INTEGRATED SAFEGUARDS DATA SHEET ADDITIONAL FINANCING Report No.: ISDSA7312 Date ISDS Prepared/Updated: 15-Apr-2014 Date ISDS Approved/Disclosed: 16-Apr-2014 I. BASIC INFORMATION 1. Basic Project Data Country: Cameroon Project ID: P146795 Parent P104525 Project ID: Project Name: Additional Financing to Cameroon Health Sector Support Project (P146795) Parent Project Cameroon Health Sector Support Investment (SWAP) (P104525) Name: Task Team Gaston Sorgho Leader: Estimated 03-Mar-2014 Estimated 21-May-2014 Appraisal Date: Board Date: Managing Unit: AFTHW Lending Investment Project Financing Instrument: Sector(s): Central government administration (20%), Sub-national government administration (10%), Health (70%) Theme(s): Health system performance (25%), Population and reproductive health (25%), Child health (25%), Tuberculosis (13%), HIV/AIDS (12%) Is this project processed under OP 8.50 (Emergency Recovery) or OP No 8.00 (Rapid Response to Crises and Emergencies)? Financing (In USD Million) Total Project Cost: 20.00 Total Bank Financing: 20.00 Financing Gap: 0.00 Financing Source Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 20.00 Total 20.00 Environmental B - Partial Assessment Category: Is this a Yes Repeater project? Page 1 of 8 2. Project Development Objective(s) A. Original Project Development Objectives – Parent To increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. B. Current Project Development Objectives – Parent C. Proposed Project Development Objectives – Additional Financing (AF) 3. Project Description The Project Development Objectives (PDO) does not change: To increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. The overall objective of this Additional Financing, which does not differ from the original project, is to improve health outcomes among women and children in targeted areas of Cameroon. To that end, the PDO is to increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. The requested additional financing will be used for two purposes: (i) to allow more time and resources for the project to meets its development objectives and complete its impact evaluation, and (ii) to extend the project targeted areas to the poorest departments of Cameroon in the northern regions of the country. The proposed Additional Financing will help to better align IDA’s support to Cameroon’s health system with an enhanced focus on results. It will also support the Government’s commitment to improve access to quality health services for women and children in rural areas with a focus on the poor. The proposed Additional Financing of a US$20 million IDA Credit will support prolongation of implementation of activities under Component 1 of the project for an additional 22 months past the original closing date of March 31st, 2014 (the project closing date was extended for 22 months through a level-2 restructuring that was completed in March 2014). Component 1: District Service Delivery uses Performance-based Financing in 26 health districts in four administrative regions (North-West, South-West, East and Littoral). The Health Results Innovation Multi Donor Trust Fund (HRITF) of US$20 million will support scale-up of Performance Based Financing to additional target populations in the poorest regions of Cameroon. Building on the successful PBF pilot in 26 health districts currently included in the operation, the government is keen to expand this initiative to the Northern Regions of the country (Adamaoua, North and Far-North). The proposed trust fund will support a range of activities under Component 1 (District Service Delivery) in the Northern Regions. This component will provide PBF payments to health facilities and community health workers in the targeted regions conditional on the quantity and quality of services delivered. The project components are as follows: Component 1: District Service Delivery (US$35 million: US$17.5 million IDA AF and HRITF US $17.5 million). In the 26 districts currently covered by the Project and the eight additional departments where PBF will be scaled-up, this component will provide PBF payments: (i) to health Page 2 of 8 facilities in the targeted regions conditional on the quantity and quality of services delivered via in- clinic activities and/or via health-outreach activities, and (ii) to community health workers for providing selected basic health services as well as ensuring community organization to support positive health behavior. Community health workers who are sub-contracted by health facilities with PBF contracts, will use PBF payments to (i) increase the quantity and the quality of (a) selected basic health services for common illnesses such as malaria, acute respiratory infections and diarrheal illnesses, (b) outreach activities in support to facility-based health workers, and (c) referrals of community members to health facilities for illness episodes that cannot be treated at the community level; and to (ii) keep a certain percentage of the payment as a bonus which will be based on their performance. Component 2: Institutional strengthening (US$5 million: US$2.5 million IDA AF and HRITF US $2.5 million). The component supports institutional strengthening at national, regional, and district levels, particularly focusing on PBF contract design and management and establishing a unified health management and geographic information system to generate up to date, reliable, financial and programmatic data. The Component also supports project management and implementation. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project is currently being implemented in the North-West, South-West, Littoral and East Regions. The Additional Financing will extend the project location to selected districts in the North, Far North and Adamaoua regions. 5. Environmental and Social Safeguards Specialists Alexandra C. Bezeredi (AFTSG) Lucienne M. M'Baipor (AFTCS) Emeran Serge M. Menang Evouna (AFTN1) 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes The project will increase the production of BP 4.01 medical waste. The Waste Management Plan produced for the Parent project will remain applicable in the case of the Additional Financing. Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources OP/ No BP 4.11 Indigenous Peoples OP/BP 4.10 Yes Indigenous peoples such as the Baka live in the original project zone of the Eastern region and the proposed Additional Financing of US$20 million IDA will support prolongation of implementation of activities under Component 1 in this region for Page 3 of 8 additional 22 months. The IPPF was developed and disclosed during the preparation of the original project. The IPPF will be updated, maintained and implemented accordingly, with specific action plans being prepared at the local level. Early on in project implementation a social audit will be conducted to assess in-depth perceived and real benefits of the project among the indigenous populations in the targeted regions. During project implementation Indigenous Peoples Plans (IPPs) will be prepared to ensure that: free, prior and informed consultations leading to broad community support are held; the IPs are not adversely affected by the project; they receive culturally appropriate benefits from the project; there is a grievance redress mechanism; and, there is monitoring and evaluation of the projects impacts on and benefits for IPs. Involuntary Resettlement OP/BP No 4.12 Safety of Dams OP/BP 4.37 No Projects on International No Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP No 7.60 II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: The Additional Financing retains the Environmental Assessment category of the original project, i. e., Category B. It also triggers the same safeguards policies as the parent project: OP/BP. 4.01- Environmental Assessment and OP/BP 4.10 - Indigenous Peoples. The project activities will not result in large scale negative impacts. Nevertheless, as the project seeks to increase of the utilization and the improvement of the quality of health services with a particular focus on child and maternal health and communicable diseases, this will, even at a small scale, increase medical waste production particularly Health Care Risk Waste (HCRW). The MWMP will remain one of the safeguards instruments for this Additional Financing and it includes relevant mitigation measures to avoid or minimize potential adverse impacts. It was disclosed in country and at the InfoShop on April 04, 2008. There are Indigenous Peoples present in the East Region of Cameroon, which is targeted by the original project and Additional Financing. The project is expected to have a positive social impact by improving access to health care services for poor and vulnerable households. Component 1 Page 4 of 8 (through the payment for performance) will provide incentives for health facilities to target vulnerable groups in their catchment areas and provided subsidized care to these groups, leading to improved financial access for the poor and vulnerable. The IPPF which was prepared, consulted upon, and disclosed in April 2008 under the original project remains valid for this AF. During implementation of the parent project, the borrower implemented measures to ensure that IPs in the project area were informed about project activities, consulted about their preferences as project beneficiaries, and able to benefit from the health services provided by the project (through pre- paid enrollment in health care mutual or direct assumption of health care costs). During implementation of this AF, a social audit will be conducted to assess in-depth perceived and real benefits of the project among the indigenous populations in the targeted regions. Indigenous Peoples Plans (IPPs) will be prepared to ensure that: free, prior and informed consultations leading to broad community support are held; the IPs are not adversely affected by the project; they receive culturally appropriate benefits from the project; there is a grievance redress mechanism; and, there is monitoring and evaluation of the projects impacts on and benefits for IPs. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Based on the project environmental studies, no indirect and/or long-term negative impacts are expected. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. None. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. The Borrower agreed to maintain the implementation of the Medical Waste management Plan prepared and disclosed for the parent project. The Ministry of Public Health has a unit that is responsible for environmental issues which works in close collaboration with the Ministry of Environment, Nature Protection and Sustainable Development (MINEPDED). The Unit has well trained staffs and when necessary seeks support from MINEPDED or external consultants. It was agreed that the same arrangement will be maintained during the implementation of the Additional Financing period. Medical Waste Management Practices are expected to improve through the intervention as they are a key component of quality of service delivery assessments that are used to pay performance subsidies to health facilities. Thus health facilities will receive direct incentives to improve medical waste management practices. The assessment of the waste management implementation was satisfactory as most of the actions proposed were implemented including follow-up workshops. Component 1: District Service Delivery (through the payment for performance) will provide incentives for health facilities to reduce staff absenteeism and to improve staff responsiveness with patients. As a result, health facilities with PBF contracts will in turn provide more and better care for medical waste management. The improved management of Medical waste will be a PBF indicator. The Government also prepared and disclosed an Indigenous Peoples Planning Framework (IPPF) in 2008 to ensure that the Indigenous Peoples located in the East region would benefit from the project. Consultations with beneficiaries, the Government, the Performance Purchasing Agency (PPA) in the East region, and local community-based organizations hired to conduct client Page 5 of 8 satisfaction surveys, have confirmed that Indigenous Peoples in the East region have been benefitting from the intervention in several ways: (i) improved availability and quality of health services, community outreach campaigns by local health agents and community leaders for improved health knowledge and health-seeking behavior, with a focus on vulnerable populations, (ii) including specific components of the intervention to push for increased access to and utilization of health services among vulnerable groups through targeted subsidies at the point of service delivery, and (iii) supervision and implementation support activities to monitor and assess if the health intervention was benefiting vulnerable groups and indigenous peoples. The PPA in the East region has maintained a continuous dialogue with indigenous groups in the region to assess their perception of the intervention and incorporate their recommendations into their PBF approach tailored for the East region. Early on in project implementation a social audit will be conducted to assess in-depth perceived and real benefits of the project among the indigenous populations in the targeted regions. During project implementation Indigenous Peoples Plans (IPPs) will be prepared to ensure that: free, prior and informed consultations leading to broad community support are held; the IPs are not adversely affected by the project; they receive culturally appropriate benefits from the project; there is a grievance redress mechanism; and, there is monitoring and evaluation of the projects impacts on and benefits for IPs. The project is expected to have a positive social impact by improving access to health care services for poor and vulnerable households. Component 1 (through the payment for performance) will provide incentives for health facilities to target vulnerable groups in their catchment areas and provided subsidized care to these groups, leading to improved financial access for the poor and vulnerable. PBF subsidies will also aim to reduce staff absenteeism and to improve staff responsiveness with patients. As a result, health facilities with PBF contracts will in turn provide increased and improved care for marginalized populations and also improve medical waste management. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The IPPF and Medical Waste Management Plan (MWMP) were originally discussed at in-country workshops with key stakeholders and local media covered the dissemination prior to the launch of the parent project. The documents were disclosed in-country on April 4, 2008 and at the Infoshop on April 3rd, 2008. It was agreed that the Medical Waste management Plan prepared in 2008 despite its relevance, will need an update early on during the AF project implementation to define more concretely what will be implemented in the new project areas sites. During the update process, all relevant stakeholders will be consulted and the updated MWMP will be disclosed in- country and at the InfoShop. During project implementation the PIU and Performance Purchasing Agency managers will consult and organize knowledge sharing sessions on waste management best practices. During implementation support missions, the World Bank environmental and Social safeguards team will ensure that the main stakeholders are consulted and also that the environmental and social indicator are integrated in the PBF payments criteria. The main stakeholders are among other: Local communities closed of the Health Care facilities Communities Based Organizations in charge to sensitize local communities National and International NGOs involved in the Health issues Health Centers staffs Page 6 of 8 Administrative and Traditional authorities The IPPF and MWMP were discussed at in-country workshops with key stakeholders and disclosed at the Infoshop and local media covered the dissemination. During the project re launching the IPPF and the MWMP will be shared by the main stakeholders. During the project implementation the PIU and the PBF managers will consult and organize knowledge sharing sessions on the waste management best practices. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 02-Apr-2008 Date of submission to InfoShop 03-Apr-2008 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure Cameroon 04-Apr-2008 Comments: Indigenous Peoples Development Plan/Framework Date of receipt by the Bank 02-Apr-2008 Date of submission to InfoShop 03-Apr-2008 "In country" Disclosure Cameroon 04-Apr-2008 Comments: If the project triggers the Pest Management and/or Physical Cultural Resources policies, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/ Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) Yes [ ] No [ ] NA [ ] report? If yes, then did the Regional Environment Unit or Sector Yes [ ] No [ ] NA [ ] Manager (SM) review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated Yes [ ] No [ ] NA [ ] in the credit/loan? OP/BP 4.10 - Indigenous Peoples Has a separate Indigenous Peoples Plan/Planning Framework Yes [ ] No [ ] NA [ ] (as appropriate) been prepared in consultation with affected Indigenous Peoples? If yes, then did the Regional unit responsible for safeguards or Yes [ ] No [ ] NA [ ] Sector Manager review the plan? Page 7 of 8 If the whole project is designed to benefit IP, has the design Yes [ ] No [ ] NA [ ] been reviewed and approved by the Regional Social Development Unit or Sector Manager? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the Yes [ ] No [ ] NA [ ] World Bank's Infoshop? Have relevant documents been disclosed in-country in a public Yes [ ] No [ ] NA [ ] place in a form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional Yes [ ] No [ ] NA [ ] responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included Yes [ ] No [ ] NA [ ] in the project cost? Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] with the borrower and the same been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader: Name: Gaston Sorgho Approved By Regional Safeguards Name: Alexandra C. Bezeredi (RSA) Date: 16-Apr-2014 Advisor: Sector Manager: Name: Trina S. Haque (SM) Date: 16-Apr-2014 Page 8 of 8