The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 05/30/2023 | Report No: ESRSAFA574 May 30, 2023 Page 1 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Honduras LATIN AMERICA AND Republic of Honduras Ministry of Health CARIBBEAN (Secretaria de Salud Honduras) Project ID Project Name P180475 Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project Parent Project ID (if any) Parent Project Name P176532 Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 5/25/2023 6/28/2023 Public Disclosure Population Financing Proposed Development Objective The objectives of the Project are to: (i) improve utilization of reproductive and child health services in priority regions, (ii) strengthen public health capacities for emergency preparedness, and (iii) in case of an Eligible Crisis or Emergency, respond promptly and effectively to it. Financing (in USD Million) Amount Current Financing 75.00 Proposed Additional Financing 0.00 Total Proposed Financing 75.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No May 30, 2023 Page 2 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The Parent Project was approved by the World Bank Board of Executive Directors on June 16, 2022. This Project is not yet effective. The Parent Project will strengthen the supply and demand for adolescent, maternal and child health services in prioritized, high burden regions of the country, as well as the capacity for the Honduran health system to prevent, detect and respond to health emergencies. This will be done by through investments to: (a) advance the country's efforts to reach partially vaccinated and 'zero-dose' children in identified areas; (b) improve the quality of and increase the demand for maternal and neonatal services to reduce pregnancy risks, preventing and addressing obstetric complications and emergencies in a timely manner, and ensuring that mothers have a safe and respectful delivery; (c) increase the quality of and access to adolescent Sexual and Reproductive Health; (d) improve the capacity of the surveillance and response system to detect diseases, communicate risks to the population, and respond adequately during health emergencies; (e) improve the quality, timeliness and resilience of the laboratory system; (f) strengthen the integration, governance and efficiency of the health information system; and (g) enhance the stewardship capacity of the Ministry of Health. This Additional Financing (AF) in the amount of US$7 million in trust funding from the Vaccine Alliance (Gavi) will support the scale up of immunization activities from 8 to 20 health regions and support the three project components: (i) Strengthening of adolescent, maternal, and child health services; (ii) Public health preparedness, response, and stewardship capacity; and (iii) Project management. Contributing to the PDO, the expected outcomes of the proposed GAVI financing include: (i) engagement and reengagement of children into the Expanded Program on Immunization; (ii) subnational commitment to routine immunizations and the zero dose agenda; (iii) improved national and subnational-level planning and implementation of immunization activities; (iv) systems digitalization and Public Disclosure interoperability to improve data timeliness, accuracy, and use for decision-making; and (v) immunization programming that is responsive to the needs of zero-dose children and children with incomplete immunization. This AF was already anticipated during the preparation of the Parent Project, through which it was agreed that the Gavi co-financing would be processed as an AF in FY23, after Gavi’s formal final approval. Immunization activities will be tailored to each region/municipality’s specific needs, to ensure a targeted and efficient approach. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The AF is expected to expand activities under Component 1 related to the immunization coverage from the eight (8) health regions originally included in the Parent Project, to include all twenty (20) health regions in Honduras. The health system in Honduras consists of 20 health regions (regiones sanitarias), which correspond to the 18 administrative departments of Honduras plus the metropolitan regions of the Municipality of the Central District (M.D.C.) and San Pedro Sula. The original health regions supported by the Parent Project under Component 1 were Atlantida, Comayagua, Cortes, Choluteca, El Paraiso, Francisco Morazan, Olancho, and the M.D.C. Metropolitan region. The AF will expand the project’s geographical area to the country’s remaining 12 health regions: Colón, Copán, Gracias A Dios, Intibucá, Islas de la Bahía, La Paz, Lempira, Ocotepeque, Santa Bárbara, Valle, Yoro, and the San Pedro Sula Metropolitan region. May 30, 2023 Page 3 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) Other activities under Component 1 include those related to improving the quality of maternal and neonatal services in selected areas, which will contribute to reducing pregnancy risks, preventing, and addressing obstetric complications and emergencies in a timely manner, and ensuring that mothers have a safe and respectful delivery. Targeted health regions for these activities include: Gracias a Dios, Comayagua, El Paraiso, Olancho, Yoro, Santa Bárbara, Colón, Intibucá, Copán, Choluteca, Atlántida, Islas de la Bahia, and Lempira. These prioritized regions for activities related to maternal and neonatal services have not changed and will remain the same as in the Parent Project. Honduras is the third poorest country in the Western Hemisphere and faces various existing health sector challenges which have been exacerbated with by the COVID-19 pandemic. The effects of the COVID-19 pandemic have had a significant impact on national health response and services, which has been augmented with difficulties in deploying and establishing the national vaccination program. Health and social challenges have accentuated as health services have experienced overburdened capacity, posing an immediate challenge to the sustainability and effective functioning of the health system. Although the public health sector in Honduras has been investing in expanding coverage and services for primary health care, coverage access and quality varies significantly across geographic regions and population groups, with age, income, and education disparities in access to and quality of services. Maternal health outcomes reflect significant inequalities in access and quality of care, with large urban rural disparities. Care during delivery and postpartum are highly influenced by income and education level, urbanicity, and geographical region, with access and quality being remarkably lower among the lowest income quintiles, those with no or little education, and rural populations. This critical health scenario is accentuated by the country’s accumulated vulnerabilities. Public Disclosure Honduras has made significant progress in maternal and child health indicators in the last two decades, but the COVID-19 pandemic has threatened to reverse gains achieved, in particular for routine immunization. In the last twenty years, child mortality rates in Honduras have been more than halved, from 37 to 17 deaths per 1,000 births, with neonatal deaths accounting for over half (55 percent) of child deaths. Inequitable and declining coverage of essential health services pose a serious threat to maintaining this progress. For the population under 1 year of age, coverage of pentavalent vaccinations, which protect against key childhood diseases, dropped from 88 percent in 2019 to 77 percent in 2021. Pentavalent vaccination national coverage dropped to below 85 percent in more than half (14) of Honduras’ 20 health regions, with five regions (including the most populous) dropping below 75 percent. This trend increases the vulnerability of the Honduran population, particularly children, threatening their lives, as well as their physical and cognitive development. Disease outbreaks are also expected to increase in frequency and severity due to climate change. There is thus an urgent need to support the restoration of routine immunization services, increasing community demand and access, and building institutional capacity to deliver an equitable immunization program (including physical and human resources, and information systems). Indigenous Peoples and Afro-Hondurans (IPAH), in particular, fare the worst both in terms of poverty and access to services and opportunities, including health and in particular maternal and neonatal health care services. The 2013 Population Census shows that out of 8,303,773 habitants in Honduras, 717,620 people (8.64 percent) self-identify as indigenous and/or afro Honduran populations. The nine Indigenous peoples are highly rural, with 82.9 percent of them (538,952 people) living in rural areas while 17.91 percent in urban settings (117,517). Health outcomes among IPAH are also far worst when compared to the non-IPAH. For example, maternal and child mortality rates are higher in regions with significant presence of IPAH, such as Gracias a Dios, Colón, Yoro and Intibucá. Also, regions with highest May 30, 2023 Page 4 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) levels of adolescent pregnancy coincide with those seeing other poor maternal health outcomes and coverage of services, which are the same as those with high IPAH populations. IPAH communities also live predominately in the departments that were most affected by the storms Eta and Iota in 2021. Countrywide, the National Center for Social Information (Centro Nacional de Información del Sector Social, CENISS) registered 2,975 communities affected by floods and landslides with a total population of 803,529 people. Regarding environmental characteristics, Honduras is exposed to extreme climatic events such as the two back-to- back tropical cyclones Eta and Iota at November of 2020, extensive droughts particularly in the region called the Dry Corridor (Corredor Seco), and periodic outbreaks of diseases such as dengue and chikungunya. Proper management of biomedical wastes in the country is generally weak or absent. While some larger hospitals in major urban areas count with equipment and systems for effective management of medical waste, smaller health centers which will be main beneficiaries of this project lack site specific plans in this respect. In addition, authorized final disposal sites do not generally have appropriate conditions for effective isolation and control of these wastes. Inhabitants in Honduras experience difficulty in accessing public services, such as health and education, partly due to the limited budgetary capacity of national institutions, which is more evident in rural regions. These threats occur in a social context with volatile indicators related to crime and violence (including GBV), uneven access to health services (particularly for the vulnerable) and the accumulated social pressures which have been exacerbated after more than a year of pandemic-related restrictions. D. 2. Borrower’s Institutional Capacity The AF poses no changes to the Project’s implementation arrangements. The Project will continue to be implemented Public Disclosure by the Ministry of Health (SESAL) of Honduras. SESAL is the leading institution regarding health services and provision and has a strong track-record of coordinating and implementing health programs with support from multiple actors. Over the past year, SESAL’s teams have progressively adapted to manage the pandemic and the ongoing vaccination campaign together with the day-to-day management of its regular health services under difficult circumstances. This has included training its staff in multiple aspects of pandemic response, from using PPE to the use of specialized equipment. In addition to this, SESAL is the national coordinator of all vaccination-related activities in the country, led by the Expanded Program for Immunizations (EPI), which has a long track record of partnerships and engagements with international organizations such as the Pan American Health Organization (PAHO) and UNICEF and leads a successful immunization effort with internationally recognized results. Through the EPI program SESAL has subcontracted and partnered with several UN agencies and/or recognized nongovernmental organizations (NGOs) to implement Project activities. Between 2020 and 2023, SESAL’s technical teams have strengthened their knowledge of environmental and social risk management and have become familiarized with the World Bank’s ESF, its E&S standards and instruments. Regarding specific experience with Bank-financed operations, since late 2021, SESAL has been implementing the Honduras COVID-19 Emergency Response Project and its Additional Financing (P173861), which entails a nation-wide vaccination campaign. Good practices and lessons learned from this experience will serve to design and implement activities related to this AF. For the implementation of the Parent Project and AF, SESAL’s existing Project Implementation Unit (PIU) for externally funded projects will be responsible for coordinating the implementation and enforcement of the environmental and May 30, 2023 Page 5 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) social risk management instruments for the Project. The PIU will coordinate the update, management, and enforcement of the ESF instruments with key units within SESAL and external actors, including the GAVI Alliance and PAHO, who are expected to provide assessments and coordination support during Project implementation. During Parent Project and AF preparation, SESAL relied on the support of the Honduras COVID19 Response Project’s (P173861) technical team, which includes a dedicated Environmental Specialist and a dedicated Social Specialist. Given the Parent Project is not effective yet, Project personnel has not yet been hired. After effectiveness of the Parent Project and AF, the PIU will recruit at least one environmental and one social specialist for this Project, separate from the COVID19 Response Project’s team. It is envisaged that these E&S specialists will be assisted by at least one environmental and one social consultant, and potentially more, to be defined during Project implementation as specific Project activities are determined in more detail. As described in the Project Paper for the AF, the Bank has identified the need to continue strengthening the team’s environmental and social risk management capacities, in particular the capacity to carry out continuous stakeholder engagement, as this will be key to managing perceptions, as well as to oversee implementation of measures for managing labor, community health and safety, and inclusion of IPAHs, and other vulnerable groups. Additional capacity building measures have been outlined in the Project’s Environmental and Social Commitment Plan (ESCP). These measures include the provision of additional training, capacity building and support for SESAL’s technical teams so that SESAL has a clear understanding and is able to develop and implement the various E&S risk management plans and instruments. In particular, a strong capacity to conduct ongoing stakeholder engagement will be key to managing perceptions, as well as overseeing the implementation of measures to manage labor, community health and safety, Public Disclosure IPAH, and the inclusion of vulnerable groups. An analysis of existing capacity and needs for strengthening biohazard waste management systems will also be conducted as part of the finalization of the Environmental & Social Management Framework (ESMF), and training actions to be identified in the ESMF will be implemented. Given the Project has a Contingent Emergency Response Component (CERC), the borrower will ensure that a CERC Manual includes a description of the ESHS assessment and management arrangements for the implementation of the CERC in accordance with the ESSs and that any necessary E&S instruments required for activities under the CERC be developed and adopted, as established in the ESCP. 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 rating remains moderate. The AF will not finance any civil works or other activities that could significantly affect the quality of air, bodies of water, soils, vegetation, wildlife, or human settlements that depend on them. Nonetheless, the proposed AF is expected to finance minor civil works at selected health facilities, laboratories, and cold chain warehouses, which may lead to a variety of site-specific and temporary construction related impacts and risks, including noise, dust, generation of solid wastes and effluents, traffic and pedestrian safety near work zones, occupational health and safety (OHS) risks, among others. The operation of health care centers, laboratories, and cold chain storage facilities to support provision of medical services including vaccination furthermore carries May 30, 2023 Page 6 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) moderate environmental and occupational health and safety risks derived from increased generation of medical waste. which may have biological risk characteristics. These risks will be site specific and managed through the application and enforcement of specific OHS protocols and control measures. With respect to environmental risks, the AF shares the following primary concerns identified for the parent project: (i) environmental and community health related risks from inadequate handling, storage, transportation and disposal of infected medical waste and expired and used vaccine vials; (ii) occupational health and safety issues related to the availability, supply and appropriate use of personal protective equipment (PPE) for healthcare workers including vaccination workers; (iii) community health and safety exposure risks in the immediate vicinity of health care facilities and vaccination centers associated with increased risks of contagion from COVID-19; and (iv) ambient pollution and human health and safety risks stemming from cleaning and disinfection products, chlorine and other hazardous byproducts including chemicals associated with vaccine cold chain requirements. No new environmental risks resulting from the project’s expanded geographical scope are expected. Social Risk Rating Moderate The social risk rating for this AF remains moderate. The AF is expected to have overall positive social impacts by reversing losses in immunization coverage to children that have occurred since before the COVID-19 pandemic and supporting the scale-up of routine vaccination coverage and health information systems country-wide. Identified social risks for this AF include: (i) potential discrimination and difficulties in access to health facilities and vaccination programs, especially for those living in remote or rural areas, potentially affecting the most marginalized and vulnerable social groups such as Indigenous Peoples and Afro-Hondurans (IPAHs), migrants, and people with disabilities; (ii) caregivers’ refusal to vaccinate newborns or zero dose children as a result of misinformation or lack of adaptation of communication strategies to inform the population of the benefits; (iii) limited outreach to zero dose Public Disclosure children if birth monitoring in local health centers is not efficient, especially in remote areas; (iv) gender-based violence (GBV)-related risks for those providing or receiving medical attention, including Sexual Exploitation and Abuse (SEA) or Sexual Harassment (SH) of patients or health staff; and (v) security risks for health staff during vaccination campaigns due to high crime rates in certain areas of the country. At the time of preparation and E&S due diligence of the Parent Project, risks related to immunization activities were initially identified. Given the AF had been anticipated during preparation of the Parent Project, the identification of environmental and social risks at the time considered risks related to a nation-wide immunization campaign. Such risks remain relevant, and no additional social risks were identified as a result of the expansion in geographical scope. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: This standard is relevant. The AF is expected to expand the immunization coverage from the eight health regions originally included in the Parent Project, to include all 20 health regions in Honduras. The AF will support the country in restoring pre-pandemic vaccination coverage rates, including reaching “zero-dose children” (those who have not received any vaccines), improve national and subnational-level planning and implementation of immunization activities, and improve responsiveness to the needs of zero-dose children and children with incomplete immunization. Immunization activities will be tailored to each region/municipality’s specific needs, to ensure a May 30, 2023 Page 7 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) targeted and efficient approach. The Parent Project initially included immunization activities under Component 1 in the following regions: Atlántida, Comayagua, Cortés, Choluteca, El Paraíso, Francisco Morazán, Olancho, and the M.D.C. and San Pedro Sula Metropolitan regions. AF funds will expand immunization activities from these eight health regions to all health regions in the country. Given the AF had been anticipated during preparation, identification of environmental and social risks at the time considered risks related to a nation-wide immunization campaign. The AF is expected to support interventions in selected facilities accesible to the public, such as health centers, laboratories, cold-chain warehouses, and vaccination sites, where there may be potential risk of fire and injury. Social risks of activities related to scaling immunization campaigns nation-wide are expected to be moderate. Some of these risks may include the potential ethnic-based discrimination of marginalized and vulnerable groups including IPAHs, who currently have among the worst healthcare outcomes and access to health services in the country. Reaching other vulnerable groups, such as persons with disabilities or communities in areas with difficult access and remote rural areas, might also face exclusion from immunization activities if brigades are not equipped or able to provide door-to-door services or if communication and information campaigns are not adequately targeted to reach these communities. Misinformation can also have a significant negative impact on immunization efforts given that parents or caregivers may become hesitant to vaccinate their children. Public health campaigns, educational materials, and outreach and communication programs that are culturally appropriate will be developed by SESAL and tailored to each region/municipality’s specific needs, to ensure a targeted and efficient approach. Public Disclosure Other social risks include GBV-related risks for those providing or receiving medical attention, including SEA/SH of patients or health staff. Expansion of the vaccination activities will also require that health brigades travel through remote areas where risks of crime, violence or intimidation to health workers are present. SESAL, however, has experience in working and delivering health services in challenging territories, where health staff is often trusted by communities and granted access without restrictions or fear of retaliation. SESAL works with community leaders to ensure health workers are welcomed and able to reach targeted groups. Among the risk mitigation strategies put in place to ensure the safe implementation of Project objectives related to the expansion of campaign for children immunization is the potential use of security forces, in accordance with provisions set forth under ESS4. During AF preparation, SESAL updated the Parent Project’s E&S instruments to reflect AF activities. To date, these instruments include the Stakeholder Engagement Plan (SEP), a disclosed draft of the Environmental and Social Management Framework (ESMF), and an Environmental and Social Commitment Plan (ESCP), which were originally published in April 2022 prior to Parent Project’s Appraisal. The updated SEP and ESMF include the new geographical scope under Component 1 as well as confirmation and additional details on risks related to the expanded scope of immunization activities, specifically for IPAHs, mitigation measures to address such risks, and consultations carried out during preparation of the AF (these were specifically targeted to IPAHs given that they had not been included in consultations during preparation of the parent Project due to short timeframes). For the AF, the updated SEP, ESMF and ESCP will be disclosed by SESAL and the Bank prior to AF Appraisal. Given the Parent Project is not yet effective, additional E&S instruments are currently under preparation by SESAL, as agreed in the parent Project’s ESCP, including a Labor Management Procedures (LMP), including a grievance redress mechanism for workers, waste management plans (WMP) to manage hazardous and non-hazardous waste associated May 30, 2023 Page 8 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) with AF activities, including infectious biomedical waste, construction waste, dismantled/disposed electronic biomedical equipment, etc., consistent with ESS3, an Indigenous and Afro-Honduran Peoples Planning Framework (IAHPPF), and a SEA/SH Action Plan for health staff, as relevant. As effectiveness of the Parent Project is not expected prior to the Appraisal of the AF, remaining instruments as well as updating and finalization of the ESMF will follow preparation timelines originally agreed in the Project’s ESCP, most of which are due 60 days after Project effectiveness. As agreed in the Parent Project and AF’s ESCP, an analysis of existing capacity and needs for strengthening biohazard waste management systems will be conducted as part of the finalization of the ESMF, and training actions to be identified in the ESMF will be implemented. ESS10 Stakeholder Engagement and Information Disclosure This standard is relevant. The Project’s SEP has been updated to include the new geographical scope under Component 1 as well as additional consultation outcomes carried out during preparation of the AF, specifically with IPAHs, which, given time constraints during preparation, remained pending. During preparation of the parent Project, expansion of immunization activities to all health regions had been anticipated. Therefore, consultations held at the time with stakeholders (except for IPAHs) and preparation of the SEP included information and identification of needs in response to a nation-wide immunization campaign. During preparation of the Parent Project, consultations with the internal and external stakeholders took place in two Public Disclosure phases: (i) in September 2021, internal stakeholders within SESAL representing all 20 health regions were consulted to gather information for Project design, which included prioritization of needs and activities as well as geographic areas of intervention; (ii) in march 2022, internal and external stakeholders were consulted to assess the Project’s environmental and social risks, identify mitigation mechanisms and define strategies for continuous stakeholder engagement, including grievance channels. Consultations at this time included the presentation of the immunization campaign as a nation-wide activity and stakeholders engaged represented all 20 health regions. Feedback from internal and external stakeholders within SESAL served to identify and prioritize the types of activities to be financed by the Project, as well as selection of prioritized regions for activities related to maternal, newborn, and adolescent health services, health centers requiring rehabilitation or expansion, equipment, and communication and outreach needs. Identification of risks related to a nation-wide immunization campaign were also identified, including differentiated strategies to reach vulnerable and marginalized groups, aspects related to security and safety of personnel and communities during these activities, and generation of waste and waste management. Internal and external stakeholders also emphasized the need for training of health workers to include considerations for cultural aspects and the needs of vulnerable sub-population groups, such as IPAH and LGBT. Communication and outreach campaigns will also be culturally, and language adjusted, including those related to vaccination efforts. During preparation of the AF, a consultation process was held by SESAL with IPAHs between January 23-31. Consultations, which covered both the parent Project as well as AF activities, included representatives from eight of the nine IPAHs, such as Negros de Habla Inglesa, Chortí, Garífuna, Lenca, Misquito, Pech, Tawahka, Tolupanes Peoples. The consultation process was grouped by ethnicity, with a high participation of women given the nature of the Project and services targeted. In addition, SESAL organized two separate focal groups, one exclusively for IPAH women, and one for IPAH youth, facilitating a detailed discussion on different aspects of the project related to May 30, 2023 Page 9 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) women and youth’s sexual and reproductive health. Consultation outcomes highlighted the need to ensure that Project activities were culturally adapted, including communication materials in local languages and that respond to cultural and local norms. Participants highlighted that outreach to IPAH communities should be done through local community leaders and considering culturally adapted decision-making processes. These aspects were considered when designing the Project’s GRM, communications strategies, and consultation methods. SESAL included results from consultations held during the preparation of the AF in the SEP and ESMF. Consultation outcomes with IPAHs will also serve to inform the preparation of the Project’s IAHPPF, which is expected to be prepared, consulted, and disclosed no later than 60 days after Project effectiveness, in line with the remaining Project E&S instruments. SESAL is currently implementing a WB-financed COVID-19 Project that includes a COVID-19 nation-wide vaccination campaign. SESAL will ensure that the Project's GRM responds to the needs of broad immunization activities and that it is available to all Project stakeholders, accessible, culturally appropriate, and guarantees confidentiality, accessibility, and translations to indigenous languages where necessary. The GRM included in the SEP meets ESS10 requirements and covers operational principles, processing responsibilities, internal administration, and the frequency of periodic monitoring reports. The Project’s GRM includes centralized channels, such as an online portal, email address, telephone number and physical addresses to receive and register grievances, as well as a decentralized mechanisms for grievances to be received, registered, and addressed at more local levels. Once received and registered, these are to be categorized and, if necessary, redirected depending on the level of urgency or categorization of the grievance. A standard period between two and seven days, and a maximum of 21 days for complex cases, has been established to address grievances or concerns. The GRM allows for anonymous complaints. The GRM also includes specific provisions for vulnerable groups and specific guidelines to address SEA/SH-related Public Disclosure complaints, as well as complaints related to the use of security forces, when relevant. The ESCP establishes that the GRM will be operational within 30 days after Project Effectiveness. 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. Labor provisions and requirements will be included in the parent Project’s Labor Management Procedures (LMP). To reflect relevant labor aspects related to the AF, the LMP will include detailed provisions for project workers hired to perform immunization activities. Most activities supported by the parent project and the AF will be conducted by publicly employed health and laboratory workers. Additional project workers will include contracted suppliers (including those involved in transport, handling and delivery of procured goods), as well as potentially some private consultants and other contract staff to support vaccination activities. Some of the key risks for project workers performing immunization activities around the country include safety and security related risks, given Honduras has one of the highest homicide rates in the region, and health staff may be at risk of violence or crime while carrying out immunization campaigns in some areas. Other safety risks are related to challenges in reaching difficult access areas due to poor infrastructure and lack of transportation. Health staff may also face resistance or hostility because of misinformation. Emerging risks related to declining mental health and fatigue may impact project workers’ capacity to carry out core functions. These risks will be included and further assessed in the Project’s LMP and mitigation measures will be identified. May 30, 2023 Page 10 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) Staff of health facilities, workers involved in vaccination activities, as well as all other workers involved in the procurement, delivery, training, use, supervision/monitoring, and/or handling and disposal of medical supplies, equipment, or waste products within the scope of the project will receive necessary training on protecting themselves and others, as well as other relevant occupational health and safety (OHS) and mental health risks and management measures. The Project will ensure the application of OHS measures as outlined in the disclosed draft ESMF. SESAL has developed guidelines following WHO criteria for health providers including procedures for protection of workers in relation to infection control precautions; provision of immediate and ongoing training on the procedures to all categories of workers, and mandating hand hygiene and personal protective equipment (PPE); ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General EHSGs and industry specific EHSGs. Staff of health facilities and those involved in vaccination activities will receive appropriate training under the project on how to use the medical equipment, supplies and vaccines financed through the Project in a way that protects their health and safety. The ESMF identified and assessed the new OHS risks to workers involved in vaccination activities, including risks such as declining mental health and fatigue, and ensured that mitigation measures are in place. In cases where there is risk of PPE shortage for health workers, the LMP will lay out measures to ensure that health staff involved in project activities is not forced to work without all necessary safety measures. The LMP will also outline key national laws and regulations protecting workers’ rights, and include a grievance mechanism to allow project workers to quickly inform management of labor issues, such as a lack of PPE, safety and security risks, or unreasonable overtime. The workers GRM will also respond to the wider scope of potential workers Public Disclosure who will be involved during the implementation of immunization activities. The use of child or forced labor will be forbidden in accordance with ESS2. ESS3 Resource Efficiency and Pollution Prevention and Management ESS3 is relevant due to the possible increase in the generation of medical waste from the expansion of immunization activities in support of restoring pre-pandemic vaccination coverage rates, including reaching “zero-dose children”; and by the possible generation of construction and demolition debris, as well as outdated electronic biomedical equipment being replaced that will need to be disposed of, generated in civil works to rehabilitate, expand health laboratories and cold-chain storage facilities, and install new electronic biomedical equipment. Medical waste and general waste from vaccination sites and health laboratories have a high potential of being contaminated with micro- organisms that can infect workers and the community at large if they are not properly disposed of. These risks are site specific; proper due diligence will be required during implementation to assess site specific risks and impacts and ensure appropriate application of the mitigation hierarchy. For physical investments to rehabilitate or expand health laboratories and/or install new electronic biomedical equipment, site specific ESMPs will be developed to outline appropriate measures to manage wastes and debris associated with those works. ESMPs will include Dismantling and Disposal Plans of Electronic Biomedical Equipment, where relevant, following the template included in annex to the draft ESMF. To address waste management issues during the operations phase of beneficiary health centers, laboratories and vaccination sites, the PIU will develop site specific Medical Waste Management and Infection Control Plans, provide capacity building to relevant staff at recipient locations, and supervise compliance with the plans, in accordance with the ESSs, national legislation, and Good International Industry Practice (including WHO May 30, 2023 Page 11 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) guidelines and World Bank Group EHS Guidelines). In addition, given that cold chain storage infrastructure is energy intensive, energy efficiency measures will be pursued where feasible in accordance with this standard, such as solar- powered energy systems for warehouses and/or solar fridges, to significantly reduce greenhouse gas emissions produced by health care infrastructure. ESS4 Community Health and Safety This standard is relevant. Gender-based violence has been identified as a potential social risk during expansion of immunization campaigns for those providing or receiving vaccines. Women and children may face specific risks, including harassment and assault, while accessing immunization services. Additionally, in some cases, the distribution of vaccines and other resources may be used as a tool of power and control, which increases risks of SEA/SH. Mitigation measures identified in the ESMF include training healthcare providers on how to identify and respond to GBV, providing safe and secure spaces for women and children to receive vaccines, and working with local community leaders to ensure proper dissemination of information related to prevention of SEA/SH and mechanisms to address SEA/SH complaints as part of the Project’s GRM. During implementation, the corresponding measures to prevent and mitigate the SEA/SH risks will be adopted and implemented through SEA/SH action plan. Minimum content of SEA/SH action plan will be included in the updated ESMF. The Project will promote the avoidance of SEA/SH by relying on the WHO Code of Ethics and Professional Conduct for all workers related to the Project who will work as part of project activities. The GRM also includes specific guidelines to address SEA/SH-related complaints, including measures to ensure confidentiality and development of a database of service providers for case referrals, and training of facilitators and other staff, in particular those in contact with communities, on appropriate conduct Public Disclosure and on how to receive GBV or SEA/SH complaints and refer participants to service providers. In Honduras, the contextual risk of crime and violence may pose a threat to local populations, potential Project beneficiaries, and health workers, particularly in some of the Project’s departments, such as Comayagua, Olancho, Yoro, Colón, Copán, Atlántida and Gracias a Dios, which have some of the highest homicide rates in the country. Vaccination campaigns, for example, require that health brigades travel through remote areas where the risks of crime, violence or intimidation to health workers. SESAL, however, has experience in working and delivering health services in challenging territories, where health staff is often trusted by communities and granted access without restrictions or fear of retaliation. For immunization activities in remote geographic areas, as well as for areas with high rates of crime and violence, the government will assess whether the use of security forces is necessary under the proposed Project. In cases where it is determined that the use of security forces will not be necessary, the final ESMF will include measures to ensure the safety and security of project personnel and community, such as working with local organizations and local leaders for safe access to communities through trusted local health staff. For cases where the use of security forces is deemed necessary, the draft ESMF includes a preliminary identification and assessment of the risks associated with engaging security personnel. The final ESMF will include more information on the specific role of security forces, if needed, in the implementation of immunization activities as well as details on their interaction with the communities, will set forth the standards and code of conduct to be adopted by such personnel, including training requirements on such standards and code of conduct, which will be in line with the guidance provided in the WB’s Technical Note “ESF Good Practice Note (GPN) on Assessing and Managing the Risks and Impacts of the Use of Security Personnel”. Any allegations of unlawful or abusive acts of any military/security personnel in connection with the project will be processed through the Project’s GRM and will be reviewed, acted (or May 30, 2023 Page 12 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) request appropriate parties to take action) to prevent recurrence and, where necessary, report unlawful and abusive acts to the relevant authorities. The ESMF will also include life & fire safety considerations for facilities accesible to the public that are expected to be intervened with support from the AF (health centers, laboratories, cold-chain warehouses, and vaccination sites). These considerations will be consistent with the guidelines stated in the Bank’s Tip Sheet on “Implementations of the Bank’s Life and Fire Safety Requirements for Building Accessible to the Public.” ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS5 is not relevant at this stage. The project does not expect to require land acquisition or resettlement and no potential risks and/or impacts relevant to ESS5 have been identified. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources ESS6 is not relevant at this stage. The activities that will be financed by this Project do not imply the direct use of ecosystem services, and will be developed in urban or rural environments already modified where it is not considered that they may represent any impact on biodiversity or natural resources. The proper management of waste that could be generated and that could represent some degree of adverse impact on the natural environment, is addressed in ESS1 and ESS3. Public Disclosure ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is relevant. Due to the national scale of intervention of the AF, Indigenous People and Afro-Hondurans (IPAH) who meet the criteria of ESS7 to be identified as IPs, are expected to be present in the Project’s area of influence. This includes Maya Chorti, Lenca, Miskitu, Nahuas, Pech, Tawahka, Tolupán, and Garífunas peoples. Afro-Hondurans that do not fit the criteria described in ESS7 have been considered as part of ESS1 in the ESMF, and will be considered in risk assessments and mitigation measures established in other relevant documents including ESMPs, SEP, and LMP. The draft ESMF prepared for the parent Prject has been updated during AF preparation to include the expanded scope under Component 1 for immunization activities, the identification of IPAHs that meet ESS7 criteria and that are present nation-wide, identification of specific risks and impacts for IPAHs as well as proposed mitigation measures. During preparation of the AF, SESAL carried out a robust consultations process with IPAHs covering both, the parent Project as well as AF activities. Consultations included representatives from eight of the nine IPAHs, including Negros de Habla Inglesa, Chortí, Garífuna, Lenca, Misquito, Pech, Tawahka, Tolupanes Peoples. The Project’s SEP and draft ESMF were updated to include consultation outcomes, which included the identification and confirmation of potential risks and impacts from project activities (parent Project and AF) to IPAHs. Such risks include discriminatory treatment in healthcare facilities, lack of culturally adapted protocols for treatment of IPAH womenthat consider health cultural norms, exclusion of IPAH children from vaccination campaigns, particularly of those in remote locations, and lack of adaptation of communication and public health campaigns to consider cultural health aspects and language. Participants also emphasized the significant access barriers IPAHs face when it comes to health services and how these should be addressed by Project-financed activities to reduce exclusion of vulnerable groups to May 30, 2023 Page 13 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) access vaccination and other sexual and reproductive services. Consultations also served to confirm and identify new mitigation measures for these risks, which have been included in the updated draft ESMF and will be further developed in IPAH specific instruments. SESAL will prepare a standalone Indigenous and Afro-Honduran Peoples Planning Framework (IAHPPF) to be consulted, disclosed and adopted within 60 days of the Effective Date, which will include the expanded scope of immunization activities and will be informed by consultations held during preparation of the AF. The IAHPPF will include a full analysis of risks and impacts, detailed budget and commitments with relevant communities and strategies tailored for IPAHs, as well as feedback obtained from initial consultations, and clear institutional responsibilities for engagement. The IAHPPF will outline general principles consistent with ESS7, including the need to respect IPs traditions, health approaches and livelihood practices while at the same time allowing them to access the benefits provided through this project. The IAHPPF will set out the common principles, objectives and inclusion strategies for the Project, existing legal frameworks and historical background of engagement. The IAHPPF will also specify the circumstances in which Free, Prior, and Informed Consent would be needed, if relevant. Risks to be assessed and, as necessary, mitigated, include exclusion from consultation processes, lack of culturally appropriate communication, potential misinformation, discrimination in labor, discrimination and exclusion from accessing project benefits, susceptibility to SEA/SH risks, and others. During project preparation IPAHs’ degree of involvement as beneficiaries of program incentives and supporting activities will be assessed, and also as influenced stakeholders through the implementation of activities. Site-specific or activity-specific Indigenous Peoples Plans (IPPs) will be prepared as necessary. The criteria to prepare IPPs as well as the content of IPPs will be set forth in the IAHPPF. Public Disclosure The IAHPPF will outline and inform how to: (i) improve targeting of IPAHs, including IPAHs children for immunization activities, particularly those in areas of difficult access, (ii) support communication and outreach challenges due to geography, culture, and at times, language, (iii) ensure that access to health services is provided in a culturally adapted manner and that necessary institutional strengthening of the PIU at the various levels is done, and (iv) strengthen grievance redress mechanisms tailored to IPAHs’ customs. The project presents opportunities for inclusion of IPAHs and other vulnerable groups and opportunities to design culturally appropriate activities in ways that are deliberately inclusive should be highlighted. The Project’s ESF instruments will be consulted with representative IPAH groups and communities, in a culturally- sensitive manner, taking into account potential COVID-19 health protections, with IPAH communities and/or their representatives, as appropriate, to ensure communities’ broad support to the Project. Feedback will be integrated into the instruments. The instruments will be disclosed, online and through other channels accessible to potentially affected communities. ESS8 Cultural Heritage ESS8 is not relevant at this stage. AF activities will not have adverse impact on tangible or intangible cultural heritage. However, some of the project beneficiaries will be IPAHs who might maintain distinct cultural health practices. Health providers should recognize these traditional methods when working with IPAH communities in health-related matters, which includes recognition of their own traditional governance structures and traditional medicine agents. May 30, 2023 Page 14 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) The AF will ensure these customs are taken into consideration when communicating with and treating these communities and will be considered in the SEP, ESMF and IAHPPF as relevant. ESS9 Financial Intermediaries This standard is not relevant. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No 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: Public Disclosure None. IV. CONTACT POINTS World Bank Contact: Courtney Price Ivins Title: Health Specialist Telephone No: +1-202-458-7724 Email: civins@worldbank.org Contact: Nicolas Antoine Robert Collin Dit De Title: Senior Economist Montesson Telephone No: +1-202-458-2120 Email: ncollin@worldbank.org Borrower/Client/Recipient Borrower: Republic of Honduras Implementing Agency(ies) Implementing Agency: Ministry of Health (Secretaria de Salud Honduras) May 30, 2023 Page 15 of 16 The World Bank Additional Financing for Honduras Restoring Essential Services for Health and Advancing Preparedness for Emergencies Project (P180475) 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): Nicolas Antoine Robert Collin Dit De Montesson, Courtney Price Ivins Practice Manager Maria Gonzalez de Asis Cleared on 23-May-2023 at 20:24:52 EDT (ENR/Social) Marco Antonio Zambrano Chavez (SAESSA) Concurred on 30-May-2023 at 13:52:13 Safeguards Advisor ESSA EDT Public Disclosure May 30, 2023 Page 16 of 16