The World Bank OECS Regional Health Project (P168539) Combined Project Information Documents / Integrated Safeguards Datasheet (PID/ISDS) Appraisal Stage | Date Prepared/Updated: 10-May-2019 | Report No: PIDISDSA25784 Apr 12, 2019 Page 1 of 20 The World Bank OECS Regional Health Project (P168539) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Caribbean P168539 OECS Regional Health Project Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) LATIN AMERICA AND CARIBBEAN 30-Apr-2019 30-Jul-2019 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Commonwealth of Dominica - Ministry of Dominica, Grenada, Saint Health and Social Lucia, Saint Vincent and Services, Grenada - the Grenadines, Caribbean Ministry of Health, Social Public Health Agency Security and International (CARPHA), Organization of Business, St. Lucia - Eastern Caribbean States Ministry of Health and (OECS) Wellness, St. Vincent and the Grenadines - Ministry of Health, Wellness and The Environment Proposed Development Objective(s) The project aims to improve preparedness capacities of health systems for public health emergencies in the OECS region. Components Improved Health Facilities and Laboratory Capacity Strengthened Public Health Surveillance and Emergency Management Institutional Capacity Building, Project Management and Coordination Contingency Emergency Response Component (CERC) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 30.60 Total Financing 30.60 of which IBRD/IDA 30.60 Apr 12, 2019 Page 2 of 20 The World Bank OECS Regional Health Project (P168539) Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 30.60 IDA Credit 21.00 IDA Grant 9.60 Environmental Assessment Category B-Partial Assessment Decision The review did authorize the team to appraise and negotiate B. Introduction and Context Regional and Country Context 1. The Organisation of Eastern Caribbean States (OECS) consists of eleven small open economies, including three British Overseas Territories and two overseas departments and regions of France. The average population of the OECS member countries is 72,000, though this ranges widely from approximately 5,000 in Montserrat to 400,000 in Martinique. OECS member states are generally highly open economies heavily dependent on tourism, which contributes at least one quarter of total economic output, except for Grenada and Saint Vincent and the Grenadines (SVG), where the contribution is much lower. Of the member countries, Dominica, Grenada, Saint Lucia, and SVG will be participating in the OECS Regional Health Project. 2. The OECS region faces several key challenges, including low growth, high debt, fiscal deficits, and vulnerabilities to external shocks. Following the 2008 financial crisis, the eastern Caribbean region has found it difficult to regain pre- crisis growth levels. Among the four project participating countries, Saint Vincent and the Grenadines has seen growth levels stay below 2 percent while Dominica, Grenada and Saint Lucia recovered more quickly, though this recovery has not been sustained. Gross National Income (GNI) per capita in the four countries ranges from US$6,990 in Dominica and SVG, to US$9,650 in Grenada (2017). Despite the limited fiscal space for public investment due to high ratios of debt to GDP, there is a high level of need for building ex-ante resilience to climate change and natural disasters. 3. Interconnected hazards, in addition to economic shocks, threaten to erode development gains. The International Monetary Fund (IMF) notes that vulnerability to natural disasters is one of the main economic challenges facing Caribbean states. Hurricanes are the most threatening natural hazard, posing significant destructive potential due to high wind speeds, heavy rains, and powerful storm surges that produce flooding, which may increase the threat from vector-borne diseases. Average annual losses from hurricanes alone are estimated at US$835 million in the Caribbean Apr 12, 2019 Page 3 of 20 The World Bank OECS Regional Health Project (P168539) region.1 Dominica most recently experienced substantial damages and losses estimated at 226 percent of 2016 GDP following Hurricane Maria in 2017; other countries have also been affected in 2013 and 2016 mainly from extensive flooding. Going forward, climate change is expected to lead to rising temperatures, changes in rainfall patterns, and an amplification of extreme weather events with implications for increasing the incidence of water-borne and vector-borne diseases. 4. Official poverty estimates in the region are limited and outdated, but consumption-based poverty rates range from 20 to 30 percent for the four participating countries.2 Available evidence suggests that extreme poverty rates are low while moderate poverty rates are high. Nonetheless, there have been considerable gains in human development as measured through the Human Development Index which ranges from 72 to 75, and life expectancy averages 75 years. Meanwhile, unemployment rates are high, at around 20 percent in Saint Lucia (2016), 28.6 percent in Grenada (2016) and 25.1 percent in SVG (2015). Sectoral and Institutional Context 5. Faced with limited capacity and fiscal space, as well as high levels of exposure to economic and weather shocks, the four participating countries have had limited success in adequately preparing for public health emergencies. Recent extreme weather events such as Hurricanes Irma and Maria (2017) and regional outbreaks of Chikungunya (2014) and Zika (2016) have highlighted weaknesses in the preparedness of health systems in the eastern Caribbean region to manage public health emergencies. Assessments conducted by the Pan-American Health Organization (PAHO) since 2015 under its Smart Health Facilities Initiative3, which aims to ensure that health facilities are environmentally friendly and resilient to disasters (mainly extreme weather events), found that in some countries more than 75 percent of facilities scored in the Category C range, indicating they would no longer be operational after a disaster. In Dominica, the impact of a disaster was seen following Hurricane Maria in 2017, where there was substantial damage to health facilities and related infrastructure, compromising access to healthcare. For example, the main hospital, Princess Margaret Hospital, sustained severe damage, with bed capacity decreased by 95 beds and only 53 percent able to function.4 In the aftermath, a 40 percent increase in persons seeking care was reported at a time when the number of hospital beds declined by 43 percent given the damages sustained to health facilities. This is particularly significant given the potential of severe weather events, frequently exacerbated by climate change,5 to reduce the health system’s capacity to care for patients as well as detect and respond to disease outbreaks. Meanwhile, the rapid spread of disease in the region can be seen with the Chikungunya outbreak, which spread to over 350,000 people between December 2013 and July 2014. Two years later, the Zika outbreak exposed gaps in public health preparedness and response that had not been adequately addressed following the 2013-14 Chikungunya outbreak. The vector-borne nature of these recent outbreaks, and the ease with which the viruses cross national borders underscores the importance of well-coordinated country and regional responses and containment strategies to avoid the high costs associated with outbreaks, including productivity and investment opportunity (tourism) loss. 1 GFDRR (2015) Small Island States Resilience Initiative. Washington, DC: Global Facility for Disaster Reduction and Recovery. 2 OECS Systematic Regional Diagnostic. World Bank. 2018. 3 The PAHO Smart Health Facilities Initiative is co-financed by the United Kingdom’s Department of International Development (DFID) to support the retrofitting of selected health facilities in the Caribbean region. 4 Post-Disaster Needs Assessment. Hurricane Maria, September 18, 2017. A Report by the Government of the Commonwealth of Dominica. 5 World Bank. 2018. Global Crisis Risk Platform (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/762621532535411008/Global-Crisis-Risk-Platform Apr 12, 2019 Page 4 of 20 The World Bank OECS Regional Health Project (P168539) 6. Preparedness in the context of this regional project refers to a range of health and non-health capabilities and operational capacities put in place at national and regional levels to ensure prevention, protection, response and recovery from public health emergencies, such as infectious disease outbreaks and extreme weather events. Natural disasters and disease outbreaks have demonstrated the cross-boundary nature of public health emergencies, underlining the need for resilient health systems and stronger inter-country collaboration. A regional approach is thereby warranted, whereby investments in preparedness are harmonized at the country level and complemented at the regional level. As part of strengthening health security for the OECS region, this project seeks to mitigate cross-border transmission of disease outbreaks and disruptions in the aftermath of an extreme weather event. This project responds to the demand for financial support for preparedness expressed by Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines, and is expected to have spillover benefits across the OECS region. 7. The health systems of the four participating countries are similarly structured and have overlapping gaps in preparedness capacity. In 2005, in response to an increase in global mobility, emergence and reemergence of diseases, nearly 200 countries across the world signed on to implement the International Health Regulations (2005) (IHR). The objective of this legally binding instrument is “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade." The IHR require countries to strengthen core surveillance and response capacities. Current IHR core capacity implementation status among the four participating countries ranges between 63-77 percent, suggesting room for improvement. Rapid needs assessments following the Zika outbreak carried out by the World Bank in collaboration with PAHO in all four project participating countries revealed the following shortcomings in infectious disease surveillance, epidemic preparedness, and response: (i) lack of an adequately trained health workforce for disease surveillance, preparedness and response across the different levels of health services; (ii) nonexistent or insufficient facility level surveillance and response structures; (iii) limited laboratory infrastructure for timely and quality diagnosis of epidemic-prone diseases; (iv) lack of interoperability of information systems hampers analysis and utilization of information for decision-making and disease mitigation measures; (v) inadequate IPC standards, infrastructure and practices; (vi) significant gaps in regional level surge capacity for outbreak response, stockpiling of essential goods, information sharing, and collaboration. At the same time, areas of heterogeneity across countries in terms of the availability of adequately trained public health specialists (e.g. epidemiologist, entomologist, etc.) suggested opportunities for sharing of expertise across countries. 8. Under the proposed project, investments in health systems strengthening will have a direct impact on improving IHR core capacities in the participating countries, particularly in the areas of surveillance, laboratories, workforce development and emergency management. Furthermore, project investments will contribute to sustainable, effective and efficient regional collaboration for mitigating and/or preventing public health risks and the economic consequences associated with infectious diseases while also improving continuity of care following a disaster. At present, weaknesses are seen in health systems infrastructure, where many facilities are unable to withstand extreme weather events. Related to this is the vulnerability of health facilities to climate change, where previously unaffected facilities may be vulnerable to rising sea levels, floods, and mudslides. At the health facility level, typically the first point of contact with the health system, current disease surveillance and response protocols are inadequate. Laboratory confirmation of diagnoses is challenging due to limited laboratory infrastructure at the national level, while laboratory infrastructure at the regional level has not been able to cope with the surge in demand during outbreaks. Although all four countries have some form of health information systems, these are not updated in real time, have limited interoperability, and are poorly connected at the regional level. These shortcomings subsequently translate to weaknesses in supply chain management and surge level capacity at the national and regional levels, making it difficult for countries and the OECS region to mount a coordinated response to public health emergencies. Apr 12, 2019 Page 5 of 20 The World Bank OECS Regional Health Project (P168539) 9. Against this backdrop, existing platforms for public health preparedness suggest high level of regional commitment. These regional collaborations have been instrumental in addressing the health needs of the population and continue to play an important role in driving the health agenda forward, particularly considering the limited economies of scale among the OECS countries. The OECS Commission has a longstanding history of regional cooperation, including in the health sector, beginning with the 1984 adoption of the Caribbean Cooperation in Health (CCH) Initiative and most recently in 2011 with the establishment of the Caribbean Public Health Agency (CARPHA) by the Caribbean Community Heads of Government (CARICOM). In 2016, the OECS Commission Health Desk was established to drive regional functional cooperation to implement the OECS Growth and Development Strategy Health Agenda 2017-2030 for the OECS health sector. PAHO maintains an Emergency Operations Center (EOC) for the LAC region that collects, monitors and disseminates information about health crises and disasters to health authorities across the LAC region and the international community to ensure timely and effective decision-making. As part of its mandate, CARPHA serves as the Caribbean Reference Laboratory, coordinates regional public health surveillance, provides support to countries in surveillance and disease control, conducts specialized training for health workers, and defines quality standards and standard operating procedures. The United States Center for Disease Control and Prevention (CDC) has focused on strengthening laboratory information systems and surveillance capacity (mainly for HIV and TB), with support to the construction of a new climate resilient national public health laboratory in Barbados that will serve other parts of the eastern Caribbean. Despite this new reference laboratory, there continues to be a gap in laboratory services for specialized tests. Other gaps in laboratory services were identified as part of the Rapid Needs Assessments conducted in 2016/2017, and an in-depth regional laboratory assessment will be conducted under the project to inform program priorities. C. Proposed Development Objective(s) Development Objective(s) (From PAD) The Project aims to improve preparedness capacities of health systems for public health emergencies in the OECS region. Key Results (i) Number of project participating countries with health system capacity to withstand extreme weather events based on A-70 rating on Smart Health Facility standards6 (ii) Number of project participating countries/regional entities with laboratory testing capacity for detection of priority diseases based on achievement/sustainment of a Joint External Evaluation (JEE) score of 4.0 or higher7 (iii) Number of project participating countries/regional entities with indicator- and event-based surveillance8 established based on achievement/sustainment of a JEE score of 4.0 or higher 6 The definition of a Smart Health Facility/Hospital is defined as HSI A and minimum Green 70%, simplified as A70. Low HSI scores such as low B and C, generally correspond to facilities with low structural and non-structural scores. Therefore, a target of an HSI score of A and a green score of 70% is combined as A70. 7 A Joint External Evaluation (JEE) is a voluntary, collaborative process that is intended to assess country capacity to prevent, detect and rapidly respond to public health threats independently of whether they are naturally occurring, deliberate or accidental. The purpose of the external evaluation is to measure country-specific status and progress in achieving the targets. Evaluations are carried out by a panel of subject matter experts. For more information, see https://www.who.int/ihr/procedures/joint-external-evaluations/en/ 8 WHO defines public health surveillance as the continuous, systematic collection, analysis and interpretation of health- related data needed for the planning, implementation, and evaluation of public health practice. Indicator-based surveillance Apr 12, 2019 Page 6 of 20 The World Bank OECS Regional Health Project (P168539) (iv) Number of project participating countries with emergency operations capacity strengthened based on achievement/sustainment of a JEE score of 4.0 or higher D. Project Description Component 1: Improved Health Facilities and Laboratory Capacity (US$14.7 million) 10. This component focuses on improving the resilience and capacity of select health facilities and laboratories to provide services to manage a public health emergency, including an emerging disease outbreak, extreme weather event or other disaster. The component will support the refurbishment and equipping of select health facilities to ensure continuity of care and improve laboratory infrastructure and equipment with corresponding training. 11. Subcomponent 1.1 Health Facilities Infrastructure and Referral Networks. This component will focus on the development of (i) resilient health facilities in participating countries; and (ii) the development of a facility inventory at the regional level, which will feed into the development of an emergency coordination mechanism at the regional level. At the national level, activities focused on health facility resilience will build on the Smart Health Facilities Initiative implemented by PAHO. Under this initiative, in-depth assessments of health facilities in all four participating countries have been conducted.9 Using the findings of these assessments, select health facilities will be upgraded to improve their resilience to extreme weather conditions. 12. At the regional level, an emergency and critical care facilities inventory, including information on human resources, will be developed by the OECS to document resources available for emergency response. As the project scope does not allow upgrading of all facilities, the facilities inventory is expected to provide useful guidance on available resources and possible referral networks10 to ensure continuity of care following a public health emergency, particularly an extreme weather event. These investments are expected to improve the continuity of care in the context of a public health emergency, reducing the need for evacuations in the event of an emergency. This component would support civil works, equipment, technical assistance and training. 13. Subcomponent 1.2 Laboratory Infrastructure and Capacity. The project will also support investments in laboratory infrastructure and capacity with the aim of improving the efficiency and quality of the laboratory network in the region. An underdeveloped laboratory network has hindered the region’s capacity to confirm and respond in a coordinated manner, as recently seen with the 2016 Zika outbreak. At the national level, this subcomponent will include (i) expansion of national laboratory services, including provision of equipment and reagents; (ii) improvements in specimen handling and supply chain management (including cold chain transport); (iii) technical support for laboratory data management systems and interoperability with health and surveillance information systems at national and regional levels; (iv) training and capacity building for laboratory services; and (v) strengthened laboratory quality management systems. 14. A corresponding set of activities will be conducted at the regional level, where project activities implemented by CARPHA will include: (i) assessment of national laboratory capacity in the target countries to provide the needed involves reports of specific diseases from healthcare providers to public health officials. Event-based surveillance focuses on news stories, rumors, reports and other information about health events that may pose a threat to public health. 9 Assessments in Dominica will need to be updated following Hurricane Maria. 10 The referral network referred to here is a health network at the facility level where a Smart health facility is networked with facilities that have not been retrofitted to ensure continuity of care following an extreme weather event. Apr 12, 2019 Page 7 of 20 The World Bank OECS Regional Health Project (P168539) laboratory services (e.g. collect, test, process, diagnose, and confirm cases); (ii) technical support to improve the link between national laboratory networks and the regional reference laboratory; (iii) enhancements to the regional reference laboratory capacity in order to provide the region with the necessary capacities in processing, diagnosing and confirming priority infectious diseases; and (v) improved laboratory safety and specimen transportation. Recognizing the small country context, support will be provided to the OECS under the project to develop a pooled procurement system for lab equipment, service contracts, and laboratory parts and reagents. A regional quality assurance program will also be supported with the implementation of common standards for national laboratories, including policies, standard operating procedures (SOPs) and related training. Component 2. Strengthening Public Health Surveillance and Emergency Management (US$11.9 million) 15. This component will support efforts to strengthen public health preparedness, including surveillance11 and response through improvement of national and regional capacities and promotion of cross-border collaboration. This component would improve the completeness and quality of the reporting chain for surveillance activities from the national to regional level, including improvements in interoperability and the development of a regional dashboard to monitor trends. Similar efforts would be made in regional preparedness and response, including the development of an emergency health services coordinating mechanism. The project would also address vulnerabilities at the national level, in areas such as port health and development of national health emergency response mechanisms and operations centers. These components are described in greater detail below. 16. Subcomponent 2.1 Public Health Surveillance. At the national level, activities under this subcomponent will focus on (i) improving the information base for surveillance through training and investments in information systems (e.g. strengthening case detection and reporting, developing environmental health tools, mapping communicable diseases using geographic information systems to identify high-risk areas); (ii) strengthening points of vulnerability through improved surveillance in targeted areas (e.g. food safety, port health and inspection, tourism); and (iii) support to national vector control programs and implementation of the Frontline and Basic Field Epidemiology Training Program (FETP). At the regional level, project activities to be implemented by CARPHA include: (i) the expansion and roll-out of the Intermediate and Advanced FETP;12 (ii) improvements in surveillance reporting to and from the regional level, including protocols for communication and data sharing and the development of a regional dashboard; and the (iii) development of an information and communication platform for surveillance and management including geographic information systems. As part of efforts to improve surveillance reporting, the project will support in-country assessments by CARPHA of participating countries’ ability to report and use surveillance information. The project will also support the implementation of the recommendations of the in-country assessment reports. Considering the possible gender implications of infectious diseases, such as recently seen with Zika and its impact on pregnant women, the project will also seek to develop protocols for sex- and gender-specific surveillance of priority infectious diseases. 17. Subcomponent 2.2 Preparedness and Response. This subcomponent will support strengthening of national and 11 According to WHO, public health surveillance is the continuous, systematic collection, analysis and interpretation of health- related data needed for the planning, implementation, and evaluation of public health practice. Such surveillance can serve as an early warning system for impending public health emergencies; document the impact of an intervention, or track progress towards specified goals; and monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategies. 12 The FETP represents one area through which investments at the national level can be leveraged. While training participation costs for basic FETP will come out of the respective country project budgets, participation costs for the advanced modules of the FETP will be covered by CARPHA. Apr 12, 2019 Page 8 of 20 The World Bank OECS Regional Health Project (P168539) regional emergency management and response capacities to respond swiftly and effectively to outbreak threats. In addition, project interventions will provide support to improve country and regional surge capacity to ensure rapid response during an emergency. Specific activities to be supported at the national level include: (i) development and/or updating of health emergency preparedness and response plans; (ii) establishment of isolation facilities for response and containment capacity in the event of an outbreak; (iii) setup and equipping of national health emergency response systems and/or operations centers (e.g. staff, protocols and procedures, communications, equipment). In Dominica and Saint Vincent and the Grenadines, biohazard waste management systems will also be strengthened. Investments at the national level will seek to address weaknesses in compliance with the 2005 IHR, and where necessary, will include training. These investments will be complemented by activities at the regional level. CARPHA will focus on the development of regional preparedness and response action plans for public health emergencies (including simulation exercises), while the OECS will focus on the development and implementation of an OECS health emergency services coordinating mechanism to strengthen regional capacity to mobilize first responders and critical health related supplies to affected areas. Component 3: Institutional Capacity Building, Project Management and Coordination (US$4.0 million) 18. Component 3 will support the critical building blocks for strong implementation and coordination required for implementing this regional project. Specific institutional capacity building activities include technical assistance for contract management, procurement, financial management (FM), environmental and social safeguards, construction supervision (e.g. engineer and/or architect), monitoring and evaluation, and project audits. With respect to project management and coordination, this component will finance personnel necessary for the execution of the project as well as regional coordination platforms for knowledge sharing among the implementing entities and collective monitoring of implementation status. Finally, related operating expenses and equipment will also be financed. Component 4. Contingency Emergency Response Component (CERC) (US$0 million) 19. This zero-cost component aims to provide immediate surge funding in the event of a public health emergency, such as a disease outbreak. The CERC is only triggered in the case of a public health emergency and when certain actions, as agreed by the Government and Bank teams, are met. These actions can include: (i) the country declares a national public health emergency; and (ii) presents a sound and actionable country-level response plan. Having the CERC in place provides a compelling platform for country-level discussions on the importance and need for country-level readiness to respond to disease outbreaks. Once triggered, the CERC is implemented following the exceptional policy requirements set out in Paragraph 12 of the IPF Policy (Projects in Situations of Urgent Need of Assistance or Capacity Constraints) and enables rapid reallocation of funds between project components following an emergency. Together with the operational, fiduciary, procurement, disbursement and financial management arrangements that underpin its implementation, the CERC provides a conduit for flow of PEF funds (in the form of grant funds) into the project. Details on triggering the CERC in terms of definition of a public health emergency will be carefully defined in the respective Financing and Grant Agreements as well as outlined in the Project Operations Manual (POM) and a CERC Operations Manual. E. Implementation Institutional and Implementation Arrangements 20. The project will be implemented primarily through the MOH Planning Units based in each respective country. National-level implementation arrangements will seek to build on existing project implementation experience and capacities both within the MOH and centralized fiduciary functions housed within Ministries of Finance. Regional level implemented activities will be housed within existing project execution and technical units of CARPHA and the OECS Apr 12, 2019 Page 9 of 20 The World Bank OECS Regional Health Project (P168539) respectively. Project Coordination and Management functions across each implementing entity will be accountable for: (i) development of annual workplans; (ii) monitoring and reporting on the Results Framework; (ii) coordination of project activities; (iv) coordination and close follow-up on project fiduciary matters. 21. Implementation of regional level activities will be carried out by CARPHA and the OECS. CARPHA will serve as the lead technical body to oversee the design, planning, and technical assistance for the implementation of select regional level activities. CARPHA would also provide technical support to select country-level activities with a regional dimension, such as compliance with regional standards. The OECS Health Unit will implement regional level activities related to the development of regional policies and legislation (e.g. cross-border laboratory specimen transportation), regional coordination mechanisms (e.g. coordination of emergency and critical care services; pooled procurement of laboratory equipment, service contracts, and laboratory reagents). 22. A dedicated regional coordination platform will be established for the duration of project implementation in the form of a Regional Steering Committee (RSC). The RSC will validate the overall technical and strategic direction of the project and review project implementation. Convened by CARPHA, the RSC will include representation from each of the project participating countries, one representative from the OECS Health Desk, and the World Bank as an observer. It is important for the RSC to be a decision-making body on the technical and strategic direction of project activities, facilitator of coordination and knowledge transfer, and resolver of bottlenecks and solutions to implementation challenges encountered at the country or regional levels. For the first year of implementation, the RSC will meet quarterly and have at least one face-to-face meeting. For the remaining project implementation period, the RSC will meet twice a year – once in person and once virtually. . F. Project location and Salient physical characteristics relevant to the safeguard analysis (if known) The project is situated across four OECS countries and activities will take place in select health facilities and laboratories in Dominica, Grenada, Saint Lucia and Saint Vincent and the Grenadines. G. Environmental and Social Safeguards Specialists on the Team Nyaneba E. Nkrumah, Environmental Specialist Christopher Mays Johnson, Social Specialist SAFEGUARD POLICIES THAT MIGHT APPLY Safeguard Policies Triggered? Explanation (Optional) This project will trigger O.P/BP 4.01 for Component Environmental Assessment OP/BP 4.01 Yes 1. Component 1 focuses on improving preparedness of health facilities and improved laboratories in the 4 Apr 12, 2019 Page 10 of 20 The World Bank OECS Regional Health Project (P168539) OECS countries to ensure that they are able to provide services in any public health emergency or extreme weather event. Possible activities include upgrading of health facilities, focusing on the refurbishment of existing health facilities, and of laboratories. In all cases, the construction is to be climate resilient. In the case of Saint Vincent and the Grenadines, a new laboratory is under discussion. However, this will be on the hospital's existing footprint. Works could range from low environmental risk type of activities (painting, grouting, tiling) to low-medium risk activities (roofing, internal wall construction, electrical works, etc). The risks related to these activities are generally small, highly localized and easily mitigated. Negative environmental impacts are likely to include noise, dust, waste management issues (solid largely, and some liquid) and operational health and safety concerns, community health and safety risk, and risks associated with the temporary interruption or relocation of services. To address construction risks, Dominica has prepared an Environmental and Social Management Framework (ESMF) prior to appraisal (because all of the facilities to be upgraded are not yet confirmed and will not be known prior to appraisal) which will be used as the generic ESMF for the project. Included in the ESMF are essential EHSG requirements for construction. The ESMF has been reviewed, approved, consulted and disclosed. Each remaining country (St Lucia, Grenada and St Vincent and the Grenadines) will build on the generic ESMF to address specific health issues and legislation that are unique to each country. These country specific ESMFs also include standardized sections from the generic ESMF that address risks and mitigation measures related to construction, specifically the renovation risks in the health facilities and laboratories, and the risks of interruptions to health service delivery. The documents will be prepared, consulted, approved and disclosed prior to the start of implementation. Component 2 also will trigger OP/BP 4.01. This is because the component will support the (a) Apr 12, 2019 Page 11 of 20 The World Bank OECS Regional Health Project (P168539) establishment of isolation facilities for response and containment in the event of a health crisis in at least one country; and (b) strengthening health facilities' internal mechanisms for managing biohazardous waste materials in Dominica, and St Vincent and the Grenadines where this is relevant. The project will not finance any improvements outside health facility buildings that are related to the processing of that waste (i.e. incineration facilities, or landfills etc). However, the project would support the use of autoclaves/grinders where appropriate. This aspect of the project will focus on efforts to improve the safe handling and in-house disposal of biomedical hazardous waste (sharps, etc). Along with this support, the project will prepare a biohazardous medical waste plan to ensure that the waste is properly handled from source to destination. This plan will be prepared, approved, consulted and disclosed within the country before any part of it gets implemented. Policies and practices on the management of biohazardous waste will also be addressed at the national level in some countries, and not limited to a specific health facility. The isolation facilities for infectious patients that are supported under the project will not be new but reconstructed from an already existing wing/section of a health facility. If the project determines that it is better to build a new isolation facility outside of an existing health facility, an ESMP will be prepared prior to construction. Component 3 (Institutional Capacity Building, Project Management and Coordination) and Component 4 (Contingency Emergency Response-0 cost- do not currently trigger any safeguards. If a national public health emergency does occur during the project period, funds will be directed to Component 4. In that case, appropriate safeguard measures for emergency situations will be applied. Potential adverse socio-environmental impacts associated with rehabilitation and/or construction of existing health facilities, include: (i) the management of labor (demolition and construction workers, specialists in debris removal), both from the perspective of health and safety in the workplace, Apr 12, 2019 Page 12 of 20 The World Bank OECS Regional Health Project (P168539) fair practice, accommodation, and community health and safety. These aspects will be addressed through Labor Management Plans and in provisions in labor contracts if required. Special attention will be paid to communities through citizen engagement. Pregnant women will likely be tracked separately as part of future surveillance efforts and as part of preparedness and response efforts. It will be important to also ensure a robust Grievance Redress Mechanism is designed that is accessible to communities, particularly vulnerable groups, including documentation and timely resolutions of complaints. In some countries, existing mechanisms in the health sector will be adapted to serve this purpose. This is a government led program and therefore will Performance Standards for Private Sector No not trigger OP 4.03 on Performance Standards for Activities OP/BP 4.03 Private Sector Activities. This policy is not triggered. Given the project’s focus on rehabilitating existing infrastructure, no impacts on natural habitats are expected and no significant conversion or degradation of critical natural habitats will occur. In continuation with current practices, Natural Habitats OP/BP 4.04 No there will be no discharge of untreated wastewater into freshwater or coastal waters, and construction waste will be disposed of appropriately. For this reason, the project will not affect areas of natural habitat. All activities will take place on a pre-existing footprint of the health facility and its extended Forests OP/BP 4.36 No facilities. For this reason, the project will not affect any forest areas. The use of pesticides and other chemicals is envisioned for St. Lucia, but not for any of the other countries. St. Lucia has requested to use a small amount of their financing for the purchase of rodent Pest Management OP 4.09 Yes control pesticides and intermittent spraying of mosquitoes and larvae. As such, a stand-alone pest management plan will be developed for St. Lucia in addition to the ESMF. This policy is not triggered as there are no known archeological resources on the sites and given the low level of renovation at the hospital and other Physical Cultural Resources OP/BP 4.11 No health facilities, uncovering material is unlikely. As such, the ESMF for each country includes a procedure to manage chance finds in line with the Apr 12, 2019 Page 13 of 20 The World Bank OECS Regional Health Project (P168539) policy provisions and national legislation, and this procedure will be in contractual agreements with companies engaged to do the works. Given the characteristics of the populations across the four islands, and the very limited nature of the Indigenous Peoples OP/BP 4.10 No project areas, OP 4.10 Indigenous Peoples Policy is not triggered. The project activities do not trigger OP 4.12 Involuntary Resettlement. Any new construction or rehabilitation of health facilities, financed by the project, will take place on public land free of occupants and not in use for any type of activity, so it does not involve any involuntary resettlement. Involuntary Resettlement OP/BP 4.12 No Existing health facilities are on long held public land where ownership is not contested, and the works will not require acquisition of new land. The rehabilitation of the existing health facilities and civil works will not disrupt livelihood activities in adjacent areas. This policy is not triggered because project activities Safety of Dams OP/BP 4.37 No will not involve construction of dams or depend on existing dams. This policy will not be triggered because the project Projects on International Waterways No will not affect international waterways as defined OP/BP 7.50 under the policy. This policy will not be triggered because the Projects in Disputed Areas OP/BP 7.60 No proposed project will not affect disputed areas as defined under the policy. KEY SAFEGUARD POLICY ISSUES AND THEIR MANAGEMENT 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: This project will finance resilient health facilities in four countries- Dominica, St Lucia, St Vincent and the Grenadines and Grenada, to improve their resiliency in the face of extreme weather conditions. The project will also support investments in laboratory infrastructure and capacity. Finally, it will strengthen public health surveillance, preparedness and response. Associated activities will include some construction (mainly rehabilitation and refurbishment) including roof repairs, painting, grouting, construction of internal walls, etc. In a few instances, additional wings may be built onto existing health facilities’ structures. None of these activities are envisioned to produce any large scale, significant or irreversible impacts because most or all construction will occur on an existing footprint. The project is rated as a Category B project. Apr 12, 2019 Page 14 of 20 The World Bank OECS Regional Health Project (P168539) 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Potential long-term impacts are not envisioned from the activities in this project because they will occur on the existing footprint of the hospital facilities, and will not compromise the air or surface and ground water systems, soils or have any impact on forests, lands or biodiversity . Future activities are likely to be similar works (renovation) on the existing footprint. Envisioned short term negative impacts will include noise pollution, dust, issues related to solid and liquid waste management, occupational health and safety risks to contracted workers and to community, particularly if works are ongoing while there are patients present in the building, etc. Project activities will most likely be relatively minor, with no negative, significant or irreversible environmental impacts expected. On the contrary, the project will support environmental sustainability in the health sector by supporting efforts to build/renovate better and more climate smart health facilities. Indirect impacts may include a higher medical waste stream than the current baseline if improvements in the facility mean more patients and/or more beds. Component 2, which will support an isolation facility in some countries, with the potential for generating more infectious waste, has however incorporated improved medical waste management practices as a key part of the project activities (see section on Component 2). Accordingly, the project will promote and finance the use of appropriate equipment to manage waste disposal and will finance the preparation of a biomedical waste management plan. Since this is a regional project, an ESMF has been prepared for the project (Dominica's) and which each of the countries will modify to prepare their own country specific ESMF. The core of the ESMF will therefore be generic, but each country will develop its own country-specific ESMF to assess and mitigate the impacts of their specific range of activities and to ensure ownership of their specific ESMF. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. One alternative considered was whether there would be one ESMF to cover all the countries or separate ESMFs. One generic ESMF would result in cost and time savings but ultimately it was determined that there was a sufficient range in activities to require a unique ESMF for each country, and the process would build capacity, ensure consultations were unique to each country, and ensure closer monitoring of the projects across the countries. The first ESMF prepared that covered a core range of activities would therefore constitute the generic ESMF which would then help the others prepare theirs in a timely manner. This generic ESMF has been prepared and includes an assessment of the project activities that will occur in the 4 countries, as well as the associated mitigation tables. Another alternative discussed was whether or not to have waste management plans as part of the ESMFs. Ultimately it was concluded that the countries did have existing medical waste management procedures (though some are quite limited) but instead of developing plans they would not use and could not finance, it would be better to understand their waste management procedures and to improve on these where possible, under the project, particularly for biohazardous waste/infectious waste. For this reason, the project, under Component 2, will fund improved waste management practices. 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. Borrower capacity differs across the four project participating countries and it is generally low. During preparation, each country designated a focal point within the Ministry of Health for the coordination of work required to prepare the ESMF. To improve this capacity, Government officials attended trainings and discussions, including a mini safeguard training between March 25-April 5th, 2019. In terms of continued support during implementation, each Apr 12, 2019 Page 15 of 20 The World Bank OECS Regional Health Project (P168539) country will designate an environment/social specialist to manage the construction and waste management issues associated with the works conducted by the contractors. Training will continue, with support from the Bank social and environmental safeguards teams. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Each country has identified key stakeholders with whom to engage with around the ESMF and this process has already been completed in Dominica. Each country will follow suit, after their modifications to the generic ESMF. Clearly no works will begin until the other country-specific ESMFs have been completed, approved, consulted and disclosed. The country specific ESMFs, once reviewed and approved by the Bank, will be published on the World Bank website and then publicly disclosed within each country, likely through the websites of each country’s health ministries and/or other internet platforms. B. Disclosure Requirements 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 02-May-2019 10-May-2019 "In country" Disclosure Dominica 13-May-2019 Comments The ESMF for the project has been consulted and disclosed. OPS_ PM_D ISCLOSURE_TA BLE Pest Management Plan Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of submission for disclosure NA "In country" Disclosure OPS_PM_ PCR_TABLE If the project triggers the Pest Management and/or Physical Cultural Resources policies, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/Audit/or EMP. Apr 12, 2019 Page 16 of 20 The World Bank OECS Regional Health Project (P168539) If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OPS_EA_COMP_TABLE OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? Yes If yes, then did the Regional Environment Unit or Practice Manager (PM) review and approve the EA report? Yes Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes OPS_ PM_COM P_TA BLE OP 4.09 - Pest Management Does the EA adequately address the pest management issues? NA Is a separate PMP required? NA If yes, has the PMP been reviewed and approved by a safeguards specialist or PM? Are PMP requirements included in project design? If yes, does the project team include a Pest Management Specialist? NA OPS_ PDI_ COMP_TA BLE The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank for disclosure? Yes 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? Yes Apr 12, 2019 Page 17 of 20 The World Bank OECS Regional Health Project (P168539) 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? No 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 Carolyn J. Shelton Senior Operations Officer Neesha Harnam Health Specialist Borrower/Client/Recipient Commonwealth of Dominica Roosevelt Skerrit Prime Minister and Minister roosevelt.skerrit@gmail.com Grenada Dr. Keith Mitchell Prime Minister & Minister of Finance PrimeMinister@gov.gd Saint Lucia Allen Chastanet Prime Minister and Minister allen.chastanet@gmail.com Saint Vincent and the Grenadines Camillo Gonsalves Apr 12, 2019 Page 18 of 20 The World Bank OECS Regional Health Project (P168539) Minister camillogonsalves@gmail.com Caribbean Public Health Agency (CARPHA) James Hospedales Executive Director hospedja@carpha.org Organization of Eastern Caribbean States (OECS) Didacus Jules Director General didacus.jules@oecs.int Implementing Agencies Dominica - Ministry of Health and Social Services Kenneth Darroux Minister darrouxkm@dominica.gov.dm Grenada - Ministry of Health, Social Security and International Business Nicholas Steele Minister min-healthgrenada@spiceisle.com St. Lucia - Ministry of Health and Wellness Mary Isaac Minister healthminister@gosl.gov.lc St. Vincent and the Grenadines - Ministry of Health, Wellness and The Environment Robert T.L.V. Browne Minister mohesvg@gov.vc 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 Apr 12, 2019 Page 19 of 20 The World Bank OECS Regional Health Project (P168539) APPROVAL Carolyn J. Shelton Task Team Leader(s): Neesha Harnam Approved By Safeguards Advisor: Practice Manager/Manager: Daniel Dulitzky 10-May-2019 Country Director: Sabine Hader 10-May-2019 Apr 12, 2019 Page 20 of 20