INTEGRATED SAFEGUARDS DATA SHEET APPRAISAL STAGE Report No.: ISDSA1427 Public Disclosure Copy Date ISDS Prepared/Updated: 03-Mar-2013 Date ISDS Approved/Disclosed: 03-Mar-2013 I. BASIC INFORMATION 1. Basic Project Data Country: Liberia Project ID: P128909 Project Name: Liberia Health Systems Strengthening (P128909) Task Team Rianna L. Mohammed-Robert Leader: Estimated 19-Feb-2013 Estimated 30-May-2013 Appraisal Date: Board Date: Managing Unit: AFTHW Lending Specific Investment Loan Instrument: Sector: Central government administration (10%), Health (90%) Theme: Health system performance (45%), Population and reproductive health (35%), Child health (20%) Financing (In USD Million) Total Project Cost: 15.00 Total Bank Financing: 10.00 Total Cofinancing: Financing Gap: 0.00 Public Disclosure Copy Financing Source Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 10.00 Health Results-based Financing 5.00 Total 15.00 Environmental B - Partial Assessment Category: Is this a No Repeater project? 2. Project Objectives The Project Development Objective (PDO) is to improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities. 3. Project Description 2. The proposed Liberia Health Systems Strengthening (HSS) Project aims to strengthen the Page 1 of 7 institutional foundations needed to improve maternal health, child health, and infectious disease related health outcomes at target facilities through an innovative approach involving systematic and coordinated improvements to the quality of services delivered at target facilities (through Public Disclosure Copy performance-based incentives), and an expansion of health worker skills. Specifically, the project will: (a) focus on improving the quality of care standards (in both diagnosis and treatment) for services with proven effectiveness; (b) increase the availability of qualified graduate physicians (pediatricians, obstetricians, general surgeons, infectious diseases internists, and anesthesiologists); (c) enhance the clinical capabilities and competencies of medical and auxiliary health workers - including nurses, midwives, and physician assistants- in emergency obstetrics, surgery, pediatrics, and infectious diseases; and, (d) improve provider-accountability mechanisms related to both the achievement of results, and health-worker performance at selected facilities. These improvements should provide a thrust towards demand-side utilization and improved outcomes. 3. To make the hospitals accountable and motivated to improve the quality of services provided, a defined quality checklist comprised of key indicators of interest pertaining to clinical outcomes (e.g. adherence to predefined obstetric protocols), structural aspects of services (e.g. availability of drugs and equipment) and intermediate outcomes (e.g. patient satisfaction) will be incentivized. This quality checklist will initially include routine high impact services, but will be updated annually, in line with the introduction of more complex services. The achievement of quality improvement will be heavily dependent on both innovative support to the GMRP, as well as enhanced in-service training of lower cadres of health workers. Notably, in-service training will be aligned with the continuous introduction of more complex skills. 4. The project will achieve its objectives through the following two components: (a) improving the institutional foundations needed to improve the quality of selected health interventions at target facilities (Component 1), and (b) improving health worker competencies to address key health- related concerns (Component 2). A third component will focus on Project Management. Component 1: Improving the quality of health services- particularly related to maternal health, child Public Disclosure Copy health, and infectious diseases at target facilities (US$10 million) 5. Recognizing that quality of care is multidimensional and encompasses both clinical processes, and structural aspects, this component aims to support improvements to the quality of care related to maternal health, child health, and infectious disease interventions at selected hospitals in Liberia through the provision of performance-based incentives to support: (a) improved clinical practice; (b) the development of and adherence to well-established and defined clinical and treatment protocols; (c) health worker motivation (both intrinsic and extrinsic); (d) structural improvements (e.g. availability of drugs and commodities, and health facility rehabilitation); (e) improved management capacity and governance at health facilities; and (f) improved monitoring and record keeping. In addition, increased access to under-utilized/ under-provided services will also be incentivized. Importantly, these improvements (as shown in Figure 1 above) will be heavily dependent on strengthened health worker competencies developed under component 2, and will be supported by (PBF) incentives. A technical overview of PBF is provided in Annex 8. Further details on this component are discussed in Annex 2. 6. This component design is innovative in that it: (i) clearly focuses on the quality of services at target hospitals, given both the existing poor quality and lessons learned from hospital PBF schemes in other countries; (ii) aims to ince ntivize appropriate clinical processes of care; and (iii) it will use a phased approach (i.e. pre-pilot in Montserrado county and larger roll out) in response to weak Page 2 of 7 capacity at target hospitals. Component 2: Improving health worker competencies to address key health-related concerns at target Public Disclosure Copy facilities (US$4.2 million) 7. Component 2 will complement efforts to improve the quality of care at the target health facilities (discussed under component 1), by improving the availability and competencies of health workers in these facilities, in critical areas- obstetrics, pediatrics, surgery and infectious diseases. Whereas PBF is expected to narrow the gap between what health workers know how to do, and actually do (by motivating them to perform better), whilst also improving both the focus on quality and the provision of funding to improve inter alia, the availability of inputs, further performance improvements are dependent on an increase in the numbers of health workers with improved competencies. 8. Component 2 will equip the 6 target hospitals with specialized faculty ( the enhancement of needed teaching infrastructure and supplies is supported under component 1), to support the government's: (a) ongoing effort to develop and implement an innovative graduate medical residency training program (GMRP) – with rotation across the 6 target facilities - to increase the number of physicians with specialized certified skills and competencies related to MCH, and hence quality of care, and (b) the development of an innovative continued professional development and outreach (targeted and needs-based) training program which leverages the increased capacity of residents and faculty under the GMRP to upgrade MCH relevant skills and competencies of lower level cadres- nurses, midwives and PAs- in intervention facilities as well as satellite health centers. 9. Aside from improving much needed health worker skills and competencies at the secondary level, the intervention supported under component 2 is expected to result in a number of additional benefits, including 1) shift the availability of higher level health worker cadres, as well as the culture of health worker training , to health facilities outside of urban Monrovia (residents will be mandated to rotate between semi-urban and rural training sites), 2) reduce the need to pursue specialization and training abroad (and thus reduce outmigration), and 3) improve the overall motivation of health Public Disclosure Copy workers, and thus quality of service delivered (opportunities for training and career development is globally linked to improvement in motivation). Component 3: Project Management 10. This component will support the operational capacity of the MoHSW to effectively manage the project. This will include support to the operational costs of a project- specific unit within the MoHSW (Project Management Unit) that will be responsible for coordinating project activities. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) 11. Targeted secondary level facilities (which include five county-level hospitals) cover approximately 30% of the population of Liberia. Target facilities include a mix of semi-urban and semi-rural health facilities, and ensure that there are close synergies between performance incentives and the health worker competencies developed under component 2. 12. The project triggers OP/BP/GP 4.01 - Environment Assessment. The project is financing drugs and medical supplies that trigger safeguard policies related to medical waste management. Renovating or extending teaching facilities and associated reconstruction of teaching lab space, and resident quarters also requires that an environmental safeguards management plan be put in place to Page 3 of 7 mitigate the possible negative impacts. No new construction will be financed. There will be training which will further enhance the understanding and therefore compliance with the triggered safeguards policy and follow-up instruments to be prepared. Public Disclosure Copy 5. Environmental and Social Safeguards Specialists Dahlia Lotayef (AFTN2) Paula F. Lytle (AFTCS) 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes The project has the potential to increase medical BP 4.01 waste from health facilities. Unregulated disposal of bio-hazardous waste can constitute a serious environmental and social issue in Liberia. Rehabilitation of teaching facilities and associated rehabilitation of teaching lab space and resident quarters also requires that an environmental safeguards management plan be in place to mitigate the possible negative impacts. Natural Habitats OP/BP 4.04 No None of the project intervention areas will be close to any protected areas, including those with any high biodiversity. Also, the incinerators that will be upgraded are not close to any critical habitats, which as as a consequence, could be negatively affected by the project. Forests OP/BP 4.36 No Pest Management OP 4.09 No Public Disclosure Copy Physical Cultural Resources OP/ No The project involves rehabilitation, not BP 4.11 construction or reconstruction. Consequently, this safeguard will not be triggered. Indigenous Peoples OP/BP 4.10 No Involuntary Resettlement OP/BP No This policy is not triggered since the project 4.12 activities do not require any land acquisition that would lead to land acquisition or restrictions of access to resources or livelihoods. Rehabilitation works are minor and within existing facilities. 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 Page 4 of 7 II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues Public Disclosure Copy 1. Describe any safeguard issues and impacts associated with the Restructured project. Identify and describe any potential large scale, significant and/or irreversible impacts: OP 4.01. The project triggers OP 4.01 on Environmental Assessment due to potential increase in generation of health care waste by the existing hospitals and health centers, and the need to properly dispose of these wastes. Some potentially adverse impacts are associated with operation of hospitals and health centers (e.g. medical waste generation and disposal through incineration, waste water disposal, general waste disposal). Land acquisition for construction of health and ancillary facilities is not envisaged. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: The project is not expected to have adverse cumulative or long-term impacts. It will on the contrary introduce better healthcare facility management practices and improved healthcare waste management systems. 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. To ensure compliance with environmental assessment requirements under the Liberia National Environment Act (1995), National Environmental Impact Assessment Regulations 13/1998, relevant Liberian health and environmental regulations, and the World Bank safeguard policies, an Environmental and Social Management Framework has been prepared, incorporating mitigation measures as well as implementation and monitoring responsibilities. There are no environmental Public Disclosure Copy or social issues which cannot be addressed through routine mitigation measures and good practices and funded within the overall level of funding allocated for the project activities. Site specific Environmental Management Plans will be prepared for each one of the few incinerators to be rehabilitated by the Project (for the various levels of health facilities), and submitted to the review of the World Bank prior to starting the actual rehabilitation works. There are no involuntary resettlement issues associated with this project and that OP 4.12 is not triggered since there will not be any land acquisition in the project. Borrower Safeguards Capacity. The borrower has no experience dealing with the World Bank’s environmental and social safeguards policies. The borrower has also limited experience applying the concepts of health care waste management, despite the existence of a national Health Care Waste Management Plan (HCWMP). The Plan outlines interventions for rationalizing, improving and monitoring medical waste management to strengthen safety, and reduce environmental impact. It includes capacity development and training measures. . On the other hand, provision of training to health care staff (professional and support staff) on healthcare waste management has been envisaged into the Project’s preparation phase, using project preparation Funds. The Project’s components and more specifically Subcomponent 1.2 (Management and Capacity building) include additional activities aiming at building the safeguards capacity of the borrower during project implementation. Page 5 of 7 Another important challenge is the poor enforcement of health and environment regulations by the concerned authorities. A review and recommendations for upgrading the existing legal and Public Disclosure Copy institutional frameworks is being also conducted as part of the project’s preparation activities. Compliance with the Project’s safeguards instruments will be the responsibility of the Environmental Health Division of the MOH which is charged with executing the environmental health plans under the overall policy guidance of the National Environmental Protection Agency. The MOHSW and PMU will also work closely to monitor implementation of the ESMF and the HCWM plan by health facilities during project implementation. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Consultations. Local consultations were carried out through meetings and interviews as part of the HCWMP updating. The consultations included the full spectrum of local stakeholders, and were recorded by the HCWMP preparation team and factored into preparation of the said document. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 24-Dec-2012 Date of submission to InfoShop 27-Feb-2013 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure Liberia 25-Feb-2013 Comments: If the project triggers the Pest Management and/or Physical Cultural Resources policies, the Public Disclosure Copy 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 Are the cost and the accountabilities for the EMP incorporated Yes [ ] No [ ] NA [ ] in the credit/loan? 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 Page 6 of 7 Have satisfactory calendar, budget and clear institutional Yes [ ] No [ ] NA [ ] responsibilities been prepared for the implementation of Public Disclosure Copy 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 [ ] 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: Rianna L. Mohammed-Robert Approved By Regional Safeguards Name: Alexandra C. Bezeredi (RSA) Date: 03-Mar-2013 Coordinator: Sector Manager: Name: Olusoji O. Adeyi (SM) Date: 28-Feb-2013 Public Disclosure Copy Page 7 of 7