The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) Integrated Safeguards Data Sheet Restructuring Stage Restructuring Stage | Date ISDS Prepared/Updated: 11-March-2020| Report No: ISDSR24881 Regional Vice President: Ferid Belhaj Country Director: Saroj Kumar Jha Regional Director: Keiko Miwa Practice Manager/Manager: Rekha Menon Task Team Leader(s): Nadwa Rafeh The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) . I. BASIC INFORMATION 1. BASIC PROJECT DATA Project ID Project Name P163476 Lebanon Health Resilience Project Task Team Leader(s) Country Nadwa Rafeh Lebanon Approval Date Environmental Category 26-Jun-2017 Partial Assessment (B) Managing Unit Is this a Repeater project? HMNHN PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 120.00 Total Financing 120.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 95.80 Non-World Bank Group Financing Trust Funds 24.20 Concessional Financing Facility 24.20 2. PROJECT INFORMATION The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) PROG_INF O Current Program Development Objective The project development objective (PDO) is to increase access to quality healthcare services to poor Lebanese and displaced Syrians in Lebanon. Proposed New PDO The project development objective (PDO) is to increase access to quality healthcare services to poor Lebanese and displaced Syrians in Lebanon and to strengthen the Government’s capacity to respond to COVID-19. . 3. PROJECT DESCRIPTION Project Status. The Lebanon Health Resilience Project (the Project) was approved by the World Bank Board of Executive Directors on June 26, 2017 and became effective after a significant delay on November 14, 2018, with a closing date of June 30, 2023. The Project Development Objective (PDO) is to increase access to quality healthcare services to poor Lebanese and displaced Syrians in Lebanon. It was financed by a US$120 million loan, consisting of a non-concessional portion of US$95.8 million financed by the International Bank for Reconstruction and Development (IBRD) and a concessional portion of US$24.2 million from the Global Concessional Financing Facility (GCFF). The Project followed condensed emergency procedures as outlined in paragraph 12 of OP 10.00 (Projects in Situations of Urgent Need of Assistance or Capacity Constraints) so that the Government of Lebanon (GOL) could continue to provide critical health services to the target population in the context of the Syrian crisis. The Ministry of Public Health (MOPH) has received US$3.24 million under the Project, consisting of US$2.64 million under the IBRD loan and US$0.6 million GCFF financing, which was approved in May 2019, but has not been disbursed. There are no outstanding audits under the Project. In the January 8, 2020 Implementation Status Report (ISR), given substantial delays in various areas of project implementation, and failure to meet with legal covenants laid out in the Loan Agreement (i.e., an acceptable finalized Project Operations Manual; the bidding and contracting process for the Third-Party Administrator was not been initiated), the PDO, Implementation Progress (IP), Components, Financial Management (FM), Procurement and Monitoring and Evaluation were rated as Moderately Unsatisfactory (MU). On January 23, 2020, the Bank issued a notice of threat of suspension to the GOL and requested that the GOL send the Bank satisfactory evidence that the GOL has made satisfactory progress on meeting the Project’s legal covenants by no later than February 24, 2020, in order to lift the threat of suspension. On February 27, 2020, the GOL provided its response to the notice of threat of suspension and in light of the satisfactory meeting of the conditions specified by the Bank, the threat of suspension was lifted on March 10, 2020. Country Context. An outbreak of COVID-19 caused by the 2019 novel coronavirus (SARS-CoV-2) has been spreading rapidly globally since December 2019, from Wuhan, Hubei Province, China to 115 countries and territories. As of March 11, 2020, the outbreak has resulted in over 114,000 cases and over 4,250 deaths world-wide. The outbreak is taking place at a time when global economic activity is facing uncertainty and governments have limited policy space to act. The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) Like its neighbors, Lebanon is also affected by the COVID-19 outbreak, which poses a threat to its heath system and beyond. The first case of COVID-19 was reported in Lebanon on February 21, 2020. As of March 11, 2020, there have been 61 confirmed cases and 2 deaths. Although a majority of confirmed cases have resulted from international travel, local transmission is highly likely to be taking place, given the disease dynamics and the current testing and containment strategies, which only focus on people with a travel history. The outbreak is expected to grow exponentially, affecting not just the health system but also the economy and security. In response, the GOL has prepared a COVID-19 Health Sector Response Plan and is developing a National Multi-Sectoral Plan. Progress has been made in risk communication to the population, port of entry screening, setting up one testing center and one treatment center. However, the unmet needs are immense. With only one hospital (the Rafik Hariri University Hospital) prepared to treat cases, Lebanon is under- equipped to respond to such a public health emergency. The outbreak is coming at a time when Lebanon’s economy is already going through the worst economic crisis in recent history and the GOL has limited resources to respond. The outbreak further clouds an already strained health sector and will further set back Lebanon’s efforts in its fight against poverty. There are concerns that the outbreak will particularly hit the poor and the refugee population. Lebanon hosts a large number of refugees. Overcrowding and poor living conditions in camps and settlements could further exacerbate the problem and make these camps a breeding ground for the disease. Rationale for restructuring. The purpose of the proposed restructuring is to support the GOL to mitigate the impact of the COVID-19 outbreak. The restructuring responds to a request from the GOL dated February 27, 2020 to add a component to the Project on COVID-19 preparedness and response that will allow for immediate support to assess country preparedness, multi-sectoral response capabilities, and to finance the procurement of medical goods and equipment, and capacity-building and training of health workers and front-line responders. Summary of proposed changes: (a) The PDO will be revised as “ to increase access to quality healthcare services to poor Lebanese and displaced Syrians in Lebanon and to strengthen the Government’s capacity to respond to COVID-19�; (b) A new component will be added “Component 4: Strengthen capacity to respond to COVID-19�; (c) Project funds will be reallocated from Components 1, 2 and 3 to Component 4; and, (d) The Results Framework (RF) will be amended to include new indicators for Component 4 and to adjust the targets for the other three components. While there will be no changes to activities to be delivered under Components 1, 2, and 3, the total cost of each component will be reduced due to the change in the period of coverage from 5 years to 3 years due to delays in project implementation. Changes in Components 1,2, and 3 will be as follows: Original Budget Budget Allocation Original Number of Revised Number of Target Allocation after the Target Groups Groups after Restructuring (Million USD) Restructuring (% of the original) (Million USD) Component 76.5 51.24 -Contracted PHCCs: -Contracted PHCCs: 170 1 204 (83.3%) Component 36.4 23.52 -Lebanese -Lebanese Beneficiaries: 2 Beneficiaries: 340,000 250,000 (73.5%) The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) Component 6.86 5 -Syrian Beneficiaries: -Syrian Beneficiaries: 250,000 3 375,000 (66.6%) Component 0 40 4 Front-end 0.24 0.24 Fee Component 4: Strengthen the capacity to respond to COVID-19. This component will finance the following activities: i. Case detection and surveillance. This will include support for: a. procuring essential commodities for case detection and surveillance such as Polymerase Chain Reaction (PCR) machines, sample collection kits, test kits, and other equipment and supplies for COVID-19 testing and surveillance; b. capacity building in testing and surveillance; and c. strengthening IT system for surveillance. ii. Case management and protection of health workers and response personnel. This will support the strengthening of selected health facilities and establishment and equipping of quarantine and treatment centers, so that they can manage COVID-19 cases, including: a. procuring beds, furniture, ventilators, pulse oximeters, laryngoscopes, oxygen generators, other equipment and supplies for COVID-19 case management; b. Capacity building and training; c. procuring Personal Protective Equipment (PPE), disinfectants and other commodities for infection prevention and control (IPC) as well as healthcare waste management; d. contracting supplementary health workers for COVID-19 treatment centers; e. paying for fees related to COVID-19 services according to a fee schedule and eligible criteria to be developed and agreed with the World Bank; and, f. capacity building in COVID-19 case management and in IPC. iii. Multisectoral response. This will finance goods, services, training and operational costs to support multisectoral activities such as: (i) the operations of command rooms at the central and regional levels, (ii) implementation of risk commutations and community engagement campaigns, (iii) implementation of containment strategies, including port-of-entry interventions, and (iv) operation of rapid response teams. . 4. PROJECT LOCATION AND SALIENT PHYSICAL CHARACTERISTICS RELEVANT TO THE SAFEGUARD ANALYSIS (IF KNOWN) The project will be implemented at the national level. 5. ENVIRONMENTAL AND SOCIAL SAFEGUARDS SPECIALISTS ON THE TEAM Michelle P. Rebosio Calderon, Social Specialist Mohamed Adnene Bezzaouia, Environmental Specialist The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) SAFEGUARD_TABLE 6. SAFEGUARD POLICIES TRIGGERED Safeguard Policies Triggered Explanation Given the scale and nature of the project, the environmental risks associate with the project activities are considered “moderate� triggering Environmental Assessment (OP) (BP 4.01) Yes OP4.01. The project is classified as environmental category “B� in accordance with Operational Policy OP 4.01 Performance Standards for Private Sector No Activities OP/BP 4.03 No interaction with any natural habitats or Natural Habitats (OP) (BP 4.04) No ecosystems are expected Forests (OP) (BP 4.36) No No interaction with any forests are expected Pest Management (OP 4.09) No Not relevant No civil works or activities, which interact with Physical Cultural Resources (OP) (BP 4.11) No physical cultural resources, are expected. Indigenous Peoples (OP) (BP 4.10) No No indigenous people identified. The project does not include any land acquisition and will not involve any displacement of people Involuntary Resettlement (OP) (BP 4.12) No from land or have negative impacts on livelihoods. Because of this, the Bank policy on Involuntary Resettlement OP 4.12 will not be triggered. The project does not have any activities related to Safety of Dams (OP) (BP 4.37) No dams. Projects on International Waterways (OP) The project does not have any activities related to No (BP 7.50) international waterways. The project will not be implemented in any Projects in Disputed Areas (OP) (BP 7.60) No disputed areas. KEY_POLICY_TABLE II. KEY SAFEGUARD POLICY ISSUES AND THEIR MANAGEMENT A. SUMMARY OF KEY SAFEGUARD ISSUES 1. Describe any safeguard issues and impacts associated with the Restructured project. Identify and describe any potential large scale, significant and/or irreversible impacts. The original project includes 3 components as follows: 1) Scaling up the scope and capacity of the PHC UHC program; 2) Provision of health care services in public hospitals; and, 3) Strengthening project management and monitoring. The associated environmental impacts includes health care waste, which includes both potential infectious and non- infectious waste materials. Infectious wastes include infectious sharps and infectious non-sharp materials. Infectious sharps consist of syringe or other needles, blades, infusion sets, broken glass or other items that can cause direct injury. Infectious non-sharps include materials that have been in contact with human blood, or its derivatives, The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) bandages, swabs or items soaked with blood, isolation wastes from highly infectious patients (including food residues), used and obsolete vaccine vials, bedding and other contaminated materials infected with human pathogens. Human excreta from patients are also included in this category. Non-infectious wastes may include materials that have not been in contact with patients such as paper and plastic packaging, metal, glass or other wastes which are similar to household wastes. If no separation of wastes takes place, the whole mixed volume of health care waste needs to be considered as being infectious. Sources of air emissions may include exhaust air from heating, ventilation, and air conditioning systems, ventilation of medical gases and fugitive emissions released from sources such as medical waste storage areas, medical technology areas, and isolation wards. Emissions may include exhaust from medical waste incineration if this waste management option is selected by the facility. In addition, air emissions may result from combustion related to power generation. Contaminated wastewater may result from discharges from laboratories (e.g. microbiological cultures, stocks of infectious agents), pharmaceutical and chemical stores; cleaning activities, and x-ray development facilities. Wastewater may also result from treatment disposal technologies and techniques, including autoclaving, microwave irradiation, chemical disinfection, and incineration (e.g. treatment of flue gas using wet scrubbers which may contain suspended solids, mercury, other heavy metals, chlorides, and sulfates). Depending on the effectiveness of hazardous waste management practices (in particular waste segregation strategies described above), hazardous health care wastes may enter the wastewater stream, including microbiological pathogens (wastewater with a high content of enteric pathogens, including bacteria, viruses, and helminthes / parasitic worms), hazardous chemicals, pharmaceuticals, and radioactive isotopes. From a social perspective, the Project may result in the involuntary exclusion of the poor, and especially those belonging to social and vulnerable groups and may also increase social tensions especially if certain groups are excluded from primary health care services. A robust grievance redress mechanism (GRM) will need to be put in place by the implementing agency. The ESMF for the Project captures all these risks and includes mitigation measures that minimize the above risks and impacts. The restructuring will include a new component, which will address the outbreak of COVID-19 caused by the 2019 novel coronavirus (SARS-CoV-2) which has been spreading rapidly globally since December 2019, from Wuhan, Hubei Province, China to 115 countries and territories. As of March 11, 2020, the outbreak has resulted in over 114,000 cases and over 4,250 deaths world-wide. The outbreak is taking place at a time when global economic activity is facing uncertainty and governments have limited policy space to act. The new Component 4 will include (i) Case detection and surveillance which includes the support for the procurement of essential commodities for case detection and surveillance and training Primary Health Centers to collect samples; (ii) Case management and protection of health worker which will finance setting up additional treatment centers at the governorate level, including procurement of beds, furniture, Personal protective equipment, and other equipment; contracting supplementary health workers; training and capacity building; and (iii) Multisectoral response which will finance goods, services, training and operational costs to support multisectoral activities. This additional component is similar in nature to the 3 components under the parent project and does not introduce new additional environmental and/or social risks. However, since the COVID19 is a new disease additional environmental, health and safety measures will need to be taken as well as increasing capacity of existing GRM. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area. The main impacts which have been identified are direct impacts related to occupational health and safety for the health workers in primary health care units. In addition, health care wastes which will potentially increase in quantities may affect the capacity of the local authorities to manage these wastes which can then result to indirect and long term environmental and public health impacts. These impacts were identified and assessed as part of an The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) Environmental and Social Management Framework (ESMF), which includes a Medical Waste Management Plan to fill any gaps and enhance current practices to help manage the increased capacity challenges. 3. Describe any potential alternatives (if relevant) considered to help avoid or minimize adverse impacts. The restructuring involves emergency response to COVID19 and there are no alternatives in this emergency situation. 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. Given the environmental, health and safety (EHS) impacts associated with health care facilities, basic EHS standards/protocols are mandated at the facility level through an accreditation system. A summary of the accreditation system is in place and an overview of general OHS practices on the ground provide the basis for the development of an ESMF, which includes a Medical Waste Management Plan, to fill any gaps or enhance current practices to manage the increased capacity challenges. The ESMF was publicly disclosed in May 2019. As part of the contracts between the healthcare providers and the PMU, the healthcare providers are required to provide evidence that existing or planned healthcare waste management, storage, collection, treatment and disposal systems are adequate and can accommodate any additional waste quantities that could occur as a result of the expanded coverage. This requirement has been reflected in the Loan Agreement and needs to also be reflected in the Operational Manual. The Ministry of Public Health (MOPH) is responsible for the application of the ESMF. As for the new component 4 under the restructuring, similar mitigation measures will be applied as per the parent project. However, given that the COVID19 is a new disease, additional measures need to be taken related to OHS, waste management, fire life safety, and wastewater management. The GRM also needs to be strengthened to include a designated line for COVID19 intake and processing. This fourth component will be implemented by UN agency(ies) who will abide by World Bank Safeguards Policies. Therefore, there will be new institutional arrangements under component 4 whereby the UN agency(ies) will be the implementing agency(ies) and MOPH will oversee and monitor overall installations. The ESMF will be updated to reflect these additional mitigation measures and institutional arrangements for the new component. Given the urgent nature of this restructuring, this update will be conducted during implementation and before any activities are started. 5. Identify the key stakeholders and describe the mechanism for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The key stakeholders of this project have been identified as follows: (i) Poor Lebanese and Displaced Syrians. Poor Lebanese and the Displaced Syrians in Lebanon, including women, will benefit from the project through a more comprehensive package of PHC services that addresses the specific health needs of this vulnerable population. (ii) Primary Health Care Centers. The project will benefit MOPH network PHCCs by upgrading the capacity of the center, and the skills of health workers and managers to effectively manage the increased demand for healthcare while delivering quality care during, and post, the crisis period. (iii) Public Hospitals. The project will benefit public hospitals by upgrading and refurbishing their equipment, training their staff, and improving the cash flow to improve the quality and efficiency of their operation (iv) The MOPH. The project will contribute to maintaining MOPH commitment to deliver services to the vulnerable population as well as build the capacity at the central level for planning, and project management. The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) The ESMF was consulted upon with the key stakeholders. The results of these consultations are incorporated into the final ESMF which was disclosed on MOPH website in May 2019. The updated ESMF will also be consulted with stakeholders, including UN agency(ies), and will be disclosed once cleared by the Bank. DISCLOSURE_TABLE B. DISCLOSURE REQUIREMENTS ENV_TABLE Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank Date of submission for disclosure For Category ‘A’ projects, date of distributing the Executive Summary of the EA to the Executive Directors “In country� Disclosure COMPLIANCE_TABLE C. COMPLIANCE MONITORING INDICATORS AT THE CORPORATE LEVEL EA_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 Yes and approve the EA report? Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes PDI_TABLE The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank for Yes disclosure? 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 Yes and local NGOs? ALL_TABLE All Safeguard Policies The World Bank RESTRUCTURING ISDS Lebanon Health Resilience Project (P163476) Have satisfactory calendar, budget and clear institutional responsibilities been Yes prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included in the project Yes cost? Does the Monitoring and Evaluation system of the project include the monitoring Yes of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed with the borrower Yes and the same been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader(s) Nadwa Rafeh Approved By Practice Manager/Manager Rekha Menon 11-Mar-2020 .