The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 03/03/2020 | Report No: ESRSA00489 Mar 03, 2020 Page 1 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Cambodia EAST ASIA AND PACIFIC P169629 Project Name Cambodia Pre-Service Training for Health Workers Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 4/8/2020 5/29/2020 Population Financing Borrower(s) Implementing Agency(ies) Kingdom of Cambodia- Kingdom of Cambodia- Ministry of Economy and Ministry of Health Finance Proposed Development Objective(s) Public Disclosure To improve the quality of education for health professionals entering the workforce in Cambodia. Financing (in USD Million) Amount Total Project Cost 15.00 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 project aims to improve the quality of education for health professionals entering the workforce in response to health system needs in Cambodia. It targets two priority areas. The first component aims to strengthen competency- based teaching and learning capacity in selected Health Training Institutions (HTIs) in delivering competency-based training program in six health professional areas: general medicine, dentistry, nursing, midwifery, laboratory, and pharmacy. The selected HTIs will receive financial performance grants to develop and deliver competency-based training programs. After implementing the grants, these HTIs are expected to improve their training quality and produce more competent graduates who will be able to pass the national exit examination before entering the healthcare workforce. The second components aims to improve the governance of health professionals’ education in Mar 03, 2020 Page 2 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) Cambodia to ensure that the selected HTIs can produce competence health professionals. This component will support the Human Resources Development Department of the Ministry of Health to strengthen the governance of health professionals education in Cambodia. The governance tools include: (i) regulations and standards for health professionals education, (ii) national competency-based exit examinations by a national examination center, and (iii) technical assistance and knowledge exchanges on health professional education. In addition, this component will support day-to-day implementation, coordination, and management of the project activities on planning and execution, financial management, procurement, supervision and reporting, internal and external audits, environmental and social safeguards management, and monitoring and evaluation. D. Environmental and Social Overview D.1. Project location(s) and salient characteristics relevant to the ES assessment [geographic, environmental, social] Health service coverage in Cambodia has improved significantly over the past two decades. Improvements include a dramatic increase in facility-based deliveries from 10 percent in 2000 to 83 percent in 2014, an uptake of antenatal care from 10 percent to 80 percent. Despite improvements, gaps remain in access to care, and there are persistent and growing disparities in maternal, newborn, nutrition, and communicable disease outcomes. The low quality of the health workforce in Cambodia stem from its pre-service education system. Key challenges lie in a mismatch between the competency of graduates and the population’s health needs, outdated curricula and regulations that do not permit updating, poor quality of instruction, ineffective use of clinical practice sites, inadequate facilities and equipment, and poor assessment of students and programs. The country’s rural, remote, indigenous, and socioeconomically challenged women and children remain Public Disclosure disproportionately affected by poor health and nutritional status. The wealth gap in child mortality has remained unchanged since 2005, at roughly three times higher for poor and rural children compared to wealthy and urban children. Cambodia’s pre-service education system for health workers would significantly benefit from better use of technology to improve curriculum content, teaching, feedback, and assessment methods. Improving the quality of education and the quality of health professionals entering the workforce will require substantial reform in governance and regulatory systems. The project aims to improve the quality of education for health professionals entering the workforce in response to health system needs, particularly at the primary care level. Under one component of the project, it is aimed to strengthen competency-based teaching and learning capacity in the UHS in Phanom Penh and the four RTCs in Kampong Cham province, Kampot province, Battambang province, and Stung Treng province. The proposed project activities aim at improving the quality of health professionals’ skills and competencies, particularly in the area of pre-service education, focusing on curricular reforms, building capacity for competency and skills training, improving testing and evaluation, and strengthening of quality assurance mechanisms and accreditation systems for medical and nursing education. This project does not plan major construction works. Overall, the proposed project is expected to have very low environmental and social impacts and risks, and it is expected to deliver a range of number of environmental and social benefits by integrating the environmental and social aspects into the project design. The scope of application of the Environmental and Social Standards (ESSs) to the project will promote the enrollment and inclusion of disadvantaged groups (women, ethnic groups) in health schools, promote entering workforce spaces Mar 03, 2020 Page 3 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) and embedding social inclusion and environmental sustainability aspects in the project activities. Especially concerning ESS1, ESS2, ESS7, and ESS10. D. 2. Borrower’s Institutional Capacity The MoH that will host the PIU has experience with the application of the World Bank’s safeguards policies through a number of IDA-financed investment projects that have been implemented during the last years. Currently, MoH is implementing the Health Equity and Quality Improvement Project (H-EQIP). The environmental and social risks and impacts associated with the financed activities are expected to be managed by appointing a designated focal person within the PMU who can be trained supported by the World Bank TT E&S specialists. The MoH has formally assigned a new ESF focal point for this project, with no previous experience in this field. Since this will be one of the first projects in Cambodia applying the new ESF, the focal point will receive training to ensure adequate capacity to implement and monitor all applicable Environmental and Social Standards (ESSs). Specific institutional capacity strengthening/ building measures are recommended in the project’s Human Resource Development Readiness Assessment and Plan for Inclusive Service Delivery (HRDRAP) and the provision of additional resources; training needs are identified and listed in the Environmental and Social Commitment Plan (ESCP) to ensure ownership and sustainability of the resources. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Low Public Disclosure Environmental Risk Rating Low The environment risk rating is classified as Low as the proposed project is not planning investments that have a physical footprint and could cause direct adverse ES risks. Also, it is extremely unlikely that any indirect, downstream environmental or social effects would be caused by the technical assistance and advice provided through the project. The project is focusing on improving the quality of health professional’s skills and competencies, particularly in the area of pre-service education. It also focuses on curricular reforms, building capacity for competency and skills training, and strengthening quality assurance mechanisms and accreditation systems for medical and nursing education. The only physical related activities under this project is upgrading physical facilities such as clinical skill laboratories, libraries, and computer lab.; supporting basic on-line database; developing clinical training resources (standardized patients, clinical training sites); and applying information and communication technologies (e-libraries, smart-classes, e-learning/distance learning platforms, computer-based testing, etc.) under component 1 of the project. All proposed subprojects related to upgrading physical facilities will be screened for eligibility and screening tools as set in the Environmental Risks Management Process of the project’s ESF tool. It is anticipated that the nature of eligible subprojects will have only no or minimal impacts on environment, and the potential impacts related to upgrading facilities during renovating period (if needed) are localized, temporary, and mitigable with appropriate measures set in the Environmentaland Social Codes of Practice (ESCOP). The project will be applying the World Bank’s Environmental and Social Framework (ESF) in a pro-active way to increase the development opportunities associated with the project. Based on the scope and the results of the assessments during project preparation, the environmental risk rating of this project is low. Social Risk Rating Low Mar 03, 2020 Page 4 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) The social risk is categorized as “Low” because the expected risks and impacts of the project on human populations are expected to be minimal. No major construction works will be financed under this project. Potential social impacts and risks related to the improvement of physical facilities or equipping the existing facilities will be addressed by the provisions included in the project’s Human Resource Development for Inclusive Service Delivery Assessment and Plan (HRDRAP). Once the selection of sites for physical refurbishment are known, in case they require the preparation of an ESMP due to expected risks associated with labor and Occupational Safety and Health (OHS), then the social risk rating may be upgraded to “Moderate” during the implementation phase. Applying the ESF in a pro-active way is expected to increase the development opportunities associated with this project. Because of that, this project’s HRDRAP and Stakeholder Engagement Plan (SEP) includes specific recommendations both to promote the enrollment and inclusion of vulnerable groups as health students and to embed social inclusion and environmental sustainability aspects in the project activities, in line with WB’s ESF standards. 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: The project is expected to cause minimal or negligible risks and impacts on human populations and the environment. Public Disclosure However, the project will have windows for the opportunities about the enhancement of ESF related behavioral aspects, including gender-based violence prevention, improvement on the health and safety conditions of the health workers, hazardous and clinical waste management, gender inclusion, and improvement of equitable access to project benefits to ethnic groups and other disadvantaged and vulnerable groups (e.g., women, disabled people, sexual orientation and gender identity (SOGI), etc.). The Ministry of Health (MoH) has prepared the project’s Human Resource Development for Inclusive Service Delivery Assessment and Plan (HRDRAP). Among other findings, the HDRAP reports that the majority of the current health students in Cambodia are women; however, there is a gender imbalance in the doctor and the midwifery students. Doctor students have only about a third woman, and midwifery has all women students. Based on the collected data, there is a very low number of students from ethnic minority groups (IP), and they are mostly concentrated at Stung Treng RTC. With the current public workforce in Cambodia, the HDRAP reports that doctors are mainly working in the hospitals with high concentration among the major public hospitals at Phnom Penh (average of 144 Doctors/hospital). Only a limited number of Doctors work in rural health centers (160 doctors among the 1,220 health centers). More than half of public primary health workers of Cambodia are women. However only less than a fifth are women doctors, a third are women nurses, and midwives are all women. Public health workers from the ethnic minority are minimal, comprising only half of one percent. The HDRAP also concludes that the current curricula for the three health courses doctors, nursing, and midwifery don not explicitly include environmental and social subjects. Based on its findings, the HDRAP proposes different measures to promote the enrollment and inclusion of disadvantaged groups (women, ethnic population groups) as students in health schools (as doctors, nurses or midwives), promote entering workforce spaces and embedding social inclusion and environmental sustainability Mar 03, 2020 Page 5 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) aspects in the project activities during the implementation phase. HDRAP recommendes mainstreaming Environmental and Social Risk Management elements into the project regarding (i) occupational health and safety environment, (ii) hazardous and clinical waste management, pollution prevention, and resource efficiency, and (iii) community health and safety. The project will ensure that relevant reliable facilities and agencies are in place in accordance with the National regulations and World Bank’s Environment Safeguards Standards for the activities that will be generating health care and laboratory wastes, and follow the procedures under the Health Care Waste Management Plan of the HDRAP. This plan also includes recommendations for the inclusion of gender-based violence prevention, an improvement on the health and safety conditions of the health workers, and hazardous and clinical waste management in the Health curricula. The plan also sets out the Environmental and Social Risks Management Process and Environmental Codes of Practice (ESCOP) to manage and mitigate potential impacts due to the infrastructure-related activities. To promote social inclusion, the HDRAP recommends to include on the Health Curricula topics on social inclusion and environmental sustainability and/or soft skills courses (behavioral science courses) for medical students for having the right attitude in dealing and treatment of the vulnerable people group. The HDRAP also recomends the promotion of equal access to opportunity for female doctors in the government hospitals, offer special support to actively promote the enrolment of disadvantaged groups as medical students or to promote Stung Treng RTC as a focal center in the country for health professional’s education with ethnic minorities. HDRAP also includes recommendations to promote public awareness raising activities among medical students for better understanding and responding in a culturally-appropriate manner to the special needs of ethnic minorities, persons with disabilities (PWD) and Sexual Orientation and Gender Identity (SOGI) aspects. The project’s HDRAP considers, in an integrated way, all relevant expected environmental and social risks and Public Disclosure impacts of the project. It includes specific provisions for Labor-Management Procedures (under ESS2). To cover the requirements of ESS10, a Stakeholder Engagement Plan and Project Grievance Mechanism have been prepared, consulted and disclosed by the MoH. An additional stand-alone document disclosed prior to appraisal is the Environmental and Social Commitment Plan (ESCP). ESS10 Stakeholder Engagement and Information Disclosure To inform project design, during the preparation stage, different consultation meetings and focus group discussions were conducted with various project players in relation to main environmental and social aspects of interest for this project: 211 people (107 women, 5 IPs, 7 PWD and SOGI representatives) were consulted in different group meetings in Phnom Penh and Stung Treng -this location was selected because of the significant proportion of the ethnic population in this area-. In addition, a Stakeholder Engagement Plan (SEP) was prepared by MoH, and consulted (including the project’s HDRAP) in a consultation workshop carried out on January 27th in Phnom Penh. Twenty four people (eight women) joined the meeting, representing a wide range of stakeholders: the MoH, Occupational Heatlh Bureau (OHB), UHS and the RTCs, Professional Council of Doctors, Pediatric Hospital, Khmer-Soviet & Khmer-Chinese Hospital and groups in representation of people with disabilities (PPCIL) and SOGI (MRI Foundations), The participants at the consultations workshop provided meaningful comments for improvement on (1) Health curricula; (2) Ways to promote more diversity in the enrollment of students; (3) How to promote male midwives; (4) how the project’s Grievance Mechanism works; (5) how to promote non-discrimination and a friendly environmental for disabled citizens (PWD) and sexual orientation and gender identity (SOGI) groups. The main issues raised at the Mar 03, 2020 Page 6 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) consultation workshop have been considered at the project’s HDRAP and SEP. The consultation report has been included as an annex to the SEP. The project’s SEP will be implemented and updated by the MoH throughout the different phases of the project life cycle. The SEP will ensure that beneficiaries and relevant stakeholders (MoH staff, UHS staff, representatives of UHS students, representatives of private health schools, etc.) will be engaged. It will ensure appropriate representation and participation of various groups of stakeholders, including women and minority students and faculty staff. The SEP includes a Project Grievance Mechanism. It will be informed publicly, and it will address complaints and suggestions coming from both project-beneficiaries parties and other interested parties. As part of the information disclosure arrangement, the Human Resource Development for Inclusive Service Delivery Assessment and Plan, the SEP (including the consultation workshop), and the ESCP have been disclosed publicly on the MoH website during February2020. 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 Activities under the Project are not expected to have any negative impact related to labor and working conditions. The project will be mainly implemented by staff from the Ministry of Health (Government Civil Servants) and professional consultants (hired as contracted workers). Most roles envisaged will be highly technical. In this project, there are no expected primary supply workers or community workers. An assessment was carried out and to Public Disclosure determine if working conditions of staff working under the project are materially consistent with ESS2, and to seek the opportunities to mainstream the ESS2 into the project’s sub-activities of curricular reforms, building capacity for competency and skills training, and strengthening quality assurance mechanisms and accreditation systems for medical and nursing education. Labor Management Procedures are incorporated under the HDRAP to address key issues for the PIU and contracted workers: working conditions and management of worker relationships, protecting the workforce, grievance mechanism, and occupational health and safety. ESS3 Resource Efficiency and Pollution Prevention and Management The project’s activities and components are not expected to result in any pollution issues. Under the Human Resource Development for Inclusive Service Delivery Assessment and Plan (HRDRAP), analysis of the existing practices of managing clinical and hazardous wastes, using energy and resourses in an efficient manner, and establishing and retaining occupational health and safety has been carried out, and recommendations for inclusion of these aspects in the curricula are included as a simple “good practices” guides have been provided. The potential impacts related to physical infrastructure improvement activities are minor, and will be mitigated through the measures set out in Environmental Codes of Practice which are part of the Environmental Risks Management Process of the project’s Human Resource Development Readiness Assessment and Plan for Inclusive Service Delivery (HRDRAP). The project will ensure that relevant reliable facilities and agencies are in place in accordance with the National regulations and Mar 03, 2020 Page 7 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) World Bank’s Environment Safeguards Standards for the activities that will be generating health care and laboratory wastes, and follow the procedures under the Health Care Waste Management Plan of the HRDRAP. ESS4 Community Health and Safety The project’s activities and components are not expected to result in any issues related to community health and safety. Good practices of community health and safety aspects have been addressed in the project’s HDRAP and integrated into the project’s design wherever possible. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Since no construction works are planned for this project (only the improvement of physical facilities or equipping the existing facilities) and no land acquisition is envisaged, then ESS5 is not expected to apply. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The demonstrated project will not have any impact on the biodiversity and natural resources. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities The project’s activities and components are not expected to cause any harm to Ethnic Groups / Indigenous Peoples. Public Disclosure Instead, the project’s Human Resource Development for Inclusive Service Delivery Assessment and Plan has included actions to promote both (i) the enrollment and inclusion of ethnic groups as students in health schools (as doctors, nurses or midwives) and (ii) the equitable access to project benefits to ethnic groups (e.g. design culturally competent health training, to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients). Among other activities, the HDRAP proposes to include topics on social inclusion and cultural competence in medical education and medical practice; promote Stung Treng RTC as a focal center in the country for health professional’s education with ethnic minorities; and provide special support (through scholarships, public awareness or other means) to actively promote the enrolment of ethnic minorities as students in medical schools. ESS8 Cultural Heritage The project’s activities and components are not expected to cause any harm to cultural heritage. ESS9 Financial Intermediaries The project will not imply the use of Financial Intermediaries. B.3 Other Relevant Project Risks It is expected that the project will not have other relevant risks. Mar 03, 2020 Page 8 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No The Project will not affect international waterways. So, this is not applicable. OP 7.60 Projects in Disputed Areas No It is not applicable because the Project will not be implemented in areas known to involve disputed areas. 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 Establish and maintain an organizational structure with qualified staff and resources to support management of E&S risks including assign an ESF Focal Point in the Project Implementation Unit to provide ongoing support, advice and monitoring to all the institutional stakeholders. Recruitment of 07/2020 part time/full time consultants as required to support the stakeholder engagement processes, technical advisory work and (in case it is required) supervise the improvement of physical facilities ENVIRONMENTAL AND SOCIAL ASSESSMENT. Adopt, implement and update the Human Resource Development Readiness Assessment and Plan for Inclusive Service Delivery (HRDRAP) in a manner Public Disclosure acceptable to the Association. Specific environmental and social risks and impacts are expected to be 07/2020 low. There are some risks linked to the renovation of physical facilities/equipping the existing facilities. Specific opportunities relating to institutional strengthening include promoting equitable access to project. MANAGEMENT OF CONTRACTORS. Incorporate the relevant aspects of the ESCP, including the relevant aspects of the Human Resource Development Readiness Assessment and Plan for Inclusive Service Delivery (HRDRAP), Stakeholder Engagement Plan (SEP), Environmental Codes of Practices 12/2020 (ECOP) and the Labor Management Procedures (LMP), into the ESHS specifications of the procurement documents. Thereafter ensure that the contractors comply with the ESHS specifications of their respective contracts. ESS 10 Stakeholder Engagement and Information Disclosure STAKEHOLDER ENGAGEMENT PLAN PREPARATION AND IMPLEMENTATION. Adopt, implement and update the Stakeholder Engagement Plan (SEP) throughout Project implementation. Specific issues 07/2020 relate to engaging fully with project beneficiaries. PROJECT GRIEVANCE MECHANISM. Adopt, implement and update the Grievance Mechanism 07/2020 throughout Project implementation included in the project’s Stakeholder Engagement plan. ESS 2 Labor and Working Conditions Mar 03, 2020 Page 9 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) LABOR MANAGEMENT PROCEDURES. Adopt, implement and update the Labor Management 07/2020 Procedures (LMP), included as part of the HRDRAP, in a manner acceptable to the Association. GRIEVANCE MECHANISM FOR PROJECT WORKERS. Establish, maintain, and operate a grievance mechanism for Project workers, as described in the Labor Management Procedures (LMP), included as 07/2020 a part of the HRDRAP, and consistent with ESS2. OCCUPATIONAL HEALTH AND SAFETY MEASURES. Adopt, implement and update the occupational, health and safety (OHS) measures specified in the Labor Management Procedure (LMP) and the 07/2020 HRDRAP in a manner acceptable to the Association. WORKER CODE OF CONDUCT. Prepare and implement code of conduct for workers as specified in the 07/2020 LMP -part of the HRDRAP-. ESS 3 Resource Efficiency and Pollution Prevention and Management HAZARDOUS AND HEALTH CARE WASTE MANAGEMENT PLAN. Adopt, implement and update the hazardous and health care waste management measures specified in the HRDRAP in a manner 07/2020 acceptable to the Association. ESS 4 Community Health and Safety COMMUNITY HEALTH AND SAFETY. Adopt, implement and update community health and safety Public Disclosure 07/2020 prevention measures specified in the LMP and the HRDRAP in a manner acceptable to the Association. GBV AND SEA RISKS DURING PROJECT IMPLEMENTATION. Adopt, implement and update the GBV and SEA prevention measures specified in the Labor Management Procedure (LMP) and the HRDRAP in a 12/2020 manner acceptable to the Association. 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 IINDIGENOUS PEOPLES. Adopt, implement and update to promote the inclusion on Indigenous 07/2020 Peoples in the HRDRAP in a manner acceptable to the Association. 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 Mar 03, 2020 Page 10 of 11 The World Bank Cambodia Pre-Service Training for Health Workers Project (P169629) Areas where “Use of Borrower Framework” is being considered: The Borrower's E&S Framework is not proposed to be relied on for the Project, in whole or in part. IV. CONTACT POINTS World Bank Contact: Ziauddin Hyder Title: Senior Health Specialist Telephone No: 1-202-730571 Email: zhyder@worldbank.org Contact: Nareth Ly Title: Senior Health Specialist Telephone No: 5721+1367 / Email: nly1@worldbank.org Borrower/Client/Recipient Borrower: Kingdom of Cambodia- Ministry of Economy and Finance Implementing Agency(ies) Implementing Agency: Kingdom of Cambodia- Ministry of Health Public Disclosure 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): Ziauddin Hyder, Nareth Ly Practice Manager (ENR/Social) Christophe Crepin Cleared on 28-Feb-2020 at 00:05:53 EST Mar 03, 2020 Page 11 of 11