The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Combined Project Information Documents / Integrated Safeguards Datasheet (PID/ISDS) Appraisal Stage | Date Prepared/Updated: 14-Feb-2019 | Report No: PIDISDSA25856 Jan 21, 2019 Page 1 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) India P167581 Andhra Pradesh Health Systems Strengthening Project Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) SOUTH ASIA 18-Feb-2019 15-May-2019 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Ministry of Finance Health, Medical and Family Welfare Department Proposed Development Objective(s) The Project Development Objectives are to improve the quality and responsiveness of public health services and increase access of the population to an expanded package of primary health services. Components Improve Quality of Care Improve Responsiveness of Public Health Services Increase Access to an Expanded Package of Primary Health Services PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 3,440.98 Total Financing 3,440.98 of which IBRD/IDA 327.67 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 327.67 Jan 21, 2019 Page 2 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Non-World Bank Group Financing Counterpart Funding 3,113.31 Local Govts. (Prov., District, City) of Borrowing Country 3,113.31 Environmental Assessment Category B-Partial Assessment Decision The review did authorize the team to appraise and negotiate B. Introduction and Context Country Context 1. India continues to be the world’s fastest growing major economy. After growing at 7.2 percent in FY2017/18, the economy expanded by 7.7 percent in the first half of the current fiscal year. This robust performance was underpinned by a revival in industrial activity, strong private consumption complemented by rising investment, and a rise in exports of goods and services. Meanwhile, the external headwinds that characterized the first half of the year have subsided. The dramatic decline in oil prices, since October 2018, has allowed the current account deficit to return to relatively benign levels. Likewise, the large portfolio capital outflows that materialized from April 2018 onwards (against the background of current account imbalances and heightened perceptions of emerging markets risk) have eased and capital inflows have resumed (resulting in a stabilization of the exchange rate and bond yields). With the normalization of external circumstances, foreign reserves have remained at around US$ 396 billion, which represents a comfortable level (equivalent to about 9 months of imports). Going forward, growth is projected to reach 7.3 percent for the full current fiscal year and to firm-up thereafter, at around 7.5 percent, primarily on account of robust private consumption, a rise in exports of goods and services, and a gradual increase in investments. However, the current account deficit is projected to remain elevated in FY2018/19. 2. Since the 2000s, India has made remarkable progress in reducing absolute poverty. Between FY 2011/12 and 2015, poverty declined from 21.6 to an estimated 13.4 percent at the international poverty line (2011 purchasing power parity (PPP) US$1.90 per person per day), continuing the earlier trend of robust reduction in poverty. Aided by robust economic growth, more than 90 million people escaped extreme poverty and improved their living standards during this period. Despite this success, poverty remains widespread in India. In 2015, with the latest estimates, 176 million Indians were living in extreme poverty while 659 million, or half the population, were below the higher poverty line commonly used for lower middle-income countries (2011 PPP US$3.20 per person per day). Recent trends in the construction sector and rural wages, a major source of employment for the poorer households, suggest that the pace of poverty eradication may have moderated. 3. Andhra Pradesh (AP) is the tenth most populous state in India, with an estimated population of 53.6 million and a population density of 304 per square kilometer (km). Its economy is growing rapidly at 11.6 Jan 21, 2019 Page 3 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) percent (constant GDP growth rate, 2016/17), higher than the national average of 6.7 percent. Its per capita gross state domestic product is about US$ 1,932 (2016) and only an estimated 9.2 percent of the population live below the official poverty line, which is much lower than the national average of 21.6 percent (2011). Approximately 70 percent of the state’s population lives in rural areas and about 17.1 and 5.3 percent of the population comprises scheduled castes and tribes respectively. Agriculture is the primary source of income for about 62 percent of the population (Socio-Economic Survey, AP). Other key sectors in the state include pharmaceuticals, automobiles and textiles. Overall, the state is doing well in promoting the private sector and ranks first in the ease of doing business index for states in India. Sectoral and Institutional Context 4. The state of Andhra Pradesh demonstrates high level of commitment to improving health outcomes. The state ranks eighth out of twenty-one large states in India on overall health performance on a National Health Index developed by the NITI Aayog, the policy think-tank of the Government of India. It ranks a slightly higher seventh on the same index when it comes to annual incremental change in performance indicating that it is not only better than the national average but is also improving rapidly on health performance. The state has also allocated 5 percent of its total public expenditure on health, which is higher than the national average of 3.9 percent. In terms of share of GDP, at 1.1 percent, it is however comparable to the national figure of approximately 1.15 percent of GDP on health. It has also clearly articulated its health sector goals in its vision document – Sunrise Andhra Pradesh - Vision 2029, as achieving a Human Development Index (HDI) of 0.9 and Healthy Adjusted Life Expectancy (HALE) of 64 years by 2029, a gain of 0.4 points in HDI and 6 years in HALE from 2015. A translation of this vision into specific strategies and commitments is further evidence of the AP’s efforts to improve its health outcomes and evolve its health sector to changing health needs and expectations of its population. 5. There have been significant declines in maternal and infant mortality rates and an increase in service coverage in Andhra Pradesh1 over the last decade. Maternal Mortality Ratio (MMR) in the state declined from 154 per 100,000 live births in 2004-062 to 74 per 100,000 live births in 2014-16 (52 percent reduction). Similarly, its Infant Mortality Ratio declined from 54 in 2005/06 to 35 per 1000 live births in 2015/16 (35 percent reduction). These declines were better than the national trends for the same period, which showed a 38 percent and 37 percent reduction respectively. At the same time, coverage of key services such as institutional deliveries, ante- natal checkups (ANCs) and immunization increased. Institutional deliveries increased from 64.4 percent in 2005/06 to 93 percent in 2015/16. ANC checkups for women in the first trimester of pregnancy increased from 66.1 to 82.3 percent and full immunization increased from 46 to 65.3 percent during the same period. 6. These trends while positive, mask the emerging and last mile challenges being faced by the state. 7. A key emerging challenge for the state is the increasing burden of NCDs, which the public health system is currently not well-positioned to address. Today, NCDs in the State constitute 59.7 percent of the disease burden, while communicable, maternal, neonatal and nutritional diseases constitute 27 percent and about 13.3 percent is from injuries. However, like most developing countries, its health system is not geared to address this challenge. Treatment at higher level facilities becomes the automatic response of the health system, as primary level facilities are neither trained nor geared to carry out preventive, promotive care or management of these chronic diseases. The result is a response that focuses on treatment rather than prevention, early detection and 1 Data from SRS, 2004-06 and 2014-16 and NFHS-3, 2005-06 and NFHS-4, 2015-16 2 Data of Andhra Pradesh prior to its bi-furcation in 2014 Jan 21, 2019 Page 4 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) management. Additionally, as NCD screening and care is currently only available at secondary level and above, it often results in poorer access. 8. Last mile challenges exist in the form of disparities in coverage of maternal and child health (MCH) services and outcomes within the state as well as in the quality of MCH service delivery 3. For example, IMR ranges from 48 per 1000 live births in Srikakulam to 25 per 1000 live births in Krishna district. Levels of full immunization too range from 77.7 percent in West Godavari district to 47.7 percent in Sri Potti Sriramulu Nellore. Gaps in the quality of service provision remain. For example, while the percentage of women with four or more ante-natal care (ANC) visits is as high as 76.3 percent, full ANC care which reflects the completeness of the services being delivered is only 43.9 percent. Furthermore, despite 91.5 percent deliveries in the state taking place in health facilities, MMR is as high as 74 per 100,000 live births. 9. Poor quality of care in public health facilities also prevents them from becoming facilities of choice. As per the NFHS-4, 2015-16, quality of care (50.5 percent) is cited as the primary reason for not using government facilities by households that do not use government facilities when sick. Other reasons include waiting time too long (37.2 percent), no nearby facility (36.5 percent), facility timing not convenient (34.6 percent), and absence of health personnel (17.8 percent). This is reflected in the lower utilization rates of public health facilities compared to private health facilities. Currently, 64 percent households (2015–16) do not use a government health facility when sick. While this is much better than the 74.3 percent in 2005–06, indicating the use of public health services is slowly increasing, over half the population goes to the private sector for health care due to issues of quality. 10. The state has initiated efforts to address these challenges and strengthen its public health system, however, there is still a long way to go. Moving forward the state aims to leverage innovative technology solutions, bring in private sector knowhow and expertise into the public health space while at the same time investing in building systems and capacities of public health facilities and staff to cater to the changing health needs of the state. World Bank assistance is sought in scaling up and increasing its pace of achievement, further innovating, consolidating, and delivering more effectively to achieve better results. C. Proposed Development Objective(s) Development Objective(s) (From PAD) 11. The Project Development Objectives (PDO) are to improve the quality and responsiveness of public health services and increase access of the population to an expanded package of primary health services. Key Results 12. The PDO will be measured through the following results indicators: (i) Increase in number of CHCs and PHCs with quality certification (PDO 1 - quality); (ii) Increase in the average patient reported experience score (PDO 2 - responsiveness); 3 Data from NFHS-4, 2015-16 and SRS, 2004-06 Jan 21, 2019 Page 5 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) (iii) Increase in percentage of patients diagnosed and at risk of hypertension and diabetes, managed as per protocol at the SC or PHC (PDO 3 - access); and (iv) Increase in the percentage of pregnant women who receive full antenatal care (PDO 3 -access). D. Project Description 13. The project is supported by an IBRD Loan in the amount of US$327.67 million4 using an Investment Project Financing (IPF) loan with Disbursement Linked Indicators (DLIs). The proposed financing instrument is deemed to be best suited for the GoAP’s results-focused approach toward public health management and the DoHFW’s institutional capacity for monitoring and evaluation, financial management (FM), budget execution, and safeguard systems. 14. The project has three components each reflecting the three parts of the PDO. 15. Component 1: Improve Quality of Care. This component will focus on improving the quality of care in CHCs and PHCs, which are often the first point of contact in the health system. This will be achieved through incentivizing facilities to achieve independent quality certification, purchasing needed clinical and nonclinical services from private providers to complement and enhance quality of public health facilities, and strengthening systems to reduce the risk of potential drug stock-outs. The specific DLIs that will be supported under this component are: (i) Increase in the number of CHCs and PHCs certified as having achieved and maintained national quality standards; (ii) Increase in the percentage of CHCs covered by a full set of performance-based private sector service contracts and improved performance of those contracts towards quality of care; and (iii) Improvement in the pharmaceutical stock management system at the PHCs and CHCs to reduce stock out risks. 16. Component 2: Improve Responsiveness of Public Health Services. This component will focus on improving the responsiveness of public health services by making them more user-friendly and responsive to peoples’ feedback. It will introduce three key institutional measures to facilitate this: (a) an integrated online patient management system that will give patients access to their own health information and facilitate their management through the public health system, (b) a policy to empanel private pharmacies to dispense state- financed drugs to improve their access to the population; and (c) a system to capture patient-reported experience and feedback for service improvement. Results under this component will complement efforts under component 1. Both the electronic patient heath records and the patient feedback systems are considered important elements of quality as they contribute to better patient management, improve feedback to facilities and accountability of service providers. The specific DLIs that will be supported under this component are: (i) Increase in the number of health facilities with an operational integrated online patient management system; 4 This amount includes the front-end fee that will be capitalized into the Loan amount. Jan 21, 2019 Page 6 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) (ii) Private pharmacies empaneled to dispense state-financed drugs, improving access to the population; and (iii) Development and implementation of a system for measuring and reporting on patient experience. 17. Component 3: Increase access to an expanded package of primary health services. This component will focus on expanding the package of services provided at PHCs and SCs to include NCD prevention, screening, and management in addition to strengthening the existing MCH services. A mix of innovative, technology-based approaches on the one hand and strengthening existing staff capacities, systems, and protocols on the other will be adopted to increase access of this expanded package of services. Private sector providers will be contracted to support this expansion. The specific DLIs that will be supported under this component are: (i) Increase in the number of functional e-subcenters; (ii) Increase in the percentage of patients diagnosed and at risk of hypertension and diabetes who are managed at the subcenter or the primary health center; (iii) Increase in the percentage of women in the target age group screened for cervical cancer at subcenters or PHC facilities; and (iv) Increase in the percentage of pregnant women who received full antenatal care. E. Implementation Institutional and Implementation Arrangements 18. The AP DoHFW will be responsible for the implementation of the project. The existing DoHFW governance and management structures and departments will be used for project implementation. The DoHFW Executive Committee (EC) under the Chairmanship of the Principal Secretary, DoHFW, will provide oversight of the project, and the SPIU, which reports to the Principal Secretary, will be responsible for project management and coordination. 19. The Principal Secretary, DoHFW, will be the Project Director and the Director, SPIU will be the Project Coordinator who will be responsible for managing the day-to-day tasks for project implementation and report to the Principal Secretary, DoHFW. Given the results focus of the project, which requires coordinated action by directorates within the DoHFW, effective coordination is possible only when led at the highest level of leadership. Therefore, the designation of the Principal Secretary, DoHFW, as the Project Director is critical to effective implementation. Further, to support day-to-day operations, results monitoring, and administrative reporting requirements, the SPIU will ensure staffing relevant to the core needs of the project. Specifically to oversee and monitor environmental and social safeguards, in addition to the specialist already supporting safeguards preparation at the state level, focal points within the district quality assurance teams will be designated. As the project will be implemented through the routine budget and execution mechanisms of the sector, the quarterly financial reports will be prepared by the finance staff responsible for financial reporting within the SPIU. Procurement, in turn, will be undertaken by the APMSIDC with guidance on technical terms of reference and scope of work from the SPIU and related directorates. 20. In line with the existing implementation structure and programmatic responsibilities within the DoHFW, there are three directorates that will primarily contribute to the achievement of project results. These are the APVVP, the SPIU, and the DPH&FW. The APVVP, which is responsible for managing secondary-level health facilities and ensuring quality of care across facilities, will lead implementation of activities contributing to Jan 21, 2019 Page 7 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) improved quality of care (Component 1). The SPIU, which is responsible for planning, monitoring, and analyzing data from the multiple data sources within the DoHFW for informed decision making, will lead implementation of activities aimed at making health services more responsive to the population (Component 2). In addition, it will coordinate overall project implementation and track results. Finally, the DPH&FW, which is responsible for all activities related to preventive, promotive, and curative services at the primary and secondary levels, will lead implementation of activities contributing to improved access to an expanded scope of services (Component 3). Under each of the three directorates, there are specific administrative staff, teams, health facility staff, and contractors at the state, district, block, and sub-block levels that will be involved in delivering the project results. Additionally, the NHM, coordinated by the State Program Manager, will provide support and financing to all three implementing directorates. 21. Given that the project is an IPF with DLIs, the SPIU will contract the third-party independent verification agency (IVA) to verify the achievement of DLIs using the agreed verification protocols. As the entity responsible for reporting on results, the SPIU will compile the data on results and evidence of DLIs achievement for submission to the IVA and the World Bank . F. Project location and Salient physical characteristics relevant to the safeguard analysis (if known) The proposed project aims to benefit the entire 53.6 million population of Andhra Pradesh. Focus will be on strengthening the 6327 Sub-centers (SCs), 1147 rural Primary Health Centers (PHCs) and 222 Urban Health Centers (UHCs) providing only primary health care services; 195 Community Health Centers (CHCs) providing both primary and secondary care (about 30-50 beds); 23 Area Hospitals (about 100 beds), 24 District Hospitals (about 200-400 beds) and 11 Teaching Hospitals providing secondary and tertiary care. The project will support improvements to meet the NQAS certification standards in PHC and CHC facilities. Hence, limited civil works are proposed under this project which will be carried out mostly within the premises of the existing health facilities. The state of Andhra Pradesh there are 11 CBMWTFs operational and catering to all 13 districts. While most of the District Hospital, Area Hospital, and CHCs are covered by the CBMWTF, the primary data suggests only few PHCs being covered by the CBMWTF, and depend on in-situ treatment and disposal mechanism for solid and liquid waste management through burial pits. Segregation of wastes takes place appropriately at CHC and DH level, but needs strengthening at PHC level. Health care and sanitation workers are being provided the necessary protective gear, but require trainings to strengthen environmental health and safety practices. There are no major accidents reported, and no healthcare facilities are located within proximity to sensitive natural habitats or physical and cultural properties, most of HCFs are connected to all weather road and on government land. The Scheduled Tribes (ST) population at the state level is 5%. The state is divided into 13 districts with presence of scheduled tribes (STs) varying across these districts. Further, five districts have blocks/agencies identified as Schedule Areas as per the Andhra State Order (Cesser), 1955 and A.P Reorganization Act, 2014. There is potential to strengthen delivery basic infrastructure across primary health care facilities, especially in tribal and rural areas across the state. patients, 52% have adequate and separate toilets and 79% of HCFs require minor civil works and refurbishments. The GoAP has created a multi-departmental Program, the Tribal Reform Yardstick, to Jan 21, 2019 Page 8 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) prioritize delivery of health services across seven designated Integrated Tribal Development Agencies (ITDAs) and achieve improvement in the health outcomes of tribal communities. G. Environmental and Social Safeguards Specialists on the Team Sangeeta Kumari, Social Specialist Pradeep Dadlani, Environmental Specialist Sharlene Jehanbux Chichgar, Environmental Specialist Kanchan Rajeevsingh Parmar, Social Specialist SAFEGUARD POLICIES THAT MIGHT APPLY Safeguard Policies Triggered? Explanation (Optional) The project is considered as a Category B. OP 4.01 is triggered as the project will include under Component 1 minor infrastructure refurbishment at PHC and CHC level. The project will also support health systems and service augmentation measures, these interventions will result in greater footfall at the facility level which will result in an incremental increase in bio-medical and other wastes, and risks arising from handling and disposal of healthcare wastes and other products (clinical and infectious waste materials, needles and sharps, and wastewater). This could lead to adverse impacts to the environment and human health if not managed Environmental Assessment OP/BP 4.01 Yes appropriately. There are no potential large-scale, significant or irreversible impacts associated with the proposed project. The risks and impacts associated with minor civil works for repair and rehabilitation will be localized and temporary. To ensure proper management of environmental impacts that might result from the implementation of the project’s interventions, an Environmental and Social Management Framework (ESMF) has been prepared by DoH, GoAP. Based on the guidance provided in the ESMF, a site-specific screening checklist will be used prior to commencement of any Jan 21, 2019 Page 9 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) works and improvements at the facility level. The ESMF provides clear environment health and safety management guidelines for health care workers hired under the various service contracts (biomedical waste management, sanitation, and medical equipment servicing). The ESMF also provides the necessary framework for (i) strengthening of the bio-medical waste management system, such that all bio-medical waste generated are collected and disposed in safe and sanitary manner (ii) health facilities have adequate storage for bio-medical waste within the premises, chemicals and wastewater management systems, and the necessary equipment for segregation of wastes for patient and worker safety, (iii) health facilities are connected to a central treatment plant, and where this is not possible, in-situ disposal mechanisms are adopted (iv) labour and healthcare staff will be provided with appropriate vaccinations, personal protective equipment, and trainings on waste handling and infection control, and (iv) all wastewater is treated and disposed to meet applicable water quality standards. The ESMF references the WBG EHS Guidelines and the sector guidance WBG Environmental Health and Safety Guidelines for Health Care Facilities. The ESMF includes detailed budget provisions for mitigation measures and capacity building, monitoring and reporting requirements at all levels of project implementation. Performance Standards for Private Sector No Activities OP/BP 4.03 OP 4.04 is not triggered as the project will not Natural Habitats OP/BP 4.04 No finance any interventions in natural habitats or that would adversely impact natural habitats. OP 4.36 is not triggered for this project. The project will not finance any interventions (health care centres including the associated facilities such as Forests OP/BP 4.36 No access roads, deep burial pits) do not impact forest areas and do not negatively affect local wildlife and no conversion/degradation of forests is envisaged. OP 4.09 is not triggered as the project will not Pest Management OP 4.09 No finance or promote the use of large scale/significant qualities of pesticides or chemical pest control Jan 21, 2019 Page 10 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) methods that would cause adverse impacts to human health and the environment. OP 4.11 is triggered as a preventative measure. All minor civil and renovation works will be restricted to already existing HCF premises, and the project interventions will not impact PCRs. However in the Physical Cultural Resources OP/BP 4.11 Yes event of unknown PCR within the area, the ESMF includes measures for screening, avoiding and managing impacts on these PCRs as well as chance- find procedures in the event new resources are discovered in the course of project implementation. The presence of STs (5% population at the state level) in the project area triggers the World Bank’s Indigenous People’s Policy (OP4.10). An Environment and Social Management Framework has been prepared under the project to a) identify gaps w.r.t to access and utilization of health services amongst tribal and vulnerable communities and b) to enhance outreach and communication strategies, strengthen village health committees, improve patient experience and usage of public health facilities amongst tribal communities and other marginalized groups. Indigenous Peoples OP/BP 4.10 Yes The draft ESMF has been consulted upon at district and state level (during development of the instrument, and prior to its disclosure) with relevant stakeholders and government institutions including representatives from tribal communities, officials from the Tribal Welfare Department of GoAP, officials from the Tribal Reform Yardstick initiative of the GoAP, health officers working in tribal areas and civil society organizations working on tribal health issues in the state. The ESMF includes a Tribal Development Framework. The project will support minor civil works including refurbishment of HCFs. Activities that can require land acquisition/resettlement are ruled out. In order to monitor application of the policy during Involuntary Resettlement OP/BP 4.12 No implementation, a checklist is prepared to ensure that no instances of land acquisition and/or encroachment are noticed within the project’s scope. The checklist is included in the ESMF. Jan 21, 2019 Page 11 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) OP 4.37 is not triggered as the project will not Safety of Dams OP/BP 4.37 No construct any new dam or carry out works on existing dams. OP 7.50 is not triggered for this project as there are Projects on International Waterways No no interventions planned/proposed that would OP/BP 7.50 impact international waterways. OP 7.60 is not triggered as the project is not Projects in Disputed Areas OP/BP 7.60 No proposed in any disputed area 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 project triggers OP 4.01 Environment Assessment and OP 4.10 Indigenous People’s Policy. The current project design does not have major, indirect or long-term environment or social impacts. No new large-scale construction activity is envisaged and any revamping of health facility infrastructure and processes that includes minor repairs and renovations will be done in the existing premises of the health care facilities, these may lead to impacts at are site specific, temporary and manageable. The key environmental safeguard issues related to this project are associated with infection control, medical waste and wastewater management. The project design by nature addresses the issue of poor health care waste management and will measure the increased number of health care facilities meeting environmental and liquid and solid waste management standards as part of NQAS, as required by the Government of Andhra Pradesh. This addresses any potential issues with health care waste management from the outset. Other potential environmental impacts include (i) soil erosion (resulting from excavations of soils for activities such as burial pits); (ii) noise and vibrations from renovation activities (iii) dust and air pollution such as exhaust air from ventilation, and air conditioning systems, and odour from medical waste storage areas (iii) risks of infections and spread of diseases if appropriate infection control measures are not implemented (iv) risks of water-borne diseases resulting from inadequate treatment of wastewater/ sewerage treatment (v) risks of hazardous health care wastes entering the wastewater stream, including chemicals, disinfectants and pharmaceuticals and (v) accidents and spills in the workplace if worker safety training is not provided effectively. An Environmental and Social Management Framework (ESMF) has been prepared as all interventions and site-specific details are not defined and will serve as a guideline to manage all environment, health and safety risks and impacts through implementation. The positive impacts of the project include improved health status of populations in AP, improved waste management practices, and hygienic, clean and healthy environments within and around health care centres. The presence of STs in the project area triggers the World Bank’s Indigenous People’s Policy (OP4.10). The state is divided into 13 districts with presence of scheduled tribes (STs) varying across these districts. Further, five districts have blocks/agencies identified as Schedule Areas as per the Andhra State Order (Cesser), 1955 and A.P Reorganization Act, 2014. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: There are no potential indirect and/or long-term adverse impacts anticipated due to the project. Jan 21, 2019 Page 12 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. Some investments into decentralized waste and wastewater management systems, and solar rooftop for energy will be made after assessing the available technology options available based on the existing site conditions. 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. An Environmental and Social Management Framework (ESMF) has been prepared under the project, in accordance with OP 4.01 Category B project requirements. The ESMF ensures appropriate assessment of potential adverse risks and impacts and outlines actions to be followed by the borrower in mitigating potential adverse impacts associated with the project. These include (a) strengthening systems and capacity for overall health care waste management (not only bio-medical wastes), wastewater management in health facilities, and worker health and safety provisions; (b) strengthening basic infrastructure/ refurbishments and equipment facilities at the PHC and sub-center-level to manage bio-medical waste, infection control measures, and provide basic provisions (drinking water, seating space, adequate lighting) to enhance overall user experience, particularly in tribal and rural areas; (c) development of IEC material in audio-visual and interactive format and in local dialects for generating awareness especially amongst the illiterate population, vulnerable and marginalized groups; (d) ensuring the proposed system for capturing patient reported experience includes mechanisms to capture grievances and complaints across facilities and districts, evaluate patterns and enhance the user experience of health care; and (e ) orienting existing Village Health Communities and Women’s Self-Help Groups on basic symptoms of different NCDs and available screening and management services to ensure flow of information at the community level. The institutional capacity assessment carried out as part of the ESMF indicates there is a good level of technical capacity within the existing system of DoHFW for environment and social management. The state level Strategic Planning and Innovations Unit (SPIU) has been designated as the PMU for the project, and contains a dedicated, full- time environment and social safeguards specialist already supporting safeguards preparation. The E&S specialist will oversee, monitor and report back on implementation of ESMF activities, and will be supported by District level safeguard specialists which are part of the district quality management teams. Further, at the HCF level, the administrative coordinator will support monitoring of E&S activities on site, as well as the screening checklist, and implementing environment and social mitigation measures at the facility level. All staff supporting safeguards implementation will be provided adequate trainings on Banks safeguards requirements, and continued and refresher training programs on specific areas such as (i) worker health and safety (ii) ESMP monitoring and (iii) bio-medical waste management and general waste management. Capacity of HCF level staff will need to be augmented furthur to manage environment and social risks. This will be assessed on a case to case basis, and preparation of capacity building plan for environment and social for different cadre of HCF staffs and will be part of the regular training calendar being used by the project. The monitoring of ESMF implementation will also be done as per the parameters set under ESMF and will be integrated into the regular monitoring of the project. Data will be collected by the health care facility in charge and collected at district level by District safeguards officer. A monitoring report for the ESMF implementation will also be part of quarterly, six monthly and annual review by the SPIU specialist. This will comprise of all trainings, SOPs developed, equipments, EMPs and SMPs implemented at the HCF level The ESMF includes detailed budget provisions for mitigation measures and capacity building, monitoring and reporting requirements at all levels of project implementation. Jan 21, 2019 Page 13 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) 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 include community members across all districts and tribal areas, local community-based organizations (CBOs), Panchayati raj Institutions (PRIs), CH&FW along with its directorates including NHM and APVVP, and other collaborating departments such as Andhra Pradesh Tribal Welfare Department (APTWD), and Andhra Pradesh Pollution Control Board (APPCB). This includes staff members of health care facilities (HCFs) at district and below and functionaries and representatives of other departments including ITDA officials and district administration. The draft ESMF has been consulted upon at district and state level during development of the instrument, and prior to its disclosure with relevant stakeholders and government institutions. Initial consultations were done during the primary data collection from about 211 HCFs across all 13 districts of AP, and district level consultations in five districts i.e. East Godavari, Guntur, Prakasam, Nellore and Kadapa. The executive summary of the document was translated in local language and made public at the local level. The draft ESMF was disclosed in country on 5 February 2019, on (http://hmfw.ap.gov.in/).) and on info shop on 5 February, 2019.The district-level consultation process was especially sensitive to the needs of the tribal population and specific efforts were undertaken to ensure adequate representation from tribal communities, civil society organizations working in the area of tribal health, representatives of the Tribal Welfare Department, officials from the Tribal Reform Yardstick of the GoAP and other relevant stakeholders. B. Disclosure Requirements OPS_EA_DISCLOSURE_TABLE Environmental Assessment/Audit/Management Plan/Other For category A projects, date of Date of receipt by the Bank Date of submission for disclosure distributing the Executive Summary of the EA to the Executive Directors 04-Feb-2019 05-Feb-2019 "In country" Disclosure OPS_I P_DIS CLOSURE_TA BLE Indigenous Peoples Development Plan/Framework Date of receipt by the Bank Date of submission for disclosure 04-Feb-2019 05-Feb-2019 "In country" Disclosure India 05-Feb-2019 Jan 21, 2019 Page 14 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Comments http://hmfw.ap.gov.in/ C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OPS_EA_COMP_TABLE 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 Practice Manager (PM) review and approve the EA report? Yes Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes OPS_ PCR_COM P_TA BLE OP/BP 4.11 - Physical Cultural Resources Does the EA include adequate measures related to cultural property? Yes Does the credit/loan incorporate mechanisms to mitigate the potential adverse impacts on cultural property? Yes OPS_I P_COM P_TA BLE OP/BP 4.10 - Indigenous Peoples Has a separate Indigenous Peoples Plan/Planning Framework (as appropriate) been prepared in consultation with affected Indigenous Peoples? Yes If yes, then did the Regional unit responsible for safeguards or Practice Manager review the plan? Yes If the whole project is designed to benefit IP, has the design been reviewed and approved by the Regional Social Development Unit or Practice Manager? NA OPS_ PDI_ COMP_TA BLE The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank for disclosure? Yes Have relevant documents been disclosed in-country in a public place in a form and language that are understandable and accessible to project-affected groups and local NGOs? Yes Jan 21, 2019 Page 15 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of measures related to safeguard policies? Yes Have costs related to safeguard policy measures been included in the project cost? Yes Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures related to safeguard policies? Yes Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? Yes CONTACT POINT World Bank Mohini Kak Senior Health Specialist Borrower/Client/Recipient Ministry of Finance Bandana Preyashi Director bandana.preyashi@gov.in Implementing Agencies Health, Medical and Family Welfare Department Dr. Poonam Malakondiah Principal Secretary prl.secy.hmfwap@gmail.com Jan 21, 2019 Page 16 of 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) 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 APPROVAL Task Team Leader(s): Mohini Kak Approved By Safeguards Advisor: Practice Manager/Manager: Rekha Menon 14-Feb-2019 Country Director: Hisham A. Abdo Kahin 15-Feb-2019 Jan 21, 2019 Page 17 of 17