The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 03/28/2023 | Report No: ESRSAFA534 Mar 29, 2023 Page 1 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Kyrgyz Republic EUROPE AND CENTRAL ASIA Ministry of Finance Ministry of Health, Mandatory Health Insurance Fund Project ID Project Name P178856 Primary Health Care Quality Improvement Program - Additional Financing Parent Project ID (if any) Parent Project Name P167598 Primary Health Care Quality Improvement Program Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Program-for-Results 4/11/2023 5/31/2023 Population Financing Public Disclosure Proposed Development Objective The Program Development Objective is to contribute to improving the quality of primary health care services in the Kyrgyz Republic. Financing (in USD Million) Amount Current Financing 414.18 Proposed Additional Financing 30.60 Total Proposed Financing 444.78 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] Mar 29, 2023 Page 2 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) The proposed Additional Financing (component 2 – IPF ) for an amount of US$ 11.45 million will have two subcomponents that will contribute to the PDO while complementing and supporting Component 1 through goods and non-consulting services, as well as technical assistance (TA). Sub-component 2.1: Goods and services to strengthen the diagnostic and clinical capacity of PHC (US$ 9.05 million) will provide PHC organizations with basic diagnostic and clinical equipment and goods to improve the quality of care across a wide range of health services, including MCH and NCDs. This will be complemented by specific services to improve the quality of care, including knowledge services (such as subscriptions to high-quality medical literature) and training. Sub-component 2.2: TA to strengthen the quality of PHC and support the achievement of the DLIs under component 1 (US$ 2.4 million) will finance the consulting services and training necessary to develop systems and tools (such as IT system for MWM, training modules for the LMS, standards, and procedures for MWM, health financing arrangements, etc.). The DLIs in component 1 will support the implementation of these systems and tools. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Health has traditionally been a priority in the Kyrgyz Republic, and the country has achieved better health outcomes than other countries with similar income levels. The population enjoys a longer life expectancy of 71.8 years in 2020, partly due to the significant progress in reducing under-5 mortality from 65.8 deaths per 1,000 live births in 1990 to 17.5 in 2020. Improvements in undernourishment have been dramatic over the past decade, and the prevalence of tuberculosis halved between 2000 and 2012. In 2015, the country officially achieved Millennium Development Goal No. 4 on reducing mortality among children under five. Public Disclosure The Kyrgyz Republic health sector regulatory framework includes both national, sub-national legislation and regulations. The country has also developed and adopted a National Plan for Public Health Emergency Preparedness and a 12-year state strategy for the development of public health, including health systems, in pursuit of universal health coverage by 2030. This strategy also addressed the Health Care Waste Management (HCWM) issue and called for the “Development and implementation of modern, efficient standards and criteria in ensuring procedure safety, control of nosocomial infections, technologies for disposal of medical waste in health care organizations, taking into account the type and volume of produced waste and the territorial location of healthcare organizations”. Many laws and regulations have also been developed to support the implementation of Multilateral Environmental Agreements requirements pertinent to healthcare waste management and infection control (e.g. Minimata Convention on Mercury, Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal). However, the compliance with the above laws and regulations is weak due to: (i) a large number of laws, sub-laws, orders, and guidelines to comply with; (ii) inadequate financial and human resources and capacities; (iii) MOH decrees and orders are mostly applicable to the public sector health system, with little focus on the private sector. Despite significant progress in recent years in multilateral epidemiological, environmental, and infection control systems, systemic gaps exist in the organization of public health. Some of these gaps are (i) while the system for infection control is adequate, it is limited to a few cities and hospitals, and (ii) the system for management/disposal of healthcare waste is generally poor at the PHC facility level, particularly in remote rural areas. Much of the medical waste from PHC facilities is sent to hospitals, overwhelming their waste handling capacity, (iii) there is no systematic approach to training medical personnel on HCWM results in occupational health and safety risks to them, the public, and the environment. The UNEP/GEF and Swiss Agency for Development and Cooperation projects initiated an alternative healthcare waste disposal at PHC facilities, but it remains relatively limited in coverage and operation. Mar 29, 2023 Page 3 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) The Environmental and Social System Assessment (ESSA) carried out for the parent Primary Health Care Quality Improvement (PHCQIP) Program for Results (PforR) identified the following environmental actions for support: 1) Review and Update Standards and Procedures for integrated infection and pollution control at the PHC level 2) Strengthen the information management framework for preventing infectious diseases and environmental pollution 3) Develop systems for capacity building on infection prevention and control and health care waste management 4) Pilot and implement healthcare waste management models in selected districts and PHC facilities No specific social actions were separately identified in parent ESSA. The program design incorporated the development and trial of a pilot mechanism to collect patient feedback on a regular and consistent basis as well as awareness raising of patients’ rights and entitlements. Training of staff to deliver on the environmental and social aspects also forms part of the PforR. The ESSA addendum identifies the following social actions for support: 1) Strengthen the Grievance Redress Mechanism to improve its effectiveness and accountability in receiving and addressing complaints at the PHC level in a timebound manner. 2) Strengthen the information management system to track the program’s effectiveness in providing health services and access to benefits under the SGBP package in an inclusive manner. D. 2. Borrower’s Institutional Capacity The Ministry of Health (MoH) is the lead partner and the main coordinator of the PforR implementation and will also implement the IPF. The Ministry has a wide range of functions. The ones relevant to the environmental impacts and their management are: a) Developing drafts of normative legal acts in the field of public health and submitting them Public Disclosure to the Government of the Kyrgyz Republic; b) Developing and implementing a strategy for the prevention of infectious and chronic non-infectious diseases; and c) Developing and implementing state policy on pharmaceuticals, public health care services, organization of quality control, and efficiency and safety of health care services. MOH’s Department of Disease Prevention and State Sanitary and Epidemiological Surveillance (DDPSSES) has a special role in the healthcare system. The DDPSSES is entrusted by the Government to conduct oversight and control over the execution of regulatory documents that govern public healthcare. The Disease Prevention Centres of the DDPSSES at all levels are key organizations for the establishment of HCWM system. DDPSSES is also responsible for government control over environmental hygiene and epidemiologic situation, including the population's chemical, biological, and radioactive safety; control and oversight over healthcare facilities (including PHC facilities). Due to the ambiguous relationship of MoH’s orders with private medical facilities, sometimes the implementation of relevant measures is not uniform. The MoH and DDPSSES have recently gained some experience in implementing and working with the World Bank Environmental & Social Framework (ESF) through their involvement in the implementation of the Kyrgyz Republic Emergency COVID-19 Project (P7366) and its additional financing (P176054). The MoH will maintain qualified personnel and resources in its line departments and affiliated institutes to support the management of ESHS risks and impacts of the activities of the IPF Component of the PHCQIP. In addition, a Program Coordinator will be recruited by project effectiveness. The Ministry has schemes and benefits packages that aim to provide primary health care (PHC) services across the country and are designed to be inclusive in nature. It has reasonable in-house Environment and Social risk management capacities, as a result of which a PforR operation was rolled out in 2019/2020. This operation will only support procurement of equipment, vehicles, IT hardware, and training services, apart from technical assistance for Mar 29, 2023 Page 4 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) development of IT and accounting systems, Monitoring Evaluation and Learning (MEL) materials, hiring of specialists and consultants as well as strengthening of environmental management systems for infection control and medical waste management. No additional social capacities are required to manage the components. The PMU at MoH, GoKR will be responsible for implementation and will need appropriate capacities to ensure adequate focus on women health workers and patient sensitivity while developing the curriculum for online courses and professional development so that health service delivery is inclusive and patient sensitive. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate Environmental Risk Rating Moderate The environmental risk of the project is rated as Moderate. The potential environmental risks and impacts are mainly attributed to: i) the generation and management of medical and healthcare waste associated with medical diagnostic and laboratory testing at the PHC facilities; ii) the generation and management of some limited quantities of electronic waste associated with the disposal of old IT equipment and/or the ones procured to support PHC quality of care, at the end of their life cycle; iii) wastes associated with the operation and maintenance of procured vehicles to support transportation of medical waste, and minor renovation works to install the equipment in the healthcare facility; and iv) the safety and OHS risks associated with all the management of all the above. The above risks and impacts are predictable and could be adequately managed by applying the existing national regulations and requirements, the World Bank Environmental and Social Standards (ESS) requirements, and the utilization of World Public Disclosure Bank Group Environmental, Health, and Safety Guidelines (EHSGs) and Good International Industry Practice (GIIP). Social Risk Rating Low The social risk rating for the operation is ‘low’. The equipment, hardware and technical assistance available through the investments will help in improving the quality and range of services and their outreach as well as ensuring safety for PHC staff and the community, while the TA is expected to improve targeting, better progress and outcome tracking of services at the PHC level. Some social risks associated with the project are: a) risk of exclusion of women professionals while hiring specialists and consultants for the line departments, b) clinical practice guidelines and course may not adequately sensitize or capacitate PHC staff to address issues related to patient sensitivity and their rights, c) occupational health risks for PHC level staff if not complemented by adequate staff training on using new diagnostic and lab equipment, d) risks due to improper transport and disposal of medical waste to community, PHC staff and contracted workers/ private service providers. e) any SEA/SH related risks for the women workers in the PHC centres. No land acquisition or related adverse resettlement impacts are expected. Most social risks are expected to be small in scale and magnitude and are reversible and can be mitigated using effective mitigation measures. Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) Risk Rating Low The SEA/SH risk rating for the operation is ‘low’. This AF will only support procurement of equipment, vehicles, IT hardware, and training services, apart from technical assistance for development of IT and accounting systems, Monitoring Evaluation and Learning (MEL) material, hiring of specialists and consultants as well as strengthening of environmental management systems for infection control and medical waste management. It needs to be ensured that there is no discrimination against women professionals while hiring specialists and consultants for the line Mar 29, 2023 Page 5 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) departments and SEA/SH related risks in PHCs. This will be ensured through appropriately covering mitigation measures in the procurement documents and code of conduct for workers in the PHC. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: The restructured Programs comprise two Components, the PforR Component (Component 1) and the IPF Component (Component 2). Component 1 will take over the disbursement-linked indicators (DLIs) and activities that currently constitute the PHCQIP (P167598). The additional financing will be entirely allocated to Component 2. Component 2 will comprise two subcomponents. Subcomponent 1 will finance goods and services, and Subcomponent 2 will finance technical assistance (consultants). Both sub-components are designed to support the achievement of the DLIs under Component 1. More specifically, the additional finance/IPF component will support: 1) Procurement of equipment to enable PHC organizations to offer diagnostic services such as electrocardiograms (ECG), echocardiography, ultrasound investigations, X-rays, and fetal heartbeat monitoring. 2) Procurement of basic equipment for PHC organizations, such as family doctor bags. 3) Procurement of goods to strengthen medical waste management capacity, including vehicles for transporting medical waste and equipment to decontaminate waste. Public Disclosure 4) Purchase IT equipment (Servers, computers, printers, software, video conferencing equipment) to support the PHC quality of care. 4) Procurement of services such as testing and maintenance of equipment and training. 5) Technical assistance to strengthen health service systems, including, inter alia, developing and delivering training modules for physicians on medical waste management (MWM). Some of the above investments and technical assistance target improved management of healthcare wastes at the PHC facilities and are expected to result in overall positive environmental impacts. These investments include the procurement of medical waste transport vehicles and medical waste decontamination equipment, the development of an automated accounting system for medical waste, an e-training module for health care staff on MWM, and the revision of standards and procedures for integrated infection control and medical waste management for all public and private PHC organizations. However, some of these investments may result in negative environmental risks. These risks are associated with the generation of medical waste (MW) resulting from medical diagnostic and laboratory testing, electronic waste associated with the disposal of old IT equipment or at their end of use, and other wastes associated with the operation and maintenance of waste transport vehicles. The above risks may also result in soil and water contamination, health safety, and OHS issues from healthcare workers. However, the above risks and impacts are predictable and can be adequately mitigated and managed by implementing relevant national regulations, WB ESF requirements, the EHSGs, and the GIIP. Mar 29, 2023 Page 6 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) Social risks are low, and the benefits from functioning and equipped health services will lead to potentially improved outcomes for patients and the communities the health services serve. As part of the Program design, a mechanism to collect patient feedback on a regular and consistent basis is being developed and trialed, as well as awareness raising of patients’ rights and entitlements. Training of staff to deliver on these also forms part of the Program. As such, no further mitigations or benefit enhancements are proposed for social aspects. An Environmental and Social Commitment Plan (ESCP) has been prepared and will be disclosed before appraisal. The ESCP includes measures for i ) the inclusion of the relevant EHS requirements in the bidding documents for the procurement, operation, and maintenance of the equipment and the medical waste transport vehicles financed under the IPF, ii) measures to ensure the safe management, and disposal of medical waste and e-waste generated by the project, iii) preparation of Standard Operating Procedures (SOPs) and/or Operation Manuals (OMs) for the safe installation, operation, and maintenance of medical diagnostic and laboratory equipment and waste transportation vehicles, iv) preparation of ESMP checklists for the minor works required to install equipment, and v) the TORs of technical assistance activities (consultancies, capacity building, and outputs) in line with the relevant ESF standards. A short environmental and social systems assessment (ESSA) addendum to address any environmental and social risks associated with the Program restructuring was also prepared, disclosed, and consulted on. A public consultation workshop was organized in Bishkek with major stakeholders, including the Government, civil society, private sector, international donor agencies, medical facilities, and representatives of non-government organizations. Major feedback received from the public consultation was incorporated into the final ESSA. Besides ESS1, ESS2, ESS3, ESS4, and ESS10 are relevant to the project. Public Disclosure ESS10 Stakeholder Engagement and Information Disclosure The project affected stakeholders under the project are the staff of MoH and MHIF, PHC level health functionaries including medical practitioners, nurses, lab technicians, medical waste disposal service providers, patients with priority conditions and pregnant women, educational and training institutions and their faculty/ staff and civil society organizations. The IPF component supports financing of goods, services, and financing of technical assistance. Primary suppliers of equipment and services, local media and patient associations will constitute the other interested parties. The vulnerable and disadvantaged group of stakeholders would include women staff and functionaries working at the MoH, MHIF and PHC institutions. Consultations with these stakeholders will be held to inform project preparation and their feedback and suggestions. Based on the nature and the low-level of risks and impacts of the IPF component and that actions for engagement are part of the design of the program and will be ongoing, it is recommended that key actions form part of the ESCP and preparation of a stand-alone Stakeholder Engagement Plan (SEP) is considered not necessary. To receive and address any requests/grievances related to the Program, the MoH utilizes an existing Grievance Redress Mechanism (GRM) in accordance with the national legislation as described in the ESSA for the Program. All grievances in the MoH system are registered in Grievance Logs at the local/rayon/oblast/central levels. It is recommended that MOH strengthens the operationalization of the system to ensure the beneficiaries and those impacted are aware of the mechanism and staff are trained in operationalizing it including recording, responding, monitoring, and reporting. Mar 29, 2023 Page 7 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This standard is relevant. The IPF supports purchase of equipment, goods, services, and financing of technical assistance. The project will employ direct workers as technical coordinators and consultants in the line departments as well as other specialists hired for implementing the training and TA activities. No significant construction or civil works will take place, other than some minor equipment or hardware installation related activities which will employ a very small force of contracted workers for limited duration at the MoH as well as Oblast and rayon level. Since the operation largely involves procurement and technical assistance, primary supply workers and impacts on them will be relevant. Considering the low risk, a separate LMP is not being prepared. Given the nature of the project, no labour influx is expected. Requirements such as a worker grievance mechanism will be incorporated into the ESCP and contractual documents. Currently, there is no systematic approach to the training of healthcare staff or waste handlers on risks of infection, injury, or long-term exposure to hazardous chemicals. Such a situation could create impacts that can manifest in the long term and be detrimental to workers’ health even after they no longer handle healthcare waste. This can be managed through a rigorous training program for healthcare personnel and waste handlers. The TA component will support the development of training modules for HCW targeting physicians, and a portion of the PforR DLI2 has been introduced to incentivize confirmation of completion of this training course. Other OHS risks may be associated with Public Disclosure some minor works for the medical equipment installation. These risks are low, and related mitigation measures will be included in the ESMP checklists. ESS3 Resource Efficiency and Pollution Prevention and Management This standard is relevant. The project will support the procurement of Lab testing and diagnostic, and IT equipment for PHC facilities and some minor renovation works for the installation of this equipment. These activities are expected to generate medical and healthcare waste and other solid waste, dust, and noise. Inappropriate disposal of untreated or incompletely treated waste could lead to, or exacerbate, land pollution where such waste is disposed of. In addition, contaminated liquid material could impact water courses nearby or seep into underground water. The above would need to be addressed through available best practices for operating and maintaining the procured equipment and waste transport vehicles and the safe management and disposal of medical waste and e-waste. The Infection Control and Medical Waste Management Plan developed by the MoH (under the COVID project) will be utilized to guide the safe handling and disposal of the waste associated with the IPF activities. ESMP checklists will be prepared to manage the impacts of the minor renovation activities as part of the installation of equipment in the health facilities. The EHS aspects of the ESMPs checklists and the procurement of medical equipment and waste transportation vehicles will be incorporated into the procurement documents and contracts with contractors. To ensure the safe installation, operation, and maintenance of medical diagnostic and laboratory equipment, and the operation and maintenance of the waste transportation vehicles, Standard Operating Procedures (SOPs) and/or Operation Manuals (OMs) will be prepared. Mar 29, 2023 Page 8 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) ESS4 Community Health and Safety This standard is relevant. The activities to be supported by the IPF could cause some potential risks and impacts to communities close to the facilities and those through which the vehicles carrying healthcare waste need to travel. Poor healthcare waste management exposes patients and the community to infection, toxic effects, and injuries. Poor management risks may include inadequate PHC housekeeping of medical and healthcare waste, accidental spillage or overloading of the waste, and inappropriate handling and disposal. Relevant World Bank Group EHS guidelines will be utilized and applied to mitigate these risks. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement It is not currently relevant. No land acquisition will take place under the project. All medical equipment and hardware deployment will take place within existing medical facilities, like the PHC institutions and testing- diagnostic laboratories and MoH offices at the national and oblast level. As a result, no adverse resettlement impact related to economic or physical displacement is anticipated under the project. Any activities involving acquisition of private land and with involuntary resettlement impacts will be excluded from project support. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard is not relevant for the project as the activities will be undertaken within the premises of the existing health care facilities and not involve any impacts on biodiversity or other living natural resources. Public Disclosure ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities It is not relevant. ESS8 Cultural Heritage The activities to be supported by the IPF are not expected to result in risks and impacts to cultural heritage or restrictions of access to cultural heritage, as such this standard is not relevant. ESS9 Financial Intermediaries The project does involve any financial intermediaries, and as such this standard is not relevant. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways OP 7.60 Projects in Disputed Areas Mar 29, 2023 Page 9 of 10 The World Bank Primary Health Care Quality Improvement Program - Additional Financing (P178856) B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: Borrower framework is not considered to be used IV. CONTACT POINTS World Bank Contact: Christel M. J. Vermeersch Title: Senior Economist Telephone No: +1-202-458-9554 Email: cvermeersch@worldbank.org Borrower/Client/Recipient Borrower: Ministry of Finance Implementing Agency(ies) Implementing Agency: Ministry of Health Public Disclosure Implementing Agency: Mandatory Health Insurance Fund V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Christel M. J. Vermeersch Practice Manager (ENR/Social) Varalakshmi Vemuru Cleared on 28-Mar-2023 at 05:11:53 EDT Mar 29, 2023 Page 10 of 10