The World Bank Institutional Foundations to Improve Services For Health (P169641) Environmental and Social Review Summary Concept Stage (ESRS Concept Stage) Public Disclosure Date Prepared/Updated: 05/13/2019 | Report No: ESRSC00538 May 13, 2019 Page 1 of 8 The World Bank Institutional Foundations to Improve Services For Health (P169641) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Liberia AFRICA P169641 Project Name Institutional Foundations to Improve Services For Health Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 10/14/2019 2/27/2020 Population Financing Borrower(s) Implementing Agency(ies) Republic of Liberia Ministry of Health Proposed Development Objective(s) Strengthening institutional management for enhanced health services to women, children and adolescents in Liberia. Public Disclosure Financing (in USD Million) Amount Total Project Cost 40.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] While considerable donor financing is provided to the health sector in Liberia, government and partners agree that despite reasonably good plans, implementation has been slow or constrained. Formal and informal discussions with different key stakeholders point to significant governance and institutional weaknesses that challenge implementation, that in turn, persistently delay achievement of expected results. However, this has not been systematically documented to be able to reach consensus for effective action. Additionally, further analysis is needed to understand better the causes, behaviors, socio-cultural influences, and distribution of teenage pregnancies and maternal mortality, to enable strengthening country-wide interventions that would enable desired improvements in these outcomes. Based on a deeper understanding of these issues, including through a stakeholder and political economy analysis, the proposed health sector project will be designed to address and incentivize improved governance and institutional system through a results-based approach: financing appropriate process driven results vs May 13, 2019 Page 2 of 8 The World Bank Institutional Foundations to Improve Services For Health (P169641) inputs. Liberia is currently receiving adequate support for strengthening systems and capacity building for surveillance and response to disease outbreaks, and hence this will not be a focus of the proposed new operation. D. Environmental and Social Overview D.1. Project location(s) and salient characteristics relevant to the ES assessment [geographic, environmental, social] The proposed project will be implemented nationally. Liberia’s territory covers 111,000 square kilometers (km). It has a 360-mile Atlantic coastline and overland borders with Sierra Leone, Guinea, and Côte d’Ivoire. The estimated population of Liberia is 4.5 million people, one-quarter of the country’s people lives in the capital city Monrovia, and in surrounding. The remaining 3.4 million people live in the other 14 counties. Poverty in Liberia is widespread, while poor households are mainly concentrated in rural areas, and urban poverty also poses a significant challenge. As a fragile post-conflict state, Liberia receives significant inflows of development assistance, but leveraging external support to create a foundation for sustainable and inclusive growth poses a persistent challenge. Since the end of the internal conflict in 2003, the process of rebuilding and transforming institutions has proceeded at a slow pace, and gains in core social indicators as well as progress toward diversifying the economic base was limited. The Human Capital Index for Liberia is 0.32, ranking 154 of 157 countries. The combination of high fertility rates and low average life expectancy make Liberia’s population very young. Over 70 percent of Liberians are under the age of 35, and a large share of young workers intensifies demand for jobs, farmland, infrastructure, and public services. Improving adolescent sexual and reproductive health outcomes is a priority area of investment to create the conditions for demographic transition and human capital accumulation for women and girls. Adolescent fertility contributes to total fertility and limits the ability of young women to accumulate human capital. Gender inequality compounds the country’s larger socioeconomic disparities, as women from poor households and vulnerable communities face Public Disclosure severely limited economic opportunities and endure worse human development outcomes. Girls and women in rural areas and poor urban communities have very little access to quality education, healthcare, and employment options. Liberian women experience high rates of early pregnancy, school dropout, and child and maternal mortality, all of which are especially common among poor households. During the conflict, rape was used as a weapon of war, and fourteen years later Liberia continues to grapple with a high incidence of rape and other forms of gender-based violence (GBV). D. 2. Borrower’s Institutional Capacity The Ministry of Health (MOH) will be the implementing agency for the proposed project. Currently, the MOH has a Project Implementation Unit (PIU) which manages and coordinates the implementation of several Bank-financed projects. The PIU has a full-time environmental and social (E&S) safeguards specialist who oversees the implementation of project safeguard instruments. In addition to this, environmental compliance at the level of the Ministry is the responsibility of the Environmental Health Division of the MOH which is charged with executing the environmental health plans under the overall policy guidance of the National Environmental Protection Agency. The E&S specialist of the PIU and staff of the Environmental Health Division work together from time to time to ensure safeguard compliance at project level. This has worked very well in the past, and it is hoped that the same approach will be adopted for this project. The E&S specialist of the PIU was one of several safeguard specialists who benefited from the ESF Borrower training delivered in FY18. Staff of the Environmental Health Division would benefit from similar training to ensure in-house capacity for safeguard implementation is developed and sustained. II. SCREENING OF POTENTIAL ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate May 13, 2019 Page 3 of 8 The World Bank Institutional Foundations to Improve Services For Health (P169641) Environmental Risk Rating Low The activities proposed in the draft project concept note will exclusively be focused on institutional strengthening, governance, and technical issues. No civil works or other activities that could potentially generate adverse environmental and social impacts and risks are envisaged under the project. The risk rating will be revised whenever there are changes in the project scope to warrant an updating of the project risk. Social Risk Rating Moderate The social risk is classified as moderate given that the potential adverse risks and impacts on human populations and/or the environment are not likely to be significant, and that the project’s risks and impacts can be easily mitigated in a predictable manner. The project proposes to enhance community engagement, involve non-state actors and local leaders to improve adolescent sexual and reproductive health, teenage pregnancies and maternal mortality. This is a sensitive issue that requires sound political economy analysis and careful identification of stakeholders, planning and engagement of communities and specific groups, such as adolescent girls (and boys), and vulnerable/disadvantaged populations. Addressing deeply entrenched social norms and behavior change requires in- depth local knowledge, culturally and socially appropriate channels of communication and messaging approaches. While the project does not anticipate to create physical/geographic footprint through direct investments the potential risks and impacts of the components on human resources management, drug procurement and supply chain management and health services data management would need to be analyzed carefully. The risk classification will be updated as more information becomes available with regards to the scope of the project. Public Disclosure B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: This ESS applies to all projects supported by the Bank throughout Investment Project Financing. No civil works are expected under the project. Nevertheless, an initial assessment of the project components anticipates potential risks and impacts related to (i) non-discrimination and inclusion of vulnerable and disadvantaged groups– this will be particularly relevant to the component that supports adolescent reproductive health and teenage pregnancy, and will include a stakeholder engagement and communication/messaging on social norms and behavior change. (ii) labor and working conditions (ESS2) of project direct workers, including staffs of project implementing agency and contracted workers under project component on the human resource management - the National Labor Laws and Labor Codes of Liberia shall be used; (iii) Community health and safety (ESS4) under supply chain management component – disposal and management of medical waste, lack of awareness among people, lack of medical waste disposal sites, proper waste management procedure for unused, expired and damaged drugs, may pose risks and threats for community health and safety. The existing medical waste management plan developed under the Bank supported Ebola Emergency Response Project and REDISEE will be also be reviewed in the context of the waste disposal of proposed project, if required then TA will be provided to strengthen the existing document to manage additional wastes generated as a result of any of this project interventions; (iv) given the focus on adolescent reproductive health, teenage pregnancy and fertility, the contextual and project-level GBV risks would be assessed by the Bank team in line with the emerging World Bank GBV risk assessment procedure. As per the findings of the GBV risk assessment, any action plan for risks management if required will be prepared prior to the appraisal; (v) The May 13, 2019 Page 4 of 8 The World Bank Institutional Foundations to Improve Services For Health (P169641) aspects of behavioral change and interventions related to adolescent health is unlikely to pose risks and threats for intangible cultural traits and traditions (ESS8). The currently available analysis of norms, behavior and knowledge related to reproductive health will be reviewed by the task team, and any further needs for analysis will be assessed during project preparation. These risks and impacts will further be assessed and reflected in the SEP and ESCP as appropriate. Further the draft SEP and ESCP will be prepared by the government and, after review and cleared by the Bank, the safeguards instruments shall be disclosed prior to the appraisal. Areas where reliance on the Borrower’s E&S Framework may be considered: The project will not use the Borrower’s E&S Framework in the assessment, development and implementation of project activities. The project will comply with relevant national legal requirements, including the following relevant EIA requirements: (i) Environmental Protection Agency Act of Liberia, (ii) Environmental Policy of Liberia, and (iii) Environmental Protection and Management Law of Liberia. ESS10 Stakeholder Engagement and Information Disclosure The project aims to undertake extensive stakeholder engagement to inform the design of the project and expected results. A wide range of relevant issues and factors underpinning the proposed components will be analyzed in consultations with key stakeholders both inside and outside of the health sector. The process will involve the following as set out in ESS10: (i) stakeholder identification and analysis; (ii) planning how the engagement with stakeholder will take place; (iii) disclosure of information; (iv) Consultation with stakeholders; (v) Addressing and responding to grievances; and (vi) Reporting to stakeholders. The draft Stakeholders Engagement Plan (SEP) will be needed to be prepared and disclosed as early as possible, and before project appraisal. The SEP will clearly set out Public Disclosure how and when the stakeholders, especially women, teenagers, adolescent and community members, leaders will be engaged and describe the timing and methods of stakeholders’ engagement and how the views of different stakeholders will be heard, and their inputs included in the plan for project implementations. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions The requirement of ESS2 will apply, and the national Liberia Labor Code, Labor and Employment Act makes adequate provisions for the requirements, and with hold for all government staff. Staff at PBF hospitals will be actual beneficiaries of the project, and not direct or indirect project workers. For any contractual staff, the PIU will ensure that the same national Act will apply and stated so in the individual contracts, and if required Liberia Labor Code, Labor and Employment Act shall be referred to address the issue. The PIU and Bank team will ensure due diligence while writing contracts and providing no objections respectively. ESS3 Resource Efficiency and Pollution Prevention and Management This Standard is relevant because the project will generate medical waste and this will directly lead to generation of pollution. The existing medical waste management plan for Bank funded REDISEE and EBOLA Emergency Response projects will be reviewed in the context of the proposed project, if required then TA will be provided, and appropriate measures and management plan shall be developed. May 13, 2019 Page 5 of 8 The World Bank Institutional Foundations to Improve Services For Health (P169641) ESS4 Community Health and Safety Component 3, the supply chain management component aimed to reach of drugs and supplies to the last mile, including family planning and reproductive health commodities. This may generate unused, expired and damaged drugs, and proper disposal and management of medical /medicine waste would be an issue for community health and safety. Lack of awareness among people, proper waste management procedure may create threats and increase risks for community health and safety. The existing medical waste management plan, established under previous Bank funded REDISEE and EBOLA Emergency Response projects, will be reviewed in the context of the quantity and types of waste generation under the proposed project and if required then TA will be provided, and appropriate measures and management plan shall be developed. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement The project activities do not involve land acquisition, physical expansion of infrastructures, restrictions on land use, and involuntary resettlement. The relevance of ESS5 will be further assessed during project preparation. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The proposed project activities do not potentially affect biodiversity or habitats or involve primary production and/or harvesting of living natural resources. ESS6 is not relevant to the project. Public Disclosure ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities No group of people were identified or categorized as indigenous people or Sub-Saharan African Historically Undeserved Traditional Local Communities in the project area. Thus, ESS7 is not relevant. ESS8 Cultural Heritage The project does not involve civil works, excavation, demolition, or changes in the physical environment. The project activities are exclusively involved for capacity building and institutional strengthening activities in the health sector. The cultural heritage considered as integral aspect of sustainable development. Any relevant sensitive cultural issues such as Liberian traditional religions and local cultural mores will be explored and analyzed for potential risks on certain intangible cultural components of the local communities, if required TA shall be provided to manage the risks. As per the current project scope ESS8 does not apply, and the relevance of ESS8 will be further assessed during project preparation. ESS9 Financial Intermediaries The project will not support FIs. Accordingly, ESS9 is not relevant. May 13, 2019 Page 6 of 8 The World Bank Institutional Foundations to Improve Services For Health (P169641) C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No III. WORLD BANK ENVIRONMENTAL AND SOCIAL DUE DILIGENCE A. Is a common approach being considered? No Financing Partners Not applicable B. Proposed Measures, Actions and Timing (Borrower’s commitments) Actions to be completed prior to Bank Board Approval: Actions to be completed prior to Bank Board Approval: 1.) Preparation and Disclosure of draft Stakeholder Engagement Plan (SEP); 2.) Preparation and Disclosure of draft ESCP. Public Disclosure Possible issues to be addressed in the Borrower Environmental and Social Commitment Plan (ESCP): Update and implementation of the Stakeholder Engagement Plan Development and implementation of project Grievance Redress Mechanism C. Timing Tentative target date for preparing the Appraisal Stage ESRS 25-Sep-2019 IV. CONTACT POINTS World Bank Contact: Sekou Abou Kamara Title: Environmental Specialist Telephone No: 5325+3017 / Email: skamara1@worldbank.org Contact: Akhilesh Ranjan Title: Senior Social Development Specialist Telephone No: 5325+3012 Email: aranjan1@worldbank.org Borrower/Client/Recipient May 13, 2019 Page 7 of 8 The World Bank Institutional Foundations to Improve Services For Health (P169641) Borrower: Republic of Liberia Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Preeti Kudesia Safeguards Advisor ESSA Hanneke Van Tilburg (SAESSA) Cleared on 13-May-2019 at 18:17:57 Public Disclosure May 13, 2019 Page 8 of 8