The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 12/09/2019 | Report No: ESRSA00340 Dec 09, 2019 Page 1 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Bangladesh SOUTH ASIA P171648 Project Name Health and Gender Support Project for Cox’s Bazar district Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 1/6/2020 2/27/2020 Population Financing Borrower(s) Implementing Agency(ies) Ministry of Health and Family Welfare, Government of Bangladesh, The People’s Republic of Bangladesh Public Disclosure Proposed Development Objective(s) Improve the access to and utilization of HNP and GBV response services among the host and the displaced Rohingya population in Cox’s Bazar district. Financing (in USD Million) Amount Total Project Cost 150.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] WBG grant financing of $150 million equivalent will support MOHFW to undertake the following four components: 1) strengthening and scaling up the integrated provision of HNP and GBV response services in all tiers of the district health care system; 2) strengthening systems capacity for HNP and GBV response service provision; 3) project management including the coordination of HNP and GBV response service provision between MOHFW and MOWCA and with other stakeholders; and 4) Contingent Emergency Response Component (CERC). The project activities will Dec 09, 2019 Page 2 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) benefit both the host communities and the DRP and mitigate the impact of the refugee crisis in CXB district. Under the oversight and management of MOHFW and building on the experience of the Sector-Wide Approach (SWAp), the project will be closely coordinated with investments in the HNP sector by other development partners, including bilateral development partners, UN agencies, and NGOs involved in GBV response services. The proposed project will be implemented over a period of three years (2020-2022). D. Environmental and Social Overview D.1. Project location(s) and salient characteristics relevant to the ES assessment [geographic, environmental, social] The project is planned for CXB district to address Health, Nutrition and Population (HNP) and Gender-Based Violence (GBV) needs and gaps. The Project area has a tropical monsoon climate with four seasons: dry or winter season (December-February); pre-monsoon or hot season (March-May); monsoon or rainy season (June-September); and post-monsoon or autumn season (October-November). Geographically, CXB is mostly hilly with forests and sea beaches. It is one of the most visited tourist destinations in Bangladesh. However, recent intrusion of DRPs in Teknaf and Ukhia Upazillas of CXB is adversely affecting the ecosystems, ground water supplies and health services in those areas. The social context also went through changes in the project area due to influx of DRPs. Within the context, the proposed project will provide Health Nutrition Program (HNP) and Gender-based Violence (GBV) response services for both host and DRP populations in CXB District through community clinics (CC), union level facilities (UHFWC), Upazilla health complexes (UzHC), family planning centers and District Sadar hospital (DSH). Given the proposed interventions, the proposed project aims to enhance the quality and accessibility of environment and social services within the project area. Public Disclosure The project will involve minor repair and renovation for the CCs, UHFWC, UzHC, DSH, OCC as well as setting up of two to three new One-Stop Crisis Cells at selected Upazillas. Provision of water supply, sanitation (including toilets) and power supply at these health clinics will also be upgraded to ensure requirements to provide services. D. 2. Borrower’s Institutional Capacity Implementation of the proposed project will be the responsibility of the MoHFW through its existing structures. However, the selected project design recognizes the Ministry of Women and Children Affairs (MoWCA) in the provision of GBV response services, and therefore strong coordination between MoHFW and MoWCA will be essential. Due to exceptional circumstances of influx of DRP in CXB, MoHFW may contract selected UN agencies to implement some of the project activities. If UN agencies are contracted to implement any of the project activities, all parties will agree on the implementation of environmental and social instruments acceptable to the Bank. Regular monitoring of project progress will be built into the design, in the form of appropriate indicators, targets, information systems, and review mechanisms. Baseline, mid-term and end-line evaluation will be included and fully financed as part of the project. MoHFW is a long time Bank client since 1998 and is currently implementing the Health Sector Support Program (HSSP) for improving health service delivery, particularly in the Chattogram and Sylhet Divisions. The Additional Financing (AF) of the HSSP supports the expansion of the provision of HNP services with a focus on Camps of DRPs and Host Communities across CXB; medical waste management, enhance community-level interventions, as well as services to address GBV and psychosocial needs. The health division is quite familiar with Bank safeguard policies and has a reasonable track record of implementing safeguard policies in Bank-financed projects. However, MoHFW will be Dec 09, 2019 Page 3 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) exposed to ESF for the first time. The capacity of MoHFW has already been assessed as part of the E&S capacity assessment of the ESA. The capacity to execute the Environment and Social Management Plan (ESMP) including various waste management plans and guideline of the health facility staffs will be assessed. ESA has proposed the recruitment of an Environment Specialist (ES), a Social Development Specialist (SDS), and a Gender Specialist (GS) for this proposed project, who will assist the development of a long-term E&S capacity building program for both agencies to be supported under the project. This has been documented in the ESCP. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The project will provide HNP and GBV response services and an ESA was carried out to identify and assess the potential environmental and social risks and impacts of the proposed project. The key environmental impact is the generation of medical, solid and liquid wastes from health services and, noise, construction waste etc. from minor construction, if not properly managed. The healthcare workers, patients, waste handlers, waste-pickers and general population may be exposed to health risks from medical, solid and liquid waste. The ESA illustrated the baseline status on the same and proposed mitigation measures to address the issue. The baseline illustrates the need for enhanced capacity induction for the healthcare workers (training and awareness raising) and development and implementation of waste management plans and systems in all tiers of health facilities at CXB to deal with the Public Disclosure potential excess generation of medical, solid and liquid waste. A similar kind of HNP service is being provided for the DRP across CXB District under the HSSP-AF, (classified as category B). An Environmental Management Framework (EMF) and Social Management Framework (SMF) were developed for HSSP AF and are being followed. WHO also assists implementing EMF worked out by DGHS by interacting with partners to develop SOPs for medical waste management, training of health care facility staff in medical waste management, provision of PPE and sharps containers to health facilities to enable safe disposal at point of use and monitoring of compliance to be carried by partners and centrally through the WHO IPC Program, on an ongoing basis. Given the present state of waste management system and practice, which is below the expected standards as was found from ESA, the HGSP will require the development and implementation of Medical Waste Management Plan (MWMP) and a Solid and Liquid Waste Management Plan (SLWMP), which have been included in the ESA for each health facility. Trainings, awareness raising, inductions and capacity development of health care workers and waste handlers will be included in the plans and recorded in the ESCP. It is noted that a British-made incinerator has been set up in the CXB District Sadar Hospital (DSH) recently with a capacity of 500 kg. At present, there are five trained operators who operate the incinerator with 250 kg per batch load. The system is running as per expected specification and the emission is well below the threshold. Dec 09, 2019 Page 4 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) The project also includes minor civil works and the construction works that may cause noise, vibrations and emissions and generate small amount of waste. Such impacts will be addressed with appropriate mitigation measures as suggested in the ESA. Considering the potential increase in generation of medical, solid and liquid wastes in health care facilities and existing poor waste management practices in CXB the Environmental risk is rated Substantial. However, this risk classification will be reviewed on a regular basis and changed (if necessary). Any change to the classification will be disclosed on the Bank’s website. Social Risk Rating Moderate No land acquisition is envisaged for the project. The small-scale construction for renovation and improvement of facilities will be within the existing health complexes where no squatters are located. However, if the need for land acquisition arises unexpectedly during implementation, ARAPs/RAPs will need to be prepared. CXB district has few small ethnic and religious minority communities. The ethnic minority communities in the project sub-districts have been identified through extensive consultation while the ESA was conducted. Since the project will not affect these people, an IPP is not required. However, in the unlikely event during project execution that any of these ethnic people are affected, appropriate consultations will be carried out, an appropriate instrument will be prepared and agreement/ consent will be obtained, in a manner that is fully cognizant of socio cultural and religious sensitivities. Further, no cultural heritage will be adversely affected by this Project. Public Disclosure As this project will include psycho-social interventions to the victims of GBV, it will be important to follow international protocol to protect service recipients from adverse impacts of seeking services. Also, women seeking services to remedy domestic and family violence may become subject to further increased violence. There might be a backlash to the victims from the family or from the perpetrators. The project seeks to mitigate this risk through community engagement, education of men and boys in the community and involving community leaders using Community Group (CG) and Community Support Group (CSG). Provisions for safe space will be included in the project. In addition, specific and ethically acceptable approach to include both victims and perpetrators may be planned to identify and address the root cause of violence. The project is situated midst a humanitarian crisis area situation and in rural and peri-urban settings, where the prevalence of possible GBV incidents tend to be higher than that of the other areas of the country. One main component of the project includes provisions of GBV response services. These response services would be adequate to mitigate risks of GBV induced by the project itself in all tiers of care in CXB. The project-specific GBV risks have been rated as “low”. No stand-alone project specific GRM for GBV will need to be developed. The project’s main GRM (which will be an integral part of the project) will be used to address such complaints. If the project GRC receives complaints on GBV, it will refer the case to the project personnel under component 2 (GBV response services in health facilities). The Project will also augment the already existing GBV response related services at DRP camps (through WFS) being provided by a number of NGOs and International Organizations. The GBV risk rating and subsequent measures has been included in the ESA. The project involves a low scale of civil works which comprises of repair/renovation and reconstruction of existing health facilities. Such scale of infrastructural development activities can be handled by the participation of local Dec 09, 2019 Page 5 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) communities; thus, the influx of outside laborers is not expected. Furthermore, the project will coordinate closely with government officials and other development organizations involved in GBV response services, which have standard rules and protocols they follow for GBV response. All these factors will benefit the project by reducing the GBV risks for service providers, service recipients and the surrounding communities. 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: ESS1 will apply and will clarify the client’s responsibilities in identifying and managing the environmental and social risks for the project. The proposed project will provide HNP and GBV response services for both host and DRP in CXB District. The health-care workers, the community members and the environment may be exposed to health risks from medical, solid and liquid wastes generated from the health facilities if not properly treated and managed. Also, minor repair and renovation works for the project may generate construction related impacts. Medical, solid and liquid wastes need to be treated as per accepted standards for which a MWMP, SLWMP have been proposed in the ESA for reference and guidance by health facilities in developing and implementing their own plans. This endeavor also will augment presently existing waste management efforts through HSSP-AF, WHO and other agencies. The anticipated impacts based on the ESA are the following: (i) due to enhancement the health services, additional Public Disclosure quantities of medical, solid and liquid wastes will increase from the current baseline; (ii) health workers, construction laborers and contractors may be exposed to health risk; iii) planned small scale civil works may cause noise and emissions, generate waste and involve risks regarding workplace and community health and safety; iv) laborers and contractors may affect the security of the communities including GBV issues; v) GBV response services may create backlash on the service seekers due to socio-cultural beliefs. However, there will be no land acquisition and no squatters have been found who may be adversely affected by the Project operation. Further there will be no adverse impact on biodiversity and any small ethnic communities present in the Project areas. These risks and impacts will need to be minimized, mitigated and managed by conforming appropriate environmental and social due diligence. An environmental and social assessment (ESA) including the required plans for E&S due diligence and management plan has already been carried out by the agency in consultation with Bank team and the draft report has been disclosed accordingly on October 30, 2019. The ESA covers all the anticipated impacts with subsequent mitigation measures due to the relevant activities to be supported under the project and the lessons learnt from the existing Bangladesh Health Sector Support Program (HSSP-AF) operations. It also includes required mitigation measures to ensure health and safety of the workers and related individuals, who will be exposed to health risk as well for providing HNP and GBV response services. The MoHFW has also prepared a Stakeholder Engagement Plan (SEP) and the draft SEP was disclosed on October 30, 2019. The ESA also includes the: (i) Environmental and Social Management Plans (ESMPs), and (ii) Medical Waste Management Plan (MWMP), Solid and Liquid Waste Management Plan (SLWMP). The ESMP includes: (i) a checklist of potential environmental and social impacts of small renovation and construction in existing health facilities and for establishing OCCs and; (ii) relevant potential environmental and social mitigation Dec 09, 2019 Page 6 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) measures. The MWMP, Solid and Liquid Waste Management Plan cover (a) anticipated waste composition and quantity; (b) existing medical, solid and liquid waste management system, including deviation and gaps from the emission standards and other protocols (c) existing regulatory framework and supervision / monitoring arrangements; (d) plan for using the existing medical, solid and liquid waste management system, including any measures to upgrade or remedy identified gaps and deviations; and (e) additional arrangements for supervision and monitoring of waste management. CXB district has few small ethnic and religious minority communities who qualify as “IP/SSAHUTLC” groups under the ESS7 criteria. These ethnic minority communities in the project sub-districts have been identified through extensive consultation while the ESA was conducted. Since the project will not affect these people, an IPP is not required. However, in the unlikely event during project execution that any of these ethnic people are affected, appropriate consultations will be carried out, an appropriate instrument will be prepared and agreement/ consent will be obtained, in a manner that is fully cognizant of socio cultural and religious sensitivities. The proper implementation of the project SEP will involve engagement with all relevant stakeholders, including the host and DRP communities. The Labor Management Procedure (LMP, or Human and Occupational Resources Management Procedures (HORMP), will lay out the policies and guidelines to be followed to manage project-level workers and laborers. In addressing applicable ESS, in consultation with the Task Team, the borrower has prepared and disclosed an environmental and social commitment plan (ESCP) which includes timeline for preparing required documents such as Human and Occupational Resources Management Procedures (HORMP), Project Grievance Redress Mechanism (GRM) etc. Public Disclosure ESS10 Stakeholder Engagement and Information Disclosure The client (MoHFW) will engage in meaningful consultations with all stakeholders throughout the project life cycle, paying special attention to the inclusion of women and vulnerable and disadvantaged groups. It has prepared a Stakeholder Engagement Plan (SEP) which has been disclosed October 30, 2019 allowing enough time for review and feedback from interested parties. The main beneficiaries of the project are the host and DRP populations in CXB District, particularly women. Stakeholder engagement, consultation and communication, as well as a functional grievance redress mechanism (GRM), will be required throughout the life of the project. Systems for grievance redressal and OCCs (GBV response cell) will be established in all the health facilities under the project. A GRM will be set up to address complaints in a timely manner, following due process. The GRM will be cognizant of and follow required levels of discretion and cultural appropriateness, especially when dealing with cases of sexual harassment and GBV. There may be complaints about hiring practices and wage differentials between male and female laborers. The GRM must be accessible to all stakeholders, especially hosts communities and DRPs. The project-specific GRM will be prepared before the project activities start. 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 Dec 09, 2019 Page 7 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) The project will recruit HNP and GBV response service providers (doctors, nurses, paramedics, counselors etc). As these workers will provide HNP service, hence the health-care workers and relevant stakeholders may be exposed to health risks from infectious waste. The project will include minor repair and renovation work in a number of health facilities. Labor requirements are expected to be low in size mostly supplied by local labor from the community who will be Contracted Workers (as per ESS2 definition). Based on the planned project activities, it is envisaged that no primary supplier of goods and construction materials will be engaged in the project. Required construction materials for very limited civil work (mainly repair and refurbishment) will be sourced from legal business entities with permits. A Project HORMP will be prepared before actual work begins which will cover issues with all types of workers. This plan will also include the assessment and required mitigation measure to ensure health and safety of the workers (Occupational Safety and Health or OHS measures) and relevant stakeholders, those may be exposed to health and other associated risks. The salient points have been addressed in the ESA and appropriate requirements have been incorporated in the ESCP as required and in Management of Contractors documents. ESS3 Resource Efficiency and Pollution Prevention and Management The project is likely to generate medical, solid and liquid wastes. These may affect the health care givers, local people and the environment. The existing HSSP-AF in the project area already have a waste management plan in execution that addresses HNP related medical, solid and liquid wastes. For HGSP, a Medical Waste Management Plan (MWMP), along with a Solid and Liquid Waste Management Plan have been prepared in the ESA to see the baselines status of the waste management and has provided recommendations to effectively manage the same. The IA will ensure the execution of the waste management plans throughout the project implementation period. The IA will also ensure Public Disclosure sustainable design (providing natural ventilation, access of sunlight, consuming renewable energy, using non fire bricks etc.) for minor renovating/ constructing existing/new community clinics. The contractor will make arrangement for water required for construction in such a way that the water availability and supply to nearby communities remain unaffected. The Contractor will be required to treat wastewater before discharging the same in to any stream or natural water bodies. ESS4 Community Health and Safety Given the planned provision of HNP and GBV resposnse services, the health complexes of CXB will be receiving additional patients which will generate excess medical, solid and liquid wastes than usual. The community may be exposed to a health and safety hazards if these wastes are not be properly managed and treated. Also, small construction activities may expose communities to minor noise and air pollution. Measures will be prepared, adopted, and implemented (Community Health and Safety measures) to assess and manage specific risks and impacts to the community arising from Project activities, including, inter alia, behavior of Project workers, response to emergency situations etc, and include these measures in the ESMP. Further a Project wise Grievance Redress Mechanism (GRM), will also be enacted to address issues with grievances by any stakeholders. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement The project will not require any land acquisition. Further, during ESA preparation no squatters were found to be located on the health facilities lands. Thus, according to the ESA, the need for the preparation of a resettlement Dec 09, 2019 Page 8 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) instrument such as RAP or ARAP is not envisaged. In case the need for resettlement arises at a later stage, resettlement instruments will be prepared and duly implemented. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The Project activities will not affect biodiversity and living natural resources, based on the findings of the ESA. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities CXB district has few small ethnic and religious minority communities who qualify as “IP/SSAHUTLC” groups under the ESS7 criteria. The ethnic minority communities in the project sub-districts have been identified through extensive consultation while the ESA was conducted. Since the project will not affect these people, an IPP is not required. However, in the unlikely event during project execution that any of these ethnic people are affected, appropriate consultations will be carried out, an appropriate instrument will be prepared and agreement/ consent will be obtained, in a manner that is fully cognizant of socio cultural and religious sensitivities. ESS8 Cultural Heritage Works will be confined within existing facilities hence it is highly unlikely that there will be project impacts on cultural heritage. A chance finds procedure will be included in works contracts and in the bidding document requiring contractors to stop construction if cultural heritage is encountered during any work and to notify and closely Public Disclosure coordinate with relevant mandated country authority for the salvaging and restoration of such cultural heritage. ESS9 Financial Intermediaries The proposed project will not involve any financial intermediaries. B.3 Other Relevant Project Risks The planned project activities are not anticipated to have long-term or indirect negative social or environmental impacts. The project is expected to enhance access to health services and increase social cohesion at the family and community level by preventing GBV. Project investments may strengthen sound environmental and social practices in the construction sector and around health facilities. Adequate awareness raising exercises and training will be implemented based on the assessed risks. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No Dec 09, 2019 Page 9 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) III. BORROWER’S ENVIRONMENTAL AND SOCIAL COMMITMENT PLAN (ESCP) DELIVERABLES against MEASURES AND ACTIONs IDENTIFIED TIMELINE ESS 1 Assessment and Management of Environmental and Social Risks and Impacts ESA has already been prepared and disclosed, ESCP have also been prepared. including ESMP, following instruments in a manner acceptable to the Bank:  Medical Waste Management Plan (MWMP)  Solid and Liquid Waste Management Plan (SLWMP)  GBV Risk Assessment 11/2019  Human and Occupational Resources Management Procedures (HORMP)  Stakeholder Engagement Plan (SEP) Since there is no land acquisition , no squatters and minor ethnic will not be affected therefore RAP and IPP are not required. ESS 10 Stakeholder Engagement and Information Disclosure An SEP has already been prepared by engaging with relevant stakeholders of the Project. The SEP has 11/2019 been disclosed. ESS 2 Labor and Working Conditions A Project wise HORMP will be prepared to address issues related to manpower/ laborers/ workers in Public Disclosure the project. Occupational Health and Safety measures will also be implemented to address issues with 02/2020 labor safety and risks. ESS 3 Resource Efficiency and Pollution Prevention and Management Project activities will generate medical, solid and liquid wastes which may affect health service 11/2019 providers and population at large. A MWMP, SLWMP have been prepared to address the issue. ESS 4 Community Health and Safety Community health and safety issues will mainly emanate freom waste generation and likelihood of GBV. Both these will be mitigatged by waste management plans and Project GRM illustrated in the 03/2020 ESMP. ESS 5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement There will be no land acquisition and squatters who may be affected by the Project activities have not been found. However, if resettlement is required at a later stage resettlement instruments will be prepared. ESS 6 Biodiversity Conservation and Sustainable Management of Living Natural Resources Dec 09, 2019 Page 10 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) According to the ESA, the Project will not affect any biodiversity and living natural resources as works will be confined within existing facilities. ESS 7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities CXB district has few small ethnic and religious minority communities. Since the project will not affect these people, an IPP is not required. If during project execution, any of these ethnic people are affected, appropriate plans will be prepared. ESS 8 Cultural Heritage The Project will not affect any cultural heritage adversely. A chance finds procedure will be included in works contracts requiring contractors to stop construction if cultural heritage is encountered during any work and to notify the authority. ESS 9 Financial Intermediaries No applicable B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Public Disclosure Areas where “Use of Borrower Framework” is being considered: The use of the Borrower Framework will not be considered for this project, although the project will meet both the requirements of the GoB and the relevant World Bank ESSs. IV. CONTACT POINTS World Bank Contact: Bushra Binte Alam Title: Senior Health Specialist Telephone No: 5764+4350 Email: balam@worldbank.org Contact: Sabah Moyeen Title: Senior Social Development Specialist Telephone No: 5764+4313 Email: smoyeen@worldbank.org Borrower/Client/Recipient Borrower: Ministry of Health and Family Welfare, Government of Bangladesh Borrower: The People’s Republic of Bangladesh Dec 09, 2019 Page 11 of 12 The World Bank Health and Gender Support Project for Cox’s Bazar district (P171648) Implementing Agency(ies) 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): Bushra Binte Alam, Sabah Moyeen Practice Manager (ENR/Social) David Seth Warren Cleared on 12-Nov-2019 at 09:48:45 EST Safeguards Advisor ESSA Charles Ankisiba (SAESSA) Concurred on 09-Dec-2019 at 09:58:53 EST Public Disclosure Dec 09, 2019 Page 12 of 12