INTEGRATED SAFEGUARDS DATASHEET APPRAISAL STAGE I. Basic Information Date prepared/updated: 12/12/2012 Report No.: AC6814 1. Basic Project Data Original Project ID: P113349 Original Project Name: Health System Improvement Project Country: Uzbekistan Project ID: P133187 Project Name: Additional Financing to Health System Improvement Project Task Team Leader: Susanna Hayrapetyan Estimated Appraisal Date: December 13, Estimated Board Date: March 21, 2013 2012 Managing Unit: ECSH1 Lending Instrument: Specific Investment Loan Sector: Health (88%);Public administration- Health (8%);Compulsory health finance (4%) Theme: Health system performance (50%);Other communicable diseases (28%);Child health (16%);Injuries and non-communicable diseases (6%) IBRD Amount (US$m.): 0 IDA Amount (US$m.): 93 GEF Amount (US$m.): 0 PCF Amount (US$m.): 0 Other financing amounts by source: BORROWER/RECIPIENT 0.00 Financing Gap 0.00 0.00 Environmental Category: B - Partial Assessment Simplified Processing Simple [] Repeater [] Is this project processed under OP 8.50 (Emergency Recovery) Yes [ ] No [X] or OP 8.00 (Rapid Response to Crises and Emergencies) 2. Project Objectives The overall Project Development Objectives (PDOs) are to (1) improve access to quality health care at the primary level and at Rayon Medical Unions (RMUs) and selected City Medical Unions (CMUs); and (2) strengthen the Government's public health response to the rise in non-communicable diseases (NCD). 3. Project Description The proposed AF would scale up some of the activities that already constitute the original project as follows: Component 1: Improving Health Service Delivery Subcomponent 1.1: Hospital Service Improvement Finance an additional fifty-seven (57) RMUs and fifteen (15) CMUs with modern diagnostic and waste management equipment and medical furniture, and training of hospital managers and staff on functional hospital design, planning, and management. Subcomponent 1.2: Primary Health Care Development Expand activities aimed at improving skills and competencies of medical personnel in early diagnosis, screening and treatment of priority NCDs, including provision of modern medical equipment to an additional 95 central rayon outpatient clinics, 189 outpatient General Practitioner (GP) departments within rayon and city outpatient clinics, 79 urban family medicine policlinics, and 126 rural primary health care (PHC) facilities. Subcomponent 1.3: Clinical Quality Enhancement Support improvements in clinical quality at 57 additional RMUs and 15 CMUs through on-site training of pediatric and internal medicine doctors and nurses in new clinical treatment standards; training in clinical case management and hospital administration; and establishment of quality improvement mechanisms to monitor implementation of the new clinical treatment standards. Component 2: Strengthening Health Financing and Management Reforms Provide support for development of a health information system for the hospital financing pilot in preparation for potential national level rollout, and expansion of the training program for PHC facility managers in financial and health care management. Component 3: Institutional Strengthening on NCD Prevention and Control Support strengthening of capacity in the control and prevention of non-communicable diseases by expanding surveillance and health promotion activities in selected regions in preparation for national level rollout. Component 4: Project Management Strengthen the capacity of the Ministry of Health (MOH), the Central Project Implementation Bureau (CPIB), and the Regional Project Implementation Bureaus for project management and implementation, monitoring and evaluation (M&E), environmental management pursuant to the Environmental Management Framework (EMF), and procurement and financial management (FM) through the provision of goods, consultants' services, training, and incremental operating costs for the additional 24 months of implementation. 4. Project Location and salient physical characteristics relevant to the safeguard analysis The project will support an additional 57 RMUs and 15 CMUs with modern diagnostic and waste management equipment and will provide training to hospital managers and staff on infection control and waste management. There can be potential environmental impacts if project activities are not well managed. As in the original project, World Bank's Environmental OP 4.01 is triggered as Project would indirectly support rehabilitation of health facilities financed by the Government budget. The project is classified as Category B. 5. Environmental and Social Safeguards Specialists Ms Roxanne Hakim (ECSSO) Ms Ruma Tavorath (SASDI) 6. Safeguard Policies Triggered Yes No Environmental Assessment (OP/BP 4.01) X Natural Habitats (OP/BP 4.04) X Forests (OP/BP 4.36) X Pest Management (OP 4.09) X Physical Cultural Resources (OP/BP 4.11) X Indigenous Peoples (OP/BP 4.10) X Involuntary Resettlement (OP/BP 4.12) X Safety of Dams (OP/BP 4.37) X Projects on International Waterways (OP/BP 7.50) X Projects in Disputed Areas (OP/BP 7.60) X 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: There are no large scale construction activities associated with this project. All activities will be within the existing facilities and most of the activities will be of rehabilitation works on existing hospital buildings. There could be a few small new constructions on existing foot print which are not significant nor have irreversible environmental impacts. The rehabilitation works are financed by government budget, not by the AF project. The AF will finance installation of solid waste management technologies, including incinerators. Project activities related to installation and operation of waste management equipment in existing health care facilities are expected to have localized and minor environmental impacts. These include issues related to poor management and disposal of construction waste, inefficient operations of waste management technologies which can result in hazardous emissions, including heavy metals, mercury and Persistent Organic Pollutants, primarily dioxins and furans. However effective mitigation measures and well-managed operations can reduce the risks related to these environmental impacts and their associated longer-term public health impacts. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: If construction activities linked to refurbishment and improvement (minor or large) are properly managed and waste management technologies are operated according to optimum requirements, there are no potential indirect or long term impacts foreseen. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. No project alternatives are considered as the project activities will be in existing locations. 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. As in the original project, OP 4.01 is triggered because the Additional Financing will support the installation of health care waste management treatment and disposal equipment. The Environmental Management Framework (EMF) was prepared for the original project which provides environmental management guidelines, including those for health care waste management. Based on the EMF, a site-specific Environmental Management Plan (EMP) is to be prepared prior to beginning construction at each site. The same procedures will be adopted for sites to be upgraded using government budget under the Additional Financing phase. Guidelines for proper operations and maintenance of waste management equipment will be detailed and followed by beneficiary hospitals. The EMF prepared under the original project detailed the monitoring methodology and the respective agencies which will be responsible for monitoring. This format will also be utilized for the proposed scaled up activities. The Government of Uzbekistan has updated the EMF to include mitigation measures related procurement and installation of medical waste equipment, steps to be taken for improving occupational health and safety measures and a detailed monitoring plan. The EMF was disclosed in-country on the MOH's Web site on November 20, 2012 and on the Bank's Infoshop on November 20, 2012. The AF does not finance any new construction of facilities. All refurbishment and improvement will take place in existing facilities and will be financed by government budget. There will be no land acquisition, relocation or any impacts on access to resources or services. Correspondingly, OP 4.12 on Involuntary Resettlement will not be triggered for the AF. Project activities will target the rural poor, especially those in more remote areas who have been identified as a vulnerable group with regard to access to health care. This will be achieved by upgrading the lower end facilities used by these groups such as outpatient departments and rayon hospitals, as well as improving transparency in the system. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The key stakeholders are hospital employees, patients and local population. Public consultations were held during preparation of the main project and advertised in the national newspapers. Participants included representatives of various medical institutions of Tashkent city and regions of the Republic, State Sanitary and Epidemiological services, State Nature Protection Committee and citizens of Tashkent. Site-specific EMPs are shared by CPIB and consulted with local communities and non-governmental organizations (NGOs). A consultation plan has been developed to continuously engage NGOs and communities on issues related to project activities. The same process will be followed for sites to be rehabilitated by MOH using government budget under the Additional Financing project period. B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 11/15/2012 Date of "in-country" disclosure 11/20/2012 Date of submission to InfoShop 12/04/2012 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Resettlement Action Plan/Framework/Policy Process: Was the document disclosed prior to appraisal? N/A Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Indigenous Peoples Plan/Planning Framework: Was the document disclosed prior to appraisal? N/A Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Pest Management Plan: Was the document disclosed prior to appraisal? N/A Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop * If the project triggers the Pest Management and/or Physical Cultural Resources, 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: n/a C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? Yes If yes, then did the Regional Environment Unit or Sector Manager (SM) Yes review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated in the N/A credit/loan? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank's Yes Infoshop? Have relevant documents been disclosed in-country in a public place in a Yes 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 responsibilities Yes been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included in the project No cost? Does the Monitoring and Evaluation system of the project include the No monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed with the Yes borrower and the same been adequately reflected in the project legal documents? D. Approvals Signed and submitted by: Name Date Task Team Leader: Ms Susanna Hayrapetyan 10/15/2012 Environmental Specialist: Mr Johnson Appavoo 12/01/2010 Social Development Specialist Ms Roxanne Hakim 12/03/2012 Additional Environmental and/or Ms Ruma Tavorath 12/02/2012 Social Development Specialist(s): Approved by: Regional Safeguards Coordinator: Mr Daniel P. Owen 12/03/2012 Comments: Disclosure prior to appraisal duly noted. Sector Manager: Mr Daniel Dulitzky 12/03/2012 Comments: