The World Bank Primary Health Care Investment Program (P173168) Program Information Documents (PID) Appraisal Stage | Date Prepared/Updated: 19-Apr-2022 | Report No: PIDA257812 Mar 15, 2022 Page 1 of 14 The World Bank Primary Health Care Investment Program (P173168) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Program Data Country Project ID Program Name Parent Project ID (if any) Ghana P173168 Ghana Primary Health Care Investment Program for Results Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) AFRICA WEST 06-Apr-2022 10-Jun-2022 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Program-for-Results Financing Republic of Ghana Ministry of Health Proposed Program Development Objective(s) To improve the quality, utilization and equity of primary health care services. COST & FINANCING SUMMARY (USD Millions) Government program Cost 374.20 Total Operation Cost 181.00 Total Program Cost 171.00 IPF Component 10.00 Total Financing 181.00 Financing Gap 0.00 FINANCING (USD Millions) Total World Bank Group Financing 150.00 World Bank Lending 150.00 Total Non-World Bank Group and Non-Client Government Financing 31.00 Mar 15, 2022 Page 2 of 14 The World Bank Primary Health Care Investment Program (P173168) Trust Funds 31.00 Decision The review did authorize the team to appraise and negotiate B. Introduction and Context Country Context 1. Ghana’s economy has grown substantially over the past decade, but the COVID-19 pandemic is severely affecting economic growth and poverty reduction. Ghana, with a population of 30.4 million, is a lower middle-income country with an annual gross domestic product (GDP) per capita of US$2,206 (2020). Economic growth has been strong over the past decade, averaging 6.8 percent annually, accompanied by substantial poverty reduction, as the proportion of the population living on less than US$1.90 per day declined from 23.4 percent in 2005 to 11.5 percent in 2019.1 With the COVID-19 pandemic starting in March 2020, real economic growth slowed to 0.4 percent in 2020, rebounding to 4.7 percent in 2021 and a projected 6.2 percent in 2022. The proportion of the population living on less than US$1.90 per day is estimated to have risen to 13.7 percent in 2021. Three-quarters of surveyed households reported a decline in income during the first three months of the crisis.1 The government’s response to the pandemic, combined with lower revenues, increased its fiscal deficit from 7.5 percent of GDP in 2019 to 16.2 percent in 2020. The pandemic has contributed to an increase in total public debt from 63 percent of GDP in 2019 to 80 percent in 2021. Ghana is assessed to be at high risk of debt distress. Public debt is assessed as sustainable, but only if the government treads a narrow fiscal path, a projected growth rebound materializes, and Ghana maintains access to the international debt market. 2. As Ghana recovers from the COVID-19 crisis, investment in human capital will be essential to take advantage of its demographic dividend for strong economic growth in the medium term. Growth in per capita income during the past decade has been less than half of absolute growth in the economy due to a high population growth rate averaging 2.3 percent annually. The country has a young age structure, with 56 percent of the population under the age of 25.2 For this young population to provide the basis for a demographic dividend, investment in human capital is a prerequisite along with economic opportunities and jobs. Ghana’s 2020 Human Capital Index of 0.45 means that a child born in Ghana today will be 45 percent as productive when she grows up as she could be if she enjoyed complete education and full health. While this index is higher than the average for Sub-Saharan Africa, it is lower than the average for lower middle-income countries. The score 1 2008 Ghana Demographic and Health Survey; 2017 Ghana Maternal Health Survey; 2017-18 Ghana Multiple Indicator Cluster Survey. 2 Ibid Mar 15, 2022 Page 3 of 14 The World Bank Primary Health Care Investment Program (P173168) reflects higher child and adult mortality, along with lower quality of education, compared with averages for lower middle-income countries.3 Sectoral and Institutional Context 3. Ghana has achieved significant improvements in health and nutrition outcomes but faces continuing and new challenges. Under-five mortality decreased from 80 per 1,000 in 2008 to 56 in 2017-18, while the prevalence of stunting among under-five children declined from 28 percent in 2008 to 18 percent in 2017-18. The maternal mortality ratio declined from 470 per 100,000 births in 2005 to 310 in 2017.4 There is a need to build on this progress and achieve still-better outcomes as Ghana transitions into middle-income status. 3 Ibid 4 2008 Ghana Demographic and Health Survey; 2017 Ghana Maternal Health Survey; 2017-18 Ghana Multiple Indicator Mar 15, 2022 Page 4 of 14 The World Bank Primary Health Care Investment Program (P173168) 4. Development of government primary health care services has increased service coverage, serving the poor in particular. Ghana’s primary health care services are composed of Community-based Health Planning and Services (CHPS) at the community level, Health Centers and Maternity Homes at the sub-district level, and District Hospitals at the district level.5 5. Further gains are needed in the coverage, equity and quality of primary health care services. Utilization of family planning in particular is lower than would be expected given Ghana’s economic level , and coverage gaps contribute to high fertility among adolescents in particular, which in turn raises risks of maternal and neonatal mortality. Inequalities in access to services persist, as for example, in 2017, 56 percent of mothers from the poorest quintile delivered in a health facility, compared to 97 percent among the highest quintile.6 The rate of stillbirths is three times the global target, and while the neonatal mortality rate (death within the first 28 days after birth) has improved over the past decade (from 30 per 1,000 in 2008 to 25 in 2017),7 it represents almost half of under-five mortality, indicating considerable scope for improvement in the quality of perinatal care. As 70 percent of neonatal mortality occurs in low birthweight babies, improving care for small and sick newborns will be critical. While Ghana’s national average child immunization rates are relatively high, 3 percent of children, usually the poorest and most vulnerable, have received no dose of the most common immunization (diptheria, pertussis, tetanus – DPT), reflecting inequalities in access to basic services. 6. Government health spending has increased in recent years, but there is a need for greater and sustainable funding of primary health care services. The government’s health budget has substantially increased in absolute terms in recent years, from GHS4.42 billion (US$0.96 billion) in 2018, to GHS8.53 billion (US$1.49 billion) in 2021 (equivalent to approximately US$50 per capita), with the increase partly reflecting the COVID-19 response.8 The National Health Insurance Scheme (NHIS) covers 54 percent of the population and is financed by earmarked taxes and social security contributions. Improving coverage of the NHIS and expanding its support to primary health care services will be critical to achieving the government’s Universal Health Coverage objectives. 7. Investments are needed to enable quality delivery of an enhanced essential services package. The government’s Universal Health Coverage Roadmap envisions an enhanced essential services package as the basis for investments in organization and delivery of primary health care services, providing standards for the services to be delivered at different levels, with the human and other resources required to do so. Currently, there are significant gaps and inequalities in the allocation of infrastructure, human resources, medicines, and other supplies. 8. Networking of primary health care services would contribute to improved management and quality. Primary health care service delivery points are currently financed and managed in an independent and fragmented fashion, impeding effective allocation and use of human, financial and material resources. Establishing financing and management as well as technical linkages between primary health care services would Cluster Survey. 5 World Health Organization. 2017. Primary health care systems (PRIMASYS): comprehensive case study from Ghana. 6 2017 Ghana Maternal Health Survey. 7 2008 Ghana Demographic and Health Survey and 2017 Ghana Maternal Health Survey. 8 World Bank staff estimates. Mar 15, 2022 Page 5 of 14 The World Bank Primary Health Care Investment Program (P173168) allow for more efficient resource allocations at the district and sub-district levels to meet the needs of the population and enhance quality of care. 9. Elements of the government’s 2022-25 Health Sector Medium Term Development Plan to be supported by the PforR will focus on improving primary health care services through development of Networks of Practice and Model Health Centres at the sub-district level. The PforR will have national scope and will be implemented during the 2022-25 timeframe of the Health Sector Medium Term Development Plan. Primary beneficiaries will be users of primary health care services in the planned 350 sub-districts where Networks of Practice are to be established, projected to total 3.1 million persons, of whom 1.6 million female. No activities under the government program have been identified that should be excluded from support by the PforR in accordance with the World Bank's Policy and Directive on Program-for-Results Financing. No high-value contracts will be supported by the PforR. Program supported by the Government program Reasons for non-alignment PforR Objective Increased access to quality To improve the quality, Achievement of the PforR objective essential health care and utilization and equity of will contribute to the overall population-based services for all primary health care objective of the government by 2030. services. program. Duration 2022-25 2022-25 Geographic National National coverage Results Budget programs: 1. Development of The PforR will support selected parts areas Networks of Practice and of the government’s overall national 1. Management and Model Health Centres health sector program that are Administration focused on networking and 2. Primary health care 2. Health Service Delivery improving delivery of primary health financing and policy care services. 3. Human Resources for Health 3. Primary health care Development service improvements 4. Regulation of the Health Sector Activities to achieve the PforR results will be embedded in relevant budget programs. The government’s budget program 1 “Management and Administration� will encompass activities contributing to the PforR Results Area 2 “Primary health care financing and policy.� The government’s budget program 2 “Health Service Delivery� will encompass activities contributing to the PforR Results Areas 1 “Development of Networks of Practice and Model Health Centres� and 3 “Primary Health Care Service Improvements. The government’s budget program 3 “Human Resources for Health Mar 15, 2022 Page 6 of 14 The World Bank Primary Health Care Investment Program (P173168) Development� will include activities to strengthen human resources under all three PforR Results Areas. Overall US$ 6.9 billion (projected) US$375.5 million (US$196 The PforR expenditure framework Financing World Bank IDA and Donor will finance activities that will funding plus US$175.5 contribute to networking and Government funding) improving delivery of primary health care services. 10. PforR Results Area 1. Networks of Practice and Model Health Centres. The PforR will support the government’s “Network of Practice� strategy for strengthening the organization and capacities of primary health care services at the sub-district level. This is based on a pilot in several districts which demonstrated positive effects on management and delivery of services, along with challenges that provide lessons for the government’s scale-up. Development of Networks of Practice will entail strengthening linkages between Health Centres (as the hubs) and CHPS and other community-level services (such as school health services) (as spokes) of each network. Along with government primary health care services, it is envisioned that the networks will engage with faith- based and non-governmental health services, as well as with the for-profit private sector, particularly laboratory services. The sub-district Networks of Practice will in turn be linked to and supported by District Hospitals (the development of which is subject of another government program) and District Health Administrations. In some cases, District Hospitals will serve as hubs of sub-district networks of primary health care services. Development of the networks will be predicated on a facility mapping exercise. 11. Strengthened technical linkages between service providers aim to foster a patient-centered continuum of care. This will involve referral and management of patients, communication and information-sharing, and technical oversight and support, including through digital innovations such as telemedicine. The networks should facilitate exchange of knowledge, group learning, and quality of care. Improving management linkages will involve resource management and allocation at the network level to improve efficiency, fill gaps, and better meet service delivery needs within each network. Areas of work will include development of the policy framework, establishing network-level monitoring, information management, and planning systems, determining decision-making processes for allocation of human resources, equipment, and supplies, and putting in place arrangements for management of funds at the network level. Technical linkages and support will be enhanced through development of supportive supervision mechanisms and capacities at the network hubs (Model Health Centres) as well as fostering the role of the District Hospitals in supporting the networks. Engagement with and accountability to communities will be encouraged through scale-up of the existing community scorecard and action plan initiative. Activities will include development of policy and guidelines for the organization and management of Networks of Practice, training, and investments in information and communications technology and systems. 12. For effective operation of the Networks of Practice, investments in service delivery and management capacities will be needed, with a focus on the sub-district Health Centres as hubs for the networks. The government plans to upgrade them, in a phased manner, to “Model Health Centres,� so that they can fulfil coordination, mentoring and supervision roles as hubs, providing technical and material support to the primary health care services within the Networks. This will require investments in human resources, including allocation and training, and in infrastructure (rehabilitation or additions to Health Centres) and equipment, as well as Mar 15, 2022 Page 7 of 14 The World Bank Primary Health Care Investment Program (P173168) recurrent support to the supply of medicines and other consumables, human resources, and other operational expenses. Investments will include improvements, as needed, to climate-friendly electricity supply and gender- sensitive and disability-friendly water and sanitation facilities for health services. In addition, the PforR will support improved availability of human resources and supply of medicines for primary health care services. 13. With support by the PforR, scale-up and development of Networks of Practice and Model Health Centres will contribute to the resilience of primary health care services in the face of the ongoing COVID-19 pandemic, as well as to preparedness for future public health emergencies. Improved linkages and service delivery capacity at the sub-district level will enhance the responsiveness of the system to the current and future crises. The PforR will support system adaptations to ensure the continuity of essential health services amidst COVID-19 disruptions and to prevent loss of progress made over recent years. As part of its support to improved delivery of the government’s package of primary health care services, the PforR will support expansion and improvement in services to respond to gender-based violence. 14. PforR Results Area 2. Primary health care policy and financing. The PforR will support policy development and improvements in financing modalities that will contribute to the government’s strategy of networking and improving primary health care services. Development of national policies and analysis will be accompanied by improved financing of primary health care services, through both the national budget and the National Health Insurance Scheme. Support to the National Health Insurance Scheme will aim to expand its coverage, both population-wide and among the extreme poor and other highly vulnerable groups. The PforR will encourage policy development and implementation of changes to insurance benefits and payment mechanisms to foster improved financing for selected individually-provided preventive health services. Developing standards and capacities for improved health insurance claims management and overall public financial management at the district and sub-district levels will be critical for effective use of increased financing for primary health care services. Activities to achieve these results will include development of policies and guidelines, training and supervision, communication campaigns and community outreach, and investments in information technology and systems. 15. PforR Results Area 3. Primary health care service improvements. The PforR will support improvements in the quality, utilization and equity of primary health care services, with a focus on those that particularly benefit from improved linkages between levels of care. The Ministry of Health is defining a national Essential Health Services Package which emphasizes primary health care, focusing on services with the highest impact on the burden of illness and mortality. The package includes reproductive, maternal, neonatal, child and adolescent health and nutrition services, along with communicable disease services, that have long been the focus of Ghana’s primary health care system. It also incorporates services for the management of non -communicable diseases, injuries and mental health conditions, that have been growing in importance in Ghana. The standards will specify the services to be provided at each level of care (i.e. CHPS and other community-level providers, Health Centres and District Hospitals), an essential policy basis for development of the Networks of Practice. Service delivery indicators to be supported by the PforR in particular areas will reflect improvements in service delivery capacities more broadly, so that they can be considered as tracers for overall improvements in delivery of primary health care services. The technical areas of support by the PforR will particularly benefit from development and scale-up of the Networks of Practice and Model Health Centres. Mar 15, 2022 Page 8 of 14 The World Bank Primary Health Care Investment Program (P173168) 16. The PforR will support improved access to quality Emergency Obstetric and Neonatal Care (EmONC), critical to reducing risks of maternal and neonatal mortality. This will include support to development of capacities to deliver quality Basic Emergency Obstetric and Neonatal Care (BEmONC) at the Health Centre level, as well as to improvements in referral and transport systems, a key component of the Networks of Practice, in order to increase timely access to Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) services that are available at the District Hospital level. The PforR will also support the government in improving family planning and adolescent health services offered by different types of networked providers, maximizing use of diverse channels to reach under-served groups, particularly adolescents. It will also enhance equity by reaching children who have had no contact with immunization services. The operation will support the government’s plans to implement its strategy to expand non-communicable disease services, also leveraging linkages between services to be fostered by the Networks of Practice, including health promotion activities and screening at the community level, and diagnosis, referral, and case management at different levels of services. Activities will include training, technical support and supervision, investments in medical and other equipment, and support to recurrent needs in terms of human resources, supply of medicines and consumables, and other operational costs. 17. A technical assistance component is needed for the financing and management of technical activities that are critical to supporting the government in achieving the PforR results but which are difficult to implement through the normal government system. A Contingent Emergency Response Component (CERC) is needed to provide a platform for rapid response to a public health emergency. C. Proposed Program Development Objective(s) 18. The PDO is to improve the quality, utilization and equity of primary health care services . PDO indicators, derived from DLIs, reflect each of these elements as follows. PDO Baselines Targets PDO Indicators Elements (2021) (2025) Quality Number of Networks of Practice functioning according to standards 0 350 (DLR 1.1) Number of Model Health Centres functioning according to standards 0 400 (DLR 1.2) Utilization Annual number of mother/newborn pairs receiving care in facilities 30,000 80,000 providing quality BEmONC, including referral and transport, according to standards (DLR 6.2) Annual number of adolescents utilizing primary health care services 250,000 450,000 at the Sub-District and community levels (disaggregated by sex) (DLR 6.4) Equity Annual proportion of indigents who are active National Health 40 80 Insurance Scheme members (disaggregated by sex) (DLR 4.2) percent percent Annual proportion of children aged 0-23 months who have received 85 97 the first does of Penta vaccination in selected districts percent percent 19. The PforR will be implemented by the Ministry of Health, the Ghana Health Service, and the National Health Insurance Authority. The Ministry of Health is responsible for leadership and oversight of the sector and the development and review of policies. Under the PforR, the Ministry of Health will play its mandated role Mar 15, 2022 Page 9 of 14 The World Bank Primary Health Care Investment Program (P173168) of providing oversight, facilitating decision-making, and ensuring national cross-agency and cross-sectoral coordination when necessary. The Ghana health service will be responsible for the implementation of the technical aspects of the Program such as the creation and operationalization of the networks of practice. GHS will at the implementation level coordinate with other service delivery agencies such as the faith-based and private health service delivery organizations, the Ambulance Service as well as the District the Assembly to ensure coordinated implementation of the network of practice. Under the Program, the NHIA will collaborate with the MoH, GHS and HeFRA on various aspects of the networks’ creation and functioning. The NHIS will also collaborate with the National Household Registry to facilitate enrollment of indigents 20. Results Verification: Independent verification of achievement of the DLRs will be done by a consortium of the Dodowa Health Research Centre located in the south of the country, Kintampo Health Research Centre in the centre, and Navrongo Health Research Centre in the north. The three research centres are government institutions under the Research and Development Division of the Ghana Health Service, one of the implementing agencies of the PforR. This raises the question of whether the consortium will have sufficient independence in filling the PforR verification function. to ensure the independence of the verification function, a Verification Oversight Committee will be formed with membership including respected figures from academia and the non- governmental sector. 21. Fiduciary Systems assessment: An integrated fiduciary risks assessment was carried out to evaluate the government’s financial management, procurement, governance, and anti-corruption systems, to inform the design and implementation of the PforR. Inherent risks are assessed as Moderate for Financial Management, Substantial for Procurement, and Moderate for Fraud and Corruption. After considering mitigation measures, overall residual fiduciary risks are assessed as substantial. Mar 15, 2022 Page 10 of 14 The World Bank Primary Health Care Investment Program (P173168) D. Environmental and Social Effects 22. An Environmental and Social Systems Assessment has been conducted for the PforR. The environmental risk rating for the Program is Moderate. Potential environmental risks and impacts are likely to emanate from Results Area 1 which includes improvement in infrastructure such as water and sanitation facilities, rehabilitation of some health facilities, and supply and installation of medical equipment. Adverse environmental impacts of civil works could include noise pollution, dust and fumes, waste generation, vibrations, and general occupational health and safety risks. Civil works may entail the use of construction materials, possibly from extraction sites that may have environmental, health and safety issues including possible spread of disease vectors in communities and risk of drowning from water-filled pits. The proposed investment in equipment for health facilities could lead to the production of electronic and hazardous waste from obsolete equipment that could be removed and also from new equipment at their end-of-use stage. Similarly, possible improvement in climate- friendly electricity supply for health centers could entail the use of solar and battery energy storage systems. These would generate electronic and hazardous waste at their end-of use stage which could potentially contaminate the soil, surface and groundwater. The installation of solar panels, depending on the alternative energy needs of a health facility, may entail vegetation clearance which may lead to moderate losses of biodiversity and habitats. 23. During operations of health care facilities, potential environmental impacts could include spread of diseases and odor from poorly managed sanitation facilities and septic tanks. Health facilities may be financially constrained, inhibiting regular management of fecal sludge and proper maintenance of facilities. In some instances, health facilities may rely on support from local administrations and communities. Poorly managed septic tanks could lead to leakages and overflows with adverse impacts on the environment and public health and safety. Other impacts could include generation of waste (domestic and hazardous/medical waste); and over- extraction of groundwater from boreholes (manual and mechanized) provided for health facilities. 24. The social risk rating for the PforR is assessed as Moderate. Overall, the Program to be supported by the PforR will have a number of potential social benefits, including improvement in coverage and quality of reproductive, maternal, neonatal, child and adolescent health and nutrition services, and potential increased population coverage of the National Health Insurance Scheme and its benefits package. The PforR will also support interventions to improve governance and accountability mechanisms. These interventions will benefit particularly women and girls, as well as poor and vulnerable households who largely rely on government services at each level of care. However, there are also some potential social risks and impacts. These may emanate from potential support to infrastructure and equipment investments, including climate-friendly electricity supply, rehabilitation of existing health facilities, and renovation or construction of gender-sensitive water and sanitation facilities for urban, peri-urban and rural health facilities. These are expected to be onsite activities in existing government health facilities, and no new land acquisition or restrictions on land use are envisaged under the Program. However limited these risks might be, the proposed interventions can lead to livelihood losses if any land necessary for such investments is currently encroached upon. Construction and refurbishment activities could present risks related to child labor and labor influx. Other related risks and impacts on the health and safety of the community and workers include risks of sexual exploitation and abuse and sexual harassment of health care workers, women, and children, in communities where the construction and renovation activities would take place. 25. Accessibility is a prerequisite for inclusion. The need for renovated or newly constructed facilities to be accessible to persons with disabilities should be highlighted. Similarly, water and sanitation facilities need to be gender-friendly, particularly for women and girls, due both to biological and cultural factors. Water and Mar 15, 2022 Page 11 of 14 The World Bank Primary Health Care Investment Program (P173168) sanitation facilities should contribute to improving the menstrual and sexual and reproductive health of women and girls. In addition, there are risks related to the sustainability of water and sanitation facilities in government buildings due to the general lack of effective operations and maintenance measures. 26. The Environmental and Social Systems Assessment finds that national legislation, regulations and policies are largely consistent with the World Bank’s six core principles for PforR operations. For instance, Ghana’s Environmental Assessment Regulations of 1999 (LI 1652) require project proponents to screen undertakings and, depending on the risk level, assess the environmental and social risks and impacts and obtain the necessary permits before commencement of activities. Despite the solid legal and policy framework in place, there are gaps which require attention. These include: (i) Program interventions largely fall outside the permissible thresholds for an Environmental and Social Impacts Assessment as per the LI 1652 Regulations; (ii) inadequate focus of the Ghana Environmental Protection Agency on social issues such as gender-based violence, sexual exploitation and abuse, and sexual harassment; (iii) lack of designated focal personel within the Ghana Health Service at different levels to oversee environmental and social management for sub-district primary health care services; (iv) poor management of health care waste, especially segregation, onsite management, disinfection and final disposal; (v) dearth of expertise to prepare social management instruments such as livelihood restoration plans and Stakeholder Engagement Plans;(vi) unrecognized rights to compensation for persons and entities who do not have a legal title to the land they occupy (including squatters and encroachers who may lose assets and/or their livelihoods) as per the current Land Act 2020 (Act 1036); and (vii) lack of clear guidance and procedures to manage inclusion of vulnerable groups. 27. The Program will not trigger OP 7.50 (International Waterways) as proposed interventions do not involve extraction or use of international waterways. For OP 7.60 (Projects in Disputed Areas), no area within Ghana currently falls under this category. 28. To mitigate the identified gaps, actions have been included in the Program Action Plan with indicative timeline, responsibility for implementation and indicators for measuring completion. 29. The environmental and social risks of the Investment Project Financing components of the Program will be Moderate. The technical assistance component will mainly support technical assistance activities, including: development of and training on policies, standards, and guidelines, to contribute to design and implementation of the Networks of Practice; and design of systems and investments to support primary health care service delivery. The technical assistance component will support data analysis and evaluation activities, including for integration and analysis of DHIMS2, health insurance, and other databases, implementation research on the Networks of Practice initiative, and independent verification of the PforR results. The environmental and social risks are mainly labor-related issues, especially when consultants will be hired to carry out the technical assistance activities. Other risks relate to potential exclusion of women and persons with disabilities in technical trainings, which would widen gender gaps in the health sector. Potential exposure to COVID-19 is also an issue if protocols are not observed. The client has prepared, consulted upon and disclosed a standalone Stakeholder Engagement Plan which will guide all stakeholder engagement activities under the technical assistance component. The client has also drafted an Environmental and Social Commitment Plan which details the measures will be implemented against clearly defined timelines to ensure compliance with the World Bank’s Environmental and Social Standards. 30. The proposed TA activities are not anticipated to present significant environmental risks and impacts as interventions are mainly consultancy assignments for development of documentation (guidelines, protocols, Mar 15, 2022 Page 12 of 14 The World Bank Primary Health Care Investment Program (P173168) manuals etc.), conduct of needs assessment, staff capacity strengthening. However, the interventions could present some moderate social risks and impacts including discrimination and exclusion of healthcare personnel in hard-to-reach communities due to location and significant gaps in human resource and infrastructure necessary for the delivery of the TA activities and to facilitate their active participation in stakeholder consultation activities. Other social risk identified include labor related risks including potential sexual exploitation and abuse/ sexual harassments (SEA/SH) given that Consultants will be hired to carry out aspects of the TA activities; exclusion of women and persons with disabilities in technical trainings; and COVID-19 exposure if protocols are not observed. . . ESF_LEGAL_T BL Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Summary of Assessment of Environmental and Social Risks and Impacts (With IPF Component for PforR) . E. Financing Program Financing Sources Amount % of Total (USD Million) International Development Association (IDA) 150.00 82.87 IDA Credit 150.00 82.87 Trust Funds 31.00 17.13 Global Financing Facility 31.00 17.13 Total Program Financing 181.00 Mar 15, 2022 Page 13 of 14 The World Bank Primary Health Care Investment Program (P173168) . CONTACT POINT World Bank Name : Patrick M. Mullen Designation : Lead Health Specialist Role : Team Leader(ADM Responsible) Telephone No : 1-202-378492 Email : pmullen@worldbank.org Borrower/Client/Recipient Borrower : Republic of Ghana Contact : Patrick Nomo Title : Mr. Telephone No : 023302747197 Email : chiefdirector@mofep.gov.gh Implementing Agencies Implementing Ministry of Health Agency : Contact : Kwabena Oku-Afari Title : Chief Director Telephone No : 233202030293 Email : kwabena.oku-afari@moh.gov.gh 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 Mar 15, 2022 Page 14 of 14