The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) Combined Project Information Documents / Integrated Safeguards Datasheet (PID/ISDS) Appraisal Stage | Date Prepared/Updated: 29-Jun-2020 | Report No: PIDISDSA28959 April 14, 2020 Page 1 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Pakistan P167312 Additional Financing for P132308 Pakistan National Immunization Support Project Parent Project Name Region Estimated Appraisal Date Estimated Board Date National Immunization Support SOUTH ASIA 04-Jun-2018 10-Jul-2020 Project Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Economic Affairs Division Federal EPI Cell, Ministry Financing of Health and Population, Benazir Income Support Program Proposed Development Objective(s) Parent The project development objective is to increase the equitable coverage of services for immunization against vaccine preventablediseases (VPD), including poliomyelitis, for children between 0 and 23 months in Pakistan. Components Component 1: Strengthening Management, Governance and Stewardship Functions Component 2: Improving Service Delivery Performance Component 3: Demand Generation Component 4:Health Systems Strengthening Component 5: Improving Capacity in Technical Areas for Increased Immunization Coverage PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 8.10 Total Financing 8.10 of which IBRD/IDA 0.00 Financing Gap 0.00 DETAILS -NewFinEnh1 June 29, 2020 Page 2 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) Non-World Bank Group Financing Trust Funds 8.10 Global Alliance for Vaccine and Immunization 8.10 Environmental Assessment Category B-Partial Assessment Decision The review did authorize the team to appraise and negotiate B. Introduction and Context Country Context Pakistan is at a crossroads as it deals with the novel coronavirus disease (COVID-19) pandemic and protecting human capital is at the core of the country’s response plan. The COVID-19 pandemic has had significant negative impacts on the economy, which is expected to contract growth of gross domestic product by 1.3 percentage points in FY20 and has placed severe stress on the primary health-care system. The latest data indicate a drop in 10 to 40 percent in outreach vaccination services across the country – consistent with global experience. The proposed additional financing (AF) will directly support urgently needed immunization services in targeted cities of all four provisions. In addition to this AF, the World Bank is supporting Pakistan through the Pandemic Response Effectiveness, repurposing ongoing projects across the country, and three recently-approved human capital projects in Balochistan, Khyber Pakhtunkhwa (KP)and Punjab. Accelerating progress in human development remains the key underpinning for sustained economic gains in Pakistan. Although, Pakistan has made great strides in service delivery over the last three decades, it has not been able to translate an increasing working age population into a strong and sustained impetus for growth. This is partly because the level of expenditure on education and health has been very limited. Pakistan is ranked as one of the lowest spenders on education and health in the region (at less than 2% of GDP). The social indicators for both health and education have remained low and lag seriously behind other countries in the region. Infant and under five mortality rates still lag behind other South Asian countries. Gender disparities persist in education, health and all economic sectors. Nutrition also remains a significant crosscutting challenge. Pakistan faces a growing burden to meet the basic needs of its population and a seemingly endless string of challenges., However, without substantial investments in human development, Pakistan is unlikely to capture a potential demographic dividend and to enjoy high levels of economic growth. Sectoral and Institutional Context June 29, 2020 Page 3 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) Pakistan’s performance in maternal and child health remains poor in the South Asia Region. Significant inequity exists in health service access and utilization, with little has changed for the poorest and rural population since the 1990s. Childhood immunization against vaccine preventable diseases presents a highly cost-effective intervention – delivering significant reductions in morbidity and mortality from inexpensive and standardized interventions. It remains one of the most fundamental competencies of public health programs. In line with international standards, the Expanded Program on Immunization (EPI) in Pakistan aims to immunize all children between 0 and 23 months against eight vaccine preventable diseases that include tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type b (Hib), and measles. Newer vaccines which will expand EPI are either in the process of roll out (pneumococcal vaccine) or under planning (rotavirus vaccine, inactivated polio vaccine). Pakistan is faced by a formidable challenge in achieving the national elimination of polio virus. Ensuring strong national routine immunization is the first essential pillar in polio eradication and has been the key to rapid control of polio in many countries. The national Routine Immunization system faces serious systemic challenges, which have also resulted in recurrent outbreaks of transmissible diseases such as measles. The National Immunization Support Project (NISP) is mobilizing resources for the Federal and provincial EPI programs to improve coverage of vaccination in children of Pakistan. The project includes IDA credit of US$50 million and trust fund of US$79.60 million with contributions from Gavi and the United States Department for International Development (USAID). The Bill & Melinda Gates Foundation has committed US$25 million for a partial, conditional buy-down of the IDA credit. NISP employs a results-linked financing mechanism to the provincial governments. A set of nine disbursement-linked indicators (DLI) incentivize process (management and information systems) and outcome (immunization coverage) performance through contingent release of MDTF grant and IDA credit funds. The proposed additional financing (AF) of NISP is grant funds of US$8.1 million that is being channeled by Gavi, the Vaccine Alliance, to improve the proportion of children who are fully immunized in urban areas of the four provinces. C. Proposed Development Objective(s) Original PDO The project development objective is to increase the equitable coverage of services for immunization against vaccine preventablediseases (VPD), including poliomyelitis, for children between 0 and 23 months in Pakistan. Current PDO The project development objective is to increase the equitable coverage of services for immunization against vaccine preventablediseases (VPD), including poliomyelitis, for children between 0 and 23 months in Pakistan. Key Results • Percent of children aged between 12-23 month old in each project province urban area, who are fully immunized. June 29, 2020 Page 4 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) • In each province, within 2 months from the time of the effectiveness of project restructuring, the departments of health continuously maintain appropriately qualified specialized staff in the each of the following provincial immunization program positions: epidemiologist, monitoring and evaluation specialist, surveillance officer, and financial management specialist; and • Percentage of zero-dose children in each city who received their overdue vaccines within six months of being identified by the polio team. D. Project Description The proposed AF of US$8.1 million in grant resources is to i) finance an additional result which will incentivize increased provincial focus on immunization service delivery in ten large urban centers and ii) finance additional technical assistance by the MoHP to the provincial governments to develop innovative service delivery models for these populations – including by contracting local Civil Society Organizations (CSO). E. Implementation Institutional and Implementation Arrangements The institutional and implementation arrangements of NISP will be continued for the proposed AF. Pakistan is a federal country, with responsibility for the financing and delivery of health services fully devolved to the four provinces. Provincial EPI program activities will be implemented by the provincial EPI cells. The proposed AF is also intended to support the Federal EPI cell under the MoHP in delivering the technical assistance to strengthen the provincial programs, monitoring, reporting and project management. An additional implementation partner, Benazir Income Support Program (BISP), has been included for piloting a co-responsibility cash transfers (CCT) to incentivize uptake of vaccination as well as other health and nutrition services. However, the responsibility for ESMP compliance will remain with the Federal EPI. . F. Project location and Salient physical characteristics relevant to the safeguard analysis (if known) The project will be implemented across the country. The proposed AF will extend immunization related service delivery in the urban areas of the country. Most of the cities being covered are diverse in terms of ethnicity, linguistic identity, and religious affiliation. In all provinces, urban settings within each province have a higher immunization coverage with the difference being larger within Sindh and Balochistan – but within cities there are stark inequities. Nearly half the population of urban areas lives in slums and squatter settlements that are characterized by: high population density; a large number of in-country migrants and refugees; location near natural drainage channels and transport systems; a general lack of schools, health and welfare facilities in the public sector, and, a significant number of unregularized, unmonitored private education and healthcare services; legal electricity and water connections; major source of employment being in the informal sector; and, lack of permanent housing for almost a quarter of the population. Studies have found that children living in slums are more susceptible to infectious diseases due to the unsanitary and congested environments in which they live. Various studies on the status of immunization in slums have June 29, 2020 Page 5 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) found that low levels of education of one or both parents, lack of awareness of immunization and immunization schedules, proximity to healthcare facilities were some of the main factors determining uptake and coverage of immunization services in these areas. G. Environmental and Social Safeguards Specialists on the Team Najm-Ul-Sahr Ata-Ullah, Social Specialist Sana Ahmed, Environmental Specialist SAFEGUARD POLICIES THAT MIGHT APPLY SAFEGUARD _TBL Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/BP 4.01 Yes Performance Standards for Private Sector No Activities OP/BP 4.03 Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources OP/BP 4.11 No Indigenous Peoples OP/BP 4.10 No Involuntary Resettlement OP/BP 4.12 No Safety of Dams OP/BP 4.37 No Projects on International Waterways No OP/BP 7.50 Projects in Disputed Areas OP/BP 7.60 No KEY SAFEGUARD POLICY ISSUES AND THEIR MANAGEMENT OPS_SAFEGUARD_SUMMARY_TBL A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: The proposed additional financing (AF) is meant for enhancing service delivery to 10 urban areas of the country already included in the parent project (NISP), aims to improve childhood immunization against vaccine preventable June 29, 2020 Page 6 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) diseases, resulting in decreased prevalence of these diseases and thus having a positive impact on the public health in the country. However, inappropriate practices during vaccine administration and associated activities can potentially cause health and safety hazards for the vaccinators as well as for children being vaccinated and also for the community at large. These include not using safe/sterilized syringes and needles, vaccinators not observing appropriate safety protocols such as wearing prick-proof gloves, and not disposing used syringes and needles in a safe and environment-friendly manner. No land acquisition and resettlement is expected to take place. Therefore OP 4.12 (Involuntary Resettlement) is not triggered. The Project supports provincial EPIs to develop province-specific advocacy plans to raise awareness among beneficiary families, number of who are located in remote areas, speak local languages with low literacy. The plans will include production of simple pictorial posters and pamphlets, additional materials for differently-abled and the elderly and a dissemination strategy by engaging CSO, NGO, and private service providers. This is expected to have a positive impact in reaching out to both women and men in households, and marginalized and poor communities who are often unable to access health services. Considering above, the Project is assessed as Category -B (as of Parent Project). OP4.01 (Environmental Assessment) is triggered for the Project as for the parent Project (NISP). The Environment and Social Management Plan (ESMP) under implementation for NISP would suffice for the component dealing with implement of immunization of the children. There is no private sector involvement in the project implementation and hence the policy related to Performance Standards for Private Sector Activities (OP/BP 4.03) is not triggered. The project intervention will not be carried out in any natural habitat areas and, therefore, Natural Habitats policy (OP/BP 4.04) is not triggered.The project activities will only be implemented in the urban, semi urban and build up areas therefore the policy relating to Forests (OP/BP 4.36) is not triggered. The project interventions will not involve direct/indirect purchase and use of pesticides. Therefore, the policy relating to Pest Management (OP/BP 4.09) is not triggered. The project interventions will not be impacted on any physical and cultural resources of the project area and hence the policy on Physical Cultural Resources (OP/BP 4.11) is not triggered. No indigenous people live in the area covered by the AF. Therefore this policy on Indigenous People (OP/BP 4.10) is not triggered. The policy on Safety of Dams (OP/BP 4.37) is not triggered project intervention is only for immunization of the children in the country. The policy related to Projects on International Waterways (OP/BP 7.50) is not triggered either as no project intervention is designed to have impact on international waterways. The policy on Projects in Disputed Areas (OP/BP 7.60) is not triggered as no project intervention is designed in any disputed areas. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: The adequate management of the health care waste which will potentially increase in quantities may affect the capacity of the local authorities to manage the waste which can then result to long term environmental and public health impact. On the other hand, a successful immunization initiative will have positive and long term impacts on the key health indicators of the country. The long term social impacts of the project are expected to be positive. It will contribute to a healthy society unencumbered by the burden of common diseases. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. The only other alternative is ‘no-project’ option, which could have detrimental effects on the childhood immunization in the country. The ‘no-project’ alternative would though avoid the adverse environmental impacts associated with the immunization particularly waste disposal and health and safety risks; however, would also result in continued exposure of children to diseases that are preventable with the help of appropriate and timely vaccination. June 29, 2020 Page 7 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. To address the potentially negative environmental impacts associated with vaccination, the GOP has prepared an ESMP for NISP, in accordance with the national regulatory requirements as well as World Bank OP 4.01. The ESMP identifies and assesses the potentially negative environmental and social impacts of the project activities, and proposes appropriate mitigation and precautionary measures, most of which are already practiced by the EPI teams. It also describes institutional and monitoring mechanisms to ensure effective implementation of the proposed mitigation and precautionary measures, and defines the associated documentation and reporting requirements. Since the risks, impacts, and mitigation measures remain the same as the parent project, the ESMP developed for the parent project will also be used for the AF component for the immunization. Overall coordination and implementation of ESMP responsibility will remain with the National Program Manager, EPI who has designated an ESM Focal Point to coordinate on his/her behalf. Environmental and Social Management Coordinator (ESMP Coordinator) at federal and provincial levels shall be responsible for the overall implementation of the ESMP under the supervision of National Program Manager EPI. The hiring of ESMP coordinators are already under process under the parent project (NISP). Each partner hospital/tertiary healthcare units has also been directed to nominate a focal person to ensure implementation of ESMP. The Provincial and Federal ESMP coordinators will ensure regular monitoring as well as maintain record at the provincial hubs and tertiary healthcare units. Quarterly progress reports at district, provincial, and national levels will capture the ESMP compliance of the project. The current Client capacity for the ESMP compliance is significantly improved during implementation of the NISP (parent Project). The Client has developed the capacity for cold chain management of vaccines, safety of syringes and safe disposal through use of autodisposible syringes and safety boxes. However, the management of health care waste remain in some of the healthcare centres. Similarly adequate staffing for ESMP will also impact the ESMP compliance during the parent project implementation. However, upon Bank recommendation, the Client has hired short term ESMP Coordinator at Federal level for ESMP monitoring and implementation since September, 2019. Based on the results of the progress on ESMP, the Bank team advised hiring of ESMP coordinators at provincial level, preparation of District Action Plans, implementation of the GRM Cell and Environmental Audit of the Project. The Client has advertised the positions for the hiring of ESMP Coordinators at four provinces and one at federal level. The environmental audit of the Project is in progress by WHO. A dedicated call centre and helpline (“Sehatman Pakistan�) has been established to address complaints/grievances and queries regarding EPI and polio vaccination services. The EPI has also nominated a GRM committee and focal person for proper implementation and monitoring of the GRM. A record of all complaints will also be maintained by the EPI and periodic analysis will be conducted. In addition to the helpline, the EPI will also receive complaints through the nationwide GRM initiative, covering all services, launched by the federal government called the Pakistan Citizen’s Portal. The concerned complaints are being forwarded to and being addressed by the EPI. A record of complaints received through the citizens portal will also be maintained as part of the EPI’s record of grievances. BISP also has a robust complaints management system in place. The social management capacity of BISP is also being supported by an ongoing Bank funded Program-for-Results (National Social Protection Program, NSPP) to ensure better service to marginalized and vulnerable beneficiaries and the performance is rated as ‘satisfactory’. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Consultations have been carried out with key stakeholders, including federal and provincial EPI cells, civil society organizations, and private service providers, while preparing the parent project ESMP. Additional consultation focusing on the issues and challenges pertaining to provision of immunization services in urban areas, particularly urban slums, was held in March 2018. The issues and challenges for provision of services enhanced through the additional financing are similar to the ones identified during parent project preparation and implementation. June 29, 2020 Page 8 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) Consultations have also been held for the implementation of the CCT Pilot and will inform the operations manual designed for this intervention. OPS_SAFEGUARD_DISCLOSURE_TBL B. Disclosure Requirements (N.B. The sections below appear only if corresponding safeguard policy is triggered) OPS_EA_DISCLOSURE_TABLE Environmental Assessment/Audit/Management Plan/Other For category A projects, date of Date of receipt by the Bank Date of submission for disclosure distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure OPS_COMPLIANCE_INDICATOR_TBL C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) (N.B. The sections below appear only if corresponding safeguard policy is triggered) OPS_EA_COMP_TABLE OPS_ PDI_ COMP_TAB LE OPS_ALL_COMP_TABLE CONTACT POINT World Bank Robert Oelrichs Senior Health Specialist Aliya Kashif Senior Health Specialist Borrower/Client/Recipient June 29, 2020 Page 9 of 10 The World Bank Additional Financing for Pakistan National Immunization Support Project (P167312) Economic Affairs Division Syed Pervaiz Abbas Secretary secretary@ead.gov.pk Implementing Agencies Federal EPI Cell, Ministry of Health and Population Naveed Kamran Baloch Secretary, MONHSRC secretarynrsd@yahoo.com Benazir Income Support Program FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Robert Oelrichs Task Team Leader(s): Aliya Kashif Approved By Safeguards Advisor: Agi Kiss 20-Apr-2020 Practice Manager/Manager: E. Gail Richardson 22-Apr-2020 Country Director: Melinda Good 29-Jun-2020 June 29, 2020 Page 10 of 10