The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) Concept Environmental and Social Review Summary Concept Stage (ESRS Concept Stage) Public Disclosure Date Prepared/Updated: 12/13/2019 | Report No: ESRSC00981 Dec 13, 2019 Page 1 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Egypt, Arab Republic of MIDDLE EAST AND NORTH P172426 AFRICA Project Name Supporting Egypt’s Universal Health Insurance System Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 1/12/2020 3/31/2020 Population Financing Borrower(s) Implementing Agency(ies) Ministry of Finance Ministry of Finance Proposed Development Objective(s) To increase the coverage of Egypt’s Universal Health Insurance System (UHIS) in Phase 1 Governorates and to Public Disclosure strengthen UHIS-related governance and institutions Financing (in USD Million) Amount Total Project Cost 511.28 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The project will support Egypt to implement its new Universal Health Insurance System (UHIS) as envisioned in the newly passed Universal Health Insurance Law (UHIL) in Phase I Governorates over a 4-year period. It uses the Investment Project Financing (IPF) instrument with a DLI approach in which the government will be reimbursed for eligible expenditures after the verified achievement of DLIs. The project will support three components: Component 1: Enrollment and empanelment of the population into UHIS Dec 13, 2019 Page 2 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) Component 2: Strengthening capacity of UHIS-related agencies, UHIS governance and creating a facilitating environment Component 3: Technical assistance, project management and M&E D. Environmental and Social Overview D.1. Project location(s) and salient characteristics relevant to the ES assessment [geographic, environmental, social] According to the universal health insurance law (No. 2/2018), health insurance shall be universal, across the whole country, over 6 phases within 15 years. The Bank project is planned to support implementation of phase 1, which should cover 6 governorates—Port Said, Suez, Ismailia, South Sinai, Luxor, and Aswan . (Note: According to law 2/2018, the phase 1 governorates are Port Said, Suez, Ismailia, South Sinai, and North Sinai. The government however removed North Sinai and shifted Luxor and Aswan from phase 2 to phase 1. The reasons behind that are indicated to be the security issues in North Sinai and infrastructure readiness in Luxor and Aswan.). The first 3 governorates are located along Suez Canal; the fourth is located in Sinai Peninsula; and the last 2 are located in Upper (southern) Egypt. The 6 governorates are home to about 5.6 million people, out of nearly 100 million at the national level. From a social perspective, the project will mainly support enrollment of target beneficiaries (Component 1), including the disadvantaged groups, primarily the poor, for whom the project shall incur contributions. These groups were defined by a Prime Minister’s decree (No. 1948/2019), and their identification is expected to entail extensive efforts, particularly since Egypt’s poverty tends to be of a shallow (rapidly changing) nature. Consequently, ineligible inclusion and exclusion is expected to be one of the key social concerns, which is likely to result in a sizable volume of grievances, particularly since the number of poor people in the targeted 6 governorates is roughly 2 million, with notable concentration in Luxor and Aswan. Public Disclosure Poverty rate in the targeted governorates is as follows: Port Said, 6.7%; Suez, 20%; Ismailia, 32%; Aswan, 46%; South Sinai, 51%; and Luxor, 55% (CAPMAS 2018). Port Said and Suez have no rural populations, South Sinai is classified as a border governorate, and the remaining 3 are predominately rural. At the same time, large proportions of South Sinai population (approximately 50%) and some of Ismailia population too are classified as tribal groups, who have their distinct customs and culture. The lack of homogeneity among target governorates, in terms of e.g. socioeconomic conditions, would require a contextually differentiated approach with respect to awareness raising and targeting of disadvantaged groups who shall be eligible for non-contributory coverage. In the meantime, the application of the accreditation criteria on service providers (facilities) is expected to result in good-quality services. However, there could be a risk that a limited number of facilities would qualify for accreditation in poorer governorates. There are also challenges across the country and particularly in remote and rural areas related to the lack of trained workforce. On the environmental side, the proposed project will not be supporting any construction works, rehabilitation, procurement of medical equipment or healthcare service provision. Component 2 will support the UHIS operating costs for orientation and training, registration and accreditation as well as other quality of care interventions. Also, component 3 will support capacity building activities and technical assistance for the UHIS-relevant agencies namely, Universal Health Insurance Agency (UHIA) and the General Authority for Healthcare Accreditation and Regulation (GAHAR). D. 2. Borrower’s Institutional Capacity The implementing agency (borrower) of this project will be the Ministry of Finance (MOF), which has been a long- standing partner with the Bank and the main borrower on behalf of the Government of Egypt (GOE). However, this IPF operation represents MOF’s first experience as an implementing agency. Furthermore, the new health insurance system tends to be institutionally transformational in the sense that it has created 3 new (nascent) entities: 1) GAHAR, which is primarily responsible for accreditation of healthcare service providers; 2) UHIA, which is responsible for Dec 13, 2019 Page 3 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) revenue collection and contracting with service providers; and 3) Health Care Organization, which is responsible for service provision. As such, the implementing agency will need to closely coordinate with each of these key entities to ensure that all activities pertaining to management of environmental and social (E&S) risks are integrated. Such activities include, but are not limited to, development of a Stakeholder Engagement Plan (SEP) and an Environmental and Social Commitment Plan (ESCP), as well as implementation of these plans in coordination with the different involved parties. The Project Management Unit (PMU) is yet to be formed under the MOF. The E&S team will therefore take the opportunity to advise the implementing agency on the expected responsibilities and the potential makeup of the PMU from an E&S perspective. In that sense, the current level of capacity of the related institutions is assessed to be limited relative to the size of the project, the associated social risk, indirect environmental risk, and the commitments needed for engaging with stakeholders as mentioned above. The Borrower’s capacity to manage E&S risks will be further assessed during project preparation to determine any capacity gaps and specific training needs in relation to the ESF. II. SCREENING OF POTENTIAL ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Moderate At this stage, the proposed project will not be supporting any construction works, rehabilitation, procurement of medical equipment or direct healthcare services provision. Also, the project may introduce “green healthcare facility” Public Disclosure principles to take advantage of the roll-out of the UHIS in channeling environmental benefits into better service provision, such as improving energy efficiency in hospitals. Consequently, no direct significant negative environmental impacts are anticipated. The project entails supporting the UHIS’s two, out of three, main entities (UHIA and GAHAR) to carry out their mandates which do not include provision of medical services. Currently the technical assistance activities are not finally identified, however they are anticipated to be limited to strengthening the institutional setup of the two mentioned entities to support the rolling out of the UHIS. Therefore, the direct environmental impacts of the project can be considered minimal. However, at the national level, investigating the effects of expanding the health insurance coverage on health care services utilization is necessary to determine if the rolling out of the UHIS will lead to increase in different health care waste streams. These associated indirect environmental impacts are considered linked to the project interventions from an environmental perspective. Accordingly a Strategic Environmental and Social Assessment (SESA) study shall be conducted to examine the environmental risks associated with the whole roll-out program and the current capacity of the government to manage potential increase of different waste streams resulting to the program implementation. Therefore, due to the fact that the project as designed now will generate minimal direct environmental risk and impact but may induce associated indirect environmental risks and the capacity of the implementing agency remains uncertain at this stage, the environmental risk rating of the project is currently considered moderate. Social Risk Rating Substantial The project will not involve construction works, land acquisition, or recruitment of a large number of workers. However, the main social risks are stemming from the transformative and very ambitious nature of the Government’s program (and consequently the project as well). Below are the main anticipated social risks: Dec 13, 2019 Page 4 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) Cultural Aspects: While the UHIS involves immense opportunity to improve access to the poor, increase utilization of health services, and reduce the burden of out-of-pocket expenditure on healthcare, its gatekeeping mechanism may challenge the deeply rooted culture of Egyptians who tend to have more trust in the specialized doctors rather than the general practitioners or the family doctors. Because this is a very widely dominating practice, it is expected that building trust in the system to reach the anticipated utilization will take time and will likely need a gradual process of testing, trial and learning. Exclusion of the intended beneficiaries if eligibility screening system does not work well: The Bank will support enrollment of the targeted population, including the disadvantaged groups, in the new UHIS (component 1). Under this component, eligible disadvantaged population will be covered for free, although there are always risks of exclusion errors that typically come with poverty targeting programs. Potential exclusion of the marginalized groups: The unified set of criteria under the afore-mentioned PM’s Decree suggests a potential risk of excluding certain groups in the cases where the Governorate context has some special characteristics (demographic, socioeconomic and cultural) such as the tribal groups in South Sinai and Ismailia. That may suggest that neither the unified criteria nor the unified style of service provision will benefit them in an ideal manner. Financial burden on the near-poor: The project entails collection of contributions from the wider Egyptian population, in a progressive manner (well-off groups with higher income will pay more) to ensure equity and solidarity. For the lowest stratum of the near-poor, there could be some negative economic impacts that need to be further assessed to avoid exposing those groups to impoverishment, because they will still be paying premiums and copayments. Potential economic risk on groups of stakeholders: Due to the complexity of the health sector stakeholders landscape Public Disclosure and interests, there are also some uncertainties related to how the project will affect certain groups. For instance, the risk on the local private clinics which are employing large number of doctors and support staff needs to be assessed further. During the first 2-3 years of the Project, it is unlikely that the private clinics will be enrolled into the system. Yet, this is not necessarily seen as risk of crowding out for them because the assumption is that patients, because of the cultural consideration, will remain at early stages inclined to follow the service model of the specialized private doctors that they are accustomed to. The assumption is that private clinics’ enrolment as well as increased utilization of the new system (by citizens) will take place gradually. Similarly, the net effect on the pharmaceutical business (which is a huge business in Egypt with 90% of medicine locally manufactured) is still uncertain. There is an assumption that the volume agreements with the new system will be profitable for the companies, yet this is still to be tested. On the level of the health insurance companies, the assumption is that the Government will develop a mechanism (agreement) to avoid crowding these companies out of the market. In light of these potential risks, coupled with limited institutional capacity of implementing agency particularly at the preparatory stage, the social risk is assessed as substantial. The risk could be revisited at following stages based on the more careful assessment of impacts which will take place as the project evolves. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: Dec 13, 2019 Page 5 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) In general, the project is expected to result in commendable social impacts, in terms of provision of financial protection to disadvantaged groups and delivery of good-quality healthcare. Due to lack of up-to-date and comprehensive socioeconomic data at the household level, coupled with the dynamic nature of poverty in Egypt, some vulnerable groups, such as the near-poor, may be left behind in terms of contribution-exemption or subsidy. Moreover, collection of contributions from such groups may result in negative socioeconomic impacts that may push them below the poverty line. Inclusion and exclusion errors are also expected. Additionally, the system does not seem to provide miscellaneous, yet essential, financial support to the disadvantaged (contribution-exempted) groups as well as their indispensable care providers/escorts. Such support includes, for instance, transport allowance for the cases which will be referred to secondary or tertiary levels for further treatment. A large portion of the population of South Sinai Governorate and some in Ismailia too are of tribal groups. Tribes in South Sinai became in recent decades more open to the tourism industry which resulted to a large extent in changing the characteristics of the local tribes by making them more open to outsiders and less attached to the geographically distinct habitats, ancestral territories, or areas of seasonal use or occupation. Despite the fact that tribes in the target area have a unique dialect, it is predominantly composed of Arabic vocabulary, which makes it understandable to most of Egyptians in normal cases. Customary institutions and tribal laws are still applying but only on land and fame related issues. The same applies to Ismailia’s local tribes. the project is not going to result in any negative impacts on the land or natural resources used by those tribes. However, these groups will require to be dealt with using special measures as marginalized groups. They will likely need contextually-sensitive criteria in terms of targeting for contribution-exemption. The same should apply to other related aspects, such as citizen engagement, GRM, and service provision which all should be tailored to be sensitive to the special characteristics of those groups. It is, for instance, common that women in these culturally-conservative Public Disclosure groups do not generally feel comfortable visiting a male doctor. It is also the case that majority of the offered classical education and health services in the tribal areas were not properly utilized because they are culturally inappropriate. Meaningful and culturally sensitive consultation with those groups will need to be conducted during the life cycle of the project. Prior to project appraisal, a Social Impact Assessment (SIA) shall be conducted to identify the potentially adverse social impacts and risks and to provide input to the design of the project at an early stage. For adaptive social risk management purpose, SIA process will continue after project appraisal and during the project implementation throughout whole project life. The SIA will feed into changes of the project implementation arrangements to ensure the social risks and impacts are adequately managed and mitigated. Overall, the project will result in minimal direct environmental impacts as the interventions do not include construction works, rehabilitation or procurement of medical equipment. The potential indirect environmental risks are associated with increasing the utilization of healthcare services due to the rolling out of the UHIS. These indirect environmental risks include increased disposal of hazardous medical waste and generation of more wastewater in addition to the associated occupational health and safety risks for workers, patients and visitors at phase 1 governorates. At the project level within the healthcare service provider boundaries, GAHAR will be responsible for accrediting healthcare facilities including hospitals, clinics, laboratories, etc. to be eligible for providing the service under the UHIS. The accreditation standards include the requirement of service providers to comply with the national laws’ requirements including environmental and labor laws. Additionally, GAHAR is developing a specific standard on environment and facility safety for healthcare service providers to detail the minimum requirements on the topics of waste management, wastewater, infection control and patients and visitors’ safety. The scope of the standard is Dec 13, 2019 Page 6 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) limited to management of various envrionmental health and safety aspects within the healthcare facility boundaries (ie. waste disposal and treatment facilities are not included). Accordingly, it is essential before appraisal stage to align GAHAR’s environment and facility safety standards with the World Bank Group’s (WBG) Environmental, Health, and Safety (EHS) guidelines for healthcare facilities. Therefore, a gap analysis is proposed to assess differences between both standards and to recommend actions to bridge any identified gap. This will ensure that service providers enrolled in the UHIS are applying international best practices during the project lifecycle. Notably, there is currently limited available information on the institutional capacity at the project level (GAHAR) to accredit the service providers and to ensure maintaining the standards. At the project’s governorates level, extending health insurance to achieve universal coverage will improve access to medical services. At this stage, it is still unidentified if this improvement will be significant to increase utilization of current healthcare facilities, create a demand for new and expansions of healthcare facilities and accordingly waste treatment and disposal facilities. Therefore, the potential environmental risks associated with the roll-out of the UHIS shall be considered during the project implementation, including the potential increase of hazardous waste and wastewater in phase 1 governorates. The borrower shall monitor the healthcare waste at the governorate level during the project implementation. The PMU will establish a monitoring system with a nationwide hospital waste production baseline. The Health care facilities involved in the program will also establish a robust hospital waste management monitoring system. The PMU will receive periodically (quarterly) all data from each health facility involved in the program and consolidate. The borrower will need to prepare and implement an ESCP, which should set out the necessary actions, with Public Disclosure timeframes, to ensure that the project is compliant with the different ESSs. The ESCP should set dates and responsibilities for preparing the SIA, the SEP and potentially LMP (Labor Management Procedures). The borrower will also need to disclose a draft ESCP, SIA and the SEP before project appraisal. Furthermore, the borrower shall commit to conduct regular social assessment throughout the project lifecycle, in order to identify potential risks or existing adverse impacts and address them in a proper and timely manner. The Bank team will be working with the implementing agency to ensure that the PMU, which will be established, hires qualified social officer(s) to work under ToRs/scope of work that is acceptable to the Bank. Additionally, it is proposed to include the following actions in the ESCP: -Prepare a Strategic Environmental and Social assessment (SESA) study to examine the environmental risks associated with the roll-out of the whole program -Conduct Monitoring of healthcare waste during the project implementation in the project governates to ensure proper treatment and disposal -Hire and maintain an environmental consultant/staff during the project implementation Areas where “Use of Borrower Framework” is being considered: The borrower’s framework will not be considered ESS10 Stakeholder Engagement and Information Disclosure The new health insurance program is universal, i.e. it will touch upon lives of virtually all the population, whether in a direct or indirect way. During phase 1 of the program, which is planned to be supported by the Bank through this Dec 13, 2019 Page 7 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) project, around 5.6 million people should be covered, including about 2 million poor people. In addition, the program is primarily operated by 3 entities, apart from the major role the MOF and MOHP (Ministry of Health and Population) will be playing. The Program is predominantly governed by the new UHIL which took several years (and multiple governments) to be developed. During the development process, many consultations were carried out with key stakeholders. These include civil society organizations; syndicates, such as those of physicians, pharmacists, and dentists; and industries, such as pharmaceuticals; trade unions; as well as independent experts. The Parliament was also involved in the development process. In addition, some civil society actors were members of the committee that developed the new law. The extent to which the feedback of the consulted stakeholders was taken into account is difficult to determine. However, recent observations are suggesting that the Government agrees to adopt a very dynamic approach in implementing the Program. Amendment of the law sounds possible whenever there is a need. For example, article 40 of the law stipulates that enterprises shall pay 0,0025% of their annual revenues for the new health insurance system as a solidarity contribution. The industries union requested that the amount should be 1% of profits rather than revenues, to avoid placing more burdens over enterprises which may run at loss (in case of their expenses outweigh profits). Accordingly, senior government officials stated, in recent media statements, that such a request is under consideration and the law could be amended to accommodate the necessary changes. The project involves a wide range of stakeholders, primarily: 1) Egyptian citizens/beneficiaries in the targeted governorates, especially the disadvantaged groups who are eligible for non-contributory coverage; 2) government health service providers, including different categories of workers from different levels; 3) private service providers, including pharmacists, doctors, and assisting staff; 4) civil society organizations of different interests and different scales; 5) professional syndicates; 6) pharmaceutical industry; 7) private health insurance companies; 8) respective international agencies; and 9) the major involved public sector and government entities, such as UHIA, GAHAR, HCO, Public Disclosure MOHP (Ministry of Health and Population), CAPMAS (official statistics body), ACA (Administrative Control Authority), and MOSS (Ministry of Social Solidarity). The preparation and the implementation of a comprehensive SEP is one of the most crucial tasks that should, not only help in sharing information about the Program, but also support establishing a constructive relationship between the Program and the different stakeholders, to enhance trust and decrease potential resistance. This is particularly important since the application of the model will entail changing in the culture of both the patients and the service providers. Given the citizens’ financial contributions under the new system, there is a need to consider that this will come with certain expectations that need to be properly managed through constant, transparent and inclusive sharing of information and allowing room for beneficiaries’ feedback. The stakeholders engagement process, should be initiated as early as possible and be carried out regularly during the lifecycle of the project, and shall involve: 1) stakeholder identification and analysis; 2) planning how the engagement with stakeholders will take place; 3) disclosure of information; 4) consultation with stakeholders; 5) addressing and responding to grievances; and 6) reporting to stakeholders. The borrower will be responsible for development of a SEP in light of the nature and scale of the potential risks of the project. The borrower shall also disclose a draft SEP before the project appraisal. The Bank team will offer the needed handholding support during the preparation of the ToRs of the SEP as well as the SEP itself. With regard to the GRM, currently there is a 24/7 call center (15344) mandated to respond to beneficiaries’ inquiries and complaints. This center is assumed to be a key uptake channel, through which complaints can be received and rerouted to respective bodies, such as GAHAR or UHIA, for further inspection and feedback. In addition, there is an officer at each healthcare facility who is responsible for client satisfaction and can therefore be one of the channels to handle complaints. Furthermore, inspecting exclusion-related complaints is stipulated by the above-mentioned PM’s decree to be the responsibility of a permanent committee that shall be formed by UHIA’s chairman . Dec 13, 2019 Page 8 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) An effective GRM should also contribute to strengthening people’s trust in the system and successful implementation throughout the subsequent rollout phases. Thus, as part of the Bank’s due diligence, the social team is currently assessing the existing GRM instruments pertaining to the new system, in order to identify possible gaps and provide the necessary support accordingly. The SEP that will be prepared by the client should provide more details about the GRM including different uptake locations, feedback cycle and litigation process. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This ESS may apply, since the PMU is expected to hire non civil servants, on a full-time basis, as well as temporary consultants who would be commissioned to carry out specific tasks under the project. Such types of workers are defined as ‘direct workers’ under ESS2. Accordingly, the borrower shall develop and implement the LMP that should set out the way in which direct workers will be managed, in accordance with the requirements of national law and this ESS2. The Eligible Expenditure Categories and project components are yet to be further elaborated; accordingly, the implementing agency will be advised by the Bank team on the components to be included under the LMP. Public Disclosure ESS3 Resource Efficiency and Pollution Prevention and Management Although the project is not financing any physical work, it will introduce “green healthcare facility” principles to take advantage of the roll-out of the UHIS in channeling environmental benefits into better service provision. The project design introduced normative performance standards (for energy efficiency) to be developed for inclusion in the accreditation criteria of health facilities under the new health insurance scheme. Also, it proposed a series of in- country energy efficiency audits of a range of healthcare facilities to be carried out with the objective to identify opportunities for energy savings in health facilities in advance of accreditation. The indirect environmental risks which need further assessment, include increased disposal of hazardous medical waste and generation of more wastewater at phase 1 governorates. At the project level, GAHAR will be responsible for accrediting healthcare facilities including hospitals, clinics, laboratories, etc. to be eligible for providing the service under the UHIS. The accreditation standards include the requirement of service providers to comply with the national laws’ requirements including environmental and labor laws. Additionally, GAHAR is developing a specific standard on environment and facility safety for healthcare service providers to detail the minimum requirements on the topics of waste management, wastewater, infection control and patients and visitors’ safety. Therefore, it is essential before appraisal stage to align GAHAR’s environment and facility safety standards with the WBG EHS guidelines for healthcare facilities. At the governorates level, the proposed actions in the ESCP shall address potential indirect adverse project impacts. Dec 13, 2019 Page 9 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) ESS4 Community Health and Safety At this stage, this ESS is precautionary and is considered relevant due to the indirect associated environmental and safety risks. Therefore, at the project level, aligning GAHAR’s environment and facility safety standards with the WBG EHS guidelines for healthcare facilities is needed. Also, at phase 1 governorates level, the proposed strategic environmental and social assessment tool will evaluate the downstream indirect impacts associated with the roll-out of the UHIS on community health and safety and propose mitigation measures proportionate to the risks. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement At this stage, this ESS is not relevant, as the project does not involve land acquisition or involuntary resettlement activities. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources At this stage, this ESS is considered not relevant. Notably, at phase 1 governorates level, the proposed strategic environmental and social assessment tool will evaluate the downstream indirect impacts associated with the roll-out of the UHIS on biodiversity. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities At this stage, this ESS is not considered relevant. Public Disclosure ESS8 Cultural Heritage Based on current project design, the project will neither finance any civil works, nor involve activities with potential risks or impacts associated with culture heritage. ESS9 Financial Intermediaries Currently, the project modality does not include financial intermediaries. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No III. WORLD BANK ENVIRONMENTAL AND SOCIAL DUE DILIGENCE A. Is a common approach being considered? No Dec 13, 2019 Page 10 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) Financing Partners Not Applicable B. Proposed Measures, Actions and Timing (Borrower’s commitments) Actions to be completed prior to Bank Board Approval: Actions to be completed prior to Appraisal: 1- The borrower shall conduct a gap analysis between GAHAR environment and facility safety standards and the WBG EHS guidelines for Health Care Facilities. The gap analysis shall recommend actions to bridge any identified gap. 2- prepare and disclose the a draft SEP, SIA and LMP 3- Prepare the ESCP Possible issues to be addressed in the Borrower Environmental and Social Commitment Plan (ESCP): -Complete staffing at the PMU including Social and Environmental consultant/staff during the project life cycle - Continue the SIA process. -LMP preparation - Prepare a Strategic Environmental and Social assessment (SESA) study shall be conducted to examine the environmental risks associated with the roll-out. This shall be done during the project implementation -Conduct Monitoring of healthcare waste during the project implementation in the project’s governates to ensure proper treatment and disposal Public Disclosure C. Timing Tentative target date for preparing the Appraisal Stage ESRS 26-Jan-2020 IV. CONTACT POINTS World Bank Contact: Elizabeth Mziray Title: Senior Operations Officer Telephone No: 5220+87036 / Email: emziray@worldbank.org Contact: Amr Elshalakani Title: Senior Health Specialist Telephone No: 5772+4405 / Email: aelshalakani@worldbank.org Borrower/Client/Recipient Borrower: Ministry of Finance Implementing Agency(ies) Implementing Agency: Ministry of Finance Dec 13, 2019 Page 11 of 12 The World Bank Supporting Egypt’s Universal Health Insurance System (P172426) V. 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 VI. APPROVAL Task Team Leader(s): Elizabeth Mziray, Amr Elshalakani Practice Manager (ENR/Social) Pia Peeters Recommended on 27-Nov-2019 at 15:09:36 EST Safeguards Advisor ESSA Surhid P. Gautam (SAESSA) Cleared on 13-Dec-2019 at 08:51:36 EST Public Disclosure Dec 13, 2019 Page 12 of 12