The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 02/08/2024 | Report No: ESRSAFA678 Feb 14, 2024 Page 1 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) I. BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Central African WESTERN AND CENTRAL Republic AFRICA Project ID Project Name P181561 Additional Financing- Car Health Service Delivery And System Strengthening Project Parent Project ID (if Parent Project Name any) P177003 CAR Health Service Delivery and System Strengthening Project (SENI-Plus) Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 1/31/2024 3/18/2024 Population Financing Public Disclosure Estimated Decision Total Project Cost Review Date 1/29/2024 24,800,000 Proposed Development Objective To increase utilization of quality essential health services, especially for women and children, in targeted areas in the Central African Republic. 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 Activities The project supports the government’s effort to improve the delivery of essential health services and strengthen the country’s health system. The project is fully aligned with the strategic priorities of the National Health Development Plan III and build on the gains made under the predecessor project SENI while ensuring complementarity with other health sector engagements and beyond. The project aims to support the government in its effort to attain Universal Health Coverage by: (i) continuing support to delivery of essential quality health services at health facilities and Feb 14, 2024 Page 2 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) extending its reach to communities; (ii) providing holistic support to gender based violence (GBV) survivors. The project will further strengthen the various pillars of the health system through: (iii) developing a functional national health supply chain; (iv) supporting targeted investments to improve hospital capacity especially at subnational levels; (v) supporting sectoral reforms in the areas of human resources for health, health management information systems (HMIS) and performance measurement, and public financial management. The project will further help the country prepare for future pandemics and emerging diseases by integrating these activities as part of health system strengthening. Component 1 seeks to: (i) continue the delivery of essential health services and support the government's provision of Targeted Free Health care through use of an adapted performance-based financing delivery model; (ii) support the delivery of community-level interventions by financing a basic package of services delivered by community health workers, and (iii) provide holistic support to GBV survivors in target districts. Component 2 will address critical bottlenecks to a functioning health system in CAR. A first set of investments will directly facilitate the delivery of essential services to women and children by accelerating the development of a functional national health supply chain (2.1) and through targeted investments to equip and conduct rehabilitation in priority hospitals outside of the capital region (2.2). The project will also support selected government reforms that are key to moving towards a stronger and sustainable health system, while ensuring the performance and sustainability of the project’s investment is met. This component will further contribute to building a sustainable and resilient health system (2.3) that is prepared to respond to future pandemics and emerging diseases (2.4). Public Disclosure Component 3 will help ensure effective and efficient technical and fiduciary management and implementation of the project. The component will support project implementation through the financing of (i) operating costs, training, and equipment; (ii) paying salaries of international and national consultants; (iii) audits and communications, and (iv) implementation and monitoring of environmental and social standards as well as project results indicators. The Project Implementation Unit responsible for day-to-day management of the project will be the current PIU responsible for managing SENI, REDISSE IV and COVID-19 projects that will also assume the responsibilities of the implementation of the SENI-plus project. Component 4 is a Contingency Emergency Response Component (CERC) which will be included under the project in accordance with World Bank IPF Policy’ paragraphs 12 and 13, for projects in Situations of Urgent Need of Assistance or Capacity Constraints. This will allow for rapid reallocation of project proceeds in the event of a natural or man- made disaster or crisis that has caused, or is likely to imminently cause, a major adverse economic and/or social impact. D. Environmental and Social Overview D.1 Overview of Environmental and Social Project Settings The SENI project covers approximately 400 health facilities in five regions, including 143, 64, 122, 22 and 60 health facilities respectively in regions 2, 3, 4, 5 and 6. (Region 1 : Ombela Mpoko - Région 3 : Ouham-Pendé andx Ouham – Region 4 : Kémo, Nana-Gribizi and Ouaka - Region 5 : Bamingui-Bangoran – Region 6 : Haut-Mbomou ). The 15 initial SENI districts are: Baboua-Abba, Bouar-Baoro, Berberati, Carnot-Gadzi, Sangha-Mbaere, Bozoum-Bossemptele, Paoua, Feb 14, 2024 Page 3 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) Kemo, Nana Grebizi (Kaga), Bambari, Kouango-Grimari, Bamingui Bangoran, Bangassou, Alindao-Mingala, Kembe- Satema, Mobaye-Zangba. Depending on the adapted PBF approach, costs and budget availability, geographical scope of the projects may be progressively expanded to other districts with poor health outcomes and where no other partners are present. Community outreach and community service delivery will be expanded incrementally , starting with the 15 SENI districts and expanding to the remaining seven districts where no other partners are present as the project progresses. Finally, from a strategic point of view, the Government has decided that (i) the 15 district hospitals initially planned under sub-component 2.2 of the parent project for upgrading will be reduced to 12 district hospitals; and (ii) instead of the three district hospitals, specific departments from three central-level teaching hospitals will be added as a target under this sub-component. The decision of this change is due to (i) the government's intention to strengthen the reference system by improving the technical platform at the central level; and (ii) the selection of departments where it is most important and aligned with project support, and where other donors are not present. The total number of target hospitals remains at 15. From the environmental side, there are two climatic seasons, in the country namely the rainy season from May to October and the dry season from November to April. The relief is not very hilly with an average altitude that varies between 650 and 850 m. The country has a very dense hydrographic network comprising 2 major rivers (Oubangui and Chari) and several rivers and streams that flow all year round. With its flat and rugged terrain, varied vegetation with a large forest cover (nearly 3.5 million hectares), a rich soil and a subsoil that contains a lot of minerals (diamonds, gold, iron, aluminum, etc.), the CAR has great natural resources that should allow it to establish sustainable development. As a result, the main economic resources come from the primary and secondary sectors: agriculture, livestock, hunting, fishing, forestry, and mining. As the project activities are maintained in the health Public Disclosure centers, they will have very little direct impact on the resources and environments described. However, the implementation of PBF systems will certainly improve the collection of infectious wastes in health centers and prevent it from ending up in the immediate environment and waterways, and the promotion of WASH systems can help reduce pollution factors. The purchase and commissioning of the incinerators approved under the project will help improve the proper disposal of biomedical waste. CAR has approximately 4.66 million inhabitants with an average density of 7.5 inhabitants/km2. The Country has suffered from decades of repeated conflicts and political instability. For a decade now, CAR has been struggling with violence and insecurity countrywide. CAR seemed to be gradually recovering in recent years when the political turmoil of December 2020 brought a sudden violence and increased insecurity throughout the country. Instability and violence in CAR have resulted in substantial deterioration of social services, including health. It also exacerbated GBV/Sexual Exploitation Abuse/Sexual Harassment (SEA/SH). In addition, hit by domestic economic disruptions in 2020, the global economic shocks from COVID-19 and the Russian invasion of Ukraine in 2022, CAR faces an unsustainable fiscal outlook. In December 2020, violence broke out around the disputed presidential elections causing a major economic disruption due to the closure of the Bangui-Douala corridor. This contributed to the economy contracting by 0.8 percent in 2020. CAR’s economic and fiscal situation then further deteriorated during COVID-19. After the SENI-Plus was approved in 2022, the Russian invasion of Ukraine further compounded the country’s economic situation, as it led to fuel shortages, increasing food prices, and a further disruption to tax receipts. Hit by these three consecutive shocks, tax and customs revenues are estimated to Feb 14, 2024 Page 4 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) have declined. The domestic fiscal deficit increased by 65 percent from 2019 to 2020, reaching more than 5 percent of gross domestic product (GDP) in 2021. SENI-Plus was restructured in October 2023, to introduce emergency financing support to protect the provision of essential social services by four ministries, including the Ministry of Health and Population (MOH), in CAR. It was part of the World Bank’s support to the Government of CAR, to help cope with a looming fiscal gap. Approximately 5100 civil servants in seven social sector ministries’ salaries and wages are supported, on an exceptional basis, through SENI-Plus and another multisectoral project, the Human Capital and Women and Girls’ Empowerment Project (Maïngo – P171158). The PDO and results framework were revised to reflect other social sectors beyond health in the project’s scope and to add an indicator related to the emergency support. A new component (Component 5) was created to finance four of the seven ministries, and as a result, US$20 million equivalent was reallocated to the newly created component. The purpose of this additional financing (AF) of SENI-Plus is two-fold and includes: (a) an IDA grant for US$20 million to replenish the amount allocated to the emergency financing support to protect the provision of essential social services; and (b) funding in the amount of US$4.8 million from the Swiss Agency for Development and Cooperation (SDC). The reallocated US$20 million for emergency salary support is expected to be fully disbursed by end 2024. With the AF, SENI-Plus will continue to be fully aligned with the strategic priorities of CAR’s National Health Development Plan and builds on the gains made under the previous project SENI while ensuring complementarity Public Disclosure with other World Bank health sector engagements. The Project aims to assist the Government in its effort to attain universal health coverage by: (a) continuing support to delivery of essential quality health services at health facilities and extending its reach to communities; and (b) providing holistic support to gender-based violence survivors. The Project further aims to strengthen the various pillars of the health system through: (a) developing a functional national health supply chain; (b) supporting targeted investments to improve hospital capacity especially at subnational levels; and (c) supporting sectoral reforms in the areas of human resources for health, health information systems and public financial management. Project districts are already known at this stage of the Project. Some of these districts have indigenous people among their communities, namely the three prefectures of Nana-Mambere, Mambere-Kadei and Sangha Mbaere. Negative impacts on vulnerable groups, indigenous people, poor households and GBV survivors will be taken into consideration by integrating gender equality and a non-discriminatory approach into project design and activities. Feb 14, 2024 Page 5 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) D.2 Overview of Borrower’s Institutional Capacity for Managing Environmental and Social Risks and Impacts The Government of CAR has experience in managing the E&S risks and impacts of WB-financed projects implemented under the Safeguard Policies. The country can also rely on an established legal framework and institutions for E&S management. However, there is limited experience in implementing projects under the ESF and experience from other Bank-financed projects highlight that the management of E&S risks and impacts still require considerable improvement, particularly in the areas of supervision, monitoring and reporting. A comprehensive training plan will be prepared by PIU after effectiveness and shall be properly resourced. The World Bank will provide guidance on preparing and implementing a capacity building and training plan to help the Borrower manage environmental and social risks throughout the project timeline proposed in the ESCP. The Ministry of Health and Population (MHP) will lead Project implementation through the PIU that currently oversees the implementation of three Bank-financed projects: the current SENI Plus-CAR Health System Strengthening Project (P177003), CAR COVID-19 Response Project (P173832) and REDISSE IV CAR Regional Diseases Surveillance System Enhancement Project (P167817). However, other ministries (Ministry for the Promotion of Women, the Family and Child Protection and the Ministry of Social Action and Gender Promotion) will be involved in the implementation of Component 1. These ministries will also be involved in the GBV component as was the case with the SENI project. The Project will work with some service providers, including UNOPS and various NGOs, who have some experience in the implementation and monitoring of safeguard instruments but limited experience with the ESF.However, a separate PIU will manage component 5 which is under the Ministry of Budget and Finance (MFB). This separate PIU which is currently in charge of the World Bank-funded Public Sector Digital Governance Project (Projet de Gouvernance Numérique du Secteur Public or PGNSP ) which will also oversee fiduciary, social and environmental Public Disclosure standards associated with component 5. This differs from regular SENI project activities, which will continue to be implemented by the MHP. The staff of PGNSP includes, among others, a citizen engagement specialist, and an environmental and social specialist are also being recruited. The SENI Plus PIU’s current E&S team includes: 1 Environmental specialist, 1 Social specialist and 3 GBV/SEA/SH specialists (1 international & 2 nationals). This team will be strengthened by adding 2 E&S assistants and 1 additional GBV specialist and a security specialist (to be shared with Maingo project) in line with ESCP to manage the E&S risks and impacts of Project activities. In addition, the PIU’s E&S team will receive regular training throughout the implementation of the project, in the form of clinics on specific issues. Based on the arrangement put in place under SENI-REDISSE IV, the National Steering Committee of the Project is hosting by the MHP and chaired by the Cabinet Director at the MHP. Membership of the MHP Steering Committee (COPIL) will be expanded to include representation from other three Ministries whose wage bills will be financed by the SENI-Plus Project. This will include the Ministries of National Education, Agriculture and Rural Development, and Livestock and Animal Health, in addition to the Ministry of Health and Population. The COPIL that oversees the implementation of the project will continue to be chaired by the MOH. Close involvement of the two Ministers responsible for public payroll and human resource policies will support effective coordination among the sector ministries and departments involved in its implementation. The COPIL will Feb 14, 2024 Page 6 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) also oversee progress in the implementation of the government’s program to increase the reliability of the public payroll. Any unforeseen difficulty will be brought to the COPIL’s attention for prompt resolution. A Dedicated Technical Committee for Payment of Social Service Wages, which is separate from the existing SENI-Plus Technical Committee, will be put in place to provide technical oversight over Component 5 and guidance during the 18 months of component implementation for both SENI-Plus and Maingo projects. The new Technical Committee for Payment of Social Service Wages will have a particular focus on monitoring the results of the physical inspections and other internal control procedures. This is essential to ensure the payroll of the seven ministries is free from errors and irregularities. One of the Technical Committee’s key responsibilities will be to review the progress of, and support, the physical verification measures to be carried out as part of Component 5, to sustain and systematize the verification procedures over the payroll implemented as part of the MFPRA-led government program. Even if the SENI Plus, COVID-19 and REDISSE IV projects, and the PGNSP are under the ESF, the MHP and MFB have not yet fully mastered the application of the ESF instruments. Thus, the E&S capacity of the MHP and MFB, as well as that of other relevant institutions (Ministries, Agencies) involved in the Project, will need to be strengthened at all levels (at the early stage of project implementation) to ensure their participation, especially given their limited knowledge of, and experience with, WB ESF requirements. Many E&S capacity building sessions are planned throughout the project implementation to mitigate this risk. At the national level, the Director General for Environment (DGE) is the main institution in the Ministry of Environment (MEDD) that is responsible for conducting and coordinating the E&S assessment process in CAR (e.g., Public Disclosure validation of ESIAs, ESMPs, field reports, inspection and E&S audits). At the departmental level, the DGE collaborates with local branches/ offices of the MEDD. However, DGE implementing capacity is low as it lacks the needed financial and technical resources. In the case of infrastructure construction and health waste management, arrangements will be put in place to ensure that appropriate OHS measures are monitored at the district/ local level, as well as community empowerment processes. This will be done through (i) training sessions for construction companies on the application of occupational health and safety measures, as well as their codes of conduct; and (ii) sensitization and training of members of district/local management committees to ensure the implementation of safeguards, access to the various GRM channels, mitigation measures for the various risks related to vulnerable and accidents, but above all to ensure the sustainability of these measures. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial A.1 Environmental Risk Rating Substantial The environmental risk rating remains substantial despite the introduction of a new component and the two objectives of the AF. The implementation of project activities will generate risks and potentially reversible impacts on Feb 14, 2024 Page 7 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) the environment. The improvement in the provision of essential services in health facilities and communities through PBF under component 1 and support to hospital capacity upgrade under component 2 will lead some beneficiary hospitals and health facilities to carry out small-scale rehabilitation of some department as paediatric, intensive care , gynecological and obstetric care services , in addition to enabling a safe space for GBV survivors to access services without being exposed. The improvement in the provision of services in health facilities will also lead to an increase in the amount of biomedical waste, as well as an increase in the health and safety risks for staff and, to a lesser extent, to communities, especially if the waste is not properly managed. Under component 2, some activities will involve civil works, notably the construction of a national and regional supply warehouses under the subcomponent 2.1. The civil works will generate negative impacts such as: construction waste, noise pollution, space conversion, destruction of vegetation cover, increase in aerosols and engine fumes, risks of transmission of STIs/HIV/AIDS due to the arrival of working personnel, and community and occupational health and safety risks(OHS) (including the risk of spreading COVID-19). Regarding the new component 5, it will generate positive and direct environmental impacts on the environment by funding the salaries and wages of workers of targeted ministries. Positive environmental impacts include the continuation of various services, programs and activities implemented in different ministries. Negative and indirect occupational health and safety impacts could arise within the Ministries’ working environment if fiscal constraints affect the implementation of effective COVID-19 control measures, which include but are not limited to solid (infectious and non-infectious) and personal protective equipment, waste management and hygiene control measures. All of these potential risks and impacts have been assessed in detail in the ESMF as well as the National Biomedical Waste Management Plan prepared for the parent project and updated in august 2023. A.2 Social Risk Rating Substantial The introduction of the new component 5 and the orientation of the two AF objectives will not change the rating of Public Disclosure the social risk which remains Substantial. Main risks are under Components 1 and 2. While the overall social benefits are expected to be positive, the anticipated social risks and impacts include security risks. The project is intending to be implemented in urban, peri-urban or rural areas in the country. Unfortunately, there may be the presence of non- state armed groups in these areas. Thus, the risk of attacks on project workers, beneficiaries, as well as their personnel should be considered. Security risk assessment was carried out for the parent project and a security management plan was prepared for the parent project as well. Both will be updated for the AF.. Other risks to be considered are risks of discrimination and exclusion; risks of non-transparency in the beneficiary selection process and recruitment of community workers which could create social tension among communities. Risks to increase HIV/AIDS transmission: measures need to be taken to mitigate risks related to the expansion of transmissible diseases (STI, HIV/AIDS, COVID-19) given that through these activities, the project will be able to reach a wide range of people, and disseminate training and information. The client shall incorporate awareness raising sessions and preventive materials into the workers' health and safety plan and the two ESMPs developed in Sibut and Grimari sites. Risks of exclusion of households led by women and other vulnerable individuals: as this project involves the selection of beneficiaries, strategic approaches have been developed in the SEP to ensure that there is no exclusion of, discrimination against, vulnerable groups and individuals, especially (GBV survivors, poor households, households with children under five years, young girls and other vulnerable people) for different services (essential health and nutrition service for maternal-child mortality and malnutrition, medical, psychosocial, and socioeconomic assistance, distribution of PEP Kit, etc.). For the new component 5 : The overall social benefits are expected to be positive, and the anticipated social risks and impacts include: (i) social tensions which might arise from the fact the project focuses on only the seven ministries covering the social sectors and not every government employee; (ii) risks of exclusion of vulnerable groups, and other rural and marginalized groups where services are not available and who may as a result be excluded as Feb 14, 2024 Page 8 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) project beneficiaries (for example among civil servants: persons with disabilities, indigenous peoples, elderly, youth, including women, minorities); (iii) lack of transparency and accountability in delivering project benefits under the current economic conditions could lead to lack of trust in the different ministries systems/services and underutilization of other public interventions; (iv) risks related to the difficulties in the application of labor and working conditions for the different services (health, education, agriculture and livestock, social protection), the PIU, as well as the contracted workers; and (v) risks of sexual exploitation and abuse and sexual harassment specific to the nature of the project, which may arise from, among other things, favor-seeking by excluded civil servants. The project will mitigate these risks mainly by applying the relevant ESF standards. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1 Relevance of Environmental and Social Standards ESS1 Assessment and Management of Environmental and Social Risks and Relevant Impacts The Environmental and Social Standards (ESS) relevant to this project are, ESS1, ESS2, ESS3, ESS4, ESS5, ESS7, ESS8, and ESS10. Assessment and management of environmental and social risks and impacts (health, hygiene and safety problems at work); proliferation of biomedical waste (healthcare services) as a potential source of groundwater and soil pollution; denaturation of the biological nature of the soil, noise pollution from machinery, nauseating odors from paints, pollution of the soil and air by dust and gas from engines; risk of transmission of STI/HIV/AIDS) will be required and are mainly associated with Component 1 (Improving essential service delivery at health facilities and in Public Disclosure communities), and Component 2 (health system strengthening for improved essential service delivery). They will support alleviating critical bottlenecks for the well-functioning of the health system. Potential impacts are expected to be site-specific. Measures will be put in place to manage impacts related to the eventual implementation of downstream activities to repair or improve health facilities. Impacts shall be adequately managed during project implementation, in accordance with the Environmental and Social Management Framework (ESMF) that has been prepared and updated to reflect the new project design. The AF the project Stakeholder Engagement Plan (SEP) will be updated and disclosed before the AF project appraisal. Given that the activities and geographical scope under AF are the same as the for restructured parent project, the existing ESMF which includes a Labor Management Plan (LMP) will be maintained for the AF project. The existing ESMF also provides clear guidance for the management of construction impacts and biomedical waste management that are compliant with WHO “Safe management of wastes from health-care activities” guidelines. Regarding the CERC component of the project, the activities under this component are not yet known at this stage. The project’s institutional arrangements for environmental and social due diligence and monitoring under this component has been included in the existing parent project ESMF. The Bank’s review considered the project’s capacity to manage its environmental and social performance as a challenge. It can therefore be concluded that the project’s environmental and social management system and procedures will need to be complemented/enhanced to comply with ESS1 requirements. The Project will address the gaps through the preparation and implementation of the Environmental and Social Commitment Plan (ESCP) which has been prepared by the Borrower, as well as targeted training and support to the environmental and social specialists recruited by the project. Feb 14, 2024 Page 9 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) Given that the AF project geographical scope and activities are the same as parent project following the October 2023 project restructuring, the following instruments which were updated during the parent project restructuring and which cover AF activities will be adopted by project appraisal and implemented by the project: - Environmental and Social Management Framework (ESMF) a Security Risk Assessment (SRA) and Security Management Plan (SMP). - a standalone SEA/SH risk assessment and Action Plan including code of conduct and accountability and response framework. - a Labor Management Procedures (LMP) including a GRM for workers as part of the ESMF; - a Biomedical Waste Management Plan waste management plan (update from parent project);) - an Indigenous People Plan (IPP); The site specific E&S instruments such as ESIA/ESMP as per ESMF screening and requirement and a RAP (including Livelihood Restoration Plan) will be prepared when specific sites marked for project works are known. These requirements are reflected in the project AF ESCP. ESS2 Labor and Working Conditions Relevant This standard is relevant. The implementation of the CAR SENI-plus project is involving various workers, ranging from the PIU and government to specialized personnel for consulting, service provision and construction firms as well as unskilled laborers and community workers. Key labor risks include : Risks of accidents, risks injuries, child and forced labor, risks of SEA/SH, Illness risks due to various pollution, etc. Public Disclosure In relation with component 5 the proposed project will involve direct workers and contracted workers. In sum, a considerable workforce are required, and the project could face difficulties in promoting sound worker-management relations and guaranteeing safe and healthy working conditions.. The component 5 civil servants to be paid with project funding will not be transferred to the project/PIU. ESS2 will therefore not apply to such government civil servants, except for the provisions of paragraphs 17 to 20 (Protecting the Workforce) and paragraphs 24 to 30 (Occupational Health and Safety). Civil servants involved with the project will remain subject to the terms and conditions of their existing public sector employment agreement or arrangement, unless there has been an effective legal transfer of their employment or engagement to the project in which case, they will become subject to ESS2 requirements for direct workers. In relation to component 5, the proposed project has involved direct workers and contracted workers. CAR’s Labor Law n°09.004, in its various articles, determines that all workers have the right to healthy conditions and protection equipment, among other measures. The LMP of SENI Plus which is currently under implementation has provided an overview of national labor law, types of personnel to be hired under the project, and measures to comply with ESS2, including: Working conditions and management of workers relationship: The existing LMP describes how project workers will be managed in accordance with the requirements of this standard and national laws. The LMPwill ensure communication in clear language and understandable by each worker of the project, information and documents (such as code of conduct and internal regulations) which describe their rights under national law (which will include the applicable collective agreements where applicable), including their rights to wages, overtime, remuneration and social benefits as Feb 14, 2024 Page 10 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) well as any other rights mentioned in the requirements of ESS2. The Borrower shall base employment relationships on the principle of equality of opportunity and treatment. Protecting the work force: The Borrower emphasizes compliance with the minimum age for employment and recruitment of project workers, which shall be at least 14 years unless the Borrower's legislation determines a higher age. The Project will not hire people younger than 18 years old for hazardous work; those between the national legal minimum age and 18 could do non-hazardous work in line with ESS2 provisions and will comply with CAR labor law. To ensure the health and safety of workers during project implementation, the ESMF has addressed Occupational Health and Safety, in line with the WBG’s EHS Guidelines and Good International Industry Practice (GIIP), including WHO guidance, particularly for the COVID-19 virus. The measures have included requirements for the use of Personal Protective Equipment (PPE), planning of training activities, and investigation/reporting of accidents, a worker Code of Conduct, and other labor issues such as labor influx, non-discrimination, equal opportunity, and prevention of all forms of forced labor including child labor and SEA/SH including the workers’ code of conduct. The project LMP applied to the AF includes grievance mechanism procedures for labor disputes of project workers and the roles and responsibilities for monitoring such workers. The establishment of a workers’ GM as developed in detail in the LMP shall allow workers to quickly inform management of labor issues, such as a lack of PPE and unreasonable overtime. A set of Environment, Social, Health and Safety requirements, as detailed in the ESMF will be included in bidding documents for all activities, and serve as the basis for the development of Contractor-specific ESMPs that will be required for all site-specific subprojects. Public Disclosure The Borrower will commit (through the ESCP) to adopt the existing LMP by project appraisal. ESS3 Resource Efficiency and Pollution Prevention and Management Relevant The project's funding in component 1 will lead to an increase in infectious waste in the project's beneficiary health facilities. The AF project will adopt the existing biomedical waste management plan prepared under the SENI project including guidance related to transportation and disposal/destruction of expired chemical products including OHS, community health and safety, and pollution (air, water, etc.) issues. This standalone Biomedical Waste Management Plan prepared, disclosed, consulted upon approved, is currently under implementation. ‘’The project may undertake downstream works related to rehabilitation/enhancement of existing facilities, so other issues may need to be managed, such as soil and water pollution due to release of petroleum-based products, noise, construction waste, air emissions from diesel engines…’’. The existing ESMF covering the parent project already includes mitigation measures to manage construction wastes (hazardous and non-hazardous) and other environmental impacts during project implementation. In case asbestos materials are found in existing buildings, handling and disposal of asbestos will be done in accordance with GIIP OHS and EHS practices, in such cases site-specifics ESIA or ESMP to be prepare during implementation for each health center or hospital target by the project will includes appropriate measures to manage civil works or construction wastes. However, the project will use resources efficiently and will not lead to any significant GHG emissions. Feb 14, 2024 Page 11 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) ESS4 Community Health and Safety Relevant This standard is relevant. Specific measures to protect the health and safety of communities in project areas are necessary, as healthcare and construction of infrastructure, and even socioeconomic and nutrition activities, are likely to have direct and indirect impacts on communities. As the likelihood of awareness raising and face-to-face training is quite high, transmitted infections diseases including COVID-19 precaution measures shall be prepared and implemented by the project in case such activities take place, to minimize the risk of infection. Community health and safety: The risk and hazard assessment (RHA) has been conducted by the project during the preparation of the ESMF shall be adopted during the implementation of the AF. The project includes activities to provide the necessary information for decision-making in terms of protection against the hazards of waste from medical products during or after treatment, if used improperly, may be hazardous to communities. As noted above, a good practice procedure for the transportation, distribution and use of medicinal products has been developed and incorporated into the ESMF to help protect communities and ecosystem services. Infrastructure construction works could lead to accidents at construction sites or on the roads serving these sites, particularly in areas where the road network is already limited and which are usually occupied by pedestrians. The updated ESMF includes measures to reduce accidents involving project vehicles during construction or during the civil servant census and monitoring activities. The contractor's site-specific ESMPs will include traffic management measures to ensure pedestrian safety, as well as requirements for the adoption of safety signs and barriers in or near work areas and safe storage arrangements for machinery and equipment. Public Disclosure Further, the existing parent project SEA/SH Assessment includes an analysis of the risk of sexual harassment (especially of women) and recommends measures to address this risk in SENI Plus parent project and AF activities. The project provides services mostly to vulnerable women who may encounter these problems. In addition, the existing ESMF also includes an analysis of the current security situation, and the risks of SEA/SH for project staff and beneficiaries. The project has screened for, and where necessary, included specific measures to address SEA/SH risks. This has been captured in the developed SEA/SH assessment and associated action plan which are currently under implementation. The project will be implemented in certain areas with security issues where armed groups continue to operate. A standalone security risk assessment (SRA) has been carried out under the parent project and security management plan (SMP) with adequate security risks mitigation measures to project’s workers, beneficiaries and assets have been developed accordingly, in line with the “UN Voluntary Principles on Security and Human Rights” to ensure that the security measures taken to protect the projects equipment and personnel are appropriate. However, final version of Security Assessment and Management Plan which have been completed, disclosed, consulted upon, approved, adopted are under implementation. The SRA/SMP have national coverage and will be applied to project and AF activities. In regard with the new component 5, specific measures shall also be taken to protect the health and safety of civil servants in ministries. The Community Health and Safety Plan (CHSP) associated with the existing ESF instruments will evaluates these risks and impacts on the health and safety of the project’s beneficiaries, and include provisions to avoid, minimize and mitigate any potential impacts during project life cycle. The CHSP associated with the SRA/SMP and SEA/SH assessment and plan also provides an analysis of the current security situation and the impact of payment of salaries and wages to targeted ministries, and SEA/SH risks for workers/civil servants, and project staff. The project Feb 14, 2024 Page 12 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) will screen for, and where necessary, include specific measures to address SEA/SH risks. This has been captured in the existing SEA/SH plan related to payment of salaries and wages of identified civil servants in targeted ministries. The SEA/SH plan would be applied to the activities related to the component 2 TF grant grant from the Swiss Development Cooperation. Existing parent SRA/SMP and SEA/SH plans have national coverage and include assessment of AF activities, thus they will be applied to both parent project and AF activities including those related to the TF grant and Related to payment of salaries and wages of identified civil servants in targeted ministries. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Relevant ESS5 is considered as relevant to the Project. The project may finance the construction of infrastructure (a central warehouse) in the targeted area. To date, site-specific location of the expected warehouse is not known. More specifically, the impacts of the anticipated civil works (warehouse.) may require land acquisition that could lead to involuntary resettlement, and loss or disruption of income or livelihood activities for individuals or groups of people. Therefore, as this is the construction of only one warehouse, the preparation of a RPF is not relevant. Once the site and type of investments are known with precision, a RAP will be prepared and implemented prior to initiating the construction activities that involve land acquisition, compensation or involuntary resettlement (including physical or economic displacement). This has been reflected in the ESCP. In addition, a screening tool has been developed as part of the ESMF, and there will be a requirement to screen all Public Disclosure sites/facilities to ensure economic or physical displacement does not occur once the site-specific activities are identified; this will especially apply in cases where the decision is taken for infrastructure to be built. At this stage of project development, the land for a possible construction of central warehouse will be made available by one of the municipalities. In principle, this will be unoccupied land. The risk of land being taken from indigenous populations is not envisaged; and the land acquisition through voluntary donation is not foreseen in the project. However, after the screening of specific project sites (if occupied), the possibilities for resettlement or compensation will be analyzed and determined. In all cases, the basic principle will always be to avoid resettlement. Nevertheless, in case land is handed over by municipalities, due diligence shall be conducted to ensure that no forced eviction took place. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources The project will not include activities that will have impacts on biodiversity or natural resources according to the ESS6. Hence this standard is not considered relevant to this project. However, the ESMF has included measures for the protection of biodiversity and natural resources specifically for civil works related to the construction of a national and regional supply warehouses. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Relevant Local Communities Feb 14, 2024 Page 13 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) ESS7 is considered relevant to the project. Indigenous Peoples (Aka/Bayaka) communities are present in the CAR and are considered vulnerable and disadvantaged. The project will be implemented in 15 health districts. The IPs are present in some of those areas, in particular Indigenous People (Aka/ Bayaka), namely in Sangha-Mbaéré, Mambere- Kadei and Nana-Mambere prefectures. However, in relation to component 5, ESS 7 is considered not relevant. Project will pay salaries and wages in the areas where IPs (Ba-Aka) are present. The updated SEP will ensure that IPs are among the beneficiaries of outreach communication activities to allow those who are civil servants and working for the four targeted ministries to be identified or enrolled in the lists of beneficiaries. In the initial SENI Plus project, the Social Assessment has, among other things, examined potential risks, impacts, and benefits for the IPs. Using a consultative approach, the Social Assessment has identified measures to mitigate risks and to ensure culturally acceptable benefits to IPs. However, no activity under this project is expected to have an adverse effect on Indigenous Peoples (displacement, land, cultural heritage, habits & behaviors). The Stakeholder Engagement Plan has included outreach programs to ensure that indigenous communities, especially those living in remote areas, are aware of the availability of essential free healthcare and nutrition services for maternal-child mortality; and malnutrition, medical, psychosocial, and socioeconomic assistance activities as well as training sessions under the project. The potential social impacts can be adequately managed/ mitigated through the development, implementation and monitoring of appropriate measures. The Borrower has proactively engaged with the IPs to ensure their ownership and participation in project design, implementation, monitoring, and evaluation. In addition, some measures provided under the project to ensure that IPs and other groups will be able to share in project benefits are: the ability to enroll beneficiaries without distinction or discrimination in their participation in health committees, and employment of animators and/or community health workers, etc., in the most equitable way. Here, particular attention has been paid to the additional disadvantages that some specific vulnerable groups—including IDPs, Peulhs Public Disclosure Mbororos, etc.—may face in terms of impacts and/or exclusion from project benefits. The Social Assessment has also explored the appropriate consultation methods for these groups and examined culturally appropriate grievance mechanisms. These measures have been detailed in an Indigenous Peoples Plan (IPP) and have been incorporated into the project design including, but not limited to the Stakeholder Engagement Plan and the grievance mechanism. It is also essential for all ethnic groups (IPs and others, including the Peulhs Mbororos where they live), without exception, to be able to access the grievance mechanism. Project activities will not cause relocation or impact resources or cultural heritage of IP groups. The IPP for the parent project which has already been prepared, consulted upon, cleared by the Bank and disclosed and has been updated before any disbursement is made for component 5 related to payment of salaries and wages of identified civil servants in targeted ministries. No further updates are required for the AF given that with the exception of component 5, AF activities are not implemented in areas with IP presence. As project sites (districts) are already known and activities are determined, the PIU has developed an Indigenous Peoples Plan (IPP), acceptable to the Bank that sets out measures through which the project ensure that: (i) IPs affected by the project receive culturally appropriate social and economic benefits; and (ii) if potential adverse effects on IPs are identified, those adverse effects are avoided, minimized, mitigated or compensated. No activity will have significant impact social norms/practices aspects of the affected Indigenous Peoples.. However, IPs’ Free, Prior and Informed Consent (FPIC) will be required if the project will : (a) have adverse impacts on land and natural resources subject to traditional ownership or under customary use or occupation; Feb 14, 2024 Page 14 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) (b) cause relocation of IPs from land and natural resources subject to traditional ownership or under customary use or occupation; or (c) have significant impacts on IPs’ cultural heritage that is material to the identity and/or cultural, ceremonial, or spiritual aspects of the affected IPs’ lives. ESS8 Cultural Heritage Relevant This Standard is relevant since the possible construction of a central warehouse may involve soil excavation. The ESMF has included provisions for site-specific screening and assessment of any known sites of cultural or historic importance which may be impacted locally, as well as identification of any sites of cultural/social importance for local communities. The ESMF has included a generic Chance Finds Procedure for all construction or works contracts, requiring civil contractors to take proper protective measures in case cultural heritage sites are discovered, including to stop construction activities if cultural property sites are encountered during construction ESS9 Financial Intermediaries Not Currently Relevant This standard is not relevant, as the project is not an FI operation. ESS10 Stakeholder Engagement and Information Disclosure Relevant In consultation with the Bank, the Borrower (under the technical guidance of the SENI safeguard/ESF unit which has Public Disclosure already acquired some experience in the preparation and implementation of the SEP for the REDISSE IV Project) has prepared and disclosed a Stakeholder Engagement Plan (SEP) proportional to the nature and scale of the project and its associated risks and impacts. SEP is under implementation and will be updated before AF Appraisal to scale up activities related to human resource for health under Comp 2 and as needed throughout the project lifecycle. The objective of the SEP is to establish a systematic approach to stakeholder engagement, maintain a constructive relationship with stakeholders, consider stakeholders’ views, promote and provide means for effective and inclusive engagement with stakeholders throughout the project life cycle, and ensure that appropriate project information is disclosed to stakeholders in a timely, understandable, culturally accessible and appropriate manner, which is free of manipulation, interference, coercion, discrimination and intimidation. To ensure this, the Borrower would need, to engage in meaningful consultations with all stakeholders while paying attention to the inclusion of vulnerable and disadvantaged groups IPs, GBV survivors, poor households, households with children under five years, young girls, etc.). Affected parties include local communities, community members and other parties who may be subject to direct project impacts. These include pregnant women; men, women and adolescents; survivors of GBV/SEA/SH, etc. Other interested parties include the traditional media, partners of the Ministry of Health and members of the health cluster, civil society organizations, etc. Component 5 also includes the workers' union; banks; telephone operators, etc. These groups include vulnerable people. In relation to IPs, the approach to stakeholder engagement has been based on the principles of meaningful consultation and disclosure of appropriate information. The Borrower has undertaken meaningful consultation in a manner that provides an opportunity for IPs to provide input on the risks, impacts and mitigation measures of the project, and for the Borrower to consider and respond to them in a culturally sensitive manner. These consultations Feb 14, 2024 Page 15 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) have been carried out on an ongoing basis, as issues, impacts and opportunities evolve. If potential adverse effects on IPs are identified, those adverse effects shall be avoided, minimized, mitigated or compensated. Once project-specific sites and activities are determined, IPs’ Free, Prior and Informed Consent (FPIC) will be required if the project will: (a) have adverse impacts on land and natural resources subject to traditional ownership or under customary use or occupation; (b) cause relocation of IPs from land and natural resources subject to traditional ownership or under customary use or occupation; or (c) have significant impacts on IPs’ cultural heritage that is material to the identity and/or cultural, ceremonial, or spiritual aspects of the affected IPs’ lives. In relation with key findings from consultations to date: Stakeholder consultations began since November 2021 and continued during the implementation of Project activities, then during the restructuring of the project from August to October 2023, and then in December 2023 for additional financing. The consultations provided an opportunity to gather stakeholders' opinions and concerns about the project. The participants were unanimously in favor of the project, and expressed the hope that it would actually go ahead. The questions raised concerned the identification of vulnerable groups, and the criteria for selecting the 7 ministries to be restructured. The concerns and needs of identified stakeholders are related to their full participation in project activities and information sharing. The MFB/SENI Plus Project takes engagement to maintain, and disclose, a documented record of stakeholder engagement, including a description of the stakeholders consulted, a summary of the feedback received, and a brief explanation of how the feedback was considered, or the reasons why it was not. Community consultations Public Disclosure with (women, young girls, and women and female heads of households) that are related to SEA/SH risk mitigation have been conducted in safe and enabling environments, such as in sex-segregated groups and with female facilitators. The project will need to identify and consult with relevant stakeholders who could promote increased adhesion and encourage retention of young girls, women leading households, and female workers within the activities. Such consultations have been focused on understanding women and girl’s risks and vulnerabilities, understand girl’s enrolment and engagement experience in healthcare, psychological, socioeconomic assistance and nutrition concerns in relation to the project. Furthermore, the consultations have included the disabled groups, disadvantaged groups and minorities within the project’s targeted communities, and have been carried out in an accessible and appropriate manner, with information provided in accessible formats. The project has set up a project-specific Grievance Mechanism (GM), sensitive to SEA/SH issues, and the ethical treatment and resolution of such complaints that is proportionate of the potential risks and impacts of the project. Due to the considerable workforce involved in the project, and the potential for SEA/SH, the GM shall refer to the Bank’s good practice note “Addressing Sexual Exploitation and Abuse and Sexual Harassment (SEA/SH) in Investment Project Financing involving Major Civil Works”, as well as the Bank’s technical note on SEA/SH in Grievance Mechanisms. The project's GRM is based on the 1212 green line and complemented by Complaints Management Committees that have been set up in the health districts. The committees have been trained and equipped, and the project has also drawn up the ''1212 call center operating manual in the operationalization of the GRM of projects in the portfolio of the Ministry of Health and Population''. Line 1212 receives complaints from all directions. Given the difficulty of tracing complaints, the project organized a capacity-building session for line 1212 managers in December 2023. This training also included how to identify GBV-related complaints and how to respond to these particular types of complaints. Feb 14, 2024 Page 16 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) As part of Component 5, a specific Grievance Mechanism (GM) procedures will be included in SEP and to be implemented by the PGNSP. The GM will be provide guidelines for resolving disputes involving civil servants in the four ministries which might arise from the inspections and other checks by government bodies to ascertain the presence of civil servants and the reliability of the payroll records. Moreover, stakeholders were consulted as part of the preparation/update of a Stakeholder Engagement Plan (SEP) pertaining to the payment of salaries and wages of civil servants in the social sectors. The updated SEP sets forth the activities to engage with stakeholders throughout the project’s implementation. In relation to healthcare, psychological, socioeconomic assistance and nutrition support, and to enrolment of IPs and other vulnerable groups with respect to measures to reduce various violence including exclusion and discrimination against IPs and especially on children, young girls and women, the establishment of a GBV-sensitive GM has also considered inclusion of IP counselor systems within the community, workers committee, and other community platforms. The GM also serves as a platform for continuous feedback from project-affected communities, other interested stakeholders and implementing partners. In addition, citizen perception surveys will be conducted at different times over the life of the project to gather feedback on the actual presence of teachers, healthcare workers and other social-sector civil servants. The project-specific GM has been outlined in the SEP for people to report concerns or complaints, and the comprehensive GM for civil servants to be updated will result from assessment of the following features: a) Different ways in which stakeholders can submit grievances, including submissions in person, by phone, text message, mail, e-mail, or via a website and accessibility features for people with hearing and speech impairments. Public Disclosure b) A log where grievances are registered in writing and maintained in a database. c) Publicly advertised procedures, setting out the length of time users can expect to wait for acknowledgment, response, and resolution of their grievances. d) Transparency about the grievance procedure, governing structure, and decision-makers. e) An appeals process (including the national judiciary) to which unsatisfied grievances may be referred when the resolution of grievance has not been achieved. B.2 Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3 Other Salient Features Use of Borrower Framework No Due to the weak existing E&S frameworks, reliance on Borrower E&S Framework will not be considered in this project. Feb 14, 2024 Page 17 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) Use of Common Approach No NA C. Overview of Required Environmental and Social Risk Management Activities C.1 What Borrower environmental and social analyses, instruments, plans and/or frameworks are planned or required during implementation? For AF, only the SEP including GRM will be updated, disclosed, consulted upon, and adopted by Appraisal of Additional Financing project. Other existing ESF instruments prepared for the parent project are still relevant in covering environmental and social risks from AF activities; These documents are : - an Environment and Social Management Framework (ESMF) version updated in August 2023; - a Security Risk Assessment (SRA) and Security Management Plan (SMP); - a standalone SEA/SH risk assessment and Action Plan including code of conduct and accountability and response framework. - a Labor Management Procedures (LMP) including a GRM for workers as part of the ESMF version updated in August 2023; - a Biomedical Waste Management Plan waste management plan version updated in August 2023; - an Indigenous People Plan (IPP); Public Disclosure However, site specific E&S instruments such as ESIA/ESMP as per ESMF screening and requirement and a RAP (including Livelihood Restoration Plan) will be prepared when specific sites marked for project works are known. These requirements are reflected in the project AF ESCP. III. CONTACT POINTS World Bank Task Team Leader: Tomo Morimoto Title: Senior Health Specialist Email: tmorimoto@worldbank.org IV. FOR MORE INFORMATION CONTACT Feb 14, 2024 Page 18 of 19 The World Bank Additional Financing- CAR Health Service Delivery and System Strengthening Project (P181561) The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects V. APPROVAL Task Team Leader(s): Heriniaina Mikaela Andrianasy, Tomo Morimoto, Innocent Nukuri ADM Environmental Specialist: Charlie Foyet Sonkeng ADM Social Specialist: Barbara Metuge Emade Practice Manager (ENV/SOC) Nicolas Perrin Cleared on 12-Feb-2024 at 08:01:55 GMT-05:00 Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Concurred on 14-Feb-2024 at 05:25:35 GMT-05:00 Public Disclosure Feb 14, 2024 Page 19 of 19