The World Bank The Gambia Essential Health Services Strengthening Project (P173287) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 08/06/2020 | Report No: ESRSA00995 Aug 07, 2020 Page 1 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Gambia, The AFRICA WEST P173287 Project Name The Gambia Essential Health Services Strengthening Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 8/7/2020 8/31/2020 Population Financing Borrower(s) Implementing Agency(ies) The Gambia Ministry of Health Proposed Development Objective To improve quality and utilization of essential health services in The Gambia. Public Disclosure Financing (in USD Million) Amount Total Project Cost 30.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The proposed project will support the following: a. Delivery of essential primary health care services using Results-Based financing Approach b. Project management D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Aug 07, 2020 Page 2 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) Component 1. Improving the Delivery and Utilization of Quality Essential PHC Services using Results-Based financing Approach (US$27 million). This component has three subcomponents: Subcomponent 1.1: Improving the quality of PHC health services delivery using a Results-based Financing Approach that will finance the delivery of quality and essential health services at each level of the health care delivery system (e.g., VHSs, community clinics, minor health centers, major health centers, district hospitals, general hospitals, and the teaching hospital). This subcomponent will provide: (i) performance-based financing (PBF) grants to health facilities for the delivery of the newly defined essential health care package; (ii) verification of the quality of services; and (iii) capacity for the expansion of RBF nationally. This essential healthcare package includes integrated management of neonatal and childhood illnesses, infectious diseases, NCDs, and emergency obstetric care. This sub-component will also support capacity building for the national expansion of RBF with a NHIA processes for electronic enrollment (health insurance membership cards and means testing) and claims processing. Support will also include health care facility performance-based contracting based on quality of care and delivering the essential PHC package. Sub-component 1.2: Community engagement to improve utilization of quality health services will scale-up and expand the highly successful Social and Behavior Change Communication (SBCC) activities initiated in the MCNHRP. The SBCC Program will focus on prevention activities and delivery of PHC as well as nutrition, women and girls’ empowerment, Noncommunicable Disease (NCDs), Water, Sanitation, and Hygiene, and climate change. Sub-component 1.3. Building resilient and sustainable health systems to support the delivery of quality health services to support MOH’s resilient and sustainable health systems for the delivery of quality health services and for strengthening Civil Registration and Vital Statistics (CRVS). The Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) has allocated US$5.1 million to support health systems strengthening activities such as Health Management Public Disclosure Information System (HMIS), Monitoring and Evaluation (M&E), national public health laboratory system, supply chain for the availability of medicines and consumables, and human resources for health. This subcomponent will also support: • NCD risk factor surveys to define the NCD strategy; • updating the composition of the essential package of services • the production of survey data for the monitoring of the essential health services coverage index. Other critical activities in this subcomponent include equipping and renovation of four hospitals focusing on delivery of emergency obstetric and newborn care; expanding the Kanifing hospital with construction of a national blood transfusion center; and upgrades and improvements for healthcare waste management. Current plans are to improve energy-efficiency in these facilities by replacing building lighting, freezers and refrigeration systems. The contractors will also provide options at these hospitals for adding climate-resilient materials and other structural modifications to mitigate flood risks and other climate-related emergencies. Component 2. Project Management (US$3 million) MoH will operate the project by expanding the capacity of the existing COVID 19 PCU and share the operating costs (including salaries for project staff, office space, utilities, supplies, and transport) with other development partners such as GFATM. The management, procurement, financial management and environmental and social due diligence capacity of the PCU staff will be enhanced with a combination of on-the-job training and short courses which will also as appropriate include MOH staff. Component 3. Contingent Emergency Response Component (CERC) This component enables the rapid reallocation of project funds in the event of a natural or man-made disaster or crisis that has caused or is likely to imminently cause a major adverse economic and/or social impact. A detailed CERC Aug 07, 2020 Page 3 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) operational manual will be included in the POM. The project Operations Manual will include a dedicated chapter with detailed guidelines and instructions to trigger an emergency and the use of funds. In addition, modified Environmental and Social Management Plans (ESMPs), based on the Emergency Response screening framework will be prepared for the requested activities to be financed under this component along with a preliminary evaluation of the potential risks and corresponding mitigation measures. All of these ESDD requirments shall build upon the project ESMF provisions. D. 2. Borrower’s Institutional Capacity The project will be implemented by the Project Coordination Unit (PCU) of the Ministry of Health (MoH). The PCU has experience working on projects financed by multilateral development partners and has gained experience using the ESF by managing the COVID-19 project (P173798). The PCU has a Senior Operations Officer who is responsible for developing and monitoring E&S instruments. Additionally, the Ministry's Environmental Health Unit Program Manager and the Health Communications Program Manager will provide support on environmental and social standards respectively. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate Environmental Risk Rating Moderate The environmental risk classification for the project is moderate under the World Bank ESF, mainly due to risks linked to the management of biomedical waste but also because of the risks linked to the renovation and construction of Public Disclosure certain sanitary facilities. Labor management and health and safety risks also need to be taken into account given the limited capacity of the PIU on these issues. These risks will be mitigated through capacity building activities, by preparing required ESMPs for all renovation and expansion subprojects, and by hiring an environmental/social consulting firm to support the MOH and PCU with the implementation of environmental and social provisions. This rating was changed from substantial as the scope of construction activities was reduced. Originally, there were plans to build new health facilities, which were later changes to renovation/expansion of existing ones. Social Risk Rating Moderate The project's diverse set of activities are generally expected to provide significant social benefits to the targeted beneficiaries, including marginalized and disadvantaged people. A number of limited risks could, however, emerge. These include a) Exclusion of vulnerable groups from various outreach and registration activities (health insurance, CVRS); b) Privacy and data misuse issues due to transition from written to electronic records. c) SEA/SH risks in relation to the construction/renovation activities. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: Aug 07, 2020 Page 4 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) Implementation of the project activities will be positive and urgently needed. The potential negative impacts from project activities are expected to be moderate, localized, and temporary and can be mitigated through the implementation of the proposed environmental and social due diligence instruments of the Project. There are four main areas of risk that have been identified: a) Generation of and exposure to medical waste; b) Temporary environmental and social impacts due to renovation and expansion of health care facilities; c) exclusion of vulnerable groups from health services and registration activities; and d) potential issues of data protection as a result of the transition to electronic health records. The mitigation measures for the first two risk categories will be contained in site-specific EMPs and the existing national HCWMP, the Standard Operating Procedures (SOPs) for which were developed under the Maternal and Child Nutrition and Health Results Project (P143650). With regard to the exclusion risk, the project will continue to rely on proxy means testing and other targeting methodologies. developed for the Maternal and Child Nutrition Project. Data protection issues are currently being debated in new national legislation, and technical solutions to guarantee privacy and anonymity will be flagged in the ESMF. To address these diverse set of risks, an Environmental and Social Management Framework (ESMF) has been developed to support the environment and social due diligence provisions for activities financed by the World Bank Group (WBG). The Ministry of Health (MOH) is already implementing a recently approved COVID 19 Emergency Response Project that had an approved ESMF in June 2020 and will expand the use of the PCU for this project as well. The ESMF includes Environmental and Social Management Plans (ESMPs) which will identify potential environmental, social, health and safety issues associated with the Hospital renovations/expansions. The Environmental and Social Screening Process for Civil Works. A screening process is defined to: determine the Public Disclosure degree of environmental and social risks and impacts; identify appropriate construction and operation mitigation measures; incorporate mitigation measures into each subproject as appropriate; review and approve the subproject’s ESMP; and monitor ESDD during construction and operation. Initial screening for the 5 renovation subprojects will be carried out by a consulting firm hired by the MOH PCU in consultation with the National Environmental Authority. An Environmental and Social Screening Form was developed to identify the potential environmental and social impacts, determine their significance, and recommend the appropriate environmental category and propose appropriate environmental mitigation measures. Environmental and Social Management. For all civil works subprojects a standard ESMP template was designed by MOH to summarize all subproject actions, identify environmental and social provisions as well as applicable ESCOPs. The ESCOP checklists are included in the ESMF as appropriate measures for managing environmental and social risks and impacts for the subprojects. The ESCOP checklists cover 7 major themes and are found in the ESMF Annex as listed below. • Checklist 1. Exposure at Health Care Facility • Checklist 2. Waste Management Procedures • Checklist 3. Community and Social Inclusion • Checklist 4. Small Scale Construction, Upgrades, Rehab, Expansion • Checklist 5. Codes of Conduct • Checklist 6. Medical Equipment and Supplies – Delivery • Checklist 7. Construction Sites in Heath Care Facilities Aug 07, 2020 Page 5 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) As highlighted in the ESMF, specific Management Plans are to be finalized to support the implementation of each Hospital project. The timing of the development of the plans may be staged, ensuring that the appropriate focus and level of detail is provided for construction and operational activities. They will be finalized by the Contractor with MOH coordination, and will need to be approved by the World Bank. When appropriate, the Contractors and MOH will meet and consult other government agencies (as described in the ESMF) and other key stakeholders. The contents of the Management Plans are outlined in the ESMF annexes. The ESMF will be amended in case the CERC gets activated. ESS10 Stakeholder Engagement and Information Disclosure In consultation with the Bank, the client has prepared a Stakeholder Engagement Plan (SEP). The SEP has identified the major stakeholders such as health care workers, local communities in the vicinity of construction sites and the public at large, as well as civil society organizations providing support in the health sector. The platform for stakeholder consultations so far has been the National Risk Communication and Community Engagement (NRCCE) Sub-Committee, which consists of members from public institutions, private sector, NGOs, CSOs, Faith-Based Organisations, Local Government Representatives among others. For the next couple of months, further consultations are scheduled, both virtually, and – where possible – in the field. The grievance redress mechanism (GRM), developed for the COVID-19 project will be used for this project. Public Disclosure B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions The PCU is expected to be staffed by around 6 direct workers and possibly, civil servants. As direct workers performing critical project functions, requirements under ESS2 will be applicable to both the PCU and relevant support institutions. Key issues to be addressed in the Labor Management Procedures include terms and conditions of employment, nondiscrimination and equal opportunity, worker’s organizations. The Labor Management Procedures (LMPs) describe how project workers will be managed in accordance with the requirements of national law and the ESS2. Due diligence is also described in the ESMF to ensure Borrower meets requirements on child labor, forced labor and occupational health and safety apply to employees of the MOH and all contractors and subcontractors.. Civil servants will be bound by their public sector contracts, unless their contract has been transferred to the project. The LMP will include measures to ensure that labor is provided on a voluntary basis and will further ensure that the health and safety of workers, especially women are given adequate attention. It will also have the details of the grievance redress mechanism for workers and the roles and responsibilities for monitoring such workers. The ESMF provides specific environmental and social codes of practice (ESCOPs) to address these issues across the project activites and renovation construction. Contracting for the minor renovations will be through local contractors and there will not be any labor camps. Aug 07, 2020 Page 6 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) ESS3 Resource Efficiency and Pollution Prevention and Management Resource Efficiency: Each of the Project Hospital renovation plans shall contain an assessment of energy efficiency improvements. This will be initiated as part of the ESMP development creating a prototype for approriate enegy use surveys across the national Health facilities. for adding climate-resilient materials and other structural modifications to mitigate flood risks and other climate-related emergencies. Environmental, Health and Safety: All civil works planned to be executed under this project will be located on the public lands within the compound of health centers or referral hospitals. These upgrades/renovations of health care facilities may generate limited adverse impacts such as dust, noise, vibration, building waste, wastewater, traffic obstruction, safety issue, construction workers hygiene and sanitation to the environment and surrounding residents. These impacts are assessed to be of site-specific, temporary and can be mitigated with good design and construction practices. A generic environmental management plan checklist (which include ECOPs) will be followed to avoid/minimize impacts from these minor civil works. Air emissions: During the 4 Hospital renovations, all construction and/or retrofitting shall be undertaken observing appropriate health and safty measures for workers and all hospital staff and patients. The Kanifing Hospital expansion will observe measures to reduce and ensure minimal particulate/dust impacts or health risks. Measures such as dust suppression and vehicle maintenance will minimize the impact of air emissions during construction. All of these provisions are detailed in the ESMF ESCOPs. Public Disclosure Healthcare Waste Management: To operationalize the HCWM plan, the MOH has developed Health Care Waste Management – Standard Operating Procedures (HCWM SOP). The SOP has been designed as a means of accomplishing what is embodied in the HCWM policy and plan. It provides instructions on how to carry out the policy expressed in the plan and communicates who will perform the task, what materials are necessary, where the task will take place, when the task shall be performed, and how the responsible person will actually execute the task. The SOP covers all the relevant activities that are necessary to manage any HCW that can be generated from any health care facility. It traces the activities from “cradle to grave”. Construction Waste: The ESMPs, to be prepared for each of the 5 project Hospitals will include procedures for handling construction waste. Additional risk and impact concerns across managing construction waste will be managed by the contractors with supervision by representatives of MOH and the PCU. Asbestos: A generic concern with such minor construction upgrades is exposure to asbestos if such materials were used in past building programs. The MOH will verify whether asbestos is present in existing structures and if construction activities could release noxious particulates. If that’s the case, the contractors will adhere to appropriate occupational health and environmental mitigation measures. These measures are addressed in the ESMP checklists. ESS4 Community Health and Safety Aug 07, 2020 Page 7 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) Community Health and Safety impacts could primarily arise from the provision of essential health serives in the COVID context and the construction activities in 5 health facilities. The latter would include temporary exposure to pollution, increased traffic leading to accidents and the potential for gender-based violence committed by the workforce. Given the small scale of renovation activities these risks are considered to be low to moderate. To mitigate against them the ESMF will provide guidance on how to minimize the potential for community exposure to communicable diseases; ensure that individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable, have access to the development benefits resulting from the Project; and manage the risks of labor influx; and prevent and respond to SEA/SH. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This subcomponent will finance the following activities: (a) provision of equipment to and renovation of selected health facilities (Bwiam hospital, Brikama hospital, Basse hospital, and EFSTH) and (b) establishment of a national blood transfusion center. All the renovations will be within the compounds of existing health facilities with no new land acquisition. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The ESMF will provide guidance on screening and mitigation measures to ensure that project activities do not alter or Public Disclosure cause destruction of any critical or sensitive natural habitats. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard is not relevant as there are no Indigenous Peoples/Sub-Saharan Historically Underserved Traditional Local Communities in the project area of influence. ESS8 Cultural Heritage This standard is not relevant at this time as the limited civil works are unlikely to affect cultural heritage. The ESMF will include measures for “Chance Finds” of archaeological or other cultural heritage. ESS9 Financial Intermediaries This is not relevant as it is not an FI operation. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No Aug 07, 2020 Page 8 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) III. BORROWER’S ENVIRONMENTAL AND SOCIAL COMMITMENT PLAN (ESCP) DELIVERABLES against MEASURES AND ACTIONs IDENTIFIED TIMELINE ESS 1 Assessment and Management of Environmental and Social Risks and Impacts ESMF 08/2020 ESS 10 Stakeholder Engagement and Information Disclosure Final SEP 08/2020 ESS 2 Labor and Working Conditions LMP 08/2020 ESS 3 Resource Efficiency and Pollution Prevention and Management Addressed in ESMF and existing Health Care Waste Management Plan and its SOPs 08/2020 ESS 4 Community Health and Safety SEA/SH assessment and mitigation measures as part of ESMF 08/2020 Public Disclosure ESS 5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS 6 Biodiversity Conservation and Sustainable Management of Living Natural Resources ESS 7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS 8 Cultural Heritage ESS 9 Financial Intermediaries B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: Use of Borrower Framework is not being considered for this project. IV. CONTACT POINTS World Bank Aug 07, 2020 Page 9 of 10 The World Bank The Gambia Essential Health Services Strengthening Project (P173287) Contact: Samuel Lantei Mills Title: Senior Health Specialist Telephone No: 5381+39100 / 1-202-473-9100 Email: smills@worldbank.org Borrower/Client/Recipient Borrower: The Gambia Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Samuel Lantei Mills Public Disclosure Practice Manager (ENR/Social) Aly Zulficar Rahim Cleared on 05-Aug-2020 at 12:22:24 EDT Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Concurred on 06-Aug-2020 at 20:39:6 EDT Aug 07, 2020 Page 10 of 10