INTEGRATED SAFEGUARDS DATA SHEET APPRAISAL STAGE Report No.: ISDSA7372 Public Disclosure Copy Date ISDS Prepared/Updated: 31-Jan-2014 Date ISDS Approved/Disclosed: 05-Feb-2014 I. BASIC INFORMATION 1. Basic Project Data Country: Gambia, The Project ID: P143650 Project Name: Maternal and Child Nutrition and Health Results Project (P143650) Task Team Menno Mulder-Sibanda Leader: Estimated 29-Jan-2014 Estimated 25-Mar-2014 Appraisal Date: Board Date: Managing Unit: AFTHW Lending Investment Project Financing Instrument: Sector(s): Health (60%), Other social services (40%) Theme(s): Health system performance (25%), Nutrition and food security (35%), Child health (20%), Population and reproductive health (20%) Is this project processed under OP 8.50 (Emergency Recovery) or OP No 8.00 (Rapid Response to Crises and Emergencies)? Financing (In USD Million) Public Disclosure Copy Total Project Cost: 8.70 Total Bank Financing: 3.70 Financing Gap: 0.00 Financing Source Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 3.70 Health Results-based Financing 5.00 Total 8.70 Environmental B - Partial Assessment Category: Is this a No Repeater project? 2. Project Development Objective(s) A. Proposed Development Objective Page 1 of 6 The development objective of the project is to increase the utilization of community nutrition and primary maternal and child health services in selected regions in the Recipient’s territory. 3. Project Description Public Disclosure Copy Project Description To achieve the expected improvement in health and nutrition outcomes, this project will prioritize selected interventions directly linked to the reduction of maternal and child under-nutrition, morbidity and mortality. Interventions will focus on strengthening community structures and the PHC system to enhance the quality and quantity of services by empowering individual women, communities (including community groups) and front line health workers to improve uptake, participation, ownership, caring practices and accountability for maternal and child health and nutrition. This project will support activities aimed at improving service delivery and utilization as well as knowledge and behaviors to improve maternal and child health and nutrition. Innovative aspects of this project are the combined use of RBF approaches on the demand- and supply-sides and at the community and PHC levels to improve health and nutrition outcomes. The proposed project envisages the following components: (1) facilitating community mobilization for social and behavior change; (2) enhancing delivery of PHC services; and (3) building capacity for service delivery and RBF. As such, components 1 and 2 will apply RBF mechanisms to address demand- and supply-side challenges as well as social and behavioral issues for improving maternal and child health and nutrition outcomes, respectively. Component 3 will strengthen overall management capacity (including monitoring and evaluation) of communities, local government and the health system to effectively engage in results-based management. The roll-out of supply-side and demand interventions will be geographically coordinated to ensure operational costs and subsidy payments are kept within reason. Overall, the project design will look as follows: Component 1: Community mobilization for social and behavior change (IDA US$1.06 million; MDFT-HRI US$1.44 million): This component will focus on community-based promotion of key Public Disclosure Copy family practices (i.e., the 12 family and community practices that promote child survival, growth and development) and health care seeking behaviors for improved maternal, reproductive and child health and nutrition outcomes. Two different RBF mechanisms, combining demand-and supply-side incentives, will be applied: (i) conditional cash transfer (CCT) to individual women to increase demand for health and nutrition services (e.g., antenatal care, delivery care, post-natal care); (ii) conditional cash transfers to communities and support groups (VDCs and VSGs) to increase demand for health and nutrition services through counseling and behavior change communication (BCC) and timely referrals for life-saving health services (e.g., hygiene, sanitation, counseling on infant and young child feeding, delayed first pregnancy and child spacing, referral of pregnant women and children with danger signs to health centers). CCTs will be provided to women for utilizing selected health and nutrition services. Use of the services will be verified by NaNA using health center records and counter-verified by an Independent Verification Agent (IVA) through sample-based verification. Once the data has been verified, payments will be transferred to women by the health centers where the services were provided. VDCs will sign an RBF contract with the RHT. Payments will be quarterly or six-monthly for achieved performance on predefined indicators. NaNA will verify the achievement of results and Page 2 of 6 Community-Based Organizations (CBO) will counter-verify a sample of these results through patient-tracing and client satisfaction surveys. The list of incentivized indicators defined by consensus by NaNA and the MOHSW focus primarily on maternal and child health and nutrition. Public Disclosure Copy Achievement of BCC targets will be verified through reliability assessment of routine monitoring report and community surveys. In addition, equity criteria will be developed to reward geographically remote communities with larger payment amounts to compensate for the additional cost of mobilizing communities and delivering services. A remoteness criterion will be outlined in the Project Implementation Manual (PIM). VDCs can use their payments for operating costs, community mobilization and performance-based incentives to individual members of the VSGs. VDCs, which act on behalf of their communities, can use the cash for community development activities to attain results and benefit the wellbeing of women and children, according to the Financing Instructions and General Orders by the Government. Altogether, this component will finance results, training and workshops, communication, material and equipment (i.e., startup costs) and operating costs. Component 2: Delivery of selected primary health care services (IDA US$1.62 million; MDTF-HRI $2.18 million): Through performance-based incentives, this component aims to support the delivery of selected nutrition and health care services at primary, and, where needed, referral health care levels. A fee-for-services mechanism which includes quantity and quality payments for a defined package of maternal and child health and nutrition services will be introduced. Health centers will sign an RBF contract with the MOHSW and receive quarterly payments corresponding to their achieved performance based on quantity of services delivered and the quality of those services. Health centers can use their RBF payments for material and equipment, training, consulting services and operating costs, and staff bonuses. The component support social entrepreneurship and local level planning at health facility and community levels. Health providers will invest RBF payments to improve service delivery, motivate staff and develop innovative ways to attract more patients. As part of the RBF contracting cycle, each health provider will develop a business plan which serves as a guide for future investments and use of RBF payments. An equity bonus may be paid to offset the Public Disclosure Copy extra costs and hardships experienced by health centers in remote areas to deliver services. Health centers can be Government-run or private (not-for-profit). NaNA will verify the achievement of results and CBOs will counter-verify these on a sample basis and at periodic intervals. While performance-based payments to the health centers are made on selected indicators, RHTs will also monitor the adequate delivery of non-incentivized services. Penalties will be applied in the event of incomplete reports on non-incentivized services or disproportionate bias towards incentivized service delivery. Component 3: Capacity building for service delivery and results-based management (IDA US$1.02 million; MDTF-HRI $1.38 million): This component will support the implementing entities to set up and implement RBF (including contracting and management) as well as supervise, monitor, evaluate and document the project through: (i) long-term technical assistance; (ii) in-service and on-the-job training and consulting services; and (iii) operational research and learning activities. It will cover the costs of: supervision through RBF contracts with the RHT, the Health Centers and the MDFTs; the verification and community surveys by the IVA and CBOs; the analysis of the data to monitor trends in coverage of services in project districts; and the strategic communication and dissemination of information to all the stakeholders. In the initial phase, the capacity building will prioritize strategic purchasing of RBF services by the Project Implementation Committee (PIC) at national level and implementation of the RBF operational cycle at community and health facility levels by Page 3 of 6 VSGs and health facilities. This component will support essential improvement to the community nutrition and health data management systems to enable the roll-out of the RBF mechanism. Public Disclosure Copy The RBF program will be designed to enable learning through operational research, documentation, knowledge management and process and impact evaluations to capture the effect, efficiency and implementation challenges of the program on health and nutrition outcomes, ownership, cost- effectiveness, and other aspects of community mobilization and health system strengthening. The rolling out of process evaluations will be a key feature of the project to strengthen learning from RBF implementation. Finally, this component will cover the operating costs of the program implementation entities, i.e., NaNA, the MOHSW including the RBF Committee, and the IVA. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project will be implemented in selected Regions of the Recipient’s Territory. The selection of Regions will be based on their relative performance on the key nutrition and health outcomes. 5. Environmental and Social Safeguards Specialists Liba C. Strengerowski-Feldblyum (AFTN2) 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes BP 4.01 Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Public Disclosure Copy Physical Cultural Resources OP/ No BP 4.11 Indigenous Peoples OP/BP 4.10 No Involuntary Resettlement OP/BP No 4.12 Safety of Dams OP/BP 4.37 No Projects on International No Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP No 7.60 II. 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: The components 1 and 2 will lead to more health care interventions and therefore may generate Page 4 of 6 more health care waste. As a result, the project triggers the Environmental Assessment policy OP4.01 due to the potential for increased medical waste generation from health facilities and the need for proper management and disposal of this waste. These indirect consequences will not lead Public Disclosure Copy to any major impacts as they refer to a gradual increase in ongoing activities and can be contained provided the client pays extra attention to this issue. As a result, the Ministry of Health and Social Welfare reviewed and revised their Health Care Medical Waste Management Plan (HCWMP) which was publicly disclosed in-country on January 30, 2014 and in the Infoshop on January 22, 2014. Implementation of the HCWMP was discussed and agreed with the client and will be closely monitored during project supervision. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: N.A. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. N.A. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. The project design incorporates the safe and responsible handling and disposal of medical waste through several measures. Additionally, the quality verification tool, a supervision checklist that will be administered on a quarterly basis, includes verification of medical waste measures by the facility. Indicators of medical waste handling will therefore be monitored in every facility on a regular basis. Poor performance on the facility quality tool score impacts the level of payment a facility service provider will receive, so facilities that perform better on waste management practices receive higher payments. This will act as an incentive to health workers to adopt good waste management practices and ensure staff adheres to the guidelines. The project management team and the Regional Project Implementation Committee play an important role in monitoring this aspect of the program. The World Bank safeguard specialist on the team will provide Public Disclosure Copy additional guidance when required. The Health Care Waste Management Plan (HCWMP) has been revised, updated and disclosed. The HCWMP was publicly disclosed in country on January 30, 2014 and in the Infoshop on January 22, 2014. Implementation of the HCWMP was discussed and agreed with the client and will be closely monitored during project supervision. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The institutions to be involved in the implementation of this project, i.e., the Ministry of Health and Social Welfare including the Regional Health Teams and Health Facilities, have the capacity to deal with the rather manageable medical waste expected from the facilities to be supported under the project. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 17-Dec-2013 Date of submission to InfoShop 22-Jan-2014 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Page 5 of 6 "In country" Disclosure Gambia, The 30-Jan-2014 Comments: Public Disclosure Copy 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. If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) Yes [ ] No [ ] NA [ ] report? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the Yes [ ] No [ ] NA [ ] World Bank's Infoshop? Have relevant documents been disclosed in-country in a public Yes [ ] No [ ] NA [ ] place in a form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional Yes [ ] No [ ] NA [ ] responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included Yes [ ] No [ ] NA [ ] in the project cost? Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] Public Disclosure Copy include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] with the borrower and the same been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader: Name: Menno Mulder-Sibanda Approved By Regional Safeguards Name: Johanna van Tilburg (RSA) Date: 03-Feb-2014 Advisor: Sector Manager: Name: Trina S. Haque (SM) Date: 05-Feb-2014 Page 6 of 6