Republic of The Gambia Ministry of Health GAMBIA ESSENTIAL HEALTH SERVICES STRENGTHENING PROJECT (P173287) Stakeholder Engagement Plan (SEP) 3 August 2020 1 1. Introduction/Project Description The Government of The Gambia will implement THE GAMBIA ESSENTIAL HEALTH SERVICES STRENGTHENING PROJECT (P173287), with the involvement of the Ministry of Health. The International Bank for Reconstruction and Development and/or International Development Association (the Association) has agreed to provide financing for the Project. The Gambia Essential Health Services Strengthening Project aims to improve utilization and quality of essential health services as well as increase coverage of health insurance, thereby improving progress towards achieving universal health coverage in The Gambia. With a total cost of approximately $30 million, The WB supported Gambia Essential Health Services Strengthening Project will support the implementation of the 2021-2025 The Gambia National Health Strategic Plan and has three components. Component 1. Improving the Delivery and Utilization of Quality Essential Primary Health Care (PHC) Services using Results-Based financing (RBF) 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 which will finance the delivery of quality and essential health services at each level of the health care delivery system (e.g., community clinics, minor health centers, major health centers, district hospitals, general hospitals, and the teaching hospital). This subcomponent will provide: (i) RBF 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, non-communicable diseases (NCDs), and emergency obstetric care. This sub- component will also support capacity building for the national expansion of RBF with a National Health Insurance Agency (NHIA) process 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 Maternal and Child Nutrition and Health Results Project. The SBCC Program will focus on prevention activities and delivery of PHC as well as nutrition, women and girls’ empowerment, 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 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 the 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. 2 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 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. The Gambia Essential Health Services Strengthening Project (P173287) is being prepared under the World Bank’s Environment and Social Framework (ESF). As per the Environmental and Social Standard ESS 10 Stakeholders Engagement and Information Disclosure, the implementing agencies should provide stakeholders with timely, relevant, understandable and accessible information, and consult with them in a culturally appropriate manner, which is free of manipulation, interference, coercion, discrimination and intimidation. The overall objective of this Stakeholder Engagement Plan (SEP) is to define a program for stakeholder engagement, including public information disclosure and consultation, throughout the entire project cycle. The SEP outlines the ways in which the project team will communicate with stakeholders and includes a mechanism by which people can raise concerns, provide feedback, or make complaints about the project and any activities related to the project. 2. Stakeholder identification and analysis Project stakeholders are defined as individuals, groups or other entities who: (i) are impacted or likely to be impacted directly or indirectly, positively or adversely, by the Project (also known as ‘affected parties’); and (ii) may have an interest in the Project (‘interested parties’). They include individuals or groups whose interests may be affected by the Project and who have the potential to influence the Project outcomes in any way. For the purposes of effective and tailored engagement, stakeholders of the proposed project can be divided into the following core categories: Affected Parties These include local communities, community members and other parties that may be subject to direct impacts from the Project. Specifically, the following individuals and groups fall within this category: • Communities near renovation sites: Project activities include several site-specific construction sites with potential temporary negative impacts on local communities. Therefore, household in the vicinity of the sites would have a strong interest in effective implementation aof any necessary mitigation measures 3 • Workers at construction sites: Similarly, the construction work could entail harm for the workforce, particularly against the backdrop of COVID-19, and this group will need to be protected through robust OHS measures and equitable labor conditions • Clients/patients seeking PHC services at health facilities: This large group comprises in theory the whole population of The Gambia, and the potential exclusion from vital services needs to be mitigated through inclusive service provision and an effective GRM. • Health Care Workers including hospital managers: As service providers they play a crucial role in the successful implementation of the project, and their views and concerns need to be integrated at all levels of • Healthcare waste collection and disposal workers: Given the nature of project activities, the disposal of medical waste is an important issue throughout project implementation, and waste disposal enterprises and workers play an essential role, and are at risk of exposure to hazardous waste. Vulnerable Groups • The Elderly • Persons with disabilities and their caregivers • Person with chronic conditions or immune deficiencies • Women-headed households or single mothers with underage children • The unemployed All of the above groups have particularly strong interests in the project as they are more likely to need health services. At the same time, their vulnerabilities will often exclude them from the services they need most due to financial, mobility, and cultural factors. Other Interested Parties • Various Government Authorities • Development partners • Media • The public at large 3. Stakeholder Engagement Program 3.1. Summary of stakeholder engagement done during project preparation An internal stakeholder consultative engagement was held on the 8th of June 2020, involving all MoH Senior Management Team (SMT) members and the WB to discuss the proposed activities for the new health project. A presentation was made by the Bank team on the proposed list of interventions, based on previous discussions with various SMT members, to be supported by the new health project. The meeting provided some clarification on the results-based financing institutional arrangement, During pre-appraisal in July 2020 a set of consultations took place in the various districts, which focused on local communities in the proximity of the facilities slated for renovation as well as an orientation for District Chiefs on health sector activities. The first set of consultations focused on the scope of the renovations of the health facilities, including potential environmental and community risks. One of the major items raised was the presence of asbestos, and how to mitigate it. As a result specific measures have been added to the ESMF. The second set of consultations with the District Chiefs involved a general discussion about this and the COVID-19 project. Key ESF-related issues in these consultations concerned 4 the status of the GRM and waste management, both of which were clarified by the PCU. A more detailed summary of the discussions, issues and concerns is captured in the Annex. Additional consultations are being planned after the rainy season, and the SEP will be revised accordingly throughout project implementation to reflect the major milestones of stakeholder engagement. 3.2. Summary of tools and techniques for stakeholder engagement This project will support a communication, social mobilization, and community engagement campaign to raise public awareness and knowledge on prevention and control of identified project related risks among the general population. It will contribute to strengthening the capacities of community structures in promoting SBCC messages. The project will support Health Communication Unit of the Directorate of Health Promotion and Education to coordinate and monitor all communication interventions and material development at both the national and regional, and local levels. Stakeholder engagement under the project will be carried out on two fronts: (i) consultations with stakeholders throughout the entire project lifecycle to inform them about the project, including their concerns, feedback and complaints about the project and any activities related to the project; and to improve the design and implementation of the project, (ii) awareness-raising activities to sensitize communities on risks associated with the project. Strong citizen engagement being a precondition for the effectiveness of this project, in terms of consultations with stakeholders on the project design, activities and implementation arrangements, etc., the revised SEP, expected to be updated within 60 days after the project effectiveness date, and continuously updated throughout the project implementation period when required, will clearly lay out: • Type of Stakeholder to be consulted • Anticipated Issues and Interests • Stages of Involvement • Methods of Involvement • Proposed Communications Methods • Information Disclosure • Responsible authority/institution With the evolving situation, the Government of The Gambia has taken measures to impose restrictions on public gatherings, meetings and people’s movement, the general public has also become increasingly concerned about the risks of Covid-19 transmission, particularly through social interactions. Hence alternative ways (eg phone, radio, TV, social media) following World Bank guidance on “Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints on conducting public meetings� will be adopted to manage consultations and stakeholder engagement in accordance with the local laws, policies and new social norms in effect to mitigate prevention of the virus transmission until at such a time that the pandemic is declared as over during the project cycle. The table included in the following section outlines methods to be employed for stakeholder engagement activities including consultations and information dissemination. The methods vary according to the characteristics and needs of stakeholders and will be adapted according to circumstances related to the Essential Health Services Strengthening Project in light of the current COVID-19 public health emergency. 5 Project Topic of consultation / Method used Target stakeholders Responsibilities stage message Preparation • Need of the project • Phone, email, letters • Government Environment • Planned activities • Appropriate adjustments officials from and Social • E&S principles, to be made to take into Ministry of Specialist/EHU Environment and account the need for Health (MoH) social risk and social distancing (use of and other Health impact audio-visual materials, relevant line Communication management/ESMF technologies such as agencies at Unit-Directorate • Grievance telephone calls, SMS, national level of Health mechanisms (GM) emails, etc.) • Health Promotion and • Health and safety • Community Radio institutions Education impacts • Social Media • Health workers (DHPE) and experts • District-level focus groups • Affected PCU individuals and their families Implementa- • Project scope and • Training and workshops • Government Environment tion ongoing activities (which may have to be officials from and Social • ESMF and other conducted virtually) MoH and other Specialist/EHU instruments • Disclosure of information relevant line • SEP through community agencies at Health • GM radio, brochures, social national and Communication • Health and safety media, website, local level Unit-DHPE • Environmental district/village level • Health PCU concerns focus groups etc. institutions • Information desks at • Health workers municipalities offices and and experts health facilities • Appropriate adjustments to be made to take into account the need for social distancing (use of audio-visual materials, technologies such as telephone calls, SMS, emails, etc.) • Project scope and • Public meetings in • Local Environment ongoing activities affected communities and Social • ESMF and other municipalities/villages, • Vulnerable Specialist/EHU instruments where feasible groups • SEP • Brochures, posters Health • GM • Information desks in Communication • Health and safety local government offices Unit-DHPE • Environmental and health facilities. concerns PCU 6 • Appropriate adjustments to be made to take into account the need for social distancing (use of audio-visual materials, technologies such as telephone calls, SMS, emails, radio, tv etc.) 3.3. Proposed strategy for consultation The project will ensure that activities are inclusive and culturally sensitive. While projects typically involve face-to-face consultations with varying sizes of groups of stakeholders, including village communities, city neighborhoods, faith groups, women’s groups, focus group discussions and one-on-one interviews, etc. given the current COVID-19 context and restrictions in The Gambia, alternative methods of consultations taking into account social/physical distancing and crowd size will be considered. Carrying out of site visits, focus group session and/or conducting one-on-one interviews given the current realities will be carefully planned and executed. The project will explore various options for engaging stakeholder in this challenging environment, and they will be developed more fully when this SEP is updated prior to project approval. A key source of guidance on communications and stakeholder engagement that the Project will draw on is the WHO’s “COVID-19 Strategic Preparedness and Response Plan OPERATIONAL PLANNING GUIDELINES TO SUPPORT COUNTRY PREPAREDNESS AND RESPONSE� (2020). 4. Resources and Responsibilities for implementing stakeholder engagement activities 4.1. Resources The Ministry of Health will be in charge of stakeholder engagement activities. The budget for the SEP will come from Component 1, Subcomponent 1.1. 4.2. Management functions and responsibilities The Gambia MOH PCU which will be responsible for the implementation of the project, was established to provide integrated and coordinated project management interventions in health-related programs. It has some experience working on projects financed by multilateral development partners, mainly GFATM, and The Gambia COVID-19 Preparedness and Response Project (P173798) approved on April 2, 2020 is the first WBG-financed project it has managed. The PCU has gained some experience in managing the COVID-19 project. The PCU’s Senior Operations Officer, who has been recruited for safeguards implementation, will be in charge of SEP implementation, and work closely with the Environmental Health Unit and the Directorate of Health Promotion & Education. The existing multisectoral National Steering Committee (NSC) which has responsibility for oversight, stewardship and governance of the PCU is providing strategic guidance for overall project implementation. The committee has a multi-disciplinary, cross-government and development partner involvement and comprises the following: Permanent Secretary 1 of MoH as Chairperson; Permanent Secretary 2 as Deputy Chair, Deputy Permanent Secretary F&A MoH; Director of Health Services of MoH; Coordinator of MoH PCU as Secretary; Program Manager of RBF Unit as Assistant Secretary; Permanent Secretary of MoFEA; Chief Executive Officer of the NHIA; Permanent Secretary of the Ministry of Local Governments and Lands; Director of Planning and Information of MoH; Executive Director of NaNA; 7 Director of the Department of Community Development; Development Partners (including the World Bank Group, World Health Organization (WHO), UN agencies); Executive Director of the Country Coordinating Mechanism (CCM); Executive Director of The Association of Non-Government Organisations (TANGO); and the University of The Gambia (UTG) representative. 5. Grievance Mechanism The main objective of a Grievance Mechanism (GM) is to resolve complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Specifically, it provides a transparent and credible process for fair, effective and lasting outcomes. It also builds trust and cooperation as an integral component of broader community consultation that facilitates corrective actions. Specifically, the GM: • Provides affected people with avenues for making a complaint or resolving any dispute that may arise during the course of the implementation of projects; • Ensures that appropriate and mutually acceptable redress actions are identified and implemented to the satisfaction of complainants; and • Avoids the need to resort to judicial proceedings. 5.1. Framework The GRM will include the following steps: • Submission of grievances • Recording of grievance and providing the initial response • Investigating the grievance • Communication of the Response • Complainant Response • Grievance closure or taking further steps if the grievance remains open • Appeals process The following business standards will apply for the different phases of the mechanism: Step Process Time frame 1 Receive and register grievance within 24 hours 2 Acknowledge within 24 hours 3 Assess eligibility within 24 hours 4 Assign responsibility within 2 Days 5 Development of response (investigation, consultation) within 7 Days 6 Implementation of response if agreement is reached within 7 Days 7 Close grievance within 2 Days 8 Initiate grievance review process if no agreement is within 7 Days reached at the first instance 9 Implement review recommendation and close grievance within 14 Days 10 Grievance taken to court by complainant 8 5.2. Organizational Arrangements The redress system will ensure that beneficiaries have multiple channels to report grievances or suggestions such as the use of a toll free line, direct contact with a health personnel, and MOH website or Facebook page or twitter page. A call center established by MoH as part of COVID-19 response is the primary point for collecting reports of grievances and complaints. The center is being manned by dedicated MoH Staff 24hrs a day working in shifts. The call center operates on a widely publicized toll- free number (1025) that receives calls from the general public. A dashboard has been built on the national health sector’s database to log/summarize calls received. This includes summary of all grievances/complaints. The Health Communication Unit of the Directorate of Health Promotion and Education (DHPE) is the focal point for all matters relating to communications including the GRM. Upon receiving a grievance/complaint, the redress mechanism will be sought at the following levels: ➢ Community level ➢ Regional level ➢ National level First Level of Redress: Community Level The main targets at this level are the communities and project beneficiaries. In every project beneficiary community, in consultation with the Village Development Committee (VDC), four-member Community Grievance Redress Team (CGRT) shall be nominated and trained to handle complaints at community level. This team will include the community head, a woman leader, a youth leader and VDC chair/Rep. The CGRT shall work under the supervision of the VDC and shall dedicate days when they are available to receive and resolve complaints. Once they receive a complaint they shall be mandated to register the complaint, investigate and recommend an action. The received complaint shall be recorded on a form. If the complainant is not satisfied with the recommendation they shall be advised to report to the second level of redress. The CGRT shall be obligated to submit a monthly report to the Regional Health Directorates for onward transmission to the National GRM focal person (Director of Health Promotion and Education) through the Health Communication Unit Programme Manager. Mode of receipt and recording of Complaints Complaints can be made over the phone (1025 toll free line), verbally or in writing. If the complaint is made through the 1025 line, the officer receiving the complaints shall obtain relevant basic information regarding the grievance and record this into the MoH database. The call center shift supervisor shall be obligated to assess the complaint and determined with the complainant as to what level the redress could be sought. If both the shift supervisor and the complainant agreed to sought for redress at the community level, the shift supervisor shall within 24hrs forward this complaint to the concern Regional GRM (RGRM) focal person based at the Regional Health Directorate. The RGRM focal person shall also forward this matter to the CGRT within the same 24hrs period for investigation and possible redress measures. If the complaint is verbally or in writing submitted to the CGRT, the CGRT shall set a date to investigate the matter, after which they shall provide a recommendation. If necessary, meetings have to be held between the complainants and the CGRT to find a solution to the problem and make arrangements for grievance redress. The deliberations of the meetings and decisions taken shall be recorded in a form. 9 Second Level of Redress: Regional level The main targets at this level are the Health Care Workers, public and private institutions, Communities and project beneficiaries and their related institutions. At every Regional level, the Regional Health Directorate shall form a five-member team comprising the Regional Public Health Officer, Regional Public Health Nurse, Regional Health Promotion and Education Officer, Regional Administrator and Nutrition Focal Officer to handle grievances. The Regional Health Promotion and Education Officer shall serve as the RGRM focal person within the team. This team shall work under the supervision of the Regional Director of Health Services. All stakeholders shall be informed of the existence of the RGRM team. The team shall dedicate days when they are available to receive and resolve complaints. Once the team receives a complaint it shall be mandated to register the complaint, investigate and recommend an action. If the complainant is not satisfied with the recommendation they shall be advised to report to the third level of redress. The RGRM focal person shall be obligated to submit a monthly report to the National GRM focal person through the Health Communication Unit Programme Manager. Mode of receipt and recording of Complaints Complaints can be made over the phone (1025 toll free line), verbally or in writing. If the complaint is made through the 1025 line, the officer receiving the complaints shall obtain relevant basic information regarding the grievance and record this into the MoH database. The call center shift supervisor shall be obligated to assess the complaint and determined with the complainant as to what level the redress could be sought. If both the shift supervisor and the complainant agreed to sought for redress at the regional level, the shift supervisor shall within 24hrs forward this complaint to the concern Regional GRM (RGRM) focal person based at the Regional Health Directorate. The RGRM focal person shall also forward this matter to the RGRM team and convene a meeting with the team within 48hr period for investigation and possible redress measures. If the complaint is verbally or in writing submitted to the RGRM team, the RGRM team shall set a date to investigate the matter, after which they shall provide a recommendation. If necessary, meetings have to be held between the complainants and the RGRM team to find a solution to the problem and make arrangements for grievance redress. The deliberations of the meetings and decisions taken shall be recorded in a form. Third Level of Redress: National level The main targets at this level are the funding agencies, project implementers, Health Care Workers, public and private institutions, Communities and project beneficiaries and their related institutions. A Grievance Redress Committee (National Grievance Redress Mechanism Committee) shall be establish to handle complaints at the national level. The National Grievance Redress Mechanism (NGRM) committee shall be multi-institutional in nature and shall comprise of public and private institutions, NGOs, CSOs, Women’s Bureau, WB Rep., faith-based organizations, Local Government Authorities, Media Reps. etc. The Permanent Secretary of the Ministry of Health shall serve as the Chair of the committee. Also, Director of Health Promotion and education shall serve as the focal person of the NGRM committee. This committee shall work under the supervision of the Honorable Minister of Health. All stakeholders across all levels shall be informed of the existence of the NGRM Committee. This committee shall dedicate days 10 when they are available to receive and resolve complaints. Once the committee receives a complaint it shall be mandated to register the complaint, investigate and recommend an action. If the complainant is not satisfied with the recommendation they shall be advised to seek other recourse measures, such as the courts. The NGRM Committee shall be obligated to do a quarterly report of registered complaints. Mode of receipt and recording of Complaints Complaints can be made over the phone (1025 toll free line), verbally or in writing. If the complaint is made through the 1025 line, the officer receiving the complaints shall obtain relevant basic information regarding the grievance and record this into the MoH database. The call center shift supervisor shall be obligated to assess the complaint and determined with the complainant as to what level the redress could be sought. If both the shift supervisor and the complainant agree to sought for redress at the National level, the shift supervisor shall within 24hrs forward this complaint to the NGRM focal person. The NGRM focal person shall be obligated to try to resolve the complaint and if the complainant is not satisfied, then the matter will be forwarded to the Office of the Permanent Secretary as the Chair to the NGRM committee for possible redress. Equally, the Permanent Secretary shall also be obligated to try to resolve the complaint and if the complainant is still not satisfied, then the Permanent Secretary shall convene a meeting of the NGRM within 48hr period to investigation and seek for possible redress measures. Similarly, If the complaint is verbally or in writing submitted to the NGRM focal person or to the Chair of the NGRM, the above mentioned steps shall be taken to seek for possible redress measures. The deliberations of the meetings and decisions taken at any level shall be recorded in a form. 11 Flow of complaint Reporting Any complaints in relation to SEA/SH will be handled confidentially, and referred to a civil society organization active in the field of GBV and/or human rights. The GRM Focal Points will establish protocols on accessible and safe uptake channels, separate information sessions for women and girls, access to medical, psychosocial, and legal services through referral protocols and procedures for managing complaints that guarantee confidentiality and focus on survivors. In addition to the project GRM, communities and people adversely affected by the project may submit grievances to the World Bank’s Grievance Redress System (GRS). Details on how to apply can be found at: www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. 12 5.3. Communications website and its social media platforms. Regional and local health facilities will use ongoing consultation mechanisms to inform local communities about the mechanism. 6. Monitoring and Reporting The SEP will be periodically revised and updated as necessary in the course of project implementation in order to ensure that the information presented herein is consistent and is the most recent, and that the identified methods of engagement remain appropriate and effective in relation to the project context and specific phases of the development. Any major changes to the project related activities and to its schedule will be duly reflected in the SEP. Quarterly summaries and internal reports on public grievances, enquiries and related incidents, together with the status of implementation of associated corrective/preventative actions will be collated by responsible staff and referred to the senior management of the project. The quarterly summaries will provide a mechanism for assessing both the number and the nature of complaints and requests for information, along with the Project’s ability to address those in a timely and effective manner. Information on public engagement activities undertaken by the Project during the year may be conveyed to the stakeholders in two possible ways: • Publication of a standalone annual report on project’s interaction with the stakeholders. • A number of Key Performance Indicators (KPIs) will also be monitored by the project on a regular basis such as the number of public hearings, consultation meetings and other public discussions/forums conducted within a reporting period, frequency of public engagement activities; number of public grievances received within a reporting period and number of those resolved within the prescribed timeline; number of press materials published/broadcast. 13 14 Annnex Summary of Field Consultations July 25-27, 2020 During July 25-27, 2020, the mission along with Mr. Gibril Jarjue, Ministry of Health (MOH) Director of Planning and Information and Mr. Modou Saidou Sowe, MOH Maintenance Manager, visited the following facilities to meet with the Officers in Charge and colleagues as part of the appraisal mission stakeholder consultations: North Bank East Regional Directorate, Farafenni reproductive maternal neonates child adolescent health clinic, Mansa Konko regional health directorate, Mansa Konko community nursing school, Soma hospital, Kudang health center, Brikama Ba health center, Bansang hospital, Bansang school for enrolled nurses and midwives, Bansang Regional Health Directorate, Basse district hospital, Gambisara health center, Bwiam hospital, and Brikama hospital. Additionally, on July 26, 2020, the mission joined an orientation of all district chiefs in-country on COVID-19 conducted by the Risk Communication and Community Engagement sub-committee of the National Health Emergency Committee on COVID-19. Common challenges were identified across the health facilities. The main issues included limited accommodation for health personnel, asbestos roofing posing health hazards, stray animals entering the premises due to lack of fencing around the perimeter, and lack of results-based financing incentive payment for the period January to June 2020. Recommendations The mission recommended the following: • The project to support the renovations of Brikama Ba health center (new operating room only), Basse district hospital, Bwiam hospital, and Brikama hospital • MOH to replace all asbestos roofs with non-asbestos roofing • An architectural firm should be recruited to assess the health facilities slated for renovation and produce architectural drawings and bill of quantities • A construction firm should be recruited to assess all the health facilities with asbestos roofing and produce a workplan with estimates for replacing them. North Bank East region North Bank East Regional Directorate • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards • No perimeter fencing allowing animals to stray in the premises • Results-based financing incentive payment used to be a source of revenue for minor renovations and operating expenses but there has been no payment for the period January-June 2020 15 Farafenni reproductive maternal neonates child adolescent health clinic • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards Lower River Region Mansa Konko regional health directorate • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards. In the same area, the buildings occupied by other ministries have replaced the asbestos roofing. • The Gambia Agency for Management of Public Works (Gamworks) constructed new staff quarters but they needs to be expanded. • The previous health center, next to the Mansa Konko community nursing school, was taken by the military and the MOH needs to request the premises to be vacated by the military Mansa Konko community nursing school • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards • Expansion of school structures Soma hospital • The operating room has been refurbished and equipped but it is not functional because there is no staff housing for the obstetrician and nurse anesthetists • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards • There is no COVID-19 treatment center • Results-based financing incentive payment used to be a source of revenue for minor renovations and operating expenses but there has been no payment for the period January-June 2020. Consequently, some staff have been laid off. • No perimeter fencing allowing animals to stray in the premises 16 Central River Region Kudang health center • No perimeter fencing allowing animals to stray in the premises • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards • Results-based financing incentive payment used to be a source of revenue for minor renovations and operating expenses but there has been no payment for the period January-June 2020. This is affecting quality of care. Brikama Ba health center • New maternity ward is under construction by Mr. Hamidou Jah of Jah oil but it is not clear when it will be completed since he is not happy that this was brought up for discussion at the National Assembly and the contractor may not be performing well • Conducted 1,474 deliveries in 2019 (i.e., about 122 per month) but the center has only two delivery beds and no operating room and obstetric complications are referred to Bansang hospital. Patients are reluctant to go to Bansang given the distance and additional cost for family members who accompany the patient • Large population density which also makes the case for an operating room to be built • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards Bansang hospital • The Gambia National Petroleum Company (GNPC) has supported renovations in the hospital: a new maternity ward (with one cubicle per patient), operating room and large pediatric ward (financed by Anita Smith from the UK). This hospital can be used as a teaching hospital • Asbestos roofing at the senior staff quarters posing health hazards • COVID-19 isolation center identified but awaiting renovation • Limited accommodation for health personnel and the ones available are in poor shape • No polyclinic to handle the large volume of outpatients Bansang school for enrolled nurses and midwives • Limited accommodation for health personnel and the ones available are in poor shape 17 • Asbestos roofing posing health hazards • Limited furniture • No funds from MOH; there is budgetary allocation but the funds are not transferred. Sometimes it is closed for lack of funds. • It prefers some autonomy from the MOH to function properly Bansang Regional Health Directorate • Asbestos roofing posing health hazards • Limited accommodation and the ones available are in poor shape Upper River Region Basse district hospital • Dilapidated hospital with a large population density • Mr. Hamidou Jah of Jah oil has promised to renovate the maternity ward but is awaiting approval from the MOH in Banjul. The Director of Planning and Information and the MOH Maintenance Manager were not aware of this. • Mortuary under construction financed by Mr. Hamidou Jah • Association of Basse residents in the diaspora has promised to renovate the children’s ward • Conducted about 123 deliveries per month in 2019 • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards • A Surgeon has been assigned but there is no functional operating room Gambisara health center • At the time of the visit, the generator was not working and there was no running water which relies on a water pump • Results-based financing incentive payment used to be a source of revenue for minor renovations and operating expenses but there has been no payment for the period January-June 2020. Consequently, some staff have been laid off. • A large building under construction by the benevolent community 18 Western Region 2 Bwiam hospital • It is the only hospital that conducts reproductive and child health outreach services in seven communities. However, transport (availability of vehicle and fuel) remains a perennial challenge • Limited accommodation for health personnel and the ones available are in poor shape • Asbestos roofing posing health hazards • There is a minor operating room and a larger room is designated to be used as a future major operating room. • There is a steep ramp to the room upstairs identified to be used as a major operating room. The mission noted that it will be challenging to wheel preoperative patients up the ramp and advised the Chief Executive Officer to rather identify another area/room for the operating room. Brikama hospital • Located in a densely populated area. The road leading to the hospital gate is overcrowded with vendors and shoppers impeding traffic flow including emergency to and from the hospital • Limited accommodation for health personnel and the ones available are in poor shape • A new operating room has been constructed with financing from philanthropists. • The rest of the hospital is in a state of disrepair. The is no resting room for doctors on call. Orientation session for 40 district chiefs A two-day orientation of all district chiefs in-country on COVID-19 was conducted by the Risk Communication and Community Engagement sub-committee of the National Health Emergency Committee on COVID-19. The orientation was conducted on the 25th and 26th of July at Farafenni, NBER. This activity, which was well attended, was conducted in the form of presentations in English and two local dialects (Wolof and Mandinka). The aim was to sensitize the chiefs on WHO/MoH guidelines and safety measures on COVID-19 awareness and prevention. The chiefs are expected to go back to their various communities and hold step-down trainings on their orientation session. During the orientation, all chiefs were handed visual aids to facilitate their planned cascade training. As part of the activity, action plans were developed by the various chiefs on their planned cascade training in their communities. The action plans detailed out the modalities of the second level training which will happen in the various communities of these chiefs and will be attended by 1,200 village heads in total. This second level training is also supported by the World Bank COVID-19 Emergency Preparedness and Response Project. A key objective of the orientation session with the chiefs was information disclosure of the current WB COVID-19 project and the pipeline GEHSSP as well as to support community leaders with knowledge and 19 skills necessary for effective implementation of recommended COVID-19 preventive and control measures. During the presentation, the WB Task Team Leader spoke extensively on the two projects and this was translated into the two local dialects for the benefit of all in attendance. After his presentation, the environmental and social safeguards (ESS) focal persons (EHU PM, HCU PM, and SOO) presented on the environmental safeguards and grievance redress mechanism. The discussions after the ESS centered around the following: 1. After receiving information on the procurement of clinical waste treatment machines (and by extension the construction of clinical waste treatment plants), the audience raised concerns about how clinical waste is disposed of indiscriminately by private practitioners and wanted to know why that is happening and whether there is a law in place for enforcement on the private health providers. They also asked whether the private sector will have to use the government owned treatment plant, which they believe should happen but at a cost. 2. With the planned construction of a National Blood Transfusion Centre, would the pipeline GEHSSP consider incentivizing voluntary blood donation in a bid to ensure that the national blood bank is always adequately stocked 3. With the increased use of facemasks, as it is now mandatory, how can the two projects contribute to the safe disposal of used masks at home level? 4. When will the call centre switchboard become fully operational, manned by permanent staff, and when will the Community Grievance Redress Team, RGRT, and NGRT be formed and become fully functional? 20