The World Bank Health System Strengthening Project (P175170) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 05/22/2022 | Report No: ESRSA02225 May 23, 2022 Page 1 of 21 The World Bank Health System Strengthening Project (P175170) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Tuvalu EAST ASIA AND PACIFIC P175170 Project Name Health System Strengthening Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 5/9/2022 6/29/2022 Population Financing Borrower(s) Implementing Agency(ies) Ministry of Finance and Ministry of Health, Social Economic Development Welfare and Gender Affairs Proposed Development Objective The Project Development Objectives (PDOs) are to improve delivery of select health services, strengthen health Public Disclosure management systems, and in case of an Eligible Crisis or Emergency, respond promptly and effectively to it. Financing (in USD Million) Amount Total Project Cost 15.00 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 C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The Tuvalu National Health Strategic Plan for 2020-2024 (NHSP) provides a point of departure to identify priority interventions, new development activities, and programs for the Tuvalu Health System Strengthening Project (HSSP). Development of the Project and its implementation will be aligned, coordinated, and planned in conjunction with engaged bilateral partners such as New Zealand and Australia, regional entities such as Secretariat of the Pacific Community (SPC), Asian Development Bank (ADB), and key technical partners, including World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF). May 23, 2022 Page 2 of 21 The World Bank Health System Strengthening Project (P175170) Component 1: Improve the Availability of Essential Public Health and Health Care Services Provided at Princess Margaret Hospital (US$9.92 million equivalent) Subcomponent 1a: Increase the Physical Capacity of the Princess Margaret Hospital (US$9.10 million equivalent). The intent of this subcomponent is to support an increase in the service capacity of PMH through the construction of a new building or wing of the hospital. The enhanced service capacity includes both clinical and public health functions. The clinical capacities include diagnostic services (notably radiology and laboratory), emergency/urgent care, basic surgical operations and post-operative recovery, intensive care, TB inpatient ward, mental health, and rehabilitation. The public health capacities will include an expansion of the laboratory’s environmental health testing capacity and expansion of the central medical store which provides warehousing capacity to centrally manage the pharmaceuticals and medical supplies. An emphasis will be placed on improving the patient experience through an integrated approach to providing health promotion, detection, and management of NCDs as well as integration of social service counselling (for GBV and other social needs) at the location of the hospital. The subcomponent activities include: (a) conducting a more detailed needs assessment to define the specific services further taking into consideration the current and emergent health needs of the population, the service requirements (human resources, equipment, space) as well as assessing the viability for providing these services in-country given the human resources options (in- country, visiting or teleconsultation), financial costs of in-country service versus overseas medical referrals and ensuring minimum standards of quality. (b) following agreement on the service description, hospital design and engineering technical assistance will be Public Disclosure provided for: (i) detailing the functional layout and physical requirements of the facility, including all necessary requirements for ensuring that the facility adapts to the local hazards, changing climatic conditions and energy efficiency; (ii) detailed review of the planned location and site specific plans for mitigation against environmental and social (E&S) impacts as specified in the requirements for environment and social standards; (iii) a procurement and contracting strategy ; and (iv) technical support to the procurement for the detailed architectural design, construction and supervision phases of the Project. (c) with the functional plan and environmental assessments agreed and in accordance with the agreed procurement and contracting strategy, hospital design and construction would include: (a) a detailed architectural design; (b) any demolition works and construction of a new hospital wing on the territory of the PMH complex, including the design characteristics for energy efficiency and resilience to significant weather and climate change events; and (c) purchase of related medical equipment (including digital to enhance teleconsultation capacity), information or communication technology equipment, furniture, and related supplies. (d) to support the functioning of the national public health laboratory and support the medical waste management (MWM) collection and disposal systems, two field vehicles for specimen collection and outreach services and a vehicle for medical waste collection (at Port, at PMH, Funafuti Island) will be supported. Eligible expenditures to support the above-described activities include technical assistance, works, medical equipment (including radiological equipment), reagents, and medical supplies, furniture, information communication technology equipment and other related goods, and vehicles. Subcomponent 1b: Increase the Human Resource Capacity of the Princess Margaret Hospital (US$0.81 million equivalent). The intent of this subcomponent is to support an increase in the service capacity of PMH by investing in different means of expanding its human resource capacity. May 23, 2022 Page 3 of 21 The World Bank Health System Strengthening Project (P175170) The subcomponent activities include: (a) the design and then implementation of a human resource development strategy on the basis of the service expansion plan of PMH. The plan will review options for (i) expanding telemedicine consultations with an international provider; (ii) contracting of international medical providers for specific periods of in-country service; (iii) upgrading of Tuvalu’s general practitioners with specialists skills; (iv) organizing short visits of international medical teams for services in Tuvalu; and (v) providing short-term training of the health and auxiliary staff including in IPC and MWM, GBV detection, treatment and referral, and other areas as the needs arise. (b) as a basis for the training in IPC and MWM, technical assistance to assess the current system, standard operating procedures, capacities of human resources and gaps against the MoH’s National IPC Policy and Guidelines to define the specifics of the training and any other support to be provided. (c) to inform the telemedicine approach, technical assistance to assess the context that would allow for making full use of telemedicine including legal environment (i.e., clarifying medical liability), assess the market for provision and contracting models, and the organization requirements for integrating the teleconsultation into the PMH clinical services. Eligible expenditures to support the above-described activities include technical assistance, training fees and related costs, travel, accommodation, contracting of health providers for in-country consultation and contracting for telemedicine consultations. Component 2: Strengthen the Delivery of Primary Health Care and Primary Prevention, with a Focus on Non- Public Disclosure Communicable Diseases (US$3.02 million equivalent) Subcomponent 2a: Improve the Delivery of Essential Primary Health Care Services at the Health Clinics, with a Focus on NCD Services (US$2.35 million equivalent). The intent of this subcomponent is to support a more comprehensive and systematic approach to early detection and routine management of NCDs, as well as ensure the readiness of the 11 health clinics to provide comprehensive PHC. The subcomponent activities include: (a) the design and implementation of an integrated screening program of the adult population (i.e., over the age of 30), including for diagnosis and risk stratification for NCDs, particularly for hypertension and diabetes on the basis of national protocols. In order to raise demand for screening, the screening program would include support community awareness raising and outreach activities. (b) adaptation and rollout of a simplified digital patient record that can be used from the point of screening, risk identification (or stratification), to the management of NCDs which could be viewed by the health clinic nurse or PMH doctor. (c) maintaining service capacity of the 11 health clinics to ensure their readiness in providing all essential PHC services through regular monitoring and addressing gaps that arise. To monitor the readiness on a regular basis, a digital system and dashboard will be supported that will routinely measure and identify gaps in service capacity at the health clinics to provide NCD and other essential PHC services, including disaster response. Maintaining updated information on service capacity will be used to inform the regular reviews and supervision visits. When gaps are identified in service capacity, the subcomponent will support addressing those gaps through training of health staff, provision of minor medical equipment and related supplies. May 23, 2022 Page 4 of 21 The World Bank Health System Strengthening Project (P175170) (d) as a foundation for improved service delivery quality, the subcomponent will support a needs assessment and following that assessment an upgrade of the water, sanitation, and hand-hygiene facilities in selective (about 5) outer island health clinics i.e., through improving and expanding the rain-water collection and storage facilities, functioning hand-washing stations with appropriate soaps, and functioning and environmentally appropriate latrines for men, women, and disabled access. Eligible expenditures to support the above-described activities include technical assistance and training; production of media materials for raising awareness; workshops; in-country transportation; medical equipment and supplies including point of care diagnostic technologies; and minor works. Subcomponent 2b: Strengthen Public Health Approaches to Primary Prevention and Behavior Change (US$0.67 million equivalent). The intent of this subcomponent is to strengthen the population-based approaches to primary prevention and behavior change in response to the defined priorities of NCDs and GBV. The subcomponent activities include: (a) support for activities that would further progress against the MANA Framework (see Annex 2). These activities would include technical assistance and workshops to reviews and to support the update of policies and regulatory frameworks; training or workshops to improve monitoring or enforcement of policies and regulatory frameworks; workshop coordination with other agencies/organizations; population-based health promotion through communications, community events, and minor equipment. While the direct objective of these activities is to support progress for NCD prevention, the intended effect is also to build the capacity of the Public Health Department for Public Disclosure strategic public health programming and behavior change communication. (b) in support of GBV victims, support provided for (i) development and implementation of integrated training approach of first responders (including police and health workers) for recognizing the signs, sensitive interviewing, and referrals; (ii) support for the certification training of social service counselors; (iii) minor repair and improvement of the shelter house that is used for temporary housing of GBV victims, to ensure its security and comfort as a place of refuge; and (iv) in-kind support kits or baskets to the relocated GBV victims. Eligible expenditures to support the above-described activities include technical assistance, training, workshops, equipment, and repair and cosmetic improvement of the house providing a temporary shelter for GBV victims and their children. Component 3: Supporting the Development of Management Systems (approximately US$ 2.07 million) Subcomponent 3a: Strengthen Management Systems for Better Service Delivery (US$0.62 million equivalent). This subcomponent will strengthen core health management systems. 40. The subcomponent activities include (a) developing a prioritized and costed facility maintenance and repair plan and establishing an asset management system that will identify the life cycle, repair, and maintenance schedule for health assets. As part of the maintenance plan, options will be evaluated for sustained maintenance, assessing both in-country support for minor maintenance, and contracting of maintenance and repair service providers. (b) an assessment of the PMH HMIS in order to lay out options for having a more functional and easier to use system that will also allow for exchange of information with other health information systems. The assessment will May 23, 2022 Page 5 of 21 The World Bank Health System Strengthening Project (P175170) look at both the option of adapting the current system; defining the changes that will need to be made; and the option of entirely replacing the current system. Implementing solutions will fall outside the scope of the Project, but any minor investments in hardware, local area network connections, or similar, that may improve the use of the existing system may be supported by the Project. (c) the development of a Public Feedback System for the health system with standard operating procedures for receiving feedback, comments, responding to the feedback provider, and analyzing feedback for informing the future directions of the health system. Eligible expenditures to support the above-described activities include technical assistance, training, and minor information technology equipment. Subcomponent 3b: Project Management, Monitoring and Technical Support (US$1.45 million equivalent). This component will support the necessary full-time consultant team that will constitute the Project Management Unit (PMU) to support the MoH in its responsibilities as the Implementing Agency of the Project; short-term technical assistance in areas of Project management as may be required, such as part-time consultants in specific areas to comply with the E&S standards; the cost of equipping and furnishing a Project office; and incremental operating costs in support of Project management, including travel related costs associated with Project management. Component 4: Contingent Emergency Response Component (CERC) (US$0.0 million equivalent). The component will support a rapid response and urgent assistance in respect of an event that has caused, or is likely to imminently cause, a major adverse economic and/or social impact to Tuvalu associated with a natural or man-made crisis or Public Disclosure disaster. In the event of an emergency, financial support could be mobilized by reallocation of funds from other components to support expenditures on a positive list of goods and/or specific works and services required for emergency recovery. A CERC operational manual, governing implementation arrangements for this component, would be prepared with financing from this Project. 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 Republic of Tuvalu lies in the western South Pacific Ocean and has a total ocean area of 900,000km2 with a land area of approximately 26km2 and maximum height of land above mean sea level typically ranges from 3.0m to 4.0 m. The mean rainfall ranges from 2,300mm to 3,700mm annually and there are no rivers. Rain catchment and wells provide the only fresh water. The estimated population of Tuvalu in 2020 was 11,792. Funafuti atoll, where the national capital is located, is home to about half of the population. The islands consist of five coralline atolls (Nanumea, Nui, Nukufetau, Funafuti, Nukulaelae), and three table reef islands (Nanumaga, Niutao, Niulakita) with one composite (coralline atoll/ table reef) island (Vaitupu). The Preliminary Environmental and Social Management Plan (Preliminary ESMP) notes several serious climatological and environmental hazards in Tuvalu including: coastal erosion, coastal flooding, deteriorating quality of groundwater especially during drought, cyclone and tsunamis, land degradation and illegal dumping of solid waste. Social issues observed include gender-based violence. Over a third of Tuvalu women reportedly has experienced physical violence during their lifetime with 25% having experienced physical violence in the previous 12 months and 8% during pregnancy. Most women reporting physical violence said that a current husband or intimate partner had been violent towards them (90%), with a small number reporting violence by a sibling (8%). May 23, 2022 Page 6 of 21 The World Bank Health System Strengthening Project (P175170) Along with changing subsistence economies and lifestyles, consumption of store-bought food has been increasing for decades. The Preliminary ESMP observes that the indigenous terrestrial flora of Tuvalu is very poor, highly disturbed, and now numerically dominated by introduced exotic species. The ESMP notes that Pulaka (swamp taro), a Tuvaluan staple, is grown in pits which have suffered from saltwater intrusion making the pits in many instances unfit for further cultivation. In some places, three-quarters of the plants have died, leaving people reliant on imported foods. The ESMP notes that salt-water intrusion has already affected communal crop gardens on six of Tuvalu's eight islands. In terms of fisheries, the ESMP notes that while there is substantial diversity in Tuvaluan inshore and offshore fisheries, almost all species have been overfished or are in declining numbers. In addition, the increasing ratio of the national population living in Funafuti, away from traditionl sources of subsistence food, also exacerbates the national food security and community health issues. Corresponding to this increasingly compromised food security and quality, the rate of non-communicable diseases (NCDs) has been steadily increasing with consequent pressure on the health system from chronic disease. The lack of connectivity and suitability of public health systems to screen, monitor and manage these illnesses results in a higher stress on acute care. The E&S Audit undertaken during preparation highlighted that around half of the conditions reported by clinics as common presentations relate to NCDs, e.g. including diabetes, hypertension, chronic disease, and NCD general. The Preliminary ESMP notes that the top 3 causes of death in Tuvalu are NCDs, namely ischemic heart disease, stroke, and diabetes. It similarly notes that six of the top 10 risk factors for disease and disability are related to NCDs and/or poor diet, namely High fasting plasma glucose (a diagnosis for diabetes), high body-mass index, high blood pressure, dietary risks, high LDL (cholesterol), and kidney dysfunction. Tuvalu has one hospital on the main island of Funafuti, PMH, two health clinics, one south and the other north of Funafuti and eight health centers covering outer islands. Many of these centers, while not particularly old, are Public Disclosure exhibiting wear and tear due to limited maintenance and need improvements as a result of the challenging climatic environment. These facilities are small in scale and staffed by nurses who mainly provide primary care and preventive services. At present, all doctors in Tuvalu are based at PMH, but also provide community outreach services to the nine outer island medical centers. The outer island health centers are expected to be staffed by a midwife, a registered nurse, a nurse aide, and an environmental health officer but this varies between islands due to staff capacity and shortages. Staff shortages, both nursing (in 2018, 15 of the 72 MoH nursing positions were vacant) and medical (of the 11 approved doctor position in 2018, 8 were training overseas) present a challenge in ensuring quality and equitable care is available to residents throughout Tuvalu. Most of the medical officers are general practitioners and eight of the current established number of doctors are currently training overseas in the specialty fields of anaesthetics, surgery, paediatrics, emergency medicine and obstetrics and gynaecology. Patients needing advanced clinic care that exceed the hospital level are required to travel overseas hospitals through the Tuvalu Medical Treatment Scheme. PMH has 50 beds with separate wards for men, women and infants. It offers basic routine medical, surgical, obstetric and gynecologic services and there is an Intensive Care Unit, a surgery room and nurses' station. PMH provides accident and emergency services. PMH also provides accident and emergency services. The hospital has established a specialist department to study and manage climate change-related illnesses, such as dengue and food-born illnesses. Funafuti is a densely populated urban environment which is also serviced by two health clinics, one south and the other north of Funafuti, providing primary clinical services. There are also NGOs such as the Tuvalu Red Cross Society, Fusi Alofa (for the care and rehabilitation of disabled children), the Tuvalu Family Health Association (providing sexual and reproductive health, and GBV counselling services) and the Tuvalu Diabetics Association all have offices in Funafuti. The Preliminary ESMP highlights that the services for the collection of solid waste are inadequate. Garbage collection is irregular and is often interrupted by mechanical problems with the rubbish collection trucks, resulting in solid waste not being collected for an extended period. The Solid Waste Authority of Tuvalu (SWAT) maintains large, communal May 23, 2022 Page 7 of 21 The World Bank Health System Strengthening Project (P175170) waste bins at selected sites around Funafuti, along the main roads, and outside all community meeting halls for people to dispose of wastes. However, illegal dumping and burning of waste are commonly practiced. In many households, waste is disposed of in the ocean, or in abandoned borrow pits. Furthermore, MoH is responsible for the management of health care waste. The main source of health care waste is the PMH as the sole hospital in the country. PMH has its own internal health care waste management system which uses a wood-fired incinerator located at the landfill. The existing system has a lot of issues. Segregation of waste is poor with large volumes of general wastes deposited into the healthcare waste stream. Waste is stored in an unsecured open area prior to collection, there are no signages, there is no training program in place for workers, management and for waste handlers, PPEs are absent or inadequate and collection and incineration are not supervised. Healthcare wastes at the outer island clinics are usually collected twice a week and incinerated. Tuvalu is currently COVID-19 free as most of the commercial flights to and from Tuvalu have been suspended, but several small repatriation flights have operated in recent months. COVID-19 testing is available at PMH. Project investments will focus on i) strengthening the capacity of core public health programs (including the design and establishment of a public health lab in the PMH, design and implementation of a health screening process for the adult population and the procurement of equipment such as laboratory equipment and reagents and vehicles as well as associated capacity building; ii) improved management of NCDs in the community and outer island clinics (including technical assistance (TA) activities and the procurement of point of care diagnostic technologies and ICT equipment); iii) strengthen infection prevention and control and medical waste management (including TA activities, the upgrade of water, sanitation and hand-hygiene facilities in the outer island clinics, small infrastructure and a waste transport Public Disclosure vehicle for use on Funafuti island; iv) strengthening information management for better service delivery (including TA activities and the procurement of ICT equipment and software); v) strengthen the health planning, budgeting and implementation (including TA activities, surveys and meetings); and vi) a CERC that will be activated in the case of an event that has caused, or is likely to imminently cause, a major adverse economic and/or social impact to Tuvalu associated with a natural or man-made crisis or disaster such as a cyclone or pandemic. Civil and construction works will be completed on previously disturbed land of low biodiversity value and the Project will coordinate activities with other organizations such as the ADB, UNICEF, Taiwan, SPC and WHO who are supporting IPC and MWM projects in the area such as the installation of an incinerator and strengthening of IPC policies and guidelines. D. 2. Borrower’s Institutional Capacity The Ministry of Finance and Economic Development (MFED) will be the excuting agency and have established the Central Project Management Office (CPMO) which is staffed with international and national consultants who are experts in project management, procurement, financial management, environment and social risk management, and monitoring and evaluation. The MoH will be the implementing agency and will establish a Project Management Unit (PMU) who will lead the day to day implementation of the project supported by the CPMO. Implementation responsibility within the MoH rests with the CEO of Health with support from technical departments, particularly the Director of Health. Given his direct role in the administration of the sector, the Director of Health will be the Project Coordinator and given responsibility for day-to-day oversight. It is also recognized that the capacity at the MoH would be stretched given its routine management functions and project responsibilities. The MoH has not had any previous experience directly executing a World Bank financed project or any other similar multi-lateral agency development projects, though there has been some experience in providing technical input to the execution of the COVID-triggered CERC. Based on lessons learned from the CERC, the May 23, 2022 Page 8 of 21 The World Bank Health System Strengthening Project (P175170) MoH has been responsive to Environmental and Social risk management requirements, however, due to low staff numbers and capacity, in-country resources are stretched and there have been significant delays in responding to project requirements, including inputs into safeguards instruments. Alongside this however, the MoH have participated in a regionally implemented project funded by the ADB related to COVID-19 vaccines, and their technical capacity in health is enhanced through a technical adviser supported by the Australian Department of Foreign Affairs and Trade on national strategy implementation and reports to the CEO. In light of the above, the CPMO’s project management leadership and support is proposed, with PMU responsible for liaising with the CPMO in implementing the project. The CPMO and PMU would also be responsible for working with the Public Works Department (PWD) of the Ministry of Public Works, Infrastructure, Environment, Labor, Meteorology, and Disaster (MPWIELMD). The CPMO under MFED is a new unit but has built capacity quickly in ESF risk management and will be providing technical support and oversight to the ESMP implementation, who has Environmental and Social Management Experts which are also supporting other World Bank Projects. An international E&S Specialist has been engaged to develop the E&S instruments during project preparation with support from the CPMO. The Project, via the PMU, will be required to recruit a national E&S Specialist for implementation to ensure that project activities are completed in compliance with the ESF, good international industry practice (GIIP) and national legislation. The incoming E&S Specialist will also be required to complete a capacity needs assessment and required training on E&S risk management compliance. Public Disclosure During the project preparation, an initial assessment of the capacity of the implementing agencies was completed (with the outcomes summarised above) and included in the ESMP. More detailed recommendations on training and capacity building needs will be made in the final ESMP to be prepared during implementation once the national E&S officer is in place. The initial areas of capacity strengthening for ESF implementation have been identified, including detailed briefings on the ESMP and familiarisation with the ESF by CPMO specialists. Further actions to build capacity have been agreed in the Environmental and Social Commitment Plan (ESCP). These will be based on assessments in the course of preparing the final ESMP and associated recommendations. The final ESMP is expected to be able to be prepared at the feasibility analysis phase of capital works when designs are known. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate Environmental Risk Rating Moderate The Project aims to deliver significant environmental benefits through the financing of MWM and infection prevention and control (IPC) improvements. The environmental risk rating for the project has been assessed to be ‘Moderate’ since the hospital and health care facilities operations are small scale whereas the environmental risks and impacts are not expected to be significant and will be easily mitigated in a predictable manner through the implementation of the Project’s E&S instruments. Various project activities such as equipping of the PMH and modernization of laboratory and radiology diagnostic services result in the downstream production of healthcare waste such as liquid contaminated waste (e.g. blood, other body fluids, and contaminated fluid), infected materials (water used, lab solutions and reagents, syringes, bedsheets, etc.), radioactive waste and expired pharmaceuticals. May 23, 2022 Page 9 of 21 The World Bank Health System Strengthening Project (P175170) The ESMP has noted that medical waste is hazardous and has the potential to be infectious to humans, or cause injury and may contaminate the environment (land, groundwater, watercourses, and lagoon/ocean environments). MWM is challenging in small atoll environments however, this is somewhat mitigated by the relatively small volumes that will be produced by a population of fewer than 12,000 people and ongoing infrastructure investments (e.g. MWM incinerator for Funafuti) and TA activities (e.g. training and the development of IPC policies and procedures) that are being supported by partners such as the ADB, UNICEF, Taiwan, SPC, and WHO. Some equipment procured by the Project will also have associated occupational and community safety risks requiring specific training and procedures. Project activities will result in resource consumption during the renovation of the left-wing PMH and minor construction/renovation works in the outer island health clinics. Examples include the use of construction materials, aggregates, water, and, energy. The ESMP has identified potential risks and impacts associated with demolition, renovation, construction, and equipping/furnishing activities including increased dust and noise, sedimentation, minor hydrocarbon spills, and waste disposal (potentially including hazardous materials such as asbestos and e- waste), and occupational health and safety risks. Operational risks and impacts, particularly for the PMH, relate to ongoing waste generation (general, healthcare, pharmaceutical, etc.), greywater and sewage management, and the equipping/furnishing of the PMH and other health facilities which will generate e-waste. While the ESMP identifies several risks in ESS2, 3, and 4 risks related to OHS, environmental contamination from healthcare waste and infrastructure failure risk from coastal flooding and/or cyclone events are rated as moderate, these are known, temporary, and/or have management measures that are predictable and likely to be effective. As noted in the Preliminary ESMP the implementation of the project will cause downstream risks and impacts such as inter-island travel and worker and community health and safety and waste disposal when working in remote locations. The E&S instruments identified and developed under the ESMP include Stakeholder Engagement Plan (SEP), Code of Good Public Disclosure Labor-Management Practice (LMP), Code of Social and Environmental Practice for Contractors (COSEP-C), Infection Prevention and Control Plan (IPCP), Waste Management Guidelines (WMG) and UXO Protocol. The design considerations shall undertake further planning and detailed design which will be undertaken by the Project Development Team at the inception of the project. Social Risk Rating Moderate The Project aims to deliver a range of social benefits in the form of improved medical services and facilities including in remote and vulnerable outer islands communities. This will benefit all citizens of the country through improved access to healthcare, facilities, diagnostic and treatment equipment and drugs supply. There are generally low to moderate level risks related to construction phase and labor influx and SEA/SH risks, along with equity in access to Project benefits. The implementing agency is new to the Worlds Bank’s ESF and has limited exposure to environment and social risk management but an E&S specialist has been engaged. The project includes the procurement of materials and equipment and providing associated training. The ESMP has assessed that there are human health risks to workers and community that may result from misuse of, poor quality, and/or poorly managed medical equipment, materials and services arising from potential constrained ability to use the equipment and materials. The ESMP has assessed that there is a potential social risk related to equity in access for marginalized, vulnerable or remote social groups to health screening services, and/or that screening programs are not administered in accordance with good international industry practice (GIIP). The Project is has been assessed to have low labor influx risks for construction works for the new wing of the PMH and outer island health center upgrades. Tuvalu has high background rates of Gender-based Violence and SEA/SH. The project’s SEA/SH rating is has been reassessed during preparation and remains ‘low’ for civil works due to a moderate scale of construction activities, limited labor influx in Funafuti, and location of civil works in an urban area in the instance of the new wing of the PMH, and small scale and limited labor influx for the outer island health center upgrades. The Project’s Preliminary ESMP has assessed SEA/SH risks and May 23, 2022 Page 10 of 21 The World Bank Health System Strengthening Project (P175170) proposed appropriate mitigation measures. The Environmental and Social Commitment Plan (ESCP) commits the MoHSWGA to the implementation of a Code of Conduct for MoHSWGA staff and contracted workers including provisions for SEA/SH prevention e.g. via training curricula and Standards Operating Procedures for identification and services referral. While there are functional GBV & SEA/SH services operating in Funafuti (the Tuvalu Family Health Association), the Preliminary ESMP has assessed that the the availability and capacity of outer island services is low. Resettlement impacts are assessed to be unlikely, but will be managed through preparation of resettlement plans, if necessary during the project implementation. Based on the risk assessment in the Preliminary ESMP the overall social risk for the project is rated as “Moderate”. 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 Project will result in positive E&S impacts as it seeks to strengthen Tuvalu's health system including investments into IPC and MWM improvements (e.g. the upgrade of sanitation facilities in outer island clinics, review, and update of procedures, capacity building, and the procurement of a waste transport vehicle). The Preliminary ESMP has assessed that Project activities present E&S and health and safety (H&S) risks for the project workforce, healthcare workers, communities, patients, and the environment. The project is not expected to involve any land acquisition or involuntary resettlement and works will be completed on previously disturbed land. No large-scale labor influx is Public Disclosure expected in sensitive receiving environments. Key E&S impacts and risks of the Project that the Preliminary ESMP has assessed include construction phase and labor influx and SEA/SH risks, equity in access to project benefits, human health risks from misuse of, poor quality, and/or poorly managed medical equipment, materials and services, the generation of medical waste and impacts from demolition and construction activities (e.g. dust and noise generation and occupational and community health and safety). Several construction phase occupational health and safety impacts are individually rated as moderate, the activities are comparatively small in scale and complexity, impacts are generally known, low in magnitude and site-specific, temporary, and reversible in nature with management measures that are predictable and likely to be effective. These do not change the overall risk rating of the project as moderate. Operational risks relate to equitable access, waste management, and occupational and community H&S. The Preliminary ESMP sets out the procedures for MoH to manage E&S risks and impacts associated with proposed Project activities in a manner that is proportionate to their significance, and which utilizes a mitigation hierarchy approach during Project preparation. The following instruments have been prepared to manage identified risks: A preliminary project-wide ESMP assesses the risks and impacts associated with the project activities and sets out appropriate mitigation measures. As far as possible without the completion of detailed designs, the Preliminary ESMP identifies project activities, sites, surrounding areas, environments, and people affected by the Project, assesses the risks and impacts, identifies the measures to eliminate or offset adverse E&S impacts, or to reduce them to acceptable levels and the actions needed to implement these measures. It identifies further investigations required for specific impacts and management measures to be undertaken when preparing a Comprehensive Project-wide May 23, 2022 Page 11 of 21 The World Bank Health System Strengthening Project (P175170) ESMP during implementation. These primarily relate to the preparation of detailed engineering plans for the new wing of the PMH and outer island clinic upgrades. The Preliminary ESMP has included: an assessment of the borrower’s capacity to manage E&S risks and impacts; E&S baseline information on Tuvalu and project description, an environmental and social audit of specific project locations on outer islands; key E&S vulnerabilities relevant to the project activities; an assessment of the most appropriate sources for energy, water and construction materials as well as mitigation measures to minimize the consumption of these resources; and identification of specific management plans to be prepared during implementation and integrated into the Project’s final ESMP including, but not limited to: an infection prevention and waste management guideline (IPC&WMG), and a framework for the assessment of climate risk for the new wing of the PMH and outer island health center upgrades. Construction activities are all planned to be undertaken on Government-owned or leased land. A final ESMP will detail all site-specific impacts and measures on completion of detailed engineering designs and prior to the commencement of any works, and include site-specific annexures for key activities, including, but not limited to the new wing of the PMH. The IPC&WMG and final ESMP will include emergency preparedness and response components for medical hazards. All requirements for the Preliminary and final ESMP will be determined in accordance with ESS #1, and will include resettlement plans, in the unlikely event these are required. A CERC-specific addendum to the ESMP will be prepared, disclosed, consulted, and adopted prior to CERC activation, based on indicative activities and using the existing CERC ESMP for COVID-19 emergency response which was prepared under the MICRO project as a reference document. A CERC Operations Manual (including eligible CERC activities) will be prepared, disclosed, consulted, and adopted by the Borrower by the project effectiveness or before activating the CERC component. Public Disclosure An E&S audit of outer island clinics has been completed during project preparation to determine the nature and extent of E&S areas of concern and to inform the development of appropriate mitigation measures and actions. The E&S Audit has provided data on the size and configuration of outer island clinics, types of services (water, electricity, waste management), available medical equipment, types of staffing and services delivered, most common presentations, surrounding land uses, and curtilage of the clinics including distance to the sea, and any prevailing social or environmental issues. The final ESMP will estimate the cost of the mitigation measures and recommend a schedule for implementation where existing infrastructure is relied upon for project activities (e.g. wastewater discharge for sanitation facilities). The E&S Audit is included in the Preliminary ESMP. The Infection Prevention and Control (IPC) Plan has been developed under the Preliminary ESMP, formulated on WHO guidelines, that addresses threats of infection from COVID-19, the vector-borne diseases which are prevalent in the pacific islands (i.e., Dengue, Zika, and Chikungunya) and STDs, noting that the preventive measures for COVID are also effective in preventing transmission of other infectious respiratory diseases such as Tuberculosis. A Waste Management Guideline has been developed under the Preliminary ESMP that contains high-level requirements, based on WHO guidance and other GIIP, for the safe operation of health facilities and associated activities and informs the development of operational management plans. The guideline includes detailed procedures for the management of e-waste, construction waste, healthcare waste, radioactive waste, expired pharmaceutical supplies including an assessment of suitable waste management options and the procedures for waste management and disposal. May 23, 2022 Page 12 of 21 The World Bank Health System Strengthening Project (P175170) UXO procedure has also been developed under the Preliminary ESMP, requiring the contractor to conduct a survey of the site, before commencing any project-related work and take necessary measures highlighted in the procedure. A Stakeholder Engagement Plan (SEP) has been developed during project preparation to outline a structured approach for community outreach and two-way engagement with stakeholders, in appropriate languages, and adopting measures to include vulnerable and disadvantaged groups (poor, disabled, elderly, isolated communities). The SEP provides a structured approach to achieving meaningful consultation and disclosure of appropriate information. The SEP includes the project Grievance Redress Mechanism (GRM). Measures to minimize the risks of COVID-19 transmission will be adopted in line with national and World Bank standards. Given the COVID-19 situation and related travel restrictions, most of the consultations during preparation were conducted in a virtual manner following the relevant interim technical note on public consultation prepared by the World Bank. A detailed strategy for communication and continued consultation is presented in the SEP for the Project. This will also help address potential issues related to Universal Access to project facilities. TA activities may lead to both E&S benefits (e.g. development of SOPs and capacity building activities) and risks and impacts (e.g. generation of medical waste and IPC risks from the health screening process). TA activities may also be leveraged to help mitigate other project risks and impacts. E&S Specialists will (i) screen TA activities to ensure that they reflect key E&S aspects and risks and mitigation measures including ESF and relevant local legal and good international industry practice (GIIP) requirements in consultancy terms of reference (TOR) and bidding documents, and (ii) review TA outputs to ensure compliance with ESF and relevant local legal and GIIP requirements. World Bank E&S Specialists will review consultancy TORs and outputs to provide a ‘No Objection’ prior to finalization to ensure Public Disclosure compliance with ESF and relevant local legal and GIIP requirements. A requirement for a Contractor's ESMP (C-ESMP) has been included in the Preliminary ESMP, and the Contractor Waste Management Plans (CWMPs) will be prepared by primary contracting companies completing demolition and civil works in compliance with both the final ESMP and local legislation prior to the commencement of demolition or construction activities. The ESCP will require that the GoTv ensures that these plans are developed and approved prior to the commencement of works. As noted in the Preliminary ESMP, site-specific plans for mitigation against environmental and social impact in compliance with the environment and social standards will be developed and implemented for each supported facility and included under Subcomponent 1a. The development of these plans will be completed during project implementation and have been included as a commitment in the ESCP. ESS10 Stakeholder Engagement and Information Disclosure This standard is considered relevant. The main institutional stakeholders are MoH, health clinics and centers at a national and local level, the health services providers (doctors, nurses, etc.) as a collective and as individuals, WHO, UNICEF, SPC, ADB, the PWD, Falekaupule, and Kaupule (The falekaupule on each island in Tuvalu is the traditional governance and decision making structure, kaupule is the administrative/government arm of the Falekaupule), Tuvalu Family Health Association, and key civil-society organizations. Funafuti and outer island communities and families who are the main beneficiaries of May 23, 2022 Page 13 of 21 The World Bank Health System Strengthening Project (P175170) the project are also key stakeholders. Component 1b includes capacity building for public health communications, particularly with respect to the screening components, and based on the outcomes of this activity, the SEP may need to be updated based on target groups identified. These may include (but are not limited to): community-based organizations particularly those for women, media outlets, religious groups, health workers unions, general population receiving the vaccination, communities located close to health facilities; and, vulnerable population (the poor, women, young girls, youth at risks, disables, others,) students, parents, teachers among others. There may be limitations to face-to-face consultation activities due to the COVID-19 pandemics, such as limitations on outer island travel or stay-at-home orders. Stakeholder engagement activities will be implemented in line with National requirements and relevant World Bank guidance. The borrower has prepared the SEP to ensure activities are accessible and culturally appropriate, considering any specific needs of groups that may be differentially or disproportionately affected by the project. The SEP outlines a) who the key stakeholders are; b) how they are to be engaged including methods, tools, techniques, and channels such as key message dissemination through community-based organizations, radio, and social media to address the gathering limitations of the COVID-19 pandemic; c) how often the engagement will occur throughout the project; d) how feedback will be solicited, recorded and monitored over the project; e) who will be charged/responsible with this engagement; f) timeline for this engagement, g) resources for engagement, and so on. The SEP, Preliminary ESMP, ESCP, and LMP have been consulted on (as per the SEP) and will be disclosed within two weeks of appraisal (estimated to be Q1-Q2 2022). The final ESMP will likewise be disclosed within two weeks of completion. The SEP will be updated as relevant throughout implementation. Public Disclosure Particular attention has been given to identifying and providing tailored and culturally sensitive stakeholder engagement opportunities to vulnerable groups, disadvantaged and remote communities. This includes meaningful consultation with remote island communities, community-based organizations, and religious groups. Grievance Redress Mechanisms (GRM) will be set up to address grievances and receive feedback from all stakeholders and beneficiaries in a timely manner and following due process. The GRM will be cognizant of and follow required levels of discretion, and cultural appropriateness, especially when dealing with cases of sexual harassment and GBV. The GRM will be accessible to all stakeholders, especially poor and vulnerable people. Specific worker GRMs relevant to ESS2 will also be set up. 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 considered relevant. Workers likely to be involved in the project include direct and contracted workers. Direct workers will include employees and consultants of the Project Technical Unit (PTU) and the CPMO. Contracted workers will likely include selected private providers and construction workers. Operational health and safety risks, including potential COVID- 19 pandemic risks, will be considered for construction workers for the renovation of PMH and outer island health infrastructure, as well as in relation to the implementation of other project activities. Use of PPE and other safety May 23, 2022 Page 14 of 21 The World Bank Health System Strengthening Project (P175170) measures at the medical facilities (particularly dealing with medical waste) will be included as part of post- construction and operational protocols. An LMP has been prepared during Project preparation which identifies a range of risks including 1. Possible non-observance of basic workers' rights (i.e., clear terms of employment, working hours, and prompt payment of wages), 2. Workers’ organization freedom of assembly and collective bargaining) 3. Possible discrimination in hiring and benefits (i.e., based on gender, religion, or ethnicity) 4. Possible engagement of child and/or forced labor by contractor, and project management. 5. Possible involvement of child labor by suppliers in the production of the embankment and aggregate materials. 6. Risk of Occupational Health and Safety (OSH)- related injuries to construction workers including manual handling slips and falls associated with poor housekeeping and, risk of falls from elevation. In addition, the ESMP identifies several operations phase risks including exposure of healthcare workers to Occupational Health and Safety (OHS) hazards such as infectious wastes, hazardous medical laboratory chemicals/reagents, and wastes. Several construction phase occupational health and safety impacts are individually rated as moderate, the nature and scope of the impacts are generally known, temporary, and have management measures that are predictable and likely to be effective. These do not change the overall risk rating of the project as moderate. In response to these risks, the LMP establishes a series of policies and procedures, and Codes of Conduct to ensure compliance with the ESF. These include policies and procedures for the following: Terms and Conditions of Employment, Equal Opportunity, and Non-discrimination, Hiring of Minors (15-18yrs), Forced Labor Violence in the Workplace, Community Workers, Primary Supply Workers, Occupational Health and Safety and Incident Reporting. The LMP includes Worker Codes of Conduct (including SEAH), Code Of Environmental And Social Practice For Contractors which also manages risks of labor influx and health and safety impacts on communities from construction Public Disclosure activities. Individuals under the age of 15 will be prohibited from working on the Project by national laws and regulations, workers aged 15-17 years will only be permitted to work on light duties. In response to operations phase risks (#7 in the paragraph above), Project Component #1 provides in-service training for technical cadres including the identification of training needs and quality standards to safely use equipment and materials, and Project Component #2 includes technical assistance to integrate long term resources to maintain these systems. The Project will include the development of standard operating procedures and associated training for equipment and infrastructure such as laboratory and water and sanitation facilities including OHS measures during operations. The Component will identify capacity-building activities required to protect project worker safety such as IPC. The LMP will also include procedures for MoH staff involved in outer island travel, for example in providing in-service training for screening program delivery. A Workers Grievance Response Mechanism (GRM) drawing on national laws and regulations and international best practices is described in the LMP. Construction and demolition activities will result in occupational health and safety risks and impacts which are have been included in the Preliminary ESMP along with mitigation measures that have been proposed in accordance with local legislation, the EHS Guidelines, and GIIP. More site and design-specific detail will be included in the final ESMP. Measures relating to OHS, to protect workers from injury, illness, or impacts associated with exposure to hazards encountered in the workplace or while working, are documented in labor-management procedures (LMP). The OHS measures have considered the World Bank Group's General EHS Guidelines and include the provision of infection prevention and control precautions, adequate supplies of PPE, etc. May 23, 2022 Page 15 of 21 The World Bank Health System Strengthening Project (P175170) In addition, the ESCP and final ESMP will require the development of Contractor waste and safety management plans by primary contracting companies. Emergency preparedness and the response have been addressed in the Infection Prevention and Control Plan (IPCP) and the waste management guideline and the emergency response plans have been developed for events such as spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, power outages, and fire in project funded facilities. ESS3 Resource Efficiency and Pollution Prevention and Management This standard is considered relevant. According to Preliminary ESMP, the renovation and rebuild of the left-wing and central medical store at the PMH and the upgrading works in the outer islands will use finite resources such as construction materials, water, and energy. The downstream impact of this plan will include an increase in the demand for construction materials as well as water and energy and this downstream impact will eventually lead to the depletion of non-renewable resources. Downstream activities will also increase the generation of sewerage, solid waste, potentially construction waste. The construction materials such as sand, gravel, and timber are mostly imported from Fiji, being the nearest readily available island. This is also due to the scarcity of materials and the village/ island by-law that does not permit sand Public Disclosure extraction from within islands in Tuvalu. The land and ocean transportation of construction material from sources in Fiji or the desired supplier to Funafuti and to the outer islands also have downstream impacts as dust pollution, noise pollution, fuel, chemical, and hazardous material contamination. To undertake mitigation measures the Contractor will prepare its own C-ESMP in line with the ESMP. The primary source of water supply in Tuvalu is rainfall and rainwater harvesting. In the early 1980s, most families took advantage of an aid project for the provision of Ferro-cement storage tanks attached to small areas of roofing sheets providing the catchment and shelter for an external kitchen area. The tank had an approximate capacity of 3.6m3 and was intended only to meet drinking water demands. Tuvalu’s power has come from electricity generation facilities that use imported diesel brought in by ships. Seven of the eight outer islands are powered by 48-80Kw each diesel generator with a total generating capacity per island averaging 176Kw. The Preliminary ESMP has included an assessment of the most appropriate energy and water supply with a focus on sustainable energy sources. The assessment shows that all clinics use solar panels for power supply, and utilizing rainwater tanks for water supply. Findings of the Preliminary ESMP will be integrated into design works to ensure that building and renovation works minimize water and power use in compliance with the EHS Guidelines. Likewise, energy efficiency will be considered when sourcing hospitals, health centers, or laboratory equipment with mitigation measures included in the final ESMP. Due to the small-scale activities, greenhouse gas (GHG) emissions will not be significant and GHG estimations will not be required. May 23, 2022 Page 16 of 21 The World Bank Health System Strengthening Project (P175170) As noted in the Preliminary ESMP, works to upgrade water, sanitation, and hand-hygiene facilities in the outer island clinics are expected to be minor however, may rely upon existing infrastructure such as wastewater discharge points. An E&S audit has been completed during project preparation to determine the potential E&S areas of concern and the appropriate measures and actions have been identified. The assessment indicates that the wastewater from the construction activity would mainly come from the concrete mixer/batching plant washings and from the worker's camp if any will be established. These are expected to be generated in low quantities and can be handled by simple settling pits in the case of the mixer washings and a standard septic tank in the case of domestic wastewater from the worker’s camp. For Sub-Component 1.4 in improving the range and quality services provided at PMH including chronic disease management, diagnostic services in laboratory and radiology will produce healthcare waste such as liquid contaminated waste (e.g. blood, other body fluids, and contaminated fluid), potential radioactive waste, infected materials (water used, lab solutions and reagents, syringes, bedsheets, etc.) and expired vaccines and other drugs. Healthcare waste poses a significant risk to nearby communities and the natural environment (land, groundwater, watercourses, and lagoon/ocean environment), therefore proper treatment and disposal is important to protect both communities and the environment. Mitigation measures for the risks and impacts associated with IPC and MWM have been identified under the Preliminary ESMP and these risks and impacts will be mitigated through both project design (e.g. the development of SOPs and capacity building and procurement of a waste transport vehicle) and implementation of the final ESMP. General construction and demolition activities may generate on-site pollution such as waste (including potentially hazardous materials such as asbestos or lead paint), dust, noise sedimentation, hydrocarbon spills, etc. These Public Disclosure construction impacts are listed under the Preliminary ESMP and will be managed through the final ESMP and its implementation. The final ESMP will include mitigation measures such as dust suppression, restricted working hours, and erosion and sediment control as required. In the preliminary ESMP, it is noted that the procurement of equipment for hospitals, laboratories, and health facilities and enhancement of information systems and connectivity will lead to the generation of e-waste. The Preliminary ESMP has included an assessment of suitable waste management options and procedures for waste management and disposal in compliance with Tuvalu legislation and Tuvalu’s Integrated Waste Policy and Action Plan 2017- 2026 and GIIP and the IPC & WMG as well as the requirement for any operational management plans to address ongoing pollution risks such as waste management and spill response. The waste management and pollution mitigation measures will be further addressed under the C-ESMP in compliance with both the final ESMP and local legislation prior to the commencement of demolition or construction activities. The potential ESS3-related risks and impacts during the construction and strenghtening health care services phase includes: (i) generation of noise and vibration at construction site, disturbing the residents within the immediate vicinity of the construction site as well as the patients and workers at the PMH; (ii) Soil erosion and sedimentation at the construction site drainage, due to possible earth movements and excavation; (iii) Deterioration of air quality within the construction site and immediate vicinity due to increase particulate matter from demolition, earth moving and operation of construction equipment and power tools; (iv) Potential nuisance from improperly disposed of construction/demolition spoils and solid wastes from workers' camp; (v) Soil/sand and water contamination due to release of hazardous materials particularly petroleum-based products, e.g., lubricants, hydraulic fluids, fuels during their storage, transfer, or use in equipment; (vi) Contamination of local waterbodies and soil with wastewater discharges from the construction activities and worker's camp; (vii) Potential damage or increased wear and tear of May 23, 2022 Page 17 of 21 The World Bank Health System Strengthening Project (P175170) public facilities used by contractors; and, (viii) Risk that supplier of project's raw materials including borrow and aggregates use environmentally and socially destructive production methods, including possible use of child labor. In order to mitigate the risks, standards, commons, and practical measures will be employed in construction activities. Primary contracting parties of construction activities are required to prepare their own C-ESMP guided by the measures identified in this ESMP. Mitigation measures for risks and impacts during construction which are related to applicable World Bank ES Standards are identified in the ESMP while an Environmental and Social Code of Practice (ESCOP) for Contractors is being provided to further guide contractors in preparing their own C-ESMP. ESS4 Community Health and Safety This standard is considered relevant. The improper handling, storage, and disposal of healthcare waste and improper design and operation of sanitation facilities may pose a risk to both community members and other stakeholders such as hospital staff. These risks have been discussed above under ESS3. Construction and demolition activities pose a risk to community members through increased noise, dust, and traffic and the incorrect disposal of hazardous materials. The Preliminary ESMP has assessed the design, demolition, construction/renovation risks to community health and safety this include:1) Exposure of the residents and hospital employees and visitors to general construction site hazards, including STDs, 2) Exposure of residents and children to construction traffic, 3) Risk of unexploded ordnance (UXO), 4) Increase in incidence of sexual exploitation/abuse and harassment within local communities and associated risk of Public Disclosure outbreak/spread of infectious diseases. Specific operational phase risks identified in the Preliminary ESMP include 1) Risk of inundation of facility during coastal flooding events, becoming non-operational during and in the aftermath of a flood causing disaster (such as cyclone or tsunami). 2) Exposure of waste collectors and handlers to hazards from ordinary municipal solid wastes from hospital operations, 3). Infrastructure risk from seismic events, 4) Risk of hospital/health care facility fire, 5) Risk of accidental spillage of infectious wastes or hazardous chemicals, 6) Poor accessibility/inability of the facility to cater services to certain groups with special needs such as PWDs, elderly, pregnant women, or person with infants. 7) Risks as a result of misuse of, poor quality, and/or poorly managed medical equipment, vehicles, materials and services include risks to patients and staff, e.g. mis-use of radiography equipment, poor storage of pharmaceuticals, incorrectly performed testing, issues with information management, 8) While the WHO note that screening programs result in overall improvements in the societal burden of disease including: increasing choice, reducing severity of disease including less invasive treatment, reducing incidence of disease, and reducing deaths, they also identify a range of negative impacts that can result from screening programs, a) false positives can lead to psychosocial effects, such as anxiety, b) false negatives can lead to the public having decreased trust and confidence in the screening programme and reduced uptake and legal issues, c) overdiagnosis where condition or problem that would never cause a person harm during their lifetime is identified, and d) over treatment where people receive more extensive or invasive treatment than is required to improve health outcomes. The Preliminary ESMP includes appropriate mitigation measures such as traffic management, access control to hazardous locations, waste management, dust control, community awareness-raising, and restrictions to operating hours. Waste is managed in accordance with the IPC&WMG and is compliant with Tuvaluan legislation, EHS Guidelines, and GIIP. SEA/SH risks will be managed through codes of conduct for workers, training, and SOPs for May 23, 2022 Page 18 of 21 The World Bank Health System Strengthening Project (P175170) health care workers for improved detection and referral of cases of SEA/SH. These risks will also be managed through the IPC&WMG, development of SOPs, and training to be delivered under Component 1, through relevant sections of the LMP, via the Preliminary ESMP, and integrated into national planning and budgeting technical assistance under component #2. The Preliminary ESMP cross-references Project Components designed to build program guidelines and SOPs which ensure quality in the design and implementation of GIIP. Emergency preparedness and response are addressed in the IPC&WMG within the Preliminary ESMP noting that emergency response plans will be developed for events such as spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, power outages, and fire in Project funded facilities during project implementation and prior to commissioning. The Preliminary ESMP includes directives regarding design and engineering responses for structures to minimize the risks of inundation during a cyclone or coastal flooding events, as well as disaster management plans. Also, during the construction work, the risks and impacts to the community health and safety will include temporarily generation of noise, transitory dust, mobile, and other machinery emissions, risks related to physical transportation of construction material and traffic and mobility safety concerns, potential risks of transmitting COVID-19 both within the worksite and for nearby communities, labor influx during the project implementation stage. Mitigation measures for these impacts are designed in the Preliminary ESMP, site-specific measures will be prepared under the final ESMP, and worker Codes of Conduct within the LMP. Public Disclosure ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This ESS is not currently relevant. The project is not expected to require any land acquisition as works are expected to take place in the boundary of existing facilities. The project will involve construction, repair, and/or refurbishment of existing structures, thus site- specific screening through an Environmental and Social Audit has been carried out during preparation. This Audit has not identified specific ESS5 risks. The Preliminary ESMP includes procedures to screen for and verify land boundaries ownership once the footprint of the outer island clinic upgrades is known, and identify whether a resettlement plan (Resettlement Action Plan (RAP) or Abbreviated Resettlement Action Plan (ARAP)) needs to be prepared prior the commencement of works. This is considered unlikely but will be further assessed during implementation on completion of concept designs in accordance with the ESF. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard is not considered relevant as works will take place on previously disturbed land away from areas of high biodiversity value. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities May 23, 2022 Page 19 of 21 The World Bank Health System Strengthening Project (P175170) This standard is not considered relevant. There are no known groups that meet the criteria in ESS7 as the overwhelming majority of people in Tuvalu (99.1%) belong to the Tuvaluan ethnic group (including 7% with mixed Tuvaluan and i-Kiribati ethnicity), who will be the overwhelming beneficiaries for the project. ESS8 Cultural Heritage The standard is currently not relevant as all construction activities are proposed to occur on already disturbed land. However, the Preliminary ESMP includes screening for potential ESS8 risks and “chance finds” procedures. This includes risks and impacts on intangible cultural heritage. ESS9 Financial Intermediaries The standard does not apply as the Project does not propose to include financial intermediaries. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No Public Disclosure 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: Use of the borrower framework is not envisaged. IV. CONTACT POINTS World Bank Contact: Kari L. Hurt Title: Senior Operations Officer Telephone No: 5740+6525 / 61-02-92356525 Email: khurt@worldbank.org Borrower/Client/Recipient Borrower: Ministry of Finance and Economic Development Implementing Agency(ies) May 23, 2022 Page 20 of 21 The World Bank Health System Strengthening Project (P175170) Implementing Agency: Ministry of Health, Social Welfare and Gender Affairs 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): Kari L. Hurt Practice Manager (ENR/Social) Susan S. Shen Cleared on 22-May-2022 at 20:37:59 GMT-04:00 Public Disclosure May 23, 2022 Page 21 of 21