SFG4020Draft Afghanistan Sehatmandi Project (P160615) Government of the Islamic Republic of Afghanistan Ministry of Public Health Environment and Social Management Framework (ESMF) January 2018 Draft CONTENTS 1 BACKGROUND & PROJECT CONTEXT 1 1.1 Project Background 1 2 BRIEF PROFILE OF AFGHANISTAN 2 2.1 Environmental Context 2 2.2 Demographic Context 3 2.3 Access to Health Facilities 4 2.4 Gender Concerns 5 3 THE PROPOSED PROJECT 7 3.1 Project Beneficiaries 7 3.2 The Project Description 7 3.3 Need for ESMF 8 4 POLICY LEGAL & REGULATORY FRAMEWORK 10 4.1 Key National Laws and Regulation 10 4.2 World Bank Safeguard Policies Applicable 13 5 ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK (ESMF) 15 5.1 Purpose of the ESMF 15 5.2 Potential Environmental and Social Impact, and Approach to Mitigation 15 5.2.1 Potential Social and Environmental Impacts 15 5.2.2 Approach to Mitigating Social and Environmental Risks 16 5.3 Safeguard Screening and Mitigation 16 5.3.1 The Approach towards Improved Health Care Waste Management Practice 18 5.4 Gender Actions 19 5.5 ESMF Implementation Arrangements 20 5.5.1 Institutional Responsibilities for ESMF Implementation 20 5.6 Capacity Building 20 5.7 Monitoring of ESMF Implementation 21 5.7.1 Third Party Monitoring and Independent Technical Audits of HCWMP Implementation 22 Draft 5.8 Budget 22 5.9 Citizen Engagement 23 5.10 Grievance Redressal Mechanism 24 5.11 Disclosure 24 Annex 1: Negative List Of Subproject Attributes 25 Annex 2: Codes of Practice for Prevention and Mitigation of Environmental Impacts 26 Annex 3: Procedures For Land Mine Risk Management 30 Annex 4: Environmental And Social Guidelines For Contractors 35 Annex 5: Grievance Redress Mechanism 37 Annex 6: Occupational Health And Safety Guideline 39 Draft ABBREVIATIONS AIMS Afghanistan Information Management System ANDS Afghanistan National Development Strategy BPHS Basic Package of Health Services EPHS Essential Package of Hospital Services EIA Environmental Impact Assessment EHD Environmental Health Department E&S Environmental & Social ESFP Environmental and Social Safeguards Focal Point ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan ESSO Environmental and Social Safeguards Officer FO Focal Officer GoA Government of Afghanistan GCMU Grants and Contracts Management Unit GRC Grievance Redress Committee HCWMP Health Care Waste Management Plan (HCWMP) HQ Headquarters HMIS Health Management Information System IDA International Development Association IFC International Finance Corporation MAPA Mine Action Program of Afghanistan NGOs Non-Governmental Organizations NEPA National Environmental Protection Agency OP/BP Operational Policy/Bank Procedure O&M Operation and Maintenance PAP Project Affected Person POP Persistent Organic Pollutants PCB & HCB Polychlorinated Dibenzo-p-dioxins, Dibenzofurans PPAs Performance-based Partnership Agreements SEHAT system enhancement for health action in transition SHARP Strengthening of Health Activities for the Rural Poor TA Technical Assistance WB World Bank WHO World Health Organization Draft Afghanistan Sehatmandi Project (P160615) Environmental and Social Management Framework 1 BACKGROUND & PROJECT CONTEXT 1.1 Project Background Despite insecurity and unstable governance since 2001, Afghanistan has made notable progress in improving maternal, new-born, and child survival, nutrition, health interventions coverage and service availability to its population. The recent 2016 Demographic and Health Survey (DHS) shows a sharp reduction in under 5 mortality rate (U5MR) to 55 per 1,000 live births from 97 per 1000 live births in 2010. The large influx of financial assistance, strong local stewardship, development of sound and stable health policy frameworks, prioritization of investments in primary care and the introduction of a basic package of health services (BPHS) and essential package of hospital services (EPHS) delivered by non-governmental organizations (NGOs), have been among some of enablers of success. For the last 15 years, the European Union (EU), the United States Agency for International Development (USAID) and the World Bank have been supporting health service delivery in Afghanistan, initially each targeting a specific set of provinces. But under System Enhancement for Health Action in Transition (SEHAT) project 2013 - 2018 resources allocated for BPHS and EPHS (on and off -budget) came under one umbrella through Afghanistan Reconstruction Trust Fund (ARTF) platform covering the entire country. Therefore, SEHAT is a nation-wide project with similar procurement and implementation approach across different provinces, which is going to continue under the proposed Sehatmandi project. The coverage of maternal, neonatal and child health services, the health outcomes remain sub- optimal in Afghanistan. Despite significant increases in skilled birth attendant deliveries maternal mortality ratio (MMR) remains very high, estimated to be 650 per 100,000 live births. Also, neo-natal mortality rates are persistently high, accounting for about 40 percent of the total under 5 mortality. The poor quality of care continues to hamper overall health improvements. Given the socio-political environment, the demand side factors influencing preventive health care services and community engagement have been relatively underplayed in the past. As a result, critical interventions such as family planning and maternal and infant and young child nutrition related behaviours remain at low levels. With Government of Afghanistan’s effort in implementing an ambitious program to strengthen community engagement and empowerment through the Citizens’ Charter Afghanistan Program (CCAP), it offers an opportunity to scale up demand side interventions, and scale-up small-scale pilots, such as, conditional cash transfers, use of mini ambulances and wider use of Community Health Workers (CHWs)etc. to the whole country. They can play a critical role in making further progress for women and children in Afghanistan. Over the last decade, the financing of health systems in Afghanistan has increased with the support of international community. However, the country still faces huge challenges in Draft providing financing for the basic health services in the country. As per the National Health Accounts (NHA) of 2014, 72% of the health expenditures in Afghanistan relies on out-of- pocket (OOP) spending; 23% relies on external aid and only 5% depends on the financing of the central government. Some of the potential drivers of such high OOP include high drug costs and payments for hospital care. 2 BRIEF PROFILE OF AFGHANISTAN 2.1 Environmental Context Afghanistan is a semi-arid land-locked country in the centre of Asia, covering an area of about 652,000 square kilometres. The country’s climate is continental, with big differences in temperature from day to night, from one season or region to the next, ranging from 20 –45°C in summer in the lowlands to minus 20–40°C in winter in the highlands. The overall average annual rainfall of about 250 millimetres conceals stark variations between different parts of the country, from 1,200 millimetres in the higher altitudes of the northeast to only 60 millimetres in the southwest. Due to its mountainous relief and the convergence of several climate systems, Afghanistan boasts an impressive diversity of ecosystems, land cover and water sources. Since the country is located in a zone of high-seismic activity, earthquakes are common. Flooding and mudslides are real dangers in the mountains and valleys, particularly in spring and summer when snow starts melting or glacier lakes suddenly burst causing destructive flash floods. Prolonged drought and dust storms can also wreak extensive damage, with nationwide impacts. Extreme winter conditions bring high losses in agriculture and infrastructure. These Draft factors add to the burden of environmental degradation and place stress on population and ecosystems. 2.2 Demographic Context The population of Afghanistan is estimated around 29.2 million as of 2016-17, of which about 71.2% live in rural areas, 23.6% live in urban areas, and remaining 5.2% are living as nomads. Approximately 47.3% of the population is under 15 years of age1, and contributes to a very high dependency ratio for the working population2. The nation is composed of a multi-ethnic and multilingual society. The largest ethnic groups are the Pashtun, followed by Tajik, Hazara, Uzbek, Aimak, Turkmen, Baloch and a few others. The adult literacy is 35.4% and the youth literacy is 53.5%. However, there is stark difference between the male and female literacy. Adult and Youth Literacy Rate 2016-17 Indicator Male Female Total Adult Literacy Rate (15 years of age and over) 50.1% 20.3% 35.4% Youth Literacy Rate (15 – 24 years of age) 67.5% 38.9% 53.5% Source: ALCS 2016-17 The share of the population living below the poverty line has increased from 36.5 percent in 2011-12 to 39.1 in the present survey. The results also indicate that the poorer segments of the population suffered more from per-capita consumption decline than the better-off population, which suggests an increase in inequality. Around one third of the Afghan population is estimated to suffer from food insecurity, with 9.3 million people facing chronic or transitory food insecurity and some 3.4 million severely food insecure3. Both quantitative and qualitative food indicators suggest better conditions in urban areas than in rural areas. 1 Afghanistan Living Conditions Survey 2016-17, CSO, GoA 2 Afghanistan Statistical Yearbook 2016-17, Government of Afghanistan 3 Afghanistan Living Conditions Survey 2013-14, CSO, GoA Draft 2.3 Access to Health Facilities Based on the data Collected on health Sector shows that in 2016-17 there were170 Government and 388 private hospitals in the country, which compared to 2015-16 Shows 11.1 percent increase in the Government hospitals and 35.6. percent increase in the private hospitals. In 2016-17, there were 417 comprehensive health centers (CHCs), 923 basic health center (BHCs) and 833 Sub health centers (SHCs)/ Primary Health Centers (PHC) which compared to previous year Shows 1.7 percent increase in the number of comprehensive health centers, but number of basic health center sub center decrease by 1.0 - 4.7 percent respectively4. The map below suggests the travel time taken to reach to nearest health facility across the country. 4 Afghanistan Statistical Handbook 2016-17 Draft 2.4 Gender Concerns Developments in the context of Afghan women’s rights are undeniable; with a number of policies and plans codified, including the Gender Strategy of Afghanistan National Development Strategy (2008-2013), and the National Action Plan for the Women of Afghanistan (NAPWA) 2007-2017. Furthermore, a new national strategy to strengthen the implementation of the Elimination of Violence against Women law was recently launched to promote Afghan women’s status and gender equality5. This has led to more women and girls visible at schools, in universities and throughout public spaces, at least in Kabul and other urban areas. However, imbalances in delivery of services and raising awareness within rural and urban settings, compounded by security threats, continue to pose challenges for women’s access to basic services such as education, health, justice and economic opportunities across the country. Despite the above-mentioned accomplishments, Afghan women’s rights achievements are still very fragile, as women continue to face challenges in different fields and high rates of violence against women persists. As per the United Nations Assistance Mission in Afghanistan Report in 2013, the annual number of reported cases of GBV was 1,669 incidents (recorded by the Ministry of Women Affairs in from 16 provinces). According to the 2015 report of United Nations Development Programme, the Gender Inequality Index (GII) value of Afghanistan in 2014 was 0.693, placing it at 152 out of 155 countries. 5 https://reliefweb.int/report/afghanistan/reducing-gender-women-problematic Draft Women’s access to health services in addition to geographical accessibility, is greatly constrained by the shortage of female health care service providers. Gender Based Violence (GBV) is widely spread in Afghanistan and exposes women, girls and adolescent boys to mental and physical abuse and thus mandating the health sector to respond adequately. The consequence of GBV on the health of the survivors can be observed in forms of fatalities (homicide and suicide), maternal mortality, injuries, and impairment. It also takes an incredible toll on the overall mental health of the victim and the children. Draft 3 THE PROPOSED PROJECT The Project Development Objective (PDO) of the proposed Afghanistan Sehatmandi Project is to increase the utilization and quality of high impact health, nutrition, and family planning services. 3.1 Project Beneficiaries The scope of this project will be nationwide, covering all 34 provinces of the country. The project’s beneficiaries would be the whole Afghan population who would benefit from better access to quality primary and secondary health, family planning, and nutrition services. The total population size that will be covered by the project is 29.7 million. Women and children would be direct beneficiary groups because the content of the BPHS and EPHS is heavily focused on maternal, child health and nutrition. Poor people will disproportionately benefit from the project because it (i) focuses on primary health care centers (PHC) where services are more likely to be accessed by the poor; (ii) focuses on rural areas where the poor are concentrated; (iii) expands the number of PHCs in lagging provinces which tend to be poorer; and (iv) supports completely free care through the BPHS facilities which reduces financial barriers to access, particularly by the poor. As an intermediate objective, the project will also strengthen the institutional capacity of MOPH, including building the capabilities of the staff of key technical departments and provincial health offices (PHO). 3.2 The Project Description The project will consist of the following three components: (1) Improving Service Delivery; (2) Strengthening the Health System and its Performance; and (3) Strengthening Community Engagement. Project funds will be disbursed through performance-based contracts for component 1 and using Disbursement Linked Indicators (DLIs), contracts and Incremental Operating Costs (IOCs) under Components 2 and 3. Component 1: Improving Service Delivery (US$550 million) This component will support the financing of performance contracts to deliver BPHS and EPHS services and establish an innovation fund: Sehatmandi project will build on the success of previous projects and support the delivery of BPHS and EPHS through performance-based contracts between MOPH and NGOs. To ensure efficiency under Sehatmandi project, BPHS and EPHS contracts will be combined into a single package and each contract will cover entire province. It will also support the government’s efforts in delivering BPHS and EPHS (known as MOPH-SM) through management contract in three provinces as well as the implementation of an urban version of the BPHS in Kabul city. As in previous contracts, the NGOs will train community midwives and community nurses based on need. BPHS will continue to be delivered through a network of community health workers (CHW), sub-centers (now called “primary health centers� or PHCs) that serve roughly 3,000 - 7,000 people, basic health centers (BHCs) that serve 15,000 – 30,000 people, comprehensive health centers (CHCs) serving 30,000 – 60,000 population, and through district hospitals, serving 100,000 – 300,000 population. Besides fixed centers, the services will also be provided through mobile and outreach activities. Under Sehatmandi project, the number of PHCs will be Draft expanded in under-served provinces as a means of increasing physical access to services. The location of the new PHCs will be determined objectively by geographical information system analysis using satellite imagery. EPHS: EPHS facilities provide secondary diagnostic and treatment service and serve as the first referral points for the BPHS facilities. There is at least one provincial hospital in each province. The main services provided in the provincial hospitals include: gynaecology, obstetrics, neonatal care, postpartum care and complications, nutrition, orthopaedics, surgical care, respiratory and gastrointestinal care. Provincial hospitals usually have around 100 beds with around 150 staff. Encouraging Innovation: To bring greater innovation in areas identified as priorities by the MOPH, namely: (i) increasing access to services; (ii) addressing demand-side constraints; and (iii) working with households to improve the health of the populations, Sehatmandi project will finance innovations to be implemented by the NGOs. Component 2 - Strengthening the Health System and its Performance (US$40 million) This component will support shifts towards greater performance management of NGOs, reform of tertiary and national hospitals and changes in the procurement and supply chain management of procurements. Underlying these priority systems will be focused investments to deepen the capacity of the Ministry and partners to generate and use data for evidence-based decision- making and management. This will also include the focus on shifting from contract management to performance management of the Health service delivery. Besides the GCMU, all other technical departments of the MOPH (central and provincial) will effectively engage in improving BPHS and EPHS services and the focus will be on outputs/outcomes rather than inputs. The project will help strengthen the management, autonomy, and governance of regional and national tertiary hospitals. And, focus on improving quality, efficiency and availability of pharmaceuticals is among the important priorities of the health sector; and third- party monitoring (TPM) that will assess the performance of BPHS and EPHS implementation. Component 3: Strengthening community engagement (US$10 million) The project will use the potential of CCAP and Community Development Committees (CDCs) to build demand for critical health and nutrition services especially for maternal health, nutrition and family planning and strengthen community oversight of health sector. In coordination with CCAP will be supported to collect and analyze performance data as a complement to existing monitoring data sources, particularly in high conflict areas. A community scorecard to monitor the delivery of services at health facility level has been developed jointly by the MOPH and CCAP. The project will support integration of community scorecard in the regular HIS of MOPH so its findings can be used by the MOPH to improve health service delivery. Also, the focus will be to operationalize Community Based Nutrition Package (CBNP) and to promote and monitor critical maternal health interventions (including family planning) at community level. 3.3 Need for ESMF To comply with WB’s safeguard policy, as all the subprojects under component 1, could not be identified by appraisal, preparation of an Environmental and Social Management Framework (ESMF) is required to ensure that the project identifies the potential environmental Draft and social impacts, and avoids, minimizes, and/or mitigates adverse impacts of proposed sub project activities and interventions including related to HCWMP. The framework will guide preparing and operationalizing ESMP for each of the HCFs where necessary. Consistent with existing national legislation and the World Bank Operational Policies on environmental and social safeguard, the objective of the Framework is to help ensure that activities under the project would:  Protect human health;  Prevent or compensate any loss of livelihood;  Prevent environmental degradation as a result of either individual subprojects or their cumulative effects;  Minimize impacts on cultural property;  Enhance positive environmental and social outcomes, and  Comply with the National and World Bank Safeguards policies Draft 4 POLICY LEGAL & REGULATORY FRAMEWORK 4.1 Key National Laws and Regulation The primary relevant laws and legislations framing social and environmental issues for the Afghanistan Sehatmandi Project are:  The Environment Law of Afghanistan (2007)  The National Environmental Impact Assessment Policy (2008)  The Law on Land Expropriation (2009)  The Law on Managing Land Affairs (2008)  The Land Policy (2007)  The Constitution of Afghanistan (2004)  MoPH Strategy 2016-20  MoPH Strategic Plan, 2011  National Infection Prevention Control Policy, 2005  Afghanistan Labor Law 2007 The Environmental Law (2007): The Environment Law is based on international standards that recognize the current state of Afghanistan’s environment, while laying a framework for the progress of governance leading to effective environmental management. It stipulates for sustainable use, rehabilitation and conservation of biological diversity, forests, land, and other natural resources; the prevention and control of pollution; conservation and rehabilitation of the environment; and the active involvement of local communities in decision-making processes, including a clearly stated opportunity for affected persons to participate in each phase of the project. The law requires the proponent of any development project, plan, policy or activity to apply for an environmental permit (Certificate of Compliance [CoC]) before the implementation of the project, by submitting an initial environmental impact assessment to the National Environmental Protection Agency (NEPA) to determine the associated potential adverse effects and possible impacts. The law also establishes a Board of Experts that reviews, assesses and considers the applications and documents before NEPA could issue or not issue the permit. The EIA Board is appointed by the General Director of the NEPA and is composed of not more than 8 members. The EIA Board of Expert’s decision can be appealed. The EIA Policy (2008): This policy document defines how the administration of Environmental Impact Assessment (EIA) procedures should be undertaken and provides the policy basis for the implementation of Chapter 3 of the Environment Law. It provides a list of projects expected to create adverse impacts (Category 1) and those that may create significant negative impacts (Category 2). It describes specific processes and procedures, and the required documents, for each category. Once the application form and other relevant documents are submitted to NEPA according to the requirements, NEPA would: (i) issue a CoC, with or without conditions, (ii) advise the applicant in writing to review the technical reports and address the concern of NEPA, or (iii) refuse the CoC with written reasons. Once permission is granted the proponent needs to implement the project within three years, otherwise the permit expires. Implementation constraints include (i) effective application of EIA procedures by Draft private and public proponents; (ii) monitoring of the implementation of the ESMP; (iii) the expertise and means for quality analysis necessary to determine compliance reports; (iv) the ownership of the EIA process by line ministries; (v) limited knowledge, experience, and capacity of staff; and (vi) the coordination, monitoring, and harmonization of various requirements by international agencies involved in technical and financial supports. The NSP and NEPA reached an agreement (Annex 15) on the need for water supply, irrigation and power projects that are considered Category 2. Since, these sub-projects are small scale and small budget community implemented projects, it was agreed that a small sample per province would be submitted to NEPA for consideration, in order not to delay the implementation of many thousands of community sub-projects. It is anticipated that a similar agreement will be reached with NEPA for the CCAP. The Law on Land Expropriation (2009) provides the legal basis for land acquisition and compensation. The law is under amendment, which will address the major gaps to protect the rights of the affected people. The Law on Managing Land Affairs (2008) aims to create a legislated unified, reliable land management system. This law also aims to provide a standard system for land titling; land segregation and registration; the prevention of illegal land acquisition and distribution; access to land; and conditions for the appropriation of land. The Land Policy (2007) was approved by the cabinet in 2007 but is yet to be operationalized. Important relevant provisions include Land Tenure/Land Acquisition. The Land Policy provides that compensation for the expropriation of ownership, or of rights over land, as enshrined in the Constitution be strictly enforced by law. Property rights may only be expropriated under defined legal procedures and for defined legal purposes. It also provides that no law may permit arbitrary deprivation of property rights. In the event that the government decides to implement a development project in the interest of the public, the value of the land prior to the announcement of the expropriation will form the basis for the amount of monetary compensation to the owners of the property. Protection of Property Rights is included within the Land Policy. It states that it is a national policy for the national and provincial governments to take measures to protect citizens, including residents of informal settlements, from arbitrary and forcible eviction. Eviction and relocation of unplanned settlement residents shall be undertaken with community involvement only for necessary spatial rearrangement that should take effect in accordance with the public’s interest. Compensation for expropriation of rights over land must be provided equitably in accordance with the law. The Constitution of Afghanistan (2004) contains some articles that relate specifically to compensation and resettlement issues. These include Article 40, ‘No one’s property shall be confiscated without the order of the law and decision of an authoritative court. Acquisition of private property shall be legally permitted only for the sake of public interests and in exchange for prior and just compensation’. MoPH Strategy (2016-20) Draft This National Health Strategy 2016–2020 has been designed and formulated within the parameters of the National Health Policy 2015-2020 to effectively implement the policy priorities and statements through focusing on the following strategic areas: 1. Governance: Accountability, responsiveness, capability, transparency, anticorruption, laws and regulations, equity and a human rights approach, and aid effectiveness 2. Institutional development: Leadership and management in health, harassment prevention and resolution, systems strengthening, health financing and revenue generation, coordination, health planning, standards, the private sector and public-private partnerships, and the provincial level and decentralization 3. Public health: Health promotion, community health and empowerment, health protection, preventive health, gender and gender-based violence, reproductive, maternal, neonatal, child, and adolescent health, communicable diseases, non-communicable diseases, nutrition, disability and physical rehabilitation, accidents and injuries, drug demand reduction, mental health, environmental health, and emergency preparedness and disaster management 4. Health services: Quality of and access to health services and clinical care, BPHS and EPHS, tertiary hospitals, pharmaceuticals, forensic medicine, and health commodities 5. Human resources for health: Human resource planning, production, procurement and development, management, and finance 6. M&E, health information, learning, and knowledge/evidence-based practices: M&E, health system research, including operations research, a culture of information generation and dissemination, and a culture of knowledge and evidence-based decision making Public health is the third strategic area of this national health strategy. Among a wider range of sub-areas for intervention, it encompasses the environmental health and focuses on reduced morbidity, mortality, and disability caused by occupational and environmental hazards. MoPH Strategic Plan (2011-15) developed by the Ministry of Public Health (MoPH) has 8 strategic Directions which also emphasis upon the regulation and standardization of quality health services, advocate and promote healthy environment. This advocates for and promotes healthy environments adopting the following strategic objectives:  Strategic Objective 1: To strengthen the stewardship role of MoPH in relation to Environmental Health by developing regulations and clarifying roles and responsibilities under the Environmental Health program  Strategic Objective 2: To advocate for increased availability of safe drinking water in order to reduce the burden of disease from contaminated water;  Strategic Objective 3: To increase food safety practices to prevent food borne illnesses in food service and retail establishments;  Strategic Objective 4: To develop a systematic framework to lead a national process to reduce air pollution and promote clean air (in collaboration with the Environmental Protection Agency)  Strategic Objective 5: To create a national multispectral radiation protection forum to agree on and advocate for safe levels of radiation in the country including increasing industry and public awareness of this issue Draft  Strategic Objective 6: To create a national multi-stakeholder mechanism for the management of garbage and hazardous wastes (including solid waste and healthcare waste)  Strategic Objective 7: To improve hygiene and sanitation throughout the country among the general public and health workers;  Strategic Objective 8: To build capacity and improve occupational health and safety among all workplaces; National Infection Prevention and Control Policy (2005) provide the broad principles of Infection Prevention and control (IPC) for all Afghanistan healthcare facilities. The procedures manual provides the specific guidelines for implementation of effective IPC program in the hospitals and health centers. The objectives of the manual are twofold i.e. i) To facilitate the implementation of effective implementation of the national IPC policy ii) To provide the technical guidance necessary for the clinical managers of health facilities to be able to implement an effective IPC program The IPC Program covers the Nosocomial Infection Surveillance system, Environmental Sampling, occupation Health Program and Safe Injection Practices. The IPC for housekeeping, waste disposal and pest control also has been provided. Afghanistan Labour Law 2007. The Afghanistan Labour Law, adopted in 2007, guarantees Afghan citizens the right to work and receive fair treatment, equitable pay, pensions, and health and safety in the work place. It protects workers from discrimination and children from forced labour practices. Under Afghanistan’s Labour Law, 18 is the minimum age for employment. Children between the ages of 15-17 are allowed to work only if the work is not harmful to them, requires less than 35 hours a week, and represents a form of vocational training. Under the law, children 14 and younger are not allowed to work. Women workers are among the most marginalized and discriminated labour-related groups in Afghanistan. This law payment of equal wages to women workers and equal opportunities to women in employment. 4.2 World Bank Safeguard Policies Applicable The objective of the World Bank's environmental and social safeguard policies is to prevent and mitigate undue harm to people and their environment in the development process. They are a cornerstone of its support to sustainable poverty reduction. Given the Sehatmandi project is classified as Category B for environmental assessment purposes, WB OP 4.01 is triggered. This is relevant because the health care wastes poses potential health and contamination risk, and hence need adequate mitigation measures by updating the existing Health Care Waste Management Plan (HCWMP). The project does not involve any construction activities and the expected planned activities cover the extension of health care facilities which will happen within the available health facilities compounds and will not affect any private land or assets; therefore, it is not expected to have land acquisition and resettlement. Accordingly, the OP/BP 4.12 Involuntary Resettlement Policy is not triggered. However, it is expected that repair and reconstruction work of the existing health Draft facility may need to be done to function as desired. This requires following standards environmental code and practices. Also, OP 4.10 is not triggered in Afghanistan because there are no indigenous people recorded, but there should be proper mechanisms to ensure all social groups (esp. vulnerable and minorities) receive equal services. Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 ✔ Natural Habitats OP/BP 4.04 ✔ Forests OP/BP 4.36 ✔ Pest Management OP 4.09 ✔ Physical Cultural Resources OP/BP 4.11 ✔ Indigenous Peoples OP/BP 4.10 ✔ Involuntary Resettlement OP/BP 4.12 ✔ Safety of Dams OP/BP 4.37 ✔ Projects on International Waterways OP/BP 7.50 ✔ Projects in Disputed Areas OP/BP 7.60 ✔ Draft 5 ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK (ESMF) 5.1 Purpose of the ESMF The ESMF has been developed specifically for the proposed project is to avoid, reduce or mitigate adverse social or environmental impact. Consistent with existing national legislation and the World Bank Operational Policies on environmental and social safeguard, the objective of the Framework is to help ensure that activities under the project would:  Protect human health;  Prevent or compensate any loss of livelihood;  Prevent environmental degradation as a result of either individual subprojects or their cumulative effects;  Minimize impacts on cultural property;  Enhance positive environmental and social outcomes, and  Comply with the National and World Bank Safeguards policies The location and details of the planned physical works are not known at the time of project appraisal and therefore a framework approach has been adopted to address potential social and environmental issues and ensure consistent treatment of social and environmental issues during its implementation. 5.2 Potential Environmental and Social Impact, and Approach to Mitigation 5.2.1 Potential Social and Environmental Impacts Potential Social Impacts: The project will be implemented across all 34 provinces of Afghanistan. The project does not involve any construction activities and the expected planned activities cover the extension of health care facilities which will happen within the available health facilities compounds and will not affect any private land or assets; therefore, it is not expected to have land acquisition and resettlement. Accordingly, the OP/BP 4.12 Involuntary Resettlement Policy is not triggered. Also, OP 4.10 is not triggered in Afghanistan because there are no indigenous people recorded, but there should be proper mechanisms to ensure all social groups (esp. vulnerable and minorities) receive equal services. Potential Environmental Impacts: The Project is classified as Category B for environmental assessment purposes, and hence, OP 4.01 is triggered. Health related activities produce a considerable amount of waste on daily basis as a result of preventive and curative service delivery. The composition of waste produced is in the form of sharps (needles, syringes), non- sharps, blood and other body fluids being infected and non-infected, chemicals, pharmaceuticals and medical devises. Health workers, waste handlers, users of health facilities and the community are all exposed to health-care related waste and ill health as a result of poor health care waste management. A good health-care waste management plan could result in healthier communities thereby reducing the cost of health-care, as well as creating Draft opportunities for recycling. Hence, the Health Care Waste Management Plan (HCWMP) should address the need of the same for all identified facilities under the project. This would further require a proper capacity building of health care staffs and other stakeholders involved in implementing HCWMP. According to the national legislation and regulations MoPH has the responsibility to address environmental concerns in the project. The Ministry had prepared a Health Care Waste Management Plan (HCWMP) that needs to be updated with the country wide scale up of the project. 5.2.2 Approach to Mitigating Social and Environmental Risks Given the project is being scaled up nationwide and to all 34 provinces providing health care through BPHS facilities (PHC, BHC, CHC and district hospitals) and EPHS facilities, the details situation of each of facility is not known at the time of the project appraisal, and hence, the framework approach has been selected for the managing potential environmental and social risks. The ESMF is based upon the national Environmental Act, its EIA regulations and World Bank Operational Policies (OP/BP 4.01) and provides general policies, guidelines, codes of practice and procedures to be followed during the project implementation. The objectives of mitigation are as follows:  Enhancing the environmental and social benefits  Avoiding, minimizing or remedying adverse impacts; and  Ensuring that residual adverse impacts are kept within an acceptable level The project does not involve any large-scale construction activities and the expected planned activities cover the extension of health care facilities which will happen within the available health facilities compounds and will not affect any private land or assets. However, it may attract minor repair and reconstruction, and hence need to follow the safety standards to avoid and unforeseen accidents and injuries. A code of practices to meet environmental norms, along with environmental and social guidelines will help address the same. Management of healthcare waste is another potential environmental risk. So far different Health Care facilities are not properly using colour coding system for segregating, transporting and disposing of medical wastes and thus are mixed with other municipal wastes and its volume is increased. The MoPH has started utilizing limited services of private sector in collection and transportation of Health Care Wastes and this role should be strengthened and enhanced, if possible, from patient’s bed and health care facility ward to the disposal site. According to the national legislation and regulations MoPH has the responsibility to address environmental concerns in the project. Identifying gaps and updating the Health Care Waste Management Plan (HCWMP) will be important to address the risk. This goes along with capacity building of health care staffs and other stakeholders involved for effective implementation of HCWMP. 5.3 Safeguard Screening and Mitigation Based on the experiences and lessons learned from SEHAT project and to adequately address the potential environmental and social impacts of infrastructure sub-projects under Sehatmandi project, the following are the general principles of this Framework: Draft  The Sehatmandi Project supports multiple sub-projects at various health facilities, the detailed designs of which are not known at appraisal. To ensure the effective application of the World Bank’s safeguard policies and Afghanistan Environmental Law and Regulations, the Framework provides guidance on the approach to be taken during implementation for the design of sub-projects, and the planning of mitigation measures.  All activities under this ESMF follow the ‘Do No Harm’ principles. All stakeholders should play their active role for a better and sustainable outcome.  This Environmental and Social Management Framework will be disclosed in Afghanistan in Dari and Pashto after approval by World Bank Board. The ESMF sets out guidelines and procedures for the following:  Assessment of potential adverse environmental and social impacts commonly associated with the sub-projects and guidelines for how to avoid, minimize or mitigate them;  Establishment of clear procedures and methodologies for the environmental and social planning, review, approval and implementation of sub-projects; and  Specification of roles and responsibilities and the necessary reporting procedures for managing and monitoring sub-project environmental and social concerns. The selection, design, contracting, monitoring and evaluation of subprojects will be consistent with the following guidelines, codes of practice and requirements:  A negative list of characteristics that would make a proposed subproject ineligible for support, as indicated in Annex 1;  Relevant elements of the codes of practice for the mitigation of potential environmental and social impacts, presented in Annex 2;  The requirement that confirmation is received through the Regional Mine Action Center that areas to be accessed during reconstruction and rehabilitation activities have been demined, see Guidelines in Annex 3.  Environmental Guidelines for Contractors in Annex 4  Grievance Redress Mechanism in Annex 5  Occupational Health and Safety Guideline in Annex 6  Adhering to health care waste management practices as detailed out in the updated HCWMP by MoPH. The ESMF stipulates that contractors hired in the project should:  Contractors must declare themselves conversant of all relevant national environmental and social legislation and Bank regulations- as well as of their environmental and social obligations as stipulated in the ESMF. Further, the contractor shall ensure compliance with the World Bank/ IFC’s General Environmental, Health and Safety Guidelines as Draft applicable to mitigate construction related impacts. Also, the repair and reconstruction work of the health facilities will follow the policies and norms set as per Afgan Labour Laws and provide payment of equal wages to women workers and equal opportunities to women in employment.  The Environmental Health Department in consultation with Sehatmandi project team and in consultation with GCMU team, through the designated Safeguards Officer, will monitor the construction work, and the Health Care Waste Management Plan (HCWMP) implementation to ensure the contractor’ works and the health care facilities and hospitals are in compliance with the guidelines set out in the ESMF.  While OP 4.10 is not triggered, issues of equity across different ethnic/religious groups is important, but (i) the project is national in scale and coverage; (ii) The poor and under-served will remain central to the project with prioritizing: a) eliminating “white areas� to the extent possible through the expansion of Primary Health Centers (formerly “sub-centers�), b) reducing out-of-pocket payments, c) exploring mechanisms to increase use of hospital services by the poor; (iii) both internal monitoring and external third party monitoring will assess the coverage and inclusiveness of the health service provision and thus provide information that will constitute basis for corrective actions, if necessary; and (iii) citizens’ scorecards and independent monitoring by civil society (NGOs and the press) will provide another mechanism to identify cases where regions or minorities will have been bypassed or marginalized, and build upon the experiences from SEHAT project in doing so. This includes improving and sustaining the scope, coverage and quality of the health services particularly for the underserved population (Nomadic, internally displaced, refuges) are still issues to be addressed under the Sehatmandi project.  The project furthermore specifically targets women’s reproductive health issues and will have increased focus on nutrition and family planning and will be further reinforcing it gender strategy during the first stage of implementation.  Employment opportunities within the projects will be available on an equal basis to all, on the basis of professional competence, irrespective of gender, or ethnic or religious group. In all projects which require consultations with local communities or beneficiaries, consultations will be conducted to elicit the views of both the male and the female population, separate consultations will be conducted with women. 5.3.1 The Approach towards Improved Health Care Waste Management Practice  While the HCWMP updated during January 2017, has come a long way from many earlier versions over the last decade, it needs to be further updated with the current context covering different type, size, and level of health care facilities in Afghanistan in the first quarter of the project implementation. There is lack of comprehensive information on bio-medical waste management practices in different health facilities across provinces and districts. A more detailed plan will be prepared in the first year of the project implementation after assessing the waste generation and current practices of bio-medical waste management i.e. segregation, storage, transportation, and disposal mechanisms being followed at different type and levels of health care facilities. This will also include the necessary interventions required for (1) IEC/ BCC activities, (2) Coordination with other departments/ Municipal bodies etc, and (3) Ensuring the facility have appropriate infrastructure and equipment for bio-medical waste management. Draft  A more holistic approach required towards the bio-medical waste management from an individual facility level in the beginning to being integrated at city/ district, province and national level. This will include both public and private health care facilities and laboratories. Given the limitations among regulatory, legislative and operational departments/ agencies such as NEPA, MoPH, Ministry of Commerce promoting private sector development, and Municipal bodies etc., and their limited priority and focus related to bio-medical waste management, poses limitation to prepare an effective city/ district level integrated HCWM plan and system for monitoring and regulating. In order to move forward in this direction, under the Sehatmandi project, MoPH will take active steps towards creating an enabling environment by better coordination and building consensus among agencies involved, by advocating with various state actors and international donor community. 5.4 Gender Actions Gender will be mainstreamed in all components of Sehatmandi. Building on lessons learned from SEHAT project, Sehatmandi will take practical measures to address gender and geographical inequities in health service delivery in all provinces. To address these challenges the project considers gender as a cross-cutting thematic area introducing gender-specific interventions under each component at both institutional level and community level. These interventions include i) improved availability of female health workers; ii) engage CDCs especially female members for awareness raising and behaviour change in key health challenges; iii) mainstreaming health response to GBV and improving reporting system for GBV management; iv) introducing measures provide enabling environment and to respond to GBV at ministry and health facility levels; and v) strengthen the gender department of ministry to provide technical support to MOPH on overall gender mainstreaming. Draft 5.5 ESMF Implementation Arrangements 5.5.1 Institutional Responsibilities for ESMF Implementation The overall responsibility of project implementation rests with the Ministry of Public Health (MoPH) while GDPM (General Directorate of the Preventive Medicine) is in charge of the implementation of HCWMP. National Level: At the national level a ESMF steering committee (with a specific ToR) comprised of the General Directorate of the Preventive Medicine (Department of Environmental Health), General Directorate of Curative Medicine, GCMU, Provincial Health Communication Directorate, EHIS and Sehatmandi project representative will ensure the implementation of the ESMP and HCWMP. The designated Safeguards Focal Officer will be identified with responsibility for overseeing the proper implementation of the ESMP and HCWMP within the GCMU at the MoPH and will be accountable for the steering committee. The Ministry’s Focal Point will be responsible for coordinating and monitoring the joint efforts of all relevant stakeholders during operations and make sure that the work is in accordance with the provisions of the social and environmental management framework. The ESMF-FO should be reporting on the gaps, constraints in the implementation of the ESMF to the Department of Environmental Health and the Management of the MoPH. Provincial Level: At the provincial level, a committee (with a specific ToR) encompassing the Provincial Health Directorate, Regional/ Provincial hospital director and implementing NGOs representative will be responsible for the implementation of HCWMP. In addition the provincial public health directorate will assign Focal Point (environmental health officer) for ESMP implementation with proper ToR and capacity building for effective implementation of the ESMP and HCWMP. District Level: At the district level, Provincial Health Directorate (PHD) and Implementing NGOs will identify District level ESMF Focal point officer at the District health facility, who will be responsible for the implementation of ESMF and HCWMP under the guidance of Provincial Level ESMF-FO. Health Facility Level: At the health facilities, this responsibility will lie with the Head of Health Facility. 5.6 Capacity Building The capacity building of the Safeguards Focal Officer and all the ESMF – FOs at Provincial level, District Level, and at the Facility level need to be trained on provisions of ESMF/ ESMP and HCWMP at the beginning of the project. During supervision of the project, the World Bank will assess the implementation of the Framework directly or through third party, and if required, will recommend additional strengthening. And based on these recommendations and/or monitoring reports of ESFM and HCWMP, the Safeguard Focal Officer at the MoPH Draft may plan further training and capacity building events for specific region/ provinces or for specific level of hierarchy of staffs involved in implementing ESMF and HCWMP. Also, all healthcare workers will be trained and equipped to implement satisfactory infection control practices and sound waste management as per HCWMP. Key trainings for safeguards team and other staff Sl.No Selected Topics Key Elements 1 Environment and Social Management Policies, guidelines, procedures, and codes Framework of practice, 2  World Bank Safeguards Policies  Relevant Afghan laws and regulations  Afghanistan Environment Law and World Bank safeguard policies and  Environmental Evaluations their application to the Sehatmandi Regulations project  The role of NEPA in ensuring safeguards  compliance  3 Social and Environmental Monitoring Identification of relevant environmental and Evaluation and social indicators. Monitoring responsibilities. Preparing monitoring reports 4 Health Care Waste Management Plan  Key risks and mitigation measures (HCWMP) implementation  Roles and responsibilities of health care staffs  Monitoring and reporting The ESMF training will be carried out at regional/ cluster of provincial level and will ensure that all ESMF-FOs including those managing health care facilities are trained. The HCWMP training and capacity building activities will be carried at the cluster of provinces to ensure all health care facility staffs including those involved in transportation and disposal of bio medical waste are trained. 5.7 Monitoring of ESMF Implementation The Environmental Health department through its Safeguards Officer, and in collaboration, with EHIS general directorate and GCMU, will be responsible for monitoring the environment and social performance aspects supported by the Sehatmandi project. The Safeguards Officer will undertake random visits to monitor construction activities and will provide technical advice to site engineers on social and environment issues if needed. The Safeguard Officer will collaborate closely with the World Bank Safeguards team and will share quarterly progress report on safeguards issues in the Project. Draft The cost of implementing and monitoring the ESMF is included in the overall budget of the Sehatmandi project. It includes, in particular, a full time Safeguards Officer in the GCMU team and the implementation of capacity building activities. Sehatmandi project, GCMU, Environmental Health Department of MoPH and its Safeguards Officer and other HCWMP staff will be closely monitoring the implementation of the HCWMP. The HCWMP monitoring will be carried out both through GDEHIS (HMIS) and by third party/ independent technical audits. Indicators addressing the following areas will be incorporated in the BPHS and EPHS score card, this includes: 1. Existence of color coded bins at various points of bio-medical waste generation? 2. Existence of IEC material describing type of waste for each color-coded bins in local language 3. Necessary equipment such as Autoclave/ microwave, needle shredder etc. exists and being used 4. Existence of trolleys for transporting the bio-medical wastes within premises 5. Existence of separate covered pits for sharps and human anatomical wastes and/ or incinerator and/or contractual agreement with centralized public/ private bio-medical waste collection and disposal agencies. 5.7.1 Third Party Monitoring and Independent Technical Audits of HCWMP Implementation A third-party monitoring agent will produce annual reports based on sample study of selected health facilities both from BPHS and EPHS covering the spread of provinces/ districts and will assess the compliance of HCWMP implementation. The agency’s reports will be informed by field observation visits and discussions with community representatives and various members of the health facility staffs. 5.8 Budget The Safeguards Focal Officer and relevant staff of Environmental and Health Department of MoPH and contractor(s) will undergo trainings in the application of the ESMF. During supervision of the project, the World Bank will assess the implementation of the Framework directly or through third party, and if required, will recommend additional strengthening. Capacity Number Details Required building budget activities Training sessions 7 (one in Training6 sessions to staff on ESMF US$29,400 to Sehatmandi each implementation (organized by Safeguards project staff Region) Officer) 6 There will be a total of 7 training sessions, one in each Region. The budget for training sessions includes; travel and accommodation cost plus training materials with stationeries. Draft Third-party Annual Sample basis covering both BPHS and TBD Monitoring EPHS facilities Training sessions TBD Training sessions on mitigation of TBD to contractors environmental and social impacts and contractor guideline Exposure visit for 20 The exposure visit will be planned to the TBD the implementer (Project region in two separate batches and project staff staff and Hospital directors) 5.9 Citizen Engagement Citizen engagement values the right of citizens to have an informed say in the decisions that affect their lives. Citizen engagement is based on a two way interaction and dialogue with government and emphasizes the sharing of power, information, and a mutual respect between government and citizens. In line with Government of Afghanistan is implementing an ambitious program to strengthen community engagement and empowerment through the Citizens’ Charter Afghanistan Program (CCAP) and the Community Development Councils (CDC) setup under the National Solidarity Program (NSP) to act as the active community institution to be informed and give feedback on implementation of ESMF. This will include social and environmental risks identified during screening and mitigation measures planned for the same for each of the health facility will be shared with community through CDC, and feedback of its implementation be sought at periodic intervals or ac part of the scorecard. Given the Sehatmandi project also plans to enhance its engagement through CDC for Community monitoring of health services through existing structures but using a community scorecard, the ESMF implementation indicators will also be included in the scorecard for effective feedback mechanism. Draft 5.10 Grievance Redressal Mechanism Public compliant and grievance mechanisms provide a formal avenue for affected groups or healthcare users to engage with the project implementers or healthcare service providers on issues of concern or unaddressed impacts. Grievances can be an indication of growing stakeholder/ healthcare users concerns (real and perceived) and could escalate if not identified and resolved. The management of grievances is therefore an important aspect of risk management for a project. The ESMF has developed a grievance redress mechanism to serve as a guide during project implementation (Annex 5) 5.11 Disclosure This Environmental and Social Management Framework (ESMF) was developed by the MoPH based on learning from SEHAT project and in consultation with various stakeholders. The ESMF was disclosed by the MoPH/ Sehatmandi project in Dari and Pashto languages as well as English on the MoPH website and in relevant places in the country places as required by law for information and comments. Public notice in the media should be served for that purpose. The English version of the ESMF is also disclosed at the World Bank’s Info Shop on ___________, 2018. The Government of Afghanistan intends to make all project documentation publicly available to the relevant stakeholders and through the Afghan Information Management System (AIMS). Draft ANNEX 1: NEGATIVE LIST OF SUBPROJECT ATTRIBUTES Subprojects with any of the attributes listed below will be ineligible for support under the Sehatmandi project operations. Attributes of Ineligible Subprojects GENERAL CHARACTERISTICS Subprojects or activities Involving the significant conversion or degradation of critical natural habitats. Including, but not limited to, any activity within:  Ab-i-Estada Waterfowl Sanctuary;  Ajar Valley (Proposed) Wildlife Reserve;  Dashte-Nawar Waterfowl Sanctuary;  Pamir-Buzurg (Proposed) Wildlife Sanctuary;  Bande Amir National Park;  Kole Hashmat Khan (Proposed) Waterfowl Sanctuary. Will significantly damage non-replicable cultural property, including but not limited to any activities that affect the following sites:  Monuments of Herat (including the Friday Mosque, ceramic tile workshop, Musallah complex, Fifth Minaret, Gawhar Shah mausoleum, mausoleum of Ali Sher Navaii, and the Shah Zadehah mausoleum complex);  Monuments of Bamiyan Valley (including Fuladi, Kakrak, Shar-i Ghulghular and Shahr-i Zuhak);  Archaeological site of Ai Khanum;  Site and monuments of Ghazni;  Minaret of Jam;  Mosque of Haji Piyada/Nu Gunbad, Balkh province;  Stupa and monastry of Guldarra;  Site and monuments of Lashkar-i Bazar, Bost;  Archaeological site of Surkh Kotal. Unofficial but recognized for significant historical and cultural value  Samangan, Takht-i-Rustam Stupa and Monastery  Logar, Mes Aynak Archaeological Site No land acquisition will be funded under this project. Involves the use of unsustainably harvested timber or fuel wood. Involves the use of hazardous substances. Draft ANNEX 2: CODES OF PRACTICE FOR PREVENTION AND MITIGATION OF ENVIRONMENTAL IMPACTS Potential Impacts Prevention and Mitigation Measures Buildings Rehabilitation and/or construction of healthcare facilities. Deforestation caused by: Replace timber beams with concrete where structurally Unsustainable use of timber. possible. Wood-firing of bricks. Ensure fired bricks are not wood-fired. Where technically and economically feasible, substitute fired bricks with alternatives, such as sun-dried mud bricks, compressed earth bricks, or rammed earth construction. Injury and death from Apply low-cost aseismic structural designs. Seismically earthquake: active or volcanic zones should be avoided if possible. If these sites must be used, then seismically resistant construction should be used in all construction activities, and early warning systems established. Injury and death from flood; Flood-vulnerable sites should be avoided. When such sites must be used, then provisions for raising ground level under structures, drainage and protective dikes are necessary. Such interventions may need to be removed during decommissioning. A local flood warning system should be established. Appropriate drainage systems will be needed during the periods of heavy rain. Provisions for safe latrine use during the rainy season will be needed as part of the management plans. Injury and death from landslides Landslide and erosion prone sites should be avoided. If not or heavy erosion; possible, natural vegetation should be maintained in the landslide-vulnerable slopes and throughout the site, the site should be terraced to limit runoff, and structures should not built on landslide-prone slopes. A local landslide warning system should be established. Injury and death from fire; Incorporate fire safety into management plan including means of warning and escape, internal fire spread, external fire spread, and access and facilities for the fire service. Draft Potential Impacts Prevention and Mitigation Measures Disease caused by inadequate Ensure designs include adequate sanitary latrines and access provision of water and sanitation: to safe water. A site should not be selected until a sustainable source of potable water is available. Injury and death from toxic Verify that there are no toxic materials present in the soil or materials on sites ground water. Verify that there are no environmentally hazardous sites (e.g. septic systems) are located where a building will be constructed. Avoid sites with a risk or air or water pollution from industrial or commercial activities. Sites should not be located within 50 meters of main roads. If such locations cannot be avoided, then site area nearest the road should be allocated to less frequently activities where possible and barriers should be placed along the road side of the site to reduce pollution and the chance of accident. Water Supply for Healthcare facilities Repair and rehabilitation of existing piped water schemes. New or expanded piped water schemes to serve healthcare facilities. Installation or rehabilitation of tube wells or dug wells. Disease caused by poor water Develop a drainage plan for the site which incorporates quality: natural drainage and drainage infrastructure. Contamination by seepage from Priorities leak detection and repair of pipe networks. latrines, municipal waste or agricultural areas. Chemical and bacteriological testing of water quality from adjacent comparable sources prior to installation of new High mineral concentrations. sources. Creation of stagnant pools of water. Redesign to prevent contamination if adjacent comparable sources are found to be contaminated. Subsequent monitoring of installed or rehabilitated sources. Appropriate location, apron and drainage around tube wells and dug wells to prevent formation of stagnant pools. Draft Potential Impacts Prevention and Mitigation Measures Provision of cover and hand-pump to prevent contamination of dug wells. Where pit latrines are used they should be located more than 10m from any water source. The base should be sealed and separated by at least 2m of sand or loamy soil from the groundwater table. Where night-soil latrines or septic tanks are built they should be sealed. Outflows should drain either to a soak-way located at least 10m from any water source or be connected to a working drain. Depletion of water source: Urban interventions and abstraction limits to be planned in the context of groundwater investigations. Over-exploitation of aquifers. Hazard of land subsidence. Local water use planning (community and technical consultation). Sanitation for healthcare facilities Latrines. Contamination of water supplies: Develop a waste water and solid waste management plan. Contamination of groundwater Where pit latrines are used they should be located more than because of seepage. 10m from any water source. The base should be sealed and separated vertically by not less than 2m of sand or loamy soil Contamination of surface waters from the ground water table. due to flooding or over-flowing. Where night soil latrines or septic tanks are built they should be sealed. Outflows should drain either to a soak away located at least 10m from any water source or be connected to a working drain. Maintenance training to be delivered along with new latrines. Disease caused by poor handling Training and health education to be provided to night soil practices of night-soil. handlers where affected by interventions. Protective clothing and appropriate containers for night-soil transportation to be provided. Draft Potential Impacts Prevention and Mitigation Measures Disease caused by inadequate Night-soil should be handled using protective clothing to excreta disposal or inappropriate prevent any contamination of workers skin or clothes. use of latrines. Where night-soil is collected for agricultural use it should be stored for a sufficient period to destroy pathogens through composting. At the minimum it should be stored in direct sunlight and turned regularly for a period of at least 6 weeks. Septic tanks should not be constructed, nor septic waste collected unless primary and secondary treatment and safe disposal is available. Health and hygiene education to be provided for all users of latrines. Awareness campaign to maintain sanitary conditions. Draft ANNEX 3: PROCEDURES FOR LAND MINE RISK MANAGEMENT Background 1. The following procedures are designed to respond to the risks caused by the presence of mines in Afghanistan, in the context of:  Community rehabilitation/construction works to be identified and implemented by the communities themselves (for small projects of up to $100,000 each);  Small and medium-size works to be identified by local authorities and implemented by local contractors (for projects up to $5m each);  Works to be implemented directly by Government departments/agencies, without use of contractors;  Large works to be implemented by contractors (for projects above $5m); 2. General comment applying to all following procedures: All risk assessment and clearance tasks shall be implemented in coordination with the Mine Action Center for Afghanistan (MACA). These procedures may need to be amended in the future depending on evolving circumstances. Procedure for Community-Managed Works Applicability: This procedure applies to community rehabilitation / construction works to be identified and implemented by the communities themselves (for small projects of up to $100,000 each). Overall approach: The communities should be responsible for making sure that the projects they propose are not in mine-contaminated areas, or have been cleared by MACA (or a mine action organization accredited by MACA). Rationale: Communities are best placed to know about mined areas in their vicinity and have a strong incentive to report them accurately as they will carry out the works themselves. 3. Communities are required to submit a reply to a questionnaire regarding the suspected presence of mines in the area where Bank-funded community-managed projects will be implemented. This questionnaire should be formally endorsed by the Mine Action Program for Afghanistan (MAPA). It will be a mandatory attachment to the project submission by the communities and should be signed by community representatives and the external project facilitator. External project facilitators will receive training from MAPA. Financing agreements with the communities should make clear that communities are solely liable in case of a mine-related accident. 4. If the community certifies that there is no known mine contamination in the area, the ministry responsible for the selection of projects should check with MACA whether any different observation is reported on MACA’s data base. Draft  If MACA’s information is the same, the project can go ahead for selection. The community takes the full responsibility for the assessment, and external organizations cannot be made liable in case of an accident.  If MACA’s information is different, the project should not go ahead for selection as long as MACA’s and community’s statements have not been reconciled. 5. If the community suspects mine contamination in the area.  If the community has included an assessment/clearance task in the project agreed to be implemented by MACA (or by a mine action organization accredited by MACA), the project can go ahead for selection.  If the community has not included an assessment / clearance task in the project, the project should not go ahead for selection as long as this has not been corrected.  Mine clearance tasks must be implemented by MACA or by a mine action organization accredited by MACA. Communities will be penalized (subsequent funding by World-Bank funded projects shall be reduced or cancelled) if they elect to clear mines on their own. Procedure for Small and Medium-size Works Contracted Out Applicability: This procedure applies to small- and medium-size works to be identified by local authorities and implemented by local contractors (for projects up to $5m each). Overall approach: MACA (or a mine action organization accredited by MACA) should provide detailed information on the mine-related risks (either based on previously done and updated general survey or on a new general survey) before projects are considered for selection. Only project sites assessed to have a nil-to-low risk would be eligible for selection, unless they have been demined by MACA or by a mine action organization accredited by MACA. Rationale: Neither local authorities nor local contractors have the capacity to assess the mine-related risks in a systematic way, while they may have incentives to underestimate them. 6. Prior to putting up a project for selection, a general survey should be carried out by MACA (or a mine action organization accredited by MACA) to assess mine-related risks in the area of the project (this should include checking information available in the MACA data base). 7. If MACA provides information suggesting a nil-to-low risk in the proposed project area, the project can go ahead for selection. 8. The contract between the responsible ministry and the contractor will include a clause stating that in case of an accident, legal liability would be fully and solely borne by the contractor. 9. If MACA assesses a potentially high risk in the area (whether due to the presence of mines or uncertainty. Draft  If the project includes an assessment/clearance task agreed to be implemented by MACA (or by a mine action organization accredited by MACA), it can go ahead for selection based on agreed funding modalities (clearance may be funded either under a contract with a Bank-funded project or under existing donor agreements with the mine action organization);  If the project does not included an assessment / clearance task, it should not go ahead for selection as long as this has not been corrected. Procedure for Works to be Implemented Directly by Government Departments/Agencies, Without the Use of Contractors Applicability: This procedure applies to works to be implemented directly by Government departments/agencies, without use of contractors. Overall approach: MACA (or a mine action organization accredited by MACA) should provide detailed information on the mine-related risks (either based on previously done and updated general survey or on a new general survey) before works or installation of goods/materials are carried out in any given area. Work would only be allowed to proceed in areas assessed to have a nil-to-low risk, unless they have been demined by a mine action organization accredited by MACA. Rationale: Government departments and agencies responsible for providing services currently do not have the capacity to assess the mine-related risks in a systematic way, and currently follow a process of consulting with MACA prior to carrying out activities. 10. Prior to carrying out work, the Government department/agency will consult with MACA to assess mine-related risks in the area (this should include checking information available in the MACA data base). If not already done, a general survey should be carried out by MACA (or by a mine action organization accredited by MACA) to assess mine-related risks in the area. 11. If MACA provides detailed information on mine-related risks which suggest a nil-to-low risk in the proposed area, the work can proceed. The Government would be solely liable in case of a mine-related accident. 12. If information provided by MACA cannot support the assessment of a nil-to-low risk in the proposed area (whether due to the presence of mines or uncertainty), works should not go ahead before MACA (or a mine action organization accredited by MACA) carries out the necessary further assessment and/or clearance for risks to be downgraded to nil-to-low, based on agreed funding modalities (clearance may be funded either under a contract with a Bank-funded project or under existing donor agreements with the mine action organization). Procedure for Large Works Using Contractors Applicability: This procedure applies to large works to be implemented by large contractors (projects above $5m). Draft Overall approach: The main contractor should be responsible for dealing with mine- related risks, in coordination with the UN Mine Action Center. 13. As part of the preparation of the bidding documents, a general survey should be carried out by MACA (or a mine action organization accredited by MACA) on all the areas where contractors may have to work (broadly defined). This survey should provide detailed information on mine-related risks in the various areas allowing for an un-ambiguous identification of areas that have a nil-to-low risk of mine/UXO contamination and areas where the risk is either higher or unknown. The survey should be financed out of the preparation costs of the bidding documents. 14. All survey information should be communicated to the bidders (with sufficient legal caveats so that it does not entail any liability), as information for the planning of their activities (e.g., location of campsites, access roads to quarries). 15. Depending on the nature and location of the project and on the available risk assessment, two different options can be used. Option 1 – Mine clearance activities are part of the general contract a) Based on the general survey results, a specific budget provision for mine action during construction is set aside as a separate provisional sum in the tender documents for the general contract. b) As a separately identified item in their bid, the bidders include a provision for a further detailed mine assessment and clearance during construction. c) On the instruction of the Supervision Engineer and drawing on the specific provisional sum for mine action in the contract, the contractor uses one of several nominated sub- contractors (or a mine action organization accredited by MACA) to be rapidly available on call, to carry out assessment prior to initiation of physical works in potentially contaminated areas, and to conduct clearance tasks as he finds may be needed. The Contractor may also hire an international specialist to assist him in preparing and supervising these tasks. The Contractor is free to choose which of the accredited sub- contractors to use, and he is fully responsible for the quality of the works and is solely liable in case of accident after an area has been demined. To avoid an “over-use� of the budget provision, the Contractor is required to inform the Supervision Engineer in writing (with a clear justification of the works to be carried out) well in advance of mobilizing the mine-clearing team. The Supervision Engineer has the capacity to object to such works. Option 2 – Mine clearance activities are carried out under a separate contract a) Specific, separately-awarded contracts are issued for further surveying and/or clearing of areas with a not-nil-to-low risk (under the supervision of the Engineer) by specialized contractors (or a mine action organization accredited by MACA). The definition of the areas to be further surveyed/cleared should be limited to those areas where any contractor would have to work, and should not include areas such as camp sites and quarries/material sites which are to be identified by the Contractor during and after Draft bidding of the works. As a result of these further surveys and possibly clearance works, mine-related risk in the entire contract area is downgraded to nil-to-low. b) The contract with the general Contractor specifies the extent of the portion of the construction site of which the Contractor is to be given possession from time to time, clearly indicating restrictions of access to areas where the mine risk is not nil-to-low. It also indicates the target dates at which these areas will be accessible. Following receipt of the notice to commence works from the Engineer, the Contractor can start work in all other areas. c) The general Contractor is invited to include in its bid an amount for mine-security, to cover any additional survey / clearance he may feel necessary to undertake the works. In case of an accident, a Board of Inquiry is assembled by MACA to investigate on the causes of the accident and determine liabilities. Large penalties should be applied on the Contractor if the Board determines that the accident resulted from a breach of safety rules. All parties involved in this process are required to closely coordinate with MACA and to provide the Government, local communities, MACA, as well as any interested party the full available information on mine-related risks that may reasonably be required (e.g., maps of identified minefields, assessments for specific areas). Draft ANNEX 4: ENVIRONMENTAL AND SOCIAL GUIDELINES FOR CONTRACTORS The following guidelines should be added to the ESMP and included in the contractual agreements:  Installation of the work site on areas far enough from water points, houses and sensitive areas;  Sanitary equipment and installations;  Site regulation (what is allowed and not allowed on work sites);  Compliance with laws, rules and other permits in vigor;  Inform the client if land is found to be contaminated;  Hygiene and security on work sites;  Protect neighboring properties;  Preserve existing fauna and flora;  Ensure the permanence of the traffic and access of neighboring populations during the works to avoid hindrance to traffic;  Protect and provide health and safety measures to staff working on work sites;  Soil, surface and groundwater protection: avoid any wastewater discharge, oil spi1l and discharge of any type of pollutants on soils, in surface or ground waters, in sewers and drainage ditches;  Protect the environment against exhaust fuels and oils;  Protect the environment against dust and other solid residues;  Waste management: install containers to collect the wastes generated next to the areas of activity;  Degradation/demolition of private properties: inform and raise the awareness of the populations before any activity causing degradation of natural vegetation and resources. Compensate beneficiaries before any work;  Use a quarry of materials according to the mining code requirements;  Compensation planting in case of deforestation or tree felling;  No waste slash and burn on site;  Speed limitation of work site vehicles and cars;  Allow the access of Public and emergency services;  Organize the storage of materials;  Organize parking and displacements of machines;  Footbridges and access of neighbors;  Signaling of works;  Respect of cultural sites;  Safe Disposal of asbestos;  Consider impacts such as noise, dust, and safety concerns on the surrounding population and schedule construction activities accordingly;  Protect soil surfaces during construction and revegetate or physically stabilize eligible surfaces;  Ensure proper drainage;  Prevent standing water in open construction pits, quarries or fill areas to avoid potential contamination of the water table and the development of a habitat for disease-carrying vectors and insects; Draft  Select sustainable construction materials and construction method;  Control and clean the construction site daily;  During construction, control dust by using water or through other means;  Provide adequate waste disposal and sanitation services at the construction site;  Dispose of oil and solid waste materials appropriately;  Preserve natural habitats along streams, steep slopes, and ecologically sensitive areas;  Develop maintenance and reclamation plans and restore vegetation.  Ensure no blockage of access to households during construction and/or provide alternative access.  Camps should be located 500 m from habitations.  Ensure security and privacy of women and households in close proximity to the camps. Draft ANNEX 5: GRIEVANCE REDRESS MECHANISM Grievances are any complaints or suggestions about the way a project is being implemented and or any complaint relating to healthcare or service delivery. They may take the form of specific complaints for damages/injury, concerns about routine project activities, or complaint regarding health care quality or services. Identifying and responding to grievances supports the development of positive relationships between projects and affected groups/communities, and healthcare service users. Objectives: The main objective of a Grievance Redress mechanism is to provide an efficient way to address concerns and grievances, mediate conflict and cut down on lengthy litigation, which often delays project civil work and or to improve delivery of healthcare services. The procedures for grievance handling will provide people who might have objections, grievances or concerns, a venue for raising their grievances and concerns, as well as a mechanism for timely and adequate solution or mitigation of these grievances and concerns. The Grievance Redress Committee: MoPH has a grievance handling system in place, but its scope and reach is limited. The MoPH will establish a grievance handling committee and involve health shura members in grievance handling process. The grievance and or complaint relating to healthcare services will be addressed at the healthcare facilities. The compliant handling committee at healthcare facility will also involve health shura members in compliant handling processes. In case the grievances could not be satisfactorily resolved at facility level, then the aggrieved parties may submit the grievance to the Grievance Redress Committee (GRC), formed at the provincial level. Based on the merits of the complaint, the GRC will address all the grievances received. Constitution of grievance committee at different level which are as follows: 1. Healthcare Facility level:  Health Shura head and or member of health Shura;  Head and or his/her representative of healthcare facility;  Complainant(s) or representative(s) to witness meeting discussing his/her complaints. 2. Provincial level:  Provincial Director/MoPH  Representative of Governor  Representative from Shura/Provincial Council  Representative from contracted NGO Submission of Grievances: The grievance handling committee at healthcare facility will receive the grievances/complaints of affected people and or users of healthcare services through written, oral, telephone, Health Draft Shura, District Governor, community elders and etc. The collected grievances will be recorded and final decision will be shared with the healthcare facility and MoPH provincial department. The MoPH will maintain a database for complaints to enable complaint tracking and review and analysis. The project will also establish different options for public information/disclosure of information for communities, healthcare services users and relevant stakeholders to be aware of processes to be followed to register complaints. Draft ANNEX 6: OCCUPATIONAL HEALTH AND SAFETY GUIDELINE Today’s health and safety is one of the main requirements of human life. Non-compliance with health and safety on the job, will create a lot of problems and troubles. Knowing the safety measures and focus on those areas of concern would be very effective and functional. Collection of articles and tips on safety and security in the working areas will be one of the principles of good practice and improvement. With sensitive tradition and customs condition in Afghanistan, using of manpower out of the village due to specific task of the project, construction of camp as a temporary shelter for the workers is one of the main issues which will cover most of the social aspects from the selection of site till the using of village recourse. So, it is important to consider this issue properly and avoid of any unexpected conflicts and its negative effects. In case, any construction camp is required for the sub-project, installation of it is responsibility of the contractor hired for the construction, while its adherence is to be ensured by the NGO/ agency hiring the contractor. The decision for installation of construction camp should be taken during the project selection and site investigation. Construction camp could be a tent or a basic and sample shelter. Health and safety Guide in Construction Site: In the past there was different accidents like, falling, sliding from heights, tipping and injuries with basic construction tools, loco due to polluted hand or chemical contamination at the construction site, which today with significant progress in different affairs particularly construction work and possibilities of using equipment, power and exposure with chemicals, the labours are exposed with quite lots of incidents while on work. Hence, the health and safety is an important aspect for safe environment and smooth working. It is important that labour should identify and adhere to the safety norms and guidelines to decrease the risk of any accidents. Reduction of number and grade of accidents at workplace would reduce the problems and cost with saving of time for during work hours (amount of time of that a helper or nurse use for an injured person). Safety and its impacts: Accidents and happenings are divided in two types: 1. Accidents which is impossible to prevent from its occurrence, 2. Foreseen accidents which needs to use cost for prevention of occurrences or risk reduction, "Construction Site" means a place where construction work is undertaken and also any area in the immediate vicinity of any such place which is used for the storage of materials or plant used or intended to be used for the purpose of the construction work. Construction work can be particularly hazardous. Personal protective equipment, fire safety, electrical safety, and other precautions are essential for safe construction work. a. The construction, erection, installation, reconstruction, repair, maintenance (including redecoration and external cleaning), renewal, removal, alteration, improvement, dismantling, or demolition of any structure or works specified in the Third Schedule; Draft b. Any wok involved in preparing for any operation referred to in paragraph (a), including the laying of foundations and the excavation of earth and rock prior to the laying of foundations; c. The use of machinery, plant, tools, gear, and materials in connection with any operation referred to in paragraph (a) or (b). Barriers and Guards Barriers, guards, and warning signs are required to ensure safety against existing hazards. Standard types of barriers and guards include the following:  Guardrails and handholds  Saw horses  Tape  Cones  Other physical barriers and solid separators (dust barriers, hazard barriers, temporary walkways, etc.) NOTE: Signs that state DANGER, WARNING, or CAUTION are also important when barriers or guards are necessary. Remember to make signs legible, visible, and brief. Areas that Need Barriers or Guards Any area that poses a physical threat to workers and/or pedestrians requires barriers or guards. Areas that typically require permanent or temporary protection include the following:  Stairways  Hatches  Chutes  Open Manholes  Elevated platforms  Areas with moving machinery  Excavation sites  Construction sites  Temporary wall or floor openings  Doors opening into construction sites  Land and stone sliding from vaccinate places or mountain, Using Barriers and Guards The following list provides guidelines for using barriers and guards:  It should be avoiding with hanging cloths (scarf, and etc…) during the work,  In case of need safeguards belt is necessary,  When necessary, reroute pedestrian and vehicular traffic to completely avoid a construction site. Draft  Guard any permanent ground opening into which a person could fall with a guardrail, loadbearing cover, or other physical barrier.  Ensure that temporary floor openings, such as pits and open manholes, are guarded by secure, removable guardrails. If guardrails are not available, have someone guard the opening.  Ensure that all stairways, ladder ways, hatchways, or chute floor openings have handrails or hinged covers.  Ensure that enclosed stairways with four or more steps have at least one railing, and that open stairways with four or more steps have two railings.  Ensure that all platforms and walkways that are elevated or located next to moving machinery are equipped with handrails, guardrails, or toe boards.  Barricade any wall openings through which a person or tools could fall. Use gates, doors, guardrails, or other physical barriers to block the opening.  Mark and /or guard any excavation that is deeper than 30cm, potholes and sidewalk damage. Hoists Only authorized employees may use hoists to move heavy objects and equipment. When using hoists remember the safety points:  Never walk, stand, or work beneath a hoist.  Isolate hoisting area with barriers, guards, and signs, as appropriate.  Never exceed the capacity limits of your hoist.  Wear gloves and other personal protective equipment, as appropriate, when working with hoists and cables.  Always hold tension on the cable when reeling it in or out.  When the work is complete, always rig the hoist down and secure it.  Be prepared to stop operations immediately if signalled by the safety watch or another person. Scaffolds When employees must conduct construction work above the ground and away from solid platforms, scaffolds may be appropriate. The following list provides guidelines for using small scaffolds. Larger scaffolds must be designed and erected in accordance with applicable standards.  Ensure that scaffold anchors are sound, rigid, and capable of supporting the maximum intended load without shifting. Scaffolds and their components should be capable of supporting at least four times their maximum load.  For freestanding, mobile scaffolds, the height should not exceed four times the minimum base dimension. If workers are riding the scaffolding, however, the base dimension should be at least one half the heights.  Do not use unstable objects such as barrels, boxes, bricks, or blocks to support scaffolds or planks. Draft  Keep floors free of debris where mobile scaffolds are used.  Lock scaffolds with wheels into position.  Either overlap multiple planking and platforms by 30cm or secure them to ensure stability. Thickness of the board should not be less than 5cm.  Secure scaffolds to permanent structures with anchor bolts or other means.  Repair damaged scaffolds immediately.  Do not work on scaffolds in high winds or during storms.  Remove ice or snow from scaffolds and apply sand to the wood before conducting work in winter weather.  Do not allow tools, equipment, or other debris to accumulate on scaffolds.  Dismantle and remove scaffolds when they are no longer needed. Do not use temporary scaffolding as a permanent installation. Safety during Concrete Casting: Concrete casting is often done by a group of people. Different places, needs its own safety conditions which include Personnel Protection Tools, skills in work and its equipment, good coordination and cooperation amongst the task team and their Job description based on their physical manner. During Concrete casting followings points should be taken into consideration:  During concrete cast the labours should be clothed with plastic boots and gloves,  Appropriate working tool should be selected; in case of not using it should be kept away in a specific area,  Damaged tools should be kept in a specific area for repairing,  Throwing of tools should be avoided,  During concrete casting it should be alert that the labour feet not clumped in bars,  Using of plunks as a pathway will be most useful,  Use appropriately of the work tools and tack care of them,  Wash hands before food and take bath after daily work to take away the cement dust,  Good condition work and good ventilation should be prepared,  A good supervisor should led the team and their learning’s,  The wire for fasten the bars should be cut in small pieces and kept near the work area,  Avoid of throwing wires everywhere,  The mash should be fasten properly,  Using of mashes in the slopes, The following tools are must in sub-projects and should be hints in CCAP Operation Manual for budget allocation and ownership at the end of the project:  First Aid kit to workers,  Safety signs  Personal Protective Equipment (PPE) for labour,  Labour camp Draft