The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) Combined Project Information Documents / Integrated Safeguards Datasheet (PID/ISDS) Appraisal Stage | Date Prepared/Updated: 25-Mar-2021 | Report No: PIDISDSA31389 Feb 02, 2021 Page 1 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Romania P175632 Additional Financing to P145174 Romania Health Sector Reform Project Parent Project Name Region Estimated Appraisal Date Estimated Board Date Health Sector Reform EUROPE AND CENTRAL 31-Mar-2021 25-May-2021 ASIA Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project ROMANIA Ministry of Health Financing Proposed Development Objective(s) Parent The Project Development Objective is to improve access to, and quality and efficiency of public health services in Romania Components Strengthening Health Service Delivery Health Sector Governance and Stewardship Improvement Project Management, and Monitoring and Evaluation Strenthening Public Health Emergency Response to COVID-19 PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 176.85 Total Financing 176.85 of which IBRD/IDA 176.41 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 176.41 Feb 02, 2021 Page 2 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) Non-World Bank Group Financing Counterpart Funding 0.44 Borrower/Recipient 0.44 Environmental Assessment Category B-Partial Assessment Decision The review did authorize the team to appraise and negotiate Other Decision (as needed) B. Introduction and Context Country Context Romania has enjoyed a decade of economic growth; however, the protracted COVID-19 pandemic crisis has affected negatively Romania’s economic activity. The economy is estimated to have contracted by 3.9percent in 2020. As a result of the Government’s efforts to address the consequences of COVID-19, the fiscal deficit is estimated to have widen to 9.8 percent of GDP in 2020, up from a planned deficit of 3.6 percent before the crisis. Inequality is persistent and increasing, with further negative effects expected from the COVID-19 pandemic. Romania has the second highest urban-rural income gap in the EU: the mean urban income is almost 50 percent higher than the mean rural income.1 Throughout the country, many communities, including many Roma communities, have no access to basic services such as piped water, sanitation, internet, or electricity. In the short run, poverty is projected to increase on the back of lower incomes among poorer segments of the population due to the COVID-19 crisis as well as the poor agricultural year and declining remittance incomes. The Government COVID-19 policy response alongside the European Union (EU) support has been critical in ensuring a sustainable economic recovery after the COVID-19 crisis. Romania is expected to receive significant resources from the EU under the multi-annual budget 2021–27 and the Recovery and Resilience Facility.2 Effective utilization of funds will be critical for Romania’s growth recovery. In the medium term, investments in infrastructure, human capital, health care, education, support for job creation, and small and medium enterprise (SME) development, in addition to tax and pension reforms, will support the recovery and household incomes. Sectoral and Institutional Context Health outcomes in Romania are lagging EU standards. The country has the third lowest life expectancy among EU countries (second for females and fourth for males), and the life expectancy gap between Romania and the 1 World Bank, 2018, Country Partnership Framework for Romania for the Period FY19–FY23. 2 As reported by Romania’s Ministry of Investments and European Projects. Feb 02, 2021 Page 3 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) EU has more than doubled since 1970; the highest maternal mortality ratio; the highest under-five mortality rate; the fourth highest premature mortality from cardiovascular disease, cancer, diabetes or chronic respiratory disease between ages 30 and 70 (third for females and fifth for males). Specifically, the country has the highest incidence and mortality rates for cervical cancer in the region due to weak preventive services. The lack of cancer screening services (including laboratory capacity to process samples in a timely manner) contributes to low screening rates, which in turn contribute to the late detection of risk factors and the diagnosis of the disease at an advanced stage. Long-term under financing of the health sector has contributed to these results. Over the past two decades, Romania has systematically had the lowest current health expenditure as a share of GDP across EU Countries. Over the past two decades, Romania has modernized part of its health infrastructure. Romania has updated its maternity services and successfully implemented a critical reform of the emergency health services system with World Bank support. This reform included the development of hospital emergency departments, implementation of telemedicine in emergency services, and development of the Mobile Emergency Service for Resuscitation and Extrication, (Serviciul Mobil de Urgenţǎ, Reanimare şi Descarcerare, SMURD). The SMURD is currently considered one of the best examples in the region. In addition, under the ongoing Health Sector Reform Project, service delivery has been strengthened in key hospital services, particularly in life-saving medical services—such as 78 hospital emergency departments, 52 intensive care units (ICUs), 13 Advanced Surveillance and Treatment Unit for Critical Cardiac Patients (USTACCs), 3 burn units, 8 radiotherapy centers, 43 medical imaging diagnosis departments and 8 mobile units for cervical cancer screening—through the procurement of medical equipment and the associated training and civil works. The modernization of ICUs and hospital emergency departments was crucial in the Government of Romania’s response to the COVID-19 pandemic, including treatment of severe cases of COVID-19 requiring ventilation. ICUs and hospital emergency departments were further supported in 2020 to strengthen the government response to the COVID-19 pandemic. There is a need to further strengthen Romania’s health infrastructure. Besides the aforementioned areas, no other significant investments have been made in the last two decades. The rest of the public health infrastructure has not been strengthened to keep up with international best practice. For example, existing burn units are not compliant with international standards for the treatment of severe burns. Severe-burn patients are, therefore, transferred abroad if they can be stabilized or treated in sub-standard burn units in Romania. The proposed Additional Financing to the Romania Health Sector Reform Project aims to continue to support the modernization of hospital infrastructure, which complements the ongoing Romania Health PforR that aims to increase the coverage of primary health care for underserved populations and improve the efficiency of health spending by addressing underlying institutional challenges. C. Proposed Development Objective(s) Original PDO The Project Development Objective is to improve access to, and quality and efficiency of public health services in Romania Current PDO The Project Development Objective is to contribute to improving access to, and quality of selected public health services. Feb 02, 2021 Page 4 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) Key Results The PDO indicators are: • Average number of modern and safe radiotherapy unit available per 1 million population; • Percentage of Advanced Surveillance and Treatment Unit of Critical Cardiac (USTACC) Patients mortality rate; • Percentage of diagnosed COVID-19 cases treated per approved protocol; and • Number of new Burn Centers operational. D. Project Description All activities under the proposed Additional Financing (AF) are in line with the existing PDO and Project components included in the parent Project’s original design. The proposed AF will fill a financing gap and the reallocation of funds to accommodate the COVID-19 response introduced in June 2020. Following project approval, feasibility studies for three burn centers (Timisoara, Targu Mures, and Bucharest) were developed in line with international norms and standards for these services.3 Based on these studies and the updated estimates for the three burn centers, financing gap emerged and is intended to be filled with the proposed AF.. The AF will support the implementation of activities that are part of the original Project design, including the construction of burn centers originally planned, the procurement of medical equipment for the burn centers, a telemedicine system for hospital emergency departments, and cervical cancer screening equipment. In addition, the proposed AF will continue to include technical assistance activities to support key health sector governance and stewardship reforms under the Government’s Health Program and create synergies with the Romania Health PforR. Component 1 (Strengthening Health Service Delivery). Under Component 1, AF activities will include: (i) support to burn centers; (ii) procurement of an updated telemedicine system for hospital emergency departments; and (iii) procurement of equipment for cervical cancer screening centers. Component 2 (Public Health Sector Governance and Stewardship Improvement). The proposed AF will provide technical assistance to support health sector governance and stewardship reforms under the Government’s Health Program. These activities may include the continuation of support to the development of standards and protocols, the development of HTA, the implementation of surveys and studies informing evidence-based health policies, the development of national health programs, and/or the strengthening of the MoH’s communications. Component 3 (Project Management, Monitoring and Evaluation). The proposed AF will fill the financing gap to ensure sufficient support to ongoing Project management and monitoring. E. Implementation Institutional and Implementation Arrangements 3 Feasibility studies were conducted based on terms of reference approved by the Bank in March 2017. Feb 02, 2021 Page 5 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) Implementation arrangements established for the parent Project will remain unchanged. However, the Project Management Unit (PMU) under the Ministry of Health will be further strengthened by bringing in external resources, building on recent positive experiences with recruitment of consultants. Similarly, project management firms will be hired to ensure timely implementation of civil works for the modern burn centers, building on the success of this approach in recent civil works in the hospital sector. . F. Project location and Salient physical characteristics relevant to the safeguard analysis (if known) Country-wide G. Environmental and Social Safeguards Specialists on the Team Cesar Niculescu, Environmental Specialist Adrian Laurentiu Mihailescu, Environmental Specialist Chifundo Patience Chilera, Social 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 Feb 02, 2021 Page 6 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) 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) for the Romania Health Sector Reform Project will fill a gap in financing due to a cost overrun under Component 1 and to the introduction of a COVID-19 component in 2020's level 4 project restructuring. All activities included in the proposed AF were included in the parent Project’s original design. Safeguards Policies will apply for this AF, as additional funding is due to a financing gap, thereby meeting the eligibility criteria for AF for Investment Project Financing (IPF). Under the proposed AF, the project’s environmental screening category would remain unchanged at Category B and no additional environmental safeguards would be triggered. The potential environmental and social impacts of the AF, similarly with the parent Project are not likely be significant, long-term, or irreversible on Romania’s environment, forests, or other natural resources. The immediate impact of the proposed AF activities on the environment would be limited and can be divided into construction impacts and operational impacts. Most of the physical works will be undertaken to rehabilitate the existing health care facilities, but also to add new structures (buildings) to the exiting health care facilities in some cases. The works will be mainly interior renovations; in a few cases, they also include additions to existing buildings within the hospital grounds. For the operational phase, the discharges from the medical facilities and disposal of medical waste could generate potential negative impacts if not managed properly. Disposal of obsolete radiation treatment equipment represents a special issue, and this is specifically addressed in the revised Project's ESMF, and further on in the site-specific ESMPs. The social impacts of the proposed Project are expected to be positive. Some health care services and inpatients could be affected during civil works, which could involve transferring of inpatients to other hospitals. In order to mitigate negative impacts, standardized procedures will be applied to: (a) inform both health service providers and patients about the planned civil works well in advance, and (b) transfer them to other hospitals through standardized procedures as outlined in the POM. Additional social issues with respect to the civil works, such as Gender-Based Violence/Sexual Exploitation, Abuse and Sexual Harassment, influx of labor, workers’ rights and equal opportunity hiring practices have been identified as risk factors; for which mitigation measures will include: a) code of conduct, b) dedicated Grievance Redress Mechanisms, c) ensuring compliance in procurement, d) trainings Any complaints or grievances stemming from civil works of the project will be managed by an existing Grievance Redress Mechanisms in accordance with national legislation to ensure that there is a reliable and responsive avenue to receive and address the concerns of construction workers, healthcare personnel, patients and persons residing or working in the vicinity. The project GRM relies on the complaints mechanism of the MoH available at central and district levels. The email and telephone number of the PMU are also available for use to register feedback. However, there has not been any feedback received through these channels. The project GRM will be reviewed for effectiveness to ensure that the uptake channels are accessible and available, and also that they have appropriate systems to record, monitor and address the complaints. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: The long-term environmental and social impacts anticipated are positive and linked to the overall project Feb 02, 2021 Page 7 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) development objectives to improve access to, and quality of public health services in Romania. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. n/a 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. In order to avoid land acquisition, the borrower reviewed the status of land ownership and use as part of the selection process of hospitals to be rehabilitated. The Project's ESMF was updated to outline the new risks and mitigating measures associated with the new Project’s Component 4 and COVID-19 outbreak. The document describes risks and mitigating measures associated with management of medical waste and disposal of obsolete radiation treatment equipment. Additional social issues have also been underlined, including influx of labor, workers’ rights and equal opportunity hiring practices, code of conduct, Grievance Redress Mechanisms (GRMs), Gender-Based Violence/Sexual Exploitation, Abuse and Sexual Harassment, as well as health and safety of workers, hospital staff, patients, and community members. The ESMF will be the basis to prepare site-specific ESMPs or Checklist ESMPs for the remaining civil works, each of which will continue to be attached to works contracts. The updated ESMF was disclosed in-country and on the Bank’s web page. The Borrower's capacity for implementation of safeguard policies is satisfactory. The Ministry of Health (MoH) has adequate in-house capacity to implement health care waste management procedures, enforce standards, and coordinate with other government actors involved in these issues (environmental authorities, local authorities and regional health authorities). The PMU's environmental safeguards specialist is responsible for coordinating and supervising the Project's environmental management plans and risk mitigation measures. However, to ensure sufficient capacity to implement and monitor the updated social aspects, dedicated social expertise is required at the PMU, to replace the current arrangement where the environmental specialist has been responsible for both environment and social issues. The social specialist will be responsible to implement and monitor the social aspects of the ESMF and the site-specific ESMPs as well as the project GRM which has been established to receive and address feedback from project beneficiaries and the public, and the scope of which has been expanded to include COVID-19 related issues. Arrangements for environmental and social monitoring will continue to imply integration of environmental and social issues into the overall technical oversight of works. Monthly field environmental and social monitoring checklists for tracking and recording status of compliance on a regular basis will be updated. MoH will continue to monitor the implementation of the updated ESMF and site-specific ESMPs, and the Bank’s team will continue to conduct field visits (if possible) and carry out reviews of the environmental safeguards application during the remaining Project and AF implementation. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The key stakeholder groups include: the MoH’s PMU, construction workers, persons residing/working in the vicinity of the construction areas, healthcare personnel/staff and patients. The PMU will ensure during the sub-projects preparation that the draft site-specific ESMPs are disclosed on the PMU’s webpage and public consultations (in-person or virtual) with representatives from the stakeholder groups are conducted in the respective locations. Based on the provided feedback, the site-specific ESMPs are finalized and re-disclosed on the PMU’s webpage Bulletin boards will be set up on construction sites to provide basic information regarding the project, the webpage where detailed information (including the ESMP) can be accessed, and the telephone number and email through which affected people can submit their feedback. Feb 02, 2021 Page 8 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) 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 17-Jun-2020 22-Jun-2020 "In country" Disclosure Romania 18-Jun-2020 Comments 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 OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? No If yes, then did the Regional Environment Unit or Sector Manager (SM) review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated in the credit/loan? OPS_ PDI_ COMP_TAB LE The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank's Infoshop? No Have relevant documents been disclosed in-country in a public place in a form and language that are understandable and accessible to project-affected groups and local NGOs? No Feb 02, 2021 Page 9 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) OPS_ALL_COMP_TABLE All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of measures related to safeguard policies? Yes Have costs related to safeguard policy measures been included in the project cost? Yes Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures related to safeguard policies? Yes Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? Yes CONTACT POINT World Bank Dorothee Chen Senior Health Specialist Carlos Marcelo Bortman Lead Health Specialist Borrower/Client/Recipient ROMANIA Boni Cucu Director General boni.cucu@mfinante.gov.ro Implementing Agencies Ministry of Health Mihai Negrea Project Coordinator mihai.negrea@ms.ro Feb 02, 2021 Page 10 of 11 The World Bank Additional Financing to Romania Health Sector Reform Project (P175632) 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 Dorothee Chen Task Team Leader(s): Carlos Marcelo Bortman Approved By Safeguards Advisor: Agnes I. Kiss 22-Mar-2021 Practice Manager/Manager: Ian Forde 23-Mar-2021 Country Director: Gallina Andronova Vincelette 26-Mar-2021 Feb 02, 2021 Page 11 of 11