INTEGRATED SAFEGUARDS DATA SHEET APPRAISAL STAGE Report No.: ISDSA3263 Public Disclosure Copy Date ISDS Prepared/Updated: 15-May-2013 Date ISDS Approved/Disclosed: 15-May-2013 I. BASIC INFORMATION 1. Basic Project Data Country: Tajikistan Project ID: P126130 Project Name: Tajikistan Health Services Improvement Project (HSIP) (P126130) Task Team Wezi Marianne Msisha Leader: Estimated 07-May-2013 Estimated 30-Jul-2013 Appraisal Date: Board Date: Managing Unit: ECSH1 Lending Investment Project Financing Instrument: Sector(s): Health (60%), Compulsory health finance (40%) Theme(s): Child health (50%), Health system performance (30%), Injuries and non- communicable diseases (20%) Is this project processed under OP 8.50 (Emergency Recovery) or OP No 8.00 (Rapid Response to Crises and Emergencies)? Financing (In USD Million) Public Disclosure Copy Total Project Cost: 23.00 Total Bank Financing: 15.00 Total Cofinancing: Financing Gap: 0.00 Financing Source Amount BORROWER/RECIPIENT 3.20 IDA Grant 15.00 Health Results-based Financing 4.80 Total 23.00 Environmental B - Partial Assessment Category: Is this a No Repeater project? 2. Project Development Objective(s) The Project Development Objective (PDO) is to contribute to the improvement of the coverage and quality of basic primary health care (PHC) services in rural health facilities in selected regions. Page 1 of 7 The Project’s main beneficiaries would be the Tajik population of selected regions who would benefit from improved PHC services. Primary health care providers would also directly benefit from the Project through performance-based incentives and capacity building. Women, especially poorer Public Disclosure Copy rural women, would be a major direct beneficiary group as much of the Project is focused on improving maternal health services in the PHC facilities. By focusing on the underserved areas in the country, the Project would reach out to target the poorer sections of the rural women. The key indicators of achievement of the Project Development Objective in the selected intervention areas are as follows: (a) Percentage of pregnant women receiving antenatal care four or more times from a skilled health provider; (b) Contraceptive prevalence rate; (c) Average Health Facility Quality of Care Score; (d) Percentage of children under-five with diarrhea treated with any Oral Rehydration Therapy. 3. Project Description The proposed project will consist of the following three components: Component 1: Performance-Based Financing (USD12.8 million, of whichUSD6.0 million from IDA Grant,USD4.8 million from HRITF, & USD2.0 million Government contribution) This component would support a performance based financing (PBF) pilot at the PHC level in eight rayons (or districts) in Khatlon and Sogd oblasts (regions). Under the PBF pilot, Rural Health Centers (RHCs) and their subsidiary Health Houses (HHs) would be eligible to receive a performance-based payment each quarter based on the quality and quantity of MCH and Non- communicable Diseases (NCD) services delivered. The first level verification of the accuracy of activities reported by the PHC facilities would be done quarterly by a District PBF Committee. The performance-based payments would then be made to a RHC and its associated HHs, to encourage Public Disclosure Copy better teamwork and co-ordination. These payments would be supplementary to the funds routinely received from the public sector budget. The use of the performance-based payments would be governed by simple spending rules designed to promote provider autonomy and ensure transparency and accountability. The payments may be used for performance bonuses to facility staff and to purchase minor health facility inputs within these spending rules. Component 2: Primary Health Care Strengthening (USD6.0 Million). This component would aim to improve the capacity of Primary Health Care (PHC) providers to deliver quality services. Sub-component 2.1 Quality Improvement (USD2.5 million). The sub-component would finance the training of PHC doctors and nurses from the project districts and selected comparison districts in a six months Family Medicine training program. Nurses and doctors from all PHC facilities in the project districts and selected comparison districts would also participate in continuous medical education on clinical treatment protocols for MCH care and selected NCDs. The training would utilize recently updated and MoH approved modules developed by other development partners including GiZ, UNICEF, UNFPA, and WHO. This sub-component would also support the introduction of a collaborative quality improvement process focusing on the management of three priority areas - preliminarily acute respiratory illness, child under-nutrition, and hypertension. Sub-component 2.2: Physical Infrastructure Improvements (USD3.5 million). This sub-component Page 2 of 7 would support the improvement of PHC infrastructure in the project districts. This would include the provision of basic medical equipment and supplies to all PHC facilities in the project districts, and some rehabilitation and reconstruction works for selected PHC facilities to ensure basic functionality. Public Disclosure Copy Approximately twenty-four PHC facilities in the project districts have been identified for works according to agreed criteria (i.e. only rural health centers, size of population catchment area, reasonably sound, feasible building superstructure facilities that are currently functional and confirmed to be on state owned land, and facilities following the Health Sector Master plan recommendations). The designs for the facilities would start to be developed upon Project effectiveness, and the actual rehabilitation work would start in the second year of the Project. Component 3 Project Management, Coordination and Monitoring & Evaluation (USD4.2 million). This component would finance the expenses associated with the implementation and management of the project at the central, regional and district levels. Recurrent costs, office equipment and furniture, vehicles for project supervision, consultant salaries, travel expenses, study tours to enhance the knowledge on PBF schemes, and training for the Coordination Group (CG) members and project implementation staff at regional and district levels, monitoring and evaluation, and project audits would be supported. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project would be implemented in 8 districts of Khatlon and Sogd regions of Tajikistan. Twenty-four PHC facilities have been identified for refurbishment based on agreed criteria The 12 sites have been screened for environment and social impacts. It has been confirmed that there will be no land acquisition, nor any restriction in access to physical assets, resources or services as a result of project works. All the sites are being used as PHCs and there are no persons from the community using that land for any other purpose nor are there any structures on it. Hence OP 4.12 is not triggered. Public Disclosure Copy The project entails civil works related to improving the physical infrastructure of Rural Health Centers, to upgrade them to basic levels of functionality to be able to provide satisfactory health services in accordance with the Project Development Objective. A preliminary assessment indicates that the facilities are substantially degraded and will need significant rehabilitation and civil works to improve availability of basic utilities and services including water, sewerage, sanitation and electricity. Older building structures may contain asbestos, which will require sound management during dismantling and disposal. While there is no foreseen substantial increase of quantity of medical waste, or change in waste types or composition, site specific assessments will be undertaken to determine appropriate waste disposal options which will be provided for sound management of infectious waste. Given the above environmental issues related to project activities, OP4.01 is being triggered. 5. Environmental and Social Safeguards Specialists Roxanne Hakim (ECSSO) Ruma Tavorath (SASDI) 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes Environmental issues related to construction and BP 4.01 rehabilitation of healthcare facilities and waste Page 3 of 7 management (construction debris, asbestos and infectious waste) necessitate triggering OP 4.01. Natural Habitats OP/BP 4.04 No Public Disclosure Copy Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources OP/ No BP 4.11 Indigenous Peoples OP/BP 4.10 No Involuntary Resettlement OP/BP No The sites are all functioning PHCs and there are 4.12 no persons who have constructed any structures on the site, nor using any resources, assets or services on the site. Hence there will be no involuntary impacts as defined by OP 4.12. Safety of Dams OP/BP 4.37 No Projects on International No Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP No 7.60 II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues Public Disclosure Copy 1. Describe any safeguard issues and impacts associated with the Restructured project. Identify and describe any potential large scale, significant and/or irreversible impacts: The project entails civil works related to improving the physical infrastructure of Rural Health Centers (RHC), to upgrade them to basic levels of functionality to be able to provide satisfactory health services in accordance with the Project Development Objective (PDO). While there is no foreseen expansion of the constructed area or substantial increase of capacity, the current situation of the facilities are quite degraded and will need significant rehabilitation and civil works to improve availability of basic utilities and services including water, sanitation and electricity. An environmental assessment of sample facilities indicates that none of them have access to safe and adequate drinking water. Water is brought carried in buckets from neighborhood residential areas and office buildings. The water is then boiled prior to use, using water heaters. Sewage systems are inadequate, and are basically essentially non-concrete pits dug out in the RHC backyards. Once filled, such pit lavatories are covered up and new pits are dug, resulting in potential gradual soil and groundwater contamination. Most RHCs have restricted power access and utilize potbelly stoves which are expensive to operate and inefficient with poor heat retention. The use of quality of the fine blend coal is poor which results in harmful indoor air emissions and, charcoal-black deposition inside buildings all of which is harmful for staff and patients. Due to the shortage of coal, firewood is used as an alternative, resulting in degradation of neighboring bushes and forests. Most of these older building structures may contain asbestos, which would require sound management during dismantling and disposal. Waste disposal facilities are inadequate, and all Page 4 of 7 categories of healthcare waste are collected in first aid boxes and burned in pits located within the premises. New pits are routinely dug, after others are filled, further resulting in soil and air contamination (mercury, dioxins and furans) and hazards due to scattered sharps. While there is no Public Disclosure Copy foreseen substantial increase of quantity of medical waste, or change in waste types or composition, but the new constructions will address environmentally sound ways of disposing infectious waste generated from healthcare services. Site specific assessments would be undertaken to determine characteristics and suitability of existing waste disposal facilities. There are no such impacts with regard to social safeguards. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Localized soil and water contamination due to poor sanitation and inadequate waste management. Toxic air emissions due to poor incineration/burning practices of unsegregated waste. Contamination due to poor management of construction waste and indiscriminate disposal of asbestos. No such impacts with regard to social safeguards. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. The MoH has undertaken an assessment of sample RHC facilities and has prepared an EMF. The EMF defines critical mitigatory measures to be taken to address environmental impacts prior to and during the construction phase. These include issues related to design, water supply, sanitation and sewerage, power supply and waste management including construction debris and asbestos. Worker safety during construction and occupational safety and healthcare waste management during facility operations are also addressed in the EMF. Site-specific Environment Management Public Disclosure Copy Plans will be prepared and approved prior to commencement of civil works at each site and EMP requirements will be included into bid contracts for civil works. In addition to regular monitoring and supervision requirements during and after construction, the EMF also requires a third-party independent assessment to be carried out 8 months prior to the end of the Project life. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The project’s main beneficiaries are the general population and specifically, women and children. The stakeholders will include healthcare staff and medical doctors from the MOH and the RHCs, the Environmental and construction management agencies which will be involved in providing clearances and undertaking the civil works, the neighborhood communities residing near the RHCs and those who utilize the services of the RHCs. The MOH has translated and re-disclosed the final EMF on their website and in the central level and regional health department offices on May 10, 2013. Consultations were held with relevant public sector agencies, CO (Community Organizations), NGOs and medical professionals starting from April 29, 2013 to get feedback on the draft EMF, before it was finalized before project approval and implementation. The community will also be consulted with regard to alternative location for continuation of RHC services during the time of construction and restoration. Site-specific EMPs will be consulted with Page 5 of 7 relevant stakeholders in the Oblasts to discuss proposed facility design, scheduling of construction hours, habitat/ecosystem management and waste management. These will include neighboring communities, patients, residents, healthcare staff and workers, local businesses and neighboring Public Disclosure Copy shops and local authorities. Grievance mechanisms need to be instituted to ensure that communities can provide feedback or voice their concerns, if any. There are no persons who will be affected by Involuntary Resettlement. The project will focus on poorer rural women as a major beneficiary group through emphasis on maternal health services in the Primary Health Center facilities in underserviced areas in the country. The improvements in infrastructure will also enhance the experience of visiting the PHCs for women due to availability of facilities like toilets, waiting areas etc. On the supply side, focus on improving nurse training and post-graduate experience would also target women in the area of service delivery, as the majority of nurses in Tajikistan are women. Children and infants are also a specific target beneficiary group. The Project Development Objective indicators show the strong focus on outcomes related to children’s health. The focus on underserved rural areas will directly target children from poorer families. Improved child health will have a direct positive impact on benefiting women who are the primary care givers, as well as school attendance rates. The project M & E will disaggregate data to the extent feasible to capture the impacts on women and children as well as the elderly. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Was the document disclosed prior to appraisal? Date of receipt by the Bank 10-May-2013 Date of submission to InfoShop 10-May-2013 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Public Disclosure Copy "In country" Disclosure Tajikistan 10-May-2013 Comments: If the project triggers the Pest Management and/or Physical Cultural Resources policies, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/ Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) Yes [ ] No [ ] NA [ ] report? If yes, then did the Regional Environment Unit or Sector Yes [ ] No [ ] NA [ ] Manager (SM) review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated Yes [ ] No [ ] NA [ ] in the credit/loan? The World Bank Policy on Disclosure of Information Page 6 of 7 Have relevant safeguard policies documents been sent to the Yes [ ] No [ ] NA [ ] World Bank's Infoshop? Public Disclosure Copy Have relevant documents been disclosed in-country in a public Yes [ ] No [ ] NA [ ] place in a form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional Yes [ ] No [ ] NA [ ] responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included Yes [ ] No [ ] NA [ ] in the project cost? Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] with the borrower and the same been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader: Wezi Marianne Msisha Approved By Regional Safeguards Name: Agnes I. Kiss (RSA) Date: 15-May-2013 Advisor: Sector Manager: Name: Daniel Dulitzky (SM) Date: 15-May-2013 Public Disclosure Copy Page 7 of 7