites for expansion or new Annex-IV details out instituting measures supervision from DPM/ construction of hospitals/ for GBV, SEA/ SH. CMHO laboratories b. Setting up gender-sensitive infrastructure for laborers especially where labor camp is set-up c. Sensitization of contractor’skey staffson prevention of GBV, SEA/ SH 96