The World Bank Tajikistan Millati Solim Project (P178831) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 07/20/2023 | Report No: ESRSA02901 Jul 26, 2023 Page 1 of 14 The World Bank Tajikistan Millati Solim Project (P178831) BASIC INFORMATION A. Basic Operation Data Operation ID Product Operation Acronym Approval Fiscal Year P178831 Investment Project Financing (IPF) Millati Solim Project 2024 Operation Name Tajikistan Millati Solim Project Country/Region Code Beneficiary country/countries Region Practice Area (Lead) (borrower, recipient) Tajikistan Tajikistan EUROPE AND CENTRAL Health, Nutrition & ASIA Population Borrower(s) Implementing Agency(ies) Estimated Appraisal Date Estimated Board Date Republic of Tajikistan Ministry of Health and Social 24-Apr-2023 19-Sep-2023 Protection Public Disclosure Proposed Development Objective The objectives of the Project are to: (i) improve the quality and efficiency of primary healthcare services in selected districts, and (ii) strengthen the national capacity to respond to public health emergencies Financing (in USD Million) Amount Total Operation Cost 57.25 B. Is the operation 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 Operation [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The Prioritized Investment Plan (PIP), which is a costed implementation plan for the National Health Strategy, provides a robust guiding framework for the Project and helps align development partners’ support with national Jul 26, 2023 Page 2 of 14 The World Bank Tajikistan Millati Solim Project (P178831) priorities. The PIP is being developed through an inclusive process led by the Government (MOF and MOHSP). This process determines critical priorities of the Government’s NHS, which orients all interventions in the sector. The PIP prioritizes four focus areas (PHC, health financing, human resources, and information systems and digitalization) to advance the Government’s commitment to achieving Universal Health Coverage. The Government has indicated that they would like to adopt the final PIP as a Government order to ensure that activities are being implemented. Within the four focus areas, it prioritizes specific activities with the corresponding cost, and sources of funding (from the state budget and by development partners) to implement the NHS and a monitoring framework that will include indicators of implementation of activities. The draft version of the PIP will be finalized in early September. To ensure that the activities supported by the project correspond to priority areas of the PIP, the consultants working on the PIP are in close contact with the team developing this Project. The proposed project includes the following components: Component 1: Quality Improvements of Primary Care through Primary Healthcare Strengthening Sub-component 1.1: Quality Improvements through investments in human resources and demand stimulation Sub-component 1.2: Physical infrastructure improvements Component 2: Digitalization and Strategic Purchasing of PHC Services Sub- component 2.1: Strategic Purchasing of PHC Services Sub-component 2.2: Digitalization of the PHC network Component 3: Health Emergency Preparedness and Response Component 4: Project management, coordination and monitoring, and evaluation These components fall within the four focus areas of the PIP. This proposed project will only support a selected set of priority activities in the PIP, while other development partners and the state budget, support the remaining activities. A detailed mapping to ensure the complementarity of efforts (rather than duplication) will happen throughout project preparation through the PIP development process and other more detailed bilateral technical discussions. The Project is aligned with the FY19-23 World Bank Country Partnership Framework (CPF) and seeks to address the binding constraints identified in the Systematic Country Diagnostics (SCD). Public Disclosure The Project contributes to achieving the objectives of Pillar 1 (Human Capital and Resilience) of improving nutrition, and hygiene, and reducing the under-five mortality rate, which is still high. It directly contributes to the second objective of the CPF, Enhancing Health Services. D. Environmental and Social Overview D.1. Detailed operation location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Despite notable accomplishments in poverty reduction over the past 20 years, Tajikistan remains a low-income IDA country with a large proportion of the population vulnerable to poverty and shocks. Tajikistan borders China, Afghanistan, Uzbekistan, and the Kyrgyz Republic, and has a population of 9.3 million. In the economic recovery after the 1992-97 civil war following the collapse of the Soviet Union, the country's economy grew by 7.3 percent per annum between 1998 and 2020, and the national poverty rate declined from 82 percent in 1999 to 26.5 percent in 2020. However, Tajikistan still has the lowest GDP per capita in the Europe and Central Asia (ECA) region (US$3,520 in PPP terms and US$900 in current US$ in 2019). Seventy-four percent of the population is rural and heavily reliant on agriculture. Service delivery to most Tajiks is challenged by a mountainous terrain, which is 93 percent of the landlocked country. The country is prone to flooding, earthquakes, and mudslides, which have a significant impact on social and economic development. This often leads to outbreaks of various infectious diseases and injuries. Tajikistan is one of the countries in the region most vulnerable to adverse impacts from external economic shocks, seasonal food insecurity, and climate change. From 1992 to 2016, disasters in Tajikistan are estimated to have caused economic losses in excess of US$1.8 billion, affecting almost 7 million people. Limited economic and employment opportunities and poverty have contributed to substantial labor migration overseas. Jul 26, 2023 Page 3 of 14 The World Bank Tajikistan Millati Solim Project (P178831) Tajikistan's Human Development Index (HDI) value for 2019 is 0.668— which put the country in the medium human development category—positioning it at 125 out of 189 countries and territories. However, when the value is discounted for inequality, the HDI falls to 0.584, a loss of 12.6 percent due to inequality in the distribution of the HDI dimension indices. The country has a Gender Inequality Index (GII) value of 0.314, ranking it 70 out of 162 countries in the 2019 index. In Tajikistan, 20.0 percent of parliamentary seats are held by women, and 93.3 percent of adult women have reached at least a secondary level of education compared to 95.7 percent of their male counterparts. For every 100,000 live births, 17.0 women die from pregnancy-related causes; and the adolescent birth rate is 57.1 births per 1,000 women of ages 15-19. Since the second half of the 2000s, the Government of Tajikistan has confirmed its commitment to a wide array of health system reforms in various policy documents. However, the development of specific reforms steps and their implementation has been lagging – in particular in the field of health financing where apart from the limited per capita financing policy outlined above and a number of regional pilot projects which have introduced performance- based financing (World Bank) and case-based payments for hospitals (Asian Development Bank) these initiatives have not been scaled-up nationwide. Healthcare sector enjoys relatively low priority in government spending, a 6.9 percent share in total government spending – the lowest share among Central Asian peers and substantively below the 9.8 percent average spending shares across ECA countries. The Tajik healthcare system is characterized by central planning, a decentralized administrative structure, insufficient input-based financing, and the public sector providing almost all healthcare services. Health outcomes still lag those of other countries in the ECA region and many of the health outcome shortfalls are amenable to improved health services. Public Disclosure The Project will be implemented in the selected urban areas and districts located throughout the country and seeks to focus on areas to improve the quality and equity of primary health care (PHC), health financing, human resources, information systems, and digitization to advance the government's commitment to achieving universal health coverage. The impacts of project activities on the receiving environment are (i) an increase in healthcare waste generation, collection, decontamination, transportation, and disposal; (ii) an increased chance of occupational health and safety (OHS) risks from the construction of PHCs; and (iii) community health and safety related to air pollution from potential incinerators and noise and dust generation from the construction of new PHCs. D. 2. Borrower’s Institutional Capacity The project will be implemented by the Ministry of Health and Social Protection of the Population (MoHSPP). The implementation responsibility will be with the Technical Support Group (TSG) within the MoHSPP, consisting of local project implementation support personnel in adequate numbers and with adequate qualifications. There will be no stand-alone PIU. The TSG will report to the First Deputy Minister and will work in close day-to-day coordination with the Reforms, Primary Healthcare, and International Relations Department (RPHCIRD) of the MoHSPP. The Ministry has years of experience working with the World Bank. The Ministry has successfully implemented Tajikistan Health Services Improvement Project (HSIP) P126130 under the World Bank’s Operational Policies (OPs). The current overall E&S safeguards performance of the HSIP is satisfactory (S), according to the latest ISR (Dec'22). Similarly, the Ministry is also implementing the Emergency COVID-19 project (TEC-19), which has been prepared under the ESF and has its experience. The current overall E&S performance of the TEC-19 is Satisfactory, according to the latest ISR. Therefore, the MoHSPP has gained experience in the implementation of environmental and social (E&S) instruments, such as Environmental and Social Management Framework (ESMF), ESCP (Environmental and Social Commitment Plan), Environmental and Social Management Plans (ESMPs), medical waste management, and Jul 26, 2023 Page 4 of 14 The World Bank Tajikistan Millati Solim Project (P178831) preparation and implementation of the ESF documents, such as Stakeholder Engagement Plan (SEP), Labor Management Procedures (LMP) and Resettlement Framework (RF). The project will hire/appoint one dedicated environmental specialist and one dedicated social specialist as defined under the project ESCP. The TSG E&S specialists to be newly appointed and/or recruited will have limited experience in ESF implementation. In this regard, the ESF capacity building and strengthening measures are detailed in the Environment and Social Commitment Plan (ESCP). II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate Environmental Risk Rating Moderate The project's environmental risk is Moderate because the project under Component 1.2 will mainly finance the rehabilitation. repair, equipping, and modernization of existing primary healthcare centers (PHCs), and the construction of limited priority PHCs and warehouses in 16 districts . Moreover, the client has previous experience in implementing ESF.i . The overall environmental risks will be of low to moderate due to limited civil works, upgradation, and rehabilitation works. Given the country's complexity terrain, the requirement for health facilities and construction/modernization may vary significantly. However, the infrastructure modernization operations may include the procurement of equipment, building warehouses, the installation or rehabilitation of incinerators, and the Public Disclosure expansion of existing health facilities which will not significantly impact on biodiversity or natural habitats. The potential environmental impacts and risks will include (i) an increase in healthcare waste due to poor waste management in terms of waste color coding, segregation, collection, decontamination, transportation, and disposal, as well as occupational health and safety (OHS) risks from contruction of PHCs; (ii) health care workers' occupational health and safety; (iii) community health and safety related to the operation of health care facilities; and (iv) air pollution from the construction of new PHCs and incinerations. These risks are expected to be site-specific, reversible, and managed through established and proven mitigation measures. These will be mitigated through: (i) capacity- building activities, aimed at strengthening health facilities to comply with the ESF requirements, particularly, ESS2 and ESS3: Resource Efficiency and Pollution Prevention and Management; (ii) the implementation of environmental safeguards’ instruments prepared for the project; and (iii) complying with international best practices during construction and operational stage. An Environmental and Social Management Framework (ESMF) is prepared during the project appraisal stage. The ESMF establishes procedures for screening sub-projects, mitigation measures, and implementation arrangements. It provides necessary provisions for storing, transporting, and disposing of medical waste.The ESMF also consists of a template for the ICWMP (infection control and waste management plan). The ICWMP shall be prepared during the early stages of project implementation that is consistent with international best practices and WHO standards. The environmental risks associated with the implementation of civil works will be mitigated by the application of the WB Environmental Health and Safety Guidelines (ESHGs) and Good International Industrial Practices (GIIPs) for civil works. Other risks related to public health and medical waste will be managed through the preparation of a generic HCWMP during the early project implementation stage. These and all other potential environmental risks are reversible and are easily managed by the implementation of proper E&S tools and plans. The Project ESCP and subsequent ESMPs and HCWMP will have sufficient guidance and provisions to mitigate any potential environmental and social risks and impacts of the project activities. Jul 26, 2023 Page 5 of 14 The World Bank Tajikistan Millati Solim Project (P178831) Social Risk Rating Moderate The project will have social positive impacts, as it will contribute to (i) improving the quality and efficiency of PHC services in selected districts/regions and (ii) strengthening the national capacity to respond to public health emergencies. Social risks could emanate from the following planned investments: (i) investments in PHC service delivery capacity (human resources, infrastructure, and equipment) in at the PHC in selected districts and at the national level, and (ii) national capacity and physical infrastructure enhancement to improve response to various emergencies, including training of health workers; repairs, rehabilitation, expansion, equipping, and modernization of public health workplaces; construction of a few new PHCs and warehouses for emergency medical equipment and goods at the regional level; and procurement of medical goods to stockpile for future emergencies. One of the key challenges for the project will be to ensure social 'inclusion'. Exclusion may happen due to differentials in (i) geography – given the vast expanse of the PHC facilities throughout the country and the fact that some of the terrains are mountainous and remote, so some remote districts and villages will be excluded ; (ii) scale of investments – large and richer districts/regions may receive preferential investments; (iii) absorption capacity - technologies developed should be more friendly to health workers at large, and (iv) administrative expediency and economy in reaching out to rural health workers and vulnerable households in remote and poor areas across the country. These risks will be addressed to a large extent through a well-crafted Stakeholder Engagement Plan (SEP) supplemented with an effective Information, Education, and Communication campaign. Subcomponents 1.2, 2.2, and 3 involve civil construction, some new and others repairs, extension, and rehabilitation. The new construction will invariably require land acquisition. While the project is expecting that the Government will make land available, due diligence is required to ensure that there is no resultant physical, and/or economic displacement. Risks related to this will need to be avoided or reduced or, if the involuntary acquisition is inevitable, then, it will have to be addressed. The project Public Disclosure has prepared, consulted upon, and disclosed a Resettlement Framework (RF). It will guide the preparation of site- specific resettlement plans, where required. Another challenge will be sensitizing the implementing agency and other relevant stakeholders to adopt and adhere to the ESF requirements, as some regional and local stakeholders will be new to ESF requirements. There are also risks related to institutional capacity, in particular concerning the transparency of decisions made on subproject prioritization and accountability on project investments. The proposed Third-Party Monitoring to be implemented by CSOs is expected to recommend areas for improvement and course correction to MoHSPP and its relevant subdivisions to complement and strengthen their existing planning, monitoring, and evaluation processes, as well as to seek ESF compliance. Labor-related risks associated with the civil works contractors and their compliance with ESS 2 are assessed as Moderate, as the national labor and OHS legislation is in place and the contractors must comply with them. The risk of child and forced labor is not expected. The social risk rating is assessed as Moderate. Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) Risk Rating Moderate The project will invest in the rehabilitation and construction of primary health centers (PHC) and other health facilities under Subcomponents 1.2, 2.2, and 3. The civil works will be implemented in the vicinity of health facilities or fenced territories. There might be some remote mountainous districts to be selected, which are hard-to-supervise. The project will include focus group discussions with women to get their feedback before civil works start. Tajikistan has a national gender-based violence (GBV) law and legislation is in place. De facto there are no systemic and adequate psychosocial service providers countrywide. The capacity of health workers on identifying and registering GBV cases needs to be strengthened. The existing referral and coordination services in the health facilities are malfunctioning, as the system does not provide comprehensive care to survivors; at the same time, the survivors are afraid to seek support from the judicial institutions and police. At the national level, clear policy guidelines and protocols to identify Jul 26, 2023 Page 6 of 14 The World Bank Tajikistan Millati Solim Project (P178831) and respond to the physical and mental health needs of survivors of physical and sexual violence shall be developed and implemented in collaboration with other government partners. To address those challenges, the Project will support the development of a national policy to guide the health sector GBV response. It will also finance the implementation of selected activities of the national policy priorities, which includes the development of expertise and training to recognize, prevent and respond to GBV at the PHC level. At the project level, adequate SEA/SH mitigation measures will be included in the site-specific ESMPs and OHS management plans to be prepared and implemented by contractors. The mitigation measures will include but are not limited to signing codes of conduct, ensuring that alternative sanitation facilities/arrangements for health facilities are envisaged during the construction stage, securing worksites to protect community members, health workers, and patients from trespassing, etc. The project grievance mechanisms will include appropriate approaches for dealing with SEA/SH complaints, including confidential and sensitive referral mechanisms. The current rating is based on the country's context of norms and legal protections for women in working environments and project-specific indicators. A SEA/SH Action Plan will be prepared for the Project within three months of the Project Effective Date. 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 Operation: ESS1 is relevant. Component 1 will mainly finance the rehabilitation and repair, equipping, and modernization of Public Disclosure Primary Care through existing PHC facilities, and the construction of new priority PHCs and warehouses in the selected district areas. Given the country's terrain complexity, the requirement for health facilities and construction/modernization may vary significantly. However, the infrastructure modernization operations may include the procurement of equipment, building warehouses, the installation or rehabilitation of incinerators, and the expansion of existing health facilities. The potential environmental impacts and risks will include (i) an increase in healthcare waste due to poor waste management in terms of waste color coding, segregation, collection, decontamination, transportation, and disposal, as well as occupational health and safety (OHS) issues; (ii) health care workers' occupational health and safety; (iii) community health and safety related to the operation of health care facilities; and (iv) air pollution. Component 2 will focus on introducing new health financing mechanisms to pay health service providers (PHCs) based on the number of registered patients in the catchment area or the number of services provided, with an initial focus on the Sughd region. However, Component 2 will not involve any procurement and facilitation of environmentally sensitive goods and services. Component 3 will be implemented nationwide, which involves improving physical infrastructure in response to various emergencies. It includes (i) repairing and equipping existing public health facilities; (ii) construction of warehouses at the regional level; (iii) procurement and stockpiling of medical goods for potential future emergencies etc. The Project will also involve stakeholder engagement activities on the need for modernization and other necessities to improve the quality of PHCs. The modernization of public health facilities will also be equipped with emergency preparedness arrangements, medical waste management, and fire safety kits. As a public access facility, the PHCs equipment will also consist of universal access features such as ramps, safe pathways, and other required facilities. Jul 26, 2023 Page 7 of 14 The World Bank Tajikistan Millati Solim Project (P178831) Modernization of PHC modernization of select health public workplaces, construction of warehouses, and potential procurement of equipment such as incinerators or bulk of medicines, and or its disposal could have potential adverse social and environmental risks and impacts. The potential environmental impacts and risks will include (i) an increase in healthcare waste due to poor waste management in terms of waste color coding, segregation, collection, decontamination, transportation, and disposal, as well as occupational health and safety (OHS) risks from the construction of PHCs; (ii) health care workers' occupational health and safety; (iii) community health and safety related to the operation of health care facilities; and (iv) air pollution from the construction of new PHCs and incinerations. These risks are expected to be site-specific, reversible, and managed through established and proven mitigation measures. These likely risks will be mitigated through: (i) capacity-building activities, aimed at strengthening health facilities to comply with the ESF requirements, particularly, ESS2 and ESS3: Resource Efficiency and Pollution Prevention and Management; (ii) the implementation of environmental safeguards’ instruments prepared for the project; and (iii) complying with international best practices during construction and operational stage. Since the details of Project activities and precise locations of implementation Health Facilities sites are yet to be determined, thus the Project has adopted a framework approach and an Environmental and Social Management Framework (ESMF) has been prepared to identify risks and provide mitigation measures to potential environmental and social risks and impacts. The environmental risks associated with the implementation of civil works will be mitigated by the application of the WB Environmental Health and Safety Guidelines (ESHGs) and Good International Industrial Practices (GIIPs) for civil works. Other risks related to public health and medical waste risks will be managed through the preparation of a bio- Public Disclosure medical waste management plan. The Infection Control and Waste Management Plan (ICWMP) will properly explain the institutional and implementation arrangements for medical waste management in the relevant healthcare facilities. The Plan will have for all relevant health facilities proper waste color coding, segregation, shredding of sharps, collection, decontamination, transportation, and disposal in the appropriate location preferably a landfill if available, carry out training need assessment, and train relevant staff, monitor staff performance and compile reports. The ICWMP would require proper hygiene, hand washing, PPE arrangements, and other relevant measures to protect the health workers, visitors, etc. from communicable diseases, including but not limited to Hepatitis, HIV/AIDS, COVID-19 and its modified versions and Infection Prevention and Control of Pandemics. The ICWMP will have an updating, checking, and improving mechanism and will require Monitoring of the Health Care Facilities and their performance and require corrective actions. The modernization of public health facilities will also be equipped with emergency preparedness arrangements, medical waste management, and fire safety kits. As a public access facility, the PHCs equipment will also consist of universal access features such as ramps, safe pathways, and other required facilities. The ESMF also guides mainstreaming of the environmental and social prerequisites during renovation and rehabilitation work. The ESMF includes environmental and social screening procedures to be implemented before the modernization of select PHCs. The screening report will form the basis to develop E&S instruments, including the site-specific Environmental and Social Management Plans (ESMPs). The ESMF also spells out necessary guidance on the preparation of the relevant E&S tools, ICWMP Guidance on OHS, and other related provisions aligned with the project scope. Jul 26, 2023 Page 8 of 14 The World Bank Tajikistan Millati Solim Project (P178831) There are three key social risks and adverse impacts anticipated. The first risk is related to possible exclusion issues. Some regions and districts are already deprived of the project investments and benefits, as the selection criteria are based on (i) poverty rates; (ii) not being/having been covered by World Bank or other IFI-funded investment projects; (iii) representation of all regions of the country. There is also the potential exclusion of PHC and health workers, especially those who lack ICT skills/experiences or technological resources to access the online platform for continued medical education and to use modernized workplaces. Some vulnerable households/groups may face barriers to receiving free services and drugs under the state-guaranteed benefit package. Second, the construction of new health facilities and warehouses will require land acquisition, which may lead to involuntary resettlement. While the project is expecting that the Government will make land available, due diligence is required to ensure that there is no resultant physical, and/or economic displacement. Rehabilitation of existing health facilities will likely have temporary impacts, such as limited access to facilities and services. The project will use the existing networks to connect/rehabilitate the water supply pipelines. In some remote areas off-grid water supply solutions will be implemented, including water tanks and other equipment to be installed within the footprint of healthcare facilities. So, no land acquisition is anticipated for rehabilitation works. Third, there is an institutional risk associated with the capacity to transparently make decisions and be accountable for project investments. Another challenge will be sensitizing the relevant stakeholders to adopt and adhere to the ESF requirements, as some regional and local stakeholders will be new to ESF requirements. The first risk will be addressed to a large extent through a well-crafted Stakeholder Engagement Plan (SEP) supplemented with an effective Information, Education, and Communication campaign. The resettlement impacts will be mitigated through a Resettlement Framework (RF) prepared, adopted, disclosed, and consulted upon prior to Appraisal. The third risk will be mitigated through the implementation of social accountability mechanisms and tools to improve project outcomes. Labor requirements are documented in labor- Public Disclosure management procedures (LMP) prepared, consulted upon, and disclosed before the project Appraisal. Relevant OHS and labor provisions will be also incorporated into the ESMPs. The MoHSP has also prepared the Environmental and Social Commitment Plan, which covers the commitments and timelines for relevant mitigation and capacity-building actions to be taken. ESS10 Stakeholder Engagement and Information Disclosure The MoHSP has already started engaging with diverse stakeholders as per ESS10 requirements. Mapping of project- affected parties, vulnerable groups, and other interested parties has been completed during project preparation. Key stakeholders include the MoHSP and its regional and local affiliates, local governments, medical service providers, community representatives, and civil society organizations dealing with community, women's, and children's health issues. A stakeholder engagement plan (SEP) has been prepared, disclosed, and consulted prior to Appraisal. The SEP defines a program for stakeholder engagement, including public information disclosure and consultations throughout the project cycle. The SEP also outlines how the MoHSP will communicate with the local partners and stakeholder communities as needed, and includes a grievance mechanism (GM) by which stakeholders can bring their concerns/feedback relating to the project activities. The MoHSP has designed an electronic GM for the healthcare sector being piloted under the WB-funded Health Sector Improvement Project (HSIP) that responds to complaints registered by citizens on any issue of concern, including issues related to the project-specific interventions. It will also accommodate the new project complaints. At the PHC level, the project will also use the existing GMs and disseminate information about the MoHSP electronic GM as soon as it is functional. The grievance mechanism will contain stipulations for sensitive grievances, including those Jul 26, 2023 Page 9 of 14 The World Bank Tajikistan Millati Solim Project (P178831) related to SEA/SH. The Project will also finance the implementation of selected activities of the national policy to guide the health sector on GBV response. It includes the development of expertise and training to recognize, prevent and respond to GBV at the PHC level. The project will also implement an annual National Patient Survey to measure the satisfaction of healthcare service users at the PHC level. It is critical to better understand the demand for PHC services and how satisfaction rates are changing over time, as project investments strengthen the target PHC services. The MoHSP has experience in third-party monitoring (TPM) of the WB operations under the TEC-19 Project. The TPM established a dialogue between the CSOs, the MoHSP, and other stakeholders, and created openings to social accountability in the health sector. The MoHSP accepted the TPM mechanism as an important external monitoring and course-correction tool to support project operations under this Project. The proposed TPM under this operation, in combination with health facility surveys to be financed under Component 4, will improve project results, and increase the transparency of the project investments. The health emergency preparedness and response under Component 3 will involve local governments and local communities in prioritizing areas of intervention for community engagement activities on public health-focused risk communication and convening activities to strengthen the national health response. For the sake of transparency and accountability, local stakeholders and local communities will be engaged in decision-making processes. B.2. Specific Risks and Impacts Public Disclosure A brief description of the potential environmental and social risks and impacts relevant to the Operation. ESS2 Labor and Working Conditions ESS2 is relevant. The project is expected to employ a small number of direct and contracted workers. While the number of workers cannot be estimated at this stage, no large workforce is expected. The Project will support the renovation and modernization of existing health facilities, and the building of warehouses that require skilled and unskilled workers. To ensure the workplace safety of workers during the project implementation phase, the project ESMF has detailed provisions on OHS (Occupational Health and Safety) management, monitoring, and reporting in line with World Bank/IFC guidelines. It will include detailed requirements for the transportation, handling, and disposal of chemicals, fuels, and other hazardous materials such as asbestos, etc. The plan will contain procedures on incident investigation and reporting/recording and reporting of non-compliances, emergency preparedness, and response procedures, and continuous training and awareness to workers. In addition, the Project has developed, adopted, disclosed, and consulted Labor Management Procedures (LMP) that set out how the project workers will be managed. The LMP includes terms and conditions of employment, nondiscrimination, and equal opportunity, workers' organization, occupational health and safety, the prohibition of child and forced labor, and a worker's grievance mechanism. On the latter, a focal point will be appointed to receive and address workplace grievances. The grievance mechanism for workers will also contain stipulations for sensitive grievances, including those related to SEA/SH. The GM will assist SEA/SH survivors by referring them to GBV Services Provider(s) for support immediately after receiving a complaint directly from a survivor. The information provided to the GM will be confidential— especially when related to the identity of the complainant. For SEA/SH, the GM will primarily serve to (i) refer Jul 26, 2023 Page 10 of 14 The World Bank Tajikistan Millati Solim Project (P178831) complainants to the GBV Services Provider; and (ii) record the resolution of the complaint. The ESCP includes appropriate actions with time-bound commitments for the mitigation of SEA/SH risk. The capacity building and training plan will also include the budget for the workers' GM, public outreach activities, training and awareness- raising on GBV/SEA/SH prevention, as well as a referral pathway for survivors. The LMP includes contractors' codes of conduct which will be included in the procurement documents. The LMP also includes mitigation measures to prevent and minimize the risk and spread of the COVID-19 virus in the Project's workplace. ESS3 Resource Efficiency and Pollution Prevention and Management ESS3 is relevant. The PHC modernization may result in the use of more electrical energy for lighting, water supply, and sanitation. Thus, the project will consider sustainable methods for energy-saving options by installing energy- efficient bulbs, an automated water flows control system, as well as a solar power generation system. While planning renovation concepts, water harvesting methods will be implemented where applicable, particularly in relevant buildings where there is severe water scarcity. The project will also consider best practices for waste management and dumping the debris from rehabilitation activities, as well as the proper operation and maintenance of incinerators to reduce air and dust pollution. There are also some levels of potential EHS risks related to exposure to ACM (asbestos-containing material) that involve the demolition/extension of existing health facilities. The ESMF provides guidelines to discourage the use of asbestos material during any modernization activities. The asbestos removal plans will be part of the site-specific ESMPs that must be prepared, consulted upon, and disclosed prior to Public Disclosure the start of any civil works. In addition, a generic ICWMP will be prepared to manage medical and biomedical waste. ESS4 Community Health and Safety ESS4 is relevant. Due to small-scale civil works, that are site-specific where the impacts and risks to communities' health and safety are expected to be minor and manageable. Since the project’s civil works will mainly be undertaken in or around existing public health facilities, it is vital to uphold the health and safety of practitioners, laborers, visitors, and nearby communities throughout the construction phase. The Project will ensure consideration of infrastructure access, toilet construction, disposal, and handling of bio-medical waste management. The instruments prepared will incorporate relevant guidance from the World Bank’s Environmental, Health, and Safety Guidelines (EHSG), i.e., general and health sector-specific guidelines. The application of good international industrial practices for civil works and laboratory installation can also help. The public health facility buildings will also be equipped with emergency preparedness and response plans, life and fire safety measures, and universal access features and utilities. Health care wastes and general waste from healthcare facilities have a high potential for carrying microorganisms that can infect the community at large if they are not properly disposed of. If the infectious microorganism is not well contained within the laboratory, it may be released into the environment due to accidents or emergencies, such as a fire response or a natural phenomenon event (such as a seismic one). The generic Infection Control Waste Management Plan (ICWMP) will be prepared, and it will be adopted by the participating health facilities before any project activities start at the sites. The risk related to traffic management is negligible due to the transportation of small quantity aggregates for civil works. Nevertheless, site-specific ESMPs will be prepared and implemented to Jul 26, 2023 Page 11 of 14 The World Bank Tajikistan Millati Solim Project (P178831) ensure risk related to appropriate community health and safety measures are in place to safeguard the public from adverse impacts related to the project activities. Given that the contractors will engage workers for construction, there is potential for the spread of infectious diseases such as COVID-19 during the construction phase. There is also a potential risk of community exposure to COVID-19 infection by the project workers. The Project will exercise appropriate precautions to protect local communities from Covid infection. The ESMF includes measures based on the World Bank interim note for COVID-19 considerations in construction/civil works projects to guide safe planning and implementation of construction works. The ESMF also guides measures to address SEA/SH risks to be included in the ESMPs. The use of security forces is not anticipated under the Project. The Project will not support investments in biosecurity activities under Component 3 as planned at the Concept Stage. It will only finance the procurement of vehicles to strengthen SES laboratory network transportation arrangements. However, the HCWMP plan will include OHS and community health & safety measures to be followed by the relevant health institutions and transportation service providers. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS5 is relevant. The Project involves civil construction, some new and others repairs, and rehabilitation. Rehabilitation works will cause temporary impacts related to limited access to healthcare facilities and services. The Public Disclosure new construction will invariably require land acquisition. While the Project is expecting that the Government will make available land, due diligence is required to ensure that there are no resultant physical, and/ or economic displacements. Risks related to this will need to be avoided or reduced or, if the involuntary acquisition is inevitable, then, it will have to be addressed. The Resettlement Framework prepared during the project preparation includes guidance for preparing and implementing site-specific resettlement plans. The Project will use the existing networks to connect/rehabilitate the water supply pipelines at the target PHCs. In some remote areas off-grid water supply solutions will be implemented, including water tanks and other equipment to be installed within the footprint of healthcare facilities. So, no land acquisition is anticipated for the rehabilitation of water supply networks. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources ESS6 is not relevant. The project's implementation sites will be inside the boundaries of already-existing public health facilities, so it won't affect biodiversity or natural habitats. The project ESMF includes specific measures to prevent or reduce adverse effects on natural habitat and biodiversity as a precaution. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities The standard is not relevant since, in accordance with the ESS7 definition; no Indigenous people are known to reside in the project area. Jul 26, 2023 Page 12 of 14 The World Bank Tajikistan Millati Solim Project (P178831) ESS8 Cultural Heritage ESS8 is not relevant. Although no impacts on cultural heritage are anticipated, the project ESMF incorporates "chance finds" procedures in the ESMF when physical cultural resources are encountered during construction. The ESMF also includes site selection criteria to avoid any construction activities on the premises of significant cultural areas. ESS9 Financial Intermediaries The standard is not relevant. No Financial Intermediaries are involved. C. Legal Operational Policies that Apply OP 7.50 Operations on International Waterways No OP 7.60 Operations in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Operation risks and impacts Is this operation being prepared for use of Borrower Framework? No Public Disclosure Areas where “Use of Borrower Framework” is being considered: The recipient framework is not being considered under this Project. IV. CONTACT POINTS World Bank Contact: Mirja Channa Sjoblom Title: Sr Economist (Health) Telephone No: 473-2894 Email: msjoblom@worldbank.org Contact: Mutriba Latypova Title: Health Specialist Telephone No: Email: mlatypova@worldbank.org Contact: Baktybek Zhumadil Title: Senior Operations Officer Telephone No: 5258+442 / 7-717-269-1442 Email: bzhumadil@worldbank.org Borrower/Client/Recipient Borrower: Republic of Tajikistan Jul 26, 2023 Page 13 of 14 The World Bank Tajikistan Millati Solim Project (P178831) Contact: Yusuf Majidi Title: Deputy Minister of Finance Telephone No: 992372214205 Email: majidi@moliya.tj Implementing Agency(ies) Implementing Ministry of Health and Social Protection Agency: Contact: Jamolliddin Abdullozoda Title: Minister - Project Director Telephone No: 9922211835102 Email: jamoliddin.abdullozoda@bk.ru Contact: Gafur Muhsinzoda Title: First Deputy Minister - Project Coordinator Telephone No: 992918421194 Email: gafur@tojikiston.com V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Public Disclosure Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Mirja Channa Sjoblom, Mutriba Latypova, Baktybek Zhumadil Practice Manager (ENR/Social) Varalakshmi Vemuru Cleared on 20-Jul-2023 at 09:15:49 EDT Jul 26, 2023 Page 14 of 14