The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) @#&OPS~Doctype~OPS^blank@pidconcoverpage#doctemplate Project Information Document (PID) Concept Stage | Date Prepared/Updated: 28-Mar-2024 | Report No: PIDDC00488 The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) @#&OPS~Doctype~OPS^dynamics@pidbasicinformation#doctemplate BASIC INFORMATION A. Basic Project Data Project Beneficiary(ies) Operation ID Operation Name Burundi, Congo, P505187 Malawi Health Emergency Preparedness, Response and Democratic Republic of, Resilience Project Using the Multiphase Programmatic Ethiopia, Kenya, Malawi, Approach Malawi, Rwanda, Sao Tome and Principe, Zambia Region Estimated Appraisal Date Estimated Approval Date Practice Area (Lead) EASTERN AND SOUTHERN 05-Apr-2024 31-May-2024 Health, Nutrition & AFRICA Population Financing Instrument Borrower(s) Implementing Agency Investment Project Republic of Malawi Ministry of Health Financing (IPF) Proposed Development Objective(s) The Project Development Objective (PDO) for Malawi is to strengthen health system resilience and multisectoral preparedness and response to health emergencies in Malawi. @#&OPS~Doctype~OPS^dynamics@pidprojectfinancing#doctemplate PROJECT FINANCING DATA (US$, Millions) Maximizing Finance for Development Is this an MFD-Enabling Project (MFD-EP)? No Is this project Private Capital Enabling (PCE)? No SUMMARY Total Operation Cost 50.00 Total Financing 50.00 of which IBRD/IDA 50.00 Financing Gap 0.00 DETAILS World Bank Group Financing Page 1 The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) International Development Association (IDA) 50.00 IDA Grant 50.00 @#&OPS~Doctype~OPS^dynamics@envsocriskclassification#doctemplate Environmental and Social Risk Classification Concept Review Decision Moderate The review did authorize the preparation to continue Other Decision (as needed) B. Introduction and Context Country Context 1. Malawi is a land-locked low-income country in south-eastern Africa, with a recent increase in poverty, and extreme vulnerability to the impacts of climate change. Alongside persistent inflation, rising domestic food prices, and recurrent climate shocks, extreme poverty as measured by the international poverty line (US$2.15 a day, 2017 purchasing power parity) has increased from 70.7 percent in 2020 to an estimated 71.7 percent in 2023. With low agricultural productivity and limited commercialization, most Malawians face stagnant incomes; along with persistent inflation, rising domestic food prices, and recurrent climate shocks. Economic development is heavily dependent on the agriculture sector. With limited land, country’s environment is already under stress, and sustained population growth will only increase this. These challenges are further complicated by Malawi’s limited regional integration, landlocked geography, lack of agricultural diversification, and the growing frequency of climate-related natural disasters, which require improved economic, social, and physical risk management. Over the past twenty years, climate related disasters in the country have increased in frequency, intensity, and magnitude contributing to destruction of infrastructure and loss of lives. Since 2010, Malawi has experienced 16 major flooding events, a rainfall related landslide, and five storm related disasters (Malawi Country Climate & Development Report, 2022). 2. While Malawi has taken bold steps to stabilize the economy, economic growth was low in 2023 and macroeconomic imbalances continue into 2024. Sustained macroeconomic imbalances, followed by the impact of the COVID-19 pandemic and various climate-related shocks, including cyclones, floods, and prolonged dry spells, have contributed to subdued economic growth. While the resumption of electricity production at the storm-damaged Kapichira hydroelectric power plant has supported economic activity, particularly in the industry and services sectors, production inputs have often been unavailable throughout 2023 and economic growth was just 1.6 percent in 2023. Recently, Malawi has taken important steps towards macroeconomic stabilization including an adjustment of the exchange rate, announcing increased flexibility of the kwacha, agreement with the International Monetary Fund (IMF) on an Extended Credit Facility and a reform program supported by a World Bank Development Policy Operation (P175072), progress on debt relief, and steps towards monetary tightening. These steps are expected to increase economic growth in 2024 and beyond, but numerous downside risks persist including vulnerability to natural disasters and volatile commodity prices. Sectoral and Institutional Context Page 2 The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) 3. Malawi has improved the health of its population over the last decade, but significant challenges remain, and the country is still lagging on critical health outcomes. Average life expectancy has increased over the last 10 years for both men and women. This is attributed mainly to reductions in adult and child mortality because of robust implementation of HIV and maternal and child health lifesaving interventions. Recent declines have been seen in the maternal mortality ratio, in child and neonatal mortality and in mortality from HIV. However, about 40 percent of the country’s children below the age of five are stunted and the adult survival rate in Malawi is also worse than the averages for regional and peer countries. Non-communicable disease and injury mortality have been increasing over the last decade and now account for over 40 percent of mortality in Malawi. Findings from the 2019 Malawi Harmonized Health Facility Assessment suggest that there are several challenges to the health system contributing to poor quality in the delivery of basic services. These include limited health worker capacity; shortage and maldistribution of health workers; inadequate medical supplies and equipment; and suboptimal governance and management of health facilities. 4. Given the existing challenges with delivering high quality basic services, even a minor health emergency would overwhelm the fragile health system. Despite prior efforts to strengthen pandemic preparedness and response, Malawi’s capacity to detect and respond to epidemic outbreak is limited. The 2019 Joint External Evaluation (JEE) of the core capacities in the International Health Regulations (IHR) assessed the strengths and weaknesses of the health system. The report acknowledged the leadership and coordination in public health activities by the Public Health Institute of Malawi (PHIM) but identified critical weaknesses, including lack of technical capacity, understaffing, and inadequate financing among others. The country is ranked 154 out of 195 countries on the 2019 Global Health Security Assessment, which suggests that its ability to prevent, detect, and respond to epidemics and/or pandemics is limited. The 2022 polio and cholera outbreaks put further intense pressure on the health system, especially on the health facilities at the district levels. 5. Climate change-related challenges that increase Malawi’s vulnerability to poor health outcomes include a wide range of climate hazards. These include extreme temperature and humidity conditions, potential changes to precipitation patterns, extreme precipitation events, seasonal aridity, droughts, and cyclones. The Health Sector Strategic Plan (HSSP) III recognizes weak disaster risk management and climate change planning and practices as one of the health systems challenges. Lack of climate-resilient and health care infrastructure exacerbates geographical health disparities and compromises the quality of health service delivery. Finally, the high cost of repairing the damage caused by disasters diverts already-scarce resources from longer term development priorities. Relationship to CPF 6. The proposed project is aligned with the World Bank Group Country Partnership Framework (CPF) for Malawi, discussed by the Board of Executive Directors on April 2, 2021 (FY21-25, Report No. 154505-MW). The project is linked to Focus Area 3 (Strengthening Human Capital Development), Objective 3.1 Accelerating Demographic Dividend through targeted Health System Strengthening; and builds on the ongoing Southern Africa Tuberculosis and Health Systems Support Project (P173228), Emergency Project to Protect Essential Health Services (P180231), and the Malawi COVID-19 Emergency Response and Health Systems Strengthening Project (P173806). It consolidates efforts of the World Bank Group and other partners to strengthen health systems to be more resilient to economic shocks, climate disasters and public HEs. Moreover, the COVID-19 pandemic has increased the priority of health protection and treatment in Malawi, and the Malawi Health Emergency Preparedness, Response, and Resilience Program (HEPRR) program is aligned to the World Bank’s response from relief to resilient recovery. 7. The proposed Project is consistent with both the adaptation and mitigation goals of the Paris Agreement. It is expected to have a considerable contribution to improving climate adaptation and resilience in line with the Paris Page 3 The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) Agreement and is not anticipated to contribute to Greenhouse Gases (GHG) emissions, which is a ligned with Malawi’s commitment to reduction of GHG. C. Proposed Development Objective(s) 8. This project is proposed under Phase 5 of the HEPRR Program using the Multiphase Programmatic Approach (MPA) approved by the World Bank’s Executive Directors on September 29, 2023 (P180127, Report No: PAD5376). Phase I of the HEPRR Program provided financing for Kenya, Ethiopia, Sao Tome and Principe, the East, Central and Southern Africa Health Community and the Intergovernmental Authority on Development. 9. Aligned with the Program Development Objective of the HEPRR Program, the Project Development Objective (PDO) for Malawi is to strengthen health system resilience and multisectoral preparedness and response to health emergencies in Malawi. Key Results (From PCN) The proposed Malawi project is adapted from the HEPRR Program’s Results Chain, which emphasizes multisectoral engagement, service delivery, and regional coordination capacities and the overall emergency response and management, at all levels of the health system. D. Concept Description 10. Four components are proposed for the Malawi operation, aligned with those of the HEPRR Program: (i) Strengthening the Preparedness and Resilience of the Health System to manage HEs (ii) Improving Early Detection and Response to HEs Through a Multisectoral Approach; (iii) Project Management; (iv) Contingent Emergency Response Component (CERC). Component 1: Strengthening the Preparedness and Resilience of the Health System to manage HEs. This component supports a comprehensive approach to enhancing the preparedness and resilience of Malawi’s health system to effectively manage HEs, while complementing overall health system strengthening. Four sub-components address key aspects of readiness and response. • Subcomponent 1.1: Enhancing Multisectoral Planning, Financing, and Governance for Improved Resilience to Health Emergencies • Subcomponent 1.2: Strengthening Health Workforce Development • Subcomponent 1.3: Improving Access to Quality Health Commodities • Subcomponent 1.4: Enhancing Information Systems for HEs and Digitalization of the Health Sector Component 2: Improving Early Detection and Response to HEs Through a Multisectoral Approach. This consists of three sub-components addressing key aspects of preparedness and response. • Subcomponent 2.1: Collaborative Multisectoral Surveillance and Laboratory Diagnostics • Subcomponent 2.2: Emergency Management, Coordination, and Essential Service Continuity Page 4 The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) • Subcomponent 2.3: Risk Communication and Community Engagement (RCCE), Empowerment, and Social Protection During HEs. Component 3: Project Management. This component will ensure efficient and effective management and implementation of the project by the Project Implementation Unit (PIU). • Subcomponent 3.1: Enhancing Project Monitoring and Evaluation (M&E) • Subcomponent 3.2: Delivering Tailored Technical Assistance and Facilitating a Learning Agenda • Subcomponent 3.3: Strengthening Project Management through Support of the Implementing Institutions and Multisectoral Collaboration. Component 4: Contingent Emergency Response Component (CERC). This component will facilitate access to rapid financing by allowing for the reallocation of uncommitted project funds in the event of a natural disaster in Malawi, either by a formal declaration of a national emergency or upon a formal request from the government. @#&OPS~Doctype~OPS^dynamics@legalpolicyandscreeningrisk#doctemplate Legal Operational Policies Triggered Last approved Current Projects on International Waterways OP 7.50 No Projects in Disputed Area OP 7.60 No Summary of Screening of Environmental and Social Risks and Impacts The project is working on strengthening systems including strengthening the preparedness and resilience of the health system to manage health emergencies. The project will not undertake any infrastructural activities, rather, the project will support Technical Assistance activities that will include i) trainings, ii) conducting of a vulnerability assessment of existing infrastructure and assessment of earmarked urban health centers to be upgraded to alleviate the congestion at district and central hospitals; iii) developing of architectural drawings, BoQs and bidding documents to enhance the capacity of the structures with a focus on adaptation to changing climate patterns and earmarked urban health centres for upgrading and iv) conducting environmental impact assessments for the earmarked urban centers. These activities may have downstream and cumulative impacts and other environmental liabilities such as management of hazardous wastes including asbestos containing materials. The project will also support procurement of ICT and digital equipment, solar systems, mobile vans, ambulances, medicines, medical equipment and reagents. The project will also develop policies, plans and install/ revamp administrative systems. Page 5 The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) The main potential environmental risks include e-waste, medical and general waste generation and poor management (segregation at source, storage, transportation and disposal); water, air and soil contamination from fumes, emissions, hydro carbons and heavy metal; OHS to workers, health and safety to patients and communities while key social risks include (a) potential exclusion of vulnerable groups of stakeholders in the design, preparation, and implementation of the project, particularly as a result of the limited experience of the participating agencies with stakeholder engagement processes; (b) labor risks, particularly associated with (b1) unfair preferential treatment to be potentially given to some people while disadvantaging and excluding others during recruitment and training, (b2) potential discrimination in the workplace, as employees with limited or no IT capacity may lag if adequate preparatory work is not done to develop their capacity to effectively use the new technologies to be introduced in their workplace, (b3) potential overburdening of health workers if new systems are introduced without a proper workload and workflow analysis, (b4) potential issues associated with the current plans to use a framework contract modality with suppliers and staff to be recruited by the Project, as part of Components 1 and 3, which might involve a level of risk if ESS2 requirements are not fully incorporated, and (b5) potential for sexual harassment in the workplace; (c) potential risks of exposure of patient-level data to unauthorized people where systems’ security is weak, or there is lack of ethics in handling such data, particularly as part of Component 2 activities that focus on improving early detection and response to health emergencies; and (d) potential risks associated to the downstream aspects of the technical assistance activities to be supported by the project. Though TA activities include preparation of designs for construction works, the scope of construction is small as it will focus on increasing capacity of urban health centres to accommodate more patients during emergencies. The set up is urban hence It is unlikely that the potential adverse risks and impacts will have impact on the environment and biodiversity. The potential risks and impacts are predictable and expected to be temporary and/or reversible; of low magnitude; site-specific, within the project footprint and the project’s risks and impacts can be easily mitigated in a predictable manner. The environmental and social risk has therefore been classified as Moderate. Based on a preliminary assessment, ESS1, ESS2, ESS3, ESS4, ESS6, ESS8 and ESS10 apply and the following instruments will be prepared i) ESCP, ii) SEP at preparation and iii) ESMF that includes generic ESMP, OHS plan, SEA/SH action plan and LMP iv) Updated ICWMP, v) CERC Manual/ESMF and vi) ESMP as part of the designs documentation at implementation. @#&OPS~Doctype~OPS^dynamics@contactpoint#doctemplate CONTACT POINT World Bank Vikram Sundara Rajan Senior Health Specialist Collins Owen Francisco Zamawe Health Specialist Borrower/Client/Recipient Page 6 The World Bank Malawi Health Emergency Preparedness, Response and Resilience Program Using the Multiphase Programmatic Approach(P505187) Republic of Malawi Betchani Tchereni, Secretary of the Treasury, secmof@finance.gov.mw Implementing Agencies Ministry of Health Samson Mndolo, Secretary for Health, samson.mndolo@mail.gov.mw 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 @#&OPS~Doctype~OPS^dynamics@approval#doctemplate APPROVAL Task Team Leader(s): Vikram Sundara Rajan, Collins Owen Francisco Zamawe Approved By Practice Manager/Manager: Country Director: Hugh Riddell 28-Mar-2024 Page 7