The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 02/04/2021 | Report No: ESRSA01207 Feb 04, 2021 Page 1 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Togo AFRICA WEST P174266 Project Name Togo Essential Quality Health Services For Universal Health Coverage Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 1/20/2021 3/11/2021 Population Financing Borrower(s) Implementing Agency(ies) Office of the President, Ministry of Health, Public Ministère de l'Economie Hygiene and Universal et des Finances Access to Care Proposed Development Objective Public Disclosure To improve the provision of essential health services and quality of care for pregnant women, children and vulnerable populations Financing (in USD Million) Amount Total Project Cost 70.00 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 proposed Togo Essential Quality Health Services for Universal Health Coverage Project will be co-financed by an IDA credit (US$30 million) and an IDA grant (US$30 million). The primary beneficiaries will be pregnant women, children under 18, and poor and vulnerable persons. Predefined criteria will be used to identify the primary target population. The project will contribute toward improving access to health and nutrition care. It intends to reach the country’s entire population by making available quality and affordable essential health services at the community and primary levels of care, improve availability of specialized services to ensure continuum of care and leverage demand side financing through social health insurance. Feb 04, 2021 Page 2 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) Previous progress on women and children health outcomes has been mixed. According to the WHO Life expectancy at birth in Togo is 60 years. Significant challenges remain on achieving Sustainable Development Goals 3. Particularly with stagnating Maternal mortality ratio (396 per 100,000 live births) and Neonatal mortality rate (25 per 1000). Under-five mortality rate (59.8 per 1000 live births) and prevalence of stunting in children under 5 years of age (27.5 percent) have moderately improved despite an increased prevalence of wasting (6.7 percent). Most maternal deaths are due to obstetrical causes such as hemorrhage (36.4 percent), eclampsia (23.5 percent), dystocia (22.3 percent), abortion complications (16.9 percent), and post-partum infections (14 percent).Skilled attendance is relatively high at 59 percent. For family planning 16.8 percent of women use modern methods. Diphtheria, Tetanus Toxoid and Pertussis (DPT3) immunization coverage among children under one year is 88 percent. Anemia in children under five is 71 percent while that in women of reproductive age is 48.9 percent. Children under five years with diarrheal disease receiving oral rehydration therapy (ORT) is 19.2 percent. Vitamin A supplementation for children under-five increased to approximately 90 percent. The Service Availability and Operational Capacity Index report (SARA, 2012 ) showed that 9 out of 10 facilities surveyed offered prenatal care services. Intermittent Preventive Therapy (IPT) against malaria and tetanus vaccination was widely available. Provision of micronutrients such as iron and folic acid to pregnant women was however at 30 percent. About 33 percent of health facilities did not have the capacity to offer antenatal services and only 25 percent of health workers have had any structured training in antenatal care within the past two years. The Government of the Republic of Togo has developed a National COVID-19 Preparedness and Response Plan. The Plan focuses on scaling-up and strengthening all aspects of preparedness and response including surveillance, laboratory, points of entry, risk communication, case management, infection control and safety, coordination, and research. Public Disclosure Equity of access to health care remains a major problem. geographical accessibility to health services has remained stable at the national level since 2016, with 30 percent of the population on average living more than 5 kilometers from a health center or in areas that are difficult to access. This rate increases to about 70 percent in the Savane region (northern part of the country). In addition, there is an unequal distribution of qualified health personnel in the country. About, 64 percent of health workers are in Lomé-Commune region against 4 percent in the Savane region. This situation is linked to poverty, which is higher in rural areas. According to the last Demographic and Health Survey 2013/2014 (EDST3), a birth was 2.25 times more likely to be attended by skilled personnel in urban areas (92 percent) than in rural areas (41 percent). Women in the richest quintile (95 percent) were 3.5 times more likely to be assisted by skilled personnel than those in the poorest quintile (27 percent). Similarly, the poorest populations with children under 5 years of age are three times more likely to die than the richest population Quality of health care provided in health facilities is low and continuum of care is not effective due to the deterioration of hospital structures, and the lack of logistics and equipment in hospitals. The government invests almost nothing in infrastructures and equipment essential for the diagnosis and treatment of diseases. The country has limited diagnostic imaging capacity. Tracer drug availability was 47 percent in 2018. Essential and generic drugs are usually substandard in quality in some parts of the country and not widely available in Togo because the supply chain is weak . The regulatory authority has recently relaunched the drug licensing commission. The Central Purchasing Agency for Medicines (CAMEG) faces structural and organizational problems that prevent it from playing its role to the fullest. National budget allocation to the health sector remains relatively low at less than 7 percent. The volume of total health expenditure increased on average by 28percent between 2013 and 2016 . The contribution of the national Feb 04, 2021 Page 3 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) budget to public expenditure remains modest: 5.95 percent in 2014 and 6.6 percent in 2018 . Households out-of- pocket expenditure accounted for 57.5 percent and 50.4 percent of totalhealth expenditure respectively in 2015 and 2016. This exposes families to the risk of tipping into extreme poverty due to catastrophic health expenditure. Decision makers have shown interest in exploring private sector participation in service delivery. The government had previously experimented with contracting management of public facilities to the private sector to improve efficiency, quality and value for money. There is a desire to expand on the approach to include private management of public funded facilities particularly of specialist and teaching hospitals. The government introduced a contributory health insurance mechanism in 2011 by decree No 2011-034/PR managed by the l’Institut National d’Assurance Maladie (INAM). The National Health Insurance Scheme (NHIS) covers only employees and retirees of the State, and their dependents. As of 2018, it had a total membership of 357,196 (5 percent of the total population), made up of 104,306 direct contributors and 252,890 dependents. The scheme has a large network of contracted service providers including 1,065 health centers and 206 pharmaceutical dispensaries across country. A school insurance scheme was also introduced in 2017 covering school during term time. The fractional coverage of the population has left large swaths of vulnerable group exposed to out-of-pocket payments for health services as described above. There is no scheme for the informal sector. This operation is an IPF with Performance Based Conditions (PBC) measured by Delivery Linked Indicators (DLIs). It aims to improve availability and access to quality and affordable health care. It promotes country led systems building and an integrated approach to primary and specialist health services delivery. The services are carefully selected and Public Disclosure known to be associated with cost effective care and facilities accountability for performance. The project also strengthens demand side financing by introducing a nationwide social health insurance scheme to advance Togo’s agenda for Universal Health Coverage. This operation is an IPF with Performance Based Conditions (PBC) measured by results indicators. The project has five components. The PBC aspect of this project is under Component 1. This Component is intended to support the availability of and access to quality health and nutrition care and services. It will consist of : (i) increasing access to essential health and nutrition services, (ii) increasing the number of poor and vulnerable people enrolled in the social health insurance scheme, (iii) improving the equitable distribution of health professionals, and (iv) increasing the availability of tracer drugs in peripheral unit care facilities. It promotes country led systems building and an integrated approach to primary and specialist health services delivery. The services are carefully selected and known to be associated with cost effective care and facilities accountability for performance. The component also strengthens demand side financing by introducing a nationwide social health insurance scheme to advance Togo’s agenda for UHC. Component 2 aims to improve the management of health facilities. This will involve: (i) increasing geographical accessibility and (ii) introducing stakeholder and private sector participation in the management of health facilities; Component 3 emphasis on strengthening the social health insurance system and will consist of : (i) establishing a social health insurance management system and (ii) promoting demand for social health insurance services. Component 4 focuses on strengthening stewardship and management. This will entail: (i) managing and coordinating the project and (ii) ensuring the environmental and social safeguards of the project. Component 5 is a standard provision for contingencies in the event of an unforeseen national or international emergency necessitating funds reallocation. Component 1: Increase availability and access to quality health and nutrition services (US$40,014,000 equivalent) Feb 04, 2021 Page 4 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) The services and performance indicators will be detailed in a project operation manual to be prepared ahead of project effectiveness and validated three months after Project Effectiveness date. The quantity and quality indicators will yield revenues for health facilities after verification by the Togo Social Health Insurance Agency (THIA), counter- verified by an independent verification agency, using 10-20 percent random sample and cleared by the World Bank. The independent verification may be done by the government audit agency, supported by an independent health expert, but the report must be accepted and cleared by the World Bank. The results will be mainly based on indicators linked to PBCs. As a default, the payment of all services under the project including medicines shall be linked to a population-based capitation payment mechanism. This component will support the overall quality of essential health and nutrition services program, including health facilities equipment and small renovation, capitated funds on a half year basis for three years to 500 health providers for the PES delivered, technical assistance to develop the PHC essential services package and operational manual, technical and managerial training for health providers and health managers, recruitment of an external verification agency, and technical assistance to develop key health promotion to promote PES uptake, through the provision of small works, goods, non-consulting services, consulting services, training and operating costs. Four performance conditions have been established to measure the performance of the Component 1 (PBC1 to PBC4). For PBC 1 on “increasing access to essential health and nutrition services,' health facilities submit their requests and reports to the health district, which then forwards them to the regional health directorate (DRS). The DRS submits the requests and reports to the Togolese Social Health Insurance Agency (THIA), which after verification submits them to the project coordination unit (PCU) for request for No Objection to the Bank; For PBC 2 on Public Disclosure 'Increasing the number of persons registered onto the health insurance scheme', the TSHIA submits the membership data registry to the local governments which validate the THIA membership data or the Régime Social Unique project validates the membership data. The local government or the Régime Social Unique project submits the validated data to the Ministry of Health, which then submits it to the World Bank for No Objection; For PBC 3 'newly recruited staff deployed to the four most deprived regions/provinces', and PBC 4 'increasing the availability of tracer drugs in primary health care facilities', after submission of data to the regional health directorate, verification will be carried out by independent consultants and reports will be submitted to the PCU for World Bank No Objection. The independent verification can be carried out by the government's verification agency, in particular the Health General Inspector (Inspecteur Général de la Santé), supported by an independent health expert, and provided that the report is approved and accepted by the World Bank. The results will be based primarily on indicators associated with PBC. By default, payment for all project services, including drugs, will be linked to a population-based capitation payment mechanism. This component will support the overall quality of the essential health and nutrition services program, including equipment and minor renovation of health facilities. Sub-component 1.1: Increase access to essential health and nutrition services (US$9,325,000 equivalent) The government will develop a Package of Essential services (PES) at primary health care (PHC) level to be provided to the population at the peripheral level - Peripheral Health Unit (PHU type I and type II) and District Hospital (DH type I and type II). The service package, as per the level type available package, will include maternal and child health and nutrition services, immunization, outpatient or inpatient care, birth deliveries and attendance, newborn care, malaria, TB, HIV/Aids, acute respiratory tract infection, diarrheal disease, hypertension, anemia, intestinal worms disorders, fevers, ear, eye, nose and oral health services; and key additional or tracer services. Infection prevention control activities (IPC), medical waste management among others) and health promotion financing will supplement on-going outreach and home-based behavior change activities related to the essential health services and in particular, IEC, Feb 04, 2021 Page 5 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) home visits, media communications. The PES will be printed and made available to providers and the public in the form of leaflets and through various communication channels. These activities complement the Togo Improving Quality and Equity of Basic Education Project (P172674) and ongoing communication on the importance of health care and user rights. Some development partners have already developed a core cadre of volunteers who are already supporting nutrition and homebased care activities. The project will seek to collaborate with these partners to enhance the project and avoid duplication. The project will support the acquisition of medical equipment to help improve the quality of health care and services. As well as rehabilitation and staffing needs, a baseline study will identify and prioritize the needs of existing health facilities. Sub-component 1.2: Increase membership of the poor and vulnerable on the insurance scheme (US$6,836,000 equivalent) The project finances will be used to support services provided to only members of the national health insurance scheme particularly the vulnerable and poor in society. The project will provide resources for a defined number of persons registered onto the scheme at a ratio that favours the poor and persons in the most deprived and rural communities. It is expected that these will also be biased towards pregnant women, children and school aged children. The registration system will be linked with the national citizens registration system. The project will leverage on the World Bank supported Safety Nets and Basic Social Services project (P157038) or e-ID project and other data base systems e.g. school enrolment to enrol members onto the scheme. Vulnerability criteria will be defined in consensus with all actors, including community-based actors (CVD, CDQ, women's groups, youth groups, etc.). The criteria will allow for the identification of individuals covered by the gratuity regime and those covered by the Public Disclosure contributory regime. A membership registration and service feedback and complaints handling call centre will be established. The project will provide resources to purchase and install membership management hardware and software. Technical assistance is provided for assessment, accreditation and contracting tools of facilities through the provision of goods, non-consulting services, consulting services and training and the financing of Operating Costs, as required to operationalize the enrolment system. Sub-component 1.3: Improve equitable distribution of health professionals (US$2,872,000 equivalent) To enhance access to quality healthcare services the project will promote the recruitment and deployment of newly qualified health professionals to the most deprived and rural communities in the three most deprived regions of the country. The project will target specifically the posting of qualified health personnel . The funds will be used to pay incentives including deprived area and hardship allowances, accommodation and relocation grant to persons accepting posting to these areas. The funds will only be released on verification of the professional taking up position in the deprived area for not less than twelve (12) months. The operations manual will detail the incentives and benefit scheme to be used. The request for release of funds will be based on a verification letter signed by the regional director of health services and the local government head of agency responsible for the province or district in which the person has assumed post. The project will support these human resources for health (HRH) deployment through the provision of goods, non-consulting services, technical assistance through consulting services and training and the financing of operating costs at the district and regional levels to ensure supervision functions. Sub-component 1.4: Increase tracer drug availability at peripheral unit care facilities (US$20,981,000 equivalent) A key complement to ensure quality healthcare services delivery is essential medicines and non-drug consumables. The project will seek to boost the availability of essential medicines by rewarding the availability of essential Feb 04, 2021 Page 6 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) medicines in health facilities accredited particularly onto the TSHIA. The list will be drawn from the countries essential medicines list and included in the operations manual (OM). The minimum tracer drug availability to receive project fund allocation will be 70 percent. The data will be based on routine reporting verified through 20 percent independent verification by an independent organization. The independent verification function may be performed by the government audit agency whose report must be cleared and accepted by the World Bank. Project resources will be made available for the provision of consulting services, non-consulting services and the financing of operating costs for the government audit agency. Component 2: Improve management of health facilities (US$14,470,000 equivalent). Sub-component 2.1: Increase geographic accessibility (US$10,086,000 equivalent) The government is also decided to improve and upgrade basic infrastructure and service availability. Based on data from the updated health map (evaluation of needs in existing health facilities and identification of areas with a shortage of health facilities), objective and consensual criteria will be defined through an inclusive process involving grassroots stakeholders. They will also serve as guidelines for the implementation of new health facilities and housing for health personnel in the most disadvantaged districts. Based on rapid assessment of beneficiary communities and locations, the project will fund the construction of peripheral health facility (PHF) and accommodation for health personnel in the four most deprived regions and provinces. The structures will mostly be prefabricated turn-key facilities with minimal on-site construction – e.g. water and sewage and connection to other public utilities. Facilities will be equipped with a solar power system to generate electricity for the health facility and housing. Health facilities to be installed will be either Type I PHUs or Type II PHUs depending on the population served and in accordance with Public Disclosure the health standards document. A prototype design will be developed and approved by the World Bank. The principle of 2,500-5,000 population per facility within a 5-kilometer radius for a Type I PHU and 5,000-15,000 for a Type II PHU will be used to determine location. Special dispensations will however be given to spatial locations with lower populations but with greater need. The project will provide for each newly built CHC, soft furnishing, motorbikes, bicycles, laptop or notepad. It will also make available healthcare equipment in compliance with the minimum package of care in accordance with the health standards document and essential inputs that supports functionality of the new facilities through the provision of small works, goods, consulting services, non-consulting services and the financing of Operating Costs for the government audit agency. Community accountability with health facility management Sub-component 2.2: Introduce stakeholders and private sector participation in health services management (US$4,384,000 equivalent) The project will support the introduction of Private Sector Management (PSM) of public facilities to improve selected secondary and tertiary hospital managerial and technical performance. This will be done using consultants and in close collaboration with development partners including the International Finance Corporation (IFC). Project proceeds will be used to fund performance-based management contracting fees, which may include elements related to financial management, drug availability, service quantity and quality outputs and outcomes for maternal and newborn care as well as surgical services, management of hazardous waste and implementation of Infection Prevention and Control (ICP) measures. A sliding scale ratio of payment of the contract between the facility and the project will be introduced after the first year based on an independent review. A decision point will be reached after two years to either continue or stop the support depending on outcome of performance. When stopped the resources will be reallocated in consultation with the government. Other stakeholders will be involved in the accountability and community participation process alongside the private sector. These include patients' associations, local elected Feb 04, 2021 Page 7 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) officials (communes), CSOs, media, etc. Project resources will be made available for the provision of consulting services, non-consulting services and the financing of operating costs. Component 3: Strengthen the national social health insurance scheme (US$3,579,000 equivalent). Sub-component 3.1: Establish a system for management of a social health insurance The project funds will support the establishment and operations of a newly established Social Health Insurance Authority building on existing systems and lessons learnt. This will consolidate the various existing schemes into a single harmonised scheme covering both the formal and informal sector. This will include both a premium-based and medical aid scheme. The government has initiated the processes for the development of a new institutional framework and legislation for implementing a national social health insurance scheme. The project will support all processes for the review and adoption of the policy, institutional framework and legislation. It will also support awareness creation for the policy and legislation of the scheme. The project will finance the establishment and the functioning of the THIA secretariat through the provision of consulting services, non-consulting services and the financing of operating costs. Enhanced biometric registration and mobile renewal systems: There are several innovative technologies being introduced to improve membership registration, retention and management. The project will leverage on the World Bank supported Safety Nets and Basic Social Services project (P157038) or eID project and other data base systems e.g. school enrolment and youth-ID card to enrol members onto the scheme. Hardware and software as well as consumables will be procured. Technical assistance will be provided to design the institutional framework; and Public Disclosure support the determination of membership fees calibrated according to the formal and informal sector and socio- economic groupings through the provision of consulting services, non-consulting services and the financing of operating costs Technical assistance will be provided to review, streamline, and rationalise various processes of the SHI scheme linked to the services financed under Component 1. Assistance will also be provided to support the determination of the tariffs and methods of payment – diagnostic related group, capitation or fee for service. The aim is to focus the scheme on prioritising primary health care while ensuring continuum of care at the specialised level. The project will fund technical assistance to review and introduce process efficiency, reduce fraud, guarantee value for money and long-term sustainability of the scheme through the provision of consulting services, non-consulting services. Strengthen the clinical standards and contracting process: The review and setting of the clinical standards and the facilities contracting process will be done. New and simpler assessment tools will be developed to rationalise facilities categorisation, licensing, accreditation and contracting in collaboration with the MHPH and all stakeholders. The aim is to reduce multiplicity and transaction cost to both providers, government, and the insurance agency. All assessment tools will be deployed electronically with automated scoring and grading system. A core group of staff will be trained to support scheme management, monitoring and evaluation of activities of the TSHIA. Where needed technical experts will be recruited or core staff trained to anchor the system for two years through the provision of goods, non- consulting services, consulting services and training and the financing of Operating Costs. Sub-component 3.2: Promote demand for health insurance services This sub-component includes the roll-out of a national health insurance campaign, education and public awareness program. This will include health education and promotion activities to inform the public of the scheme, its benefits Feb 04, 2021 Page 8 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) and the rights of the beneficiaries. Several communication support materials will be developed in print, for radio, television and social media. There will also be community level durbars and mobilization activities funded under the project. Component 4: Strengthen governance and management of the project (US$1,935,000 equivalent) Sub-component 4.1: Assure project management and coordination This sub-component includes finance for operating costs of a Project Coordinating Unit (PCU) and salaries of international and national consultants who will be hired by this unit. It will also support operating costs of including coordination, contracting, monitoring and evaluation as well as project management. There will be comprehensive training and coaching for all implementing agencies. This will include those involved in managing the contracts under the private management of public facilities scheme and performance-based contract management for the specialist facilities and the verification and counter-verification processes in the peripheral health facilities. Support will also be provided for the fiduciary functions; the exact nature will depend on needs assessment and the corresponding action plans prepared. Project resources will support the provision of goods, non-consulting services, consulting services and training and the financing of operating costs Sub-component 4.2: Assure the social, environmental safeguard of the project The social and safeguards specialists will be assigned. In addition to the environmental specialist already on board for the project, a social specialist will be assigned. Once in place these will be responsible for the development and implementation of the Environment, Social and Community Engagement plans. The government will receive technical Public Disclosure assistance to assess and improve the plans and support the installation of adapted waste disposal systems as needed to improve waste management in the project areas. Several mitigation measures may be relevant, including adjusting infrastructure norms to address known risks and possible climate change. The Project will support the provision of goods, non-consulting services, consulting services and training and the financing of operating costs. Project proceeds will not finance land acquisition. Component 5: Contingency Emergency Response Component (CERC) (US$0 equivalent) This component is included under the project in accordance with Operational Policy (OP) 10.00 paragraphs 12 and 13, for contingency emergency response to an eligible crisis or emergency, as needed. It will allow the Government to request the World Bank for rapid reallocation of project funds and respond promptly and effectively to an eligible emergency or crisis that is a natural or man-made disaster or crisis that has caused, or is likely to imminently cause, a major adverse economic and/or social impact. If the World Bank agrees with the determination of the disaster and associated response needs, this component will draw resources from the categories financing other components and/or allow the government to request the World Bank to recategorize and reallocate financing from other project components to cover emergency response and recovery costs. This component could also be used to channel additional funds should they become available because of an emergency. Disbursements will be made against a positive list of critical goods or the procurement of works and consultant services required to support the immediate response and recovery needs. The funds should be reallocated to achieve the key indicators in the Results Framework. The details will be defined on activation of the component as per World Bank Operational Policy Feb 04, 2021 Page 9 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) 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 proposed operation will be nationwide. Togo has several areas of high biodiversity value such as protected areas, wetlands and some mountain areas. The project intervention areas are urbanized and inhabited environments, and will not be in the vicinity of these high biodiversity value areas. Based on the assessment of the baseline characteristics for potential project sites, no major environmental issues are anticipated. The project’s activities combined with the enhancing of social health insurance system will lead to a high attendance to health centers and thus to an increase medical waste. These require specific attention to ensure that they are well managed and do not constitute a threat to community health, and also that groundwater resources are not placed at risk of contamination. On the social side, it is anticipated that most of the planned construction – of Community Health Clinics (CHC) and accommodation for health personnel - would take place within existing health facilities thus largely avoiding land acquisition, restrictions on land use or involuntary resettlement leading to economic and/or physical displacement. A RPF) has been prepared to address any risks of involuntary resettlement. In addition, specific social risks management measures will be established to include vulnerable groups, including persons with disabilities, among the project's beneficiaries. Measures will also be taken to support a complaints management system, citizen engagement, Sexual Exploitation and Abuse or -Sexual Harassment (SEA/SH) and Violence Against Children (VAC) and prevent child labor. Community sensitization and capacity building activities will be carried out in order to engage the project's key stakeholders in E&S risks management; sensitization will include the management of solid waste and dissemination of information on the overall delivery of health centers, complaints management, SEA-SH and VAC, citizen engagement, and so on. women are fully in charge of taking care of their household’s daily health and other needs and are often, Public Disclosure more affected by disease due to their lack of voice and their lower access to public services and to other social, political, and economic resources. This negatively impacts their capacity to receive assistance from healthcare centers amid an outbreak of disease. Women, young people, ethnic minorities, elders, and disabled people are the most vulnerable in the aftermath of disease. Therefore, the proposed project will promote building community resilience and gender empowerment as a key element to staying healthy. D. 2. Borrower’s Institutional Capacity The Government of Togo has an acceptable legal and regulatory environmental and social framework, as well as a national agency that oversees the approval of environmental and social studies, and the monitoring and evaluation of such studies. This agency is not well staffed but its capacities regarding environmental risks management are considered acceptable. On the side of social risks management, however, its capacities are deemed weak, even where it has received capacity-building support on environmental and social risk management through World Bank-financed projects, including on the Bank’s environmental and social standards requirements. Capacity building is required to enable this structure to fully play its role. The project will be implemented by the Ministry of Health and Public Hygiene (MHPH). This Ministry has implemented numerous World Bank-financed projects in the health sector over the years but this is only the second project to be prepared under the Bank’s Environmental and Social Framework (ESF) that Togo’s MHPH will implement. This capacity is acceptable to implement the Bank’s ESF through the recruitment of an environmental specialist and a social specialist who will also benefit from capacity building throughout the project implementation. The project’s Environmental and Social Commitment Plan (ESCP) will therefore include targeted support to build the capacity of MHPH staff, including training topics on environmental and social risks management. Feb 04, 2021 Page 10 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate Environmental Risk Rating Moderate The project will fund the construction of Community Health Clinics (CHC) and accommodation for health personnel to help expand health services to the most deprived regions and provinces of Togo. This new operation will also support the construction of other additional facilities as part of the Environmental, Social and Community Engagement Strategy. In addition, small investment grants will be made available to eligible public district health facilities to help them increase their services and to help prepare them to receive patient referrals from the CHC. Based on the nature and magnitude of the activities and investments planned as well as medical waste due to project activities and existing Medical Waste Management Plan (MWMP) and available incinerators in some hospitals, potentially adverse impacts on the environment and risks to it are deemed site-specific, reversible, and manageable. A hazardous waste management plan (HWMP) has been prepared to improve the technology to manage medical solid waste and waste water including those related to COVID-19. This plan focuses on the institutional capacity improvement as well as financing, monitoring and evaluation mechanisms. The draft ESMF and HWMP will be disclosed prior to the project appraisal and the appointed environmental specialist in the project preparation team will continue environmental risks management until the implementation phase. In case this option is not possible, another environmental specialist will be hired for the same responsibilities in the implementing PIU. For all these reasons, the Environmental risk is rated as Moderate. Public Disclosure Social Risk Rating Moderate The social risks associated with the project’s expected activities are considered Moderate. The proposed project will finance the construction of Community Health Clinics (CHC) and accommodation for health personnel to help expand health services, including additional facilities, as part of the Environmental, Social and Community Engagement Strategy. Although the construction of the Community Health Clinics (CHC), and of the accommodation for health personnel will be on existing site belonging to the administration, the assessment conducted during the preparation of the dropped project on which this one shows that there was some sites occupied by private constructions or used for a productive purpose (crops). The specific construction sites are not yet known. Therefore, a Resettlement Policy Framework (RPF) has been developed as due diligence to avoid or minimize issues related to land acquisition, restrictions on land use or involuntary resettlement. The RPF will guide the preparation of any subsequent site- specific Resettlement Action Plans (RAPs), to properly manage the potential negative impacts of involuntary resettlement operations. The RPF, and any RAPs, will be consulted upon, validated at national level and approved by the Bank, and disclosed within the country and on the World Bank's web site. The RPF will be validated, approved and disclosed prior to project appraisal. The other key social risks of the project are: (i) the potential exclusion of vulnerable communities (such as ethnic minorities and pastoralists) during the process to select communities to benefit from the project, despite the fact that special dispensation will be given to certain locations, such as areas with a lower population but greater need; (ii) the potential exclusion of Community Health Nurses, Physician Assistant/midwives and community health volunteers from capacity building activities and training; (iii) SEA/SH, and VAC risks, during capacity building operations and the construction of Community Health Clinics; (iv) the risk of the use of child labor during civil works; and, (v) social conflict within the same community and/or between communities during the project’s implementation. The ESCP will Feb 04, 2021 Page 11 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) include a communication strategy with sensitization/information and citizen engagement activities oriented to the project's key stakeholders (mainly local communities), as well as social risks management measures to anticipate any potential risk and impact mentioned above to meet the project-relevant ESSs of ESF requirements. The Project Implementation Unit to set up under the MoH must include a social specialist to take over social risks management during the project’s preparation and implementation phases. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: This standard is relevant. This ESS requires that the Borrower carry out an assessment of environmental and social risks and impacts of the project. An environmental and social risks assessment is required and strong measures are advocated to mitigate the specific risks and impacts accordingly. The Borrower has prepared an Environmental and Social Management Framework (ESMF), as the exact locations of activities to be financed by the operation are not known yet. The ESMF lays out procedures for screening and mitigating the potential impacts of sub-projects. It includes the following: (a) checklists of potential environmental and social impacts and their sources; (b) procedures for the participatory screening of proposed sites and activities, and the environmental and social considerations; (c) procedures for assessing the potential environmental and social impacts of the planned project's activities, including cumulative impact; (d) institutional arrangements for avoiding, minimizing, mitigating, and managing the identified impacts, according to mitigation hierarchy; (e) environmental and social management planning processes for Public Disclosure addressing negative externalities in the course of project implementation; (f) a system for monitoring the implementation of mitigation measures; and, (g) institutional capacity assessment and capacity building measures . The ESMF also includes, measures to address SEA-SH and VAC. Additionally, the ESMF makes use of the general and sector-specific World Bank Group Environmental, Health and Safety Guidelines (EHSGs) for the identified sub- projects. When project sites are identified, and based on the results of the screening, the required site specific environmental and social instruments will be prepared. In addition to the ESMF, a hazardous waste management plan has been prepared has been prepared to prevent the potential environmental, social and health impacts and risks related to the production of hazardous waste in the context of the implementation of the project. Lastly, the Borrower is preparing an ESCP that includes the commitment and the timeline for the preparation of subsequent environmental and social instruments and other actions and measures to comply with ESS1 and the other relevant ESSs requirements. ESS10 Stakeholder Engagement and Information Disclosure The Borrower has prepared an inclusive Stakeholder Engagement Plan (SEP) in consultation with the Bank that will disclose prior to the project appraisal. Key project stakeholders include: authorities responsible of health insurance agencies at national, regional and villages levels, health personnel and community health workers, population groups most at risk from malaria (pregnant women, children under 18 years old, etc.). The SEP outlines the main characteristics and interests of the relevant stakeholder groups, including potentially affected people and vulnerable groups, as well as the timing and methods of engagement envisaged throughout the project life-cycle. The SEP includes plans to ensure that vulnerable stakeholders are engaged in a way that is safe and allows them to voice their concerns, such groups separated by sex and with facilitators of the same sex as the participants. The SEP includes an Feb 04, 2021 Page 12 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) outline for the establishment of a project Grievance Mechanism (GM). It also outlines the ways in which the project team will communicate with key stakeholders and includes a mechanism by which key stakeholders—mainly those that will be potentially affected—can raise their concerns, or make complaints about activities related to the project. The approved SEP will be updated no longer than six months of the project effectiveness date, to include more detailed information regarding the methodologies for information sharing, for more robust stakeholder mapping, and for the identification of existing community-based platforms that can be used to facilitate effective community engagement and participation, as well as monitoring and evaluation . The Borrower will engage in meaningful consultations on policies, procedures, processes and practices (including grievances) with all stakeholders throughout the project implementation life cycle, and provide them with timely, relevant, understandable and accessible information. A project-wide GM, proportionate to the potential risks and impacts of the project, will be established. The GM will be accessible to the key stakeholders, that is mainly potentially affected people and vulnerable groups (including those with disabilities and those who are not literate or have a weak command of Togo’s official language). The SEP includes measures to ensure effective and appropriate communication about the existence of the GM to the key stakeholders, including potentially affected people and vulnerable groups, in accessible formats and appropriate languages. The project's GM will safely and ethically register complaints and address and properly document SEA/SH allegations during project implementation. Given the current situation of COVID-19, the SEP was drawn up in line with the guidance provided by the World Bank technical note related to public consultation in a situation of constraint, and in accordance with national measures against COVID-19. Public Disclosure B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This standard is relevant. The project activities will be carried out by a Project Implementation Unit (PIU) under the MoH. The PIU team will include civil servants and consultants hired to support the technical areas for which weak institutional capacities were assessed. The project will also include indirect workers, such as regional and provincial health administrators, community administrators, contractors and subcontractors, including potential workers from communities neighboring the investment sites and/or primary supply suppliers, as well as local community organizations and volunteers from project areas communities. The terms and conditions of the contracts of all the workers involved in the project need to be made in accordance with the national labor law and meet the requirements described in ESS2 to ensure that working conditions be acceptable. A Labor Management Procedure (LMP), drawn up in accordance with national regulations and the ESS2 requirements, has been developed and will be disclosed by the Borrower prior to project appraisal. The LMP includes the terms and conditions of employment, non- discrimination and equal opportunities, workers' organizations, measures to prohibit child labor and forced labor, grievance redress mechanisms for labor disputes, and occupational safety and health measures for the workers, including SEA-SH and VAC for both direct and contracted workers. ESS3 Resource Efficiency and Pollution Prevention and Management Feb 04, 2021 Page 13 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) Energy use efficiency: Some equipment, such as vaccine fridges, medical imaging equipment, blood cold chain systems, and other technology will need energy to operate. For energy efficient use, rationalization measures need to be determined. Similarly, vaccine fridges and blood cold chain systems could induce environmental adverse impacts such as more CO2 emissions. Therefore, site specific ESIA/ESMPs will include adequat mitigation measures to address the issues of which chemicals are permissible in keeping with national and international conventions (Montreal Protocol). Air emissions: During the project implementation phase, air emissions will be moderate, generated by vehicles, machinery and construction, and the rehabilitation of clinics and accommodation for health personnel and other additional facilities, as part of the Environmental, Social and Community Engagement Strategy. The ESMF includes general measures such as watering the ground during the work, covering materials during transportation, maintenance of vehicles and machinery to reduce the impact of dust and smoke from vehicles and machinery. Where needed, additional specific measures will be provided by the ESIA/ESMPs to meet emissions norms. Noise: Some impact from noise is foreseen during construction/rehabilitation, which could be a nuisance for the surrounding communities. The ESMF includes general mitigation measures to minimize and manage the level of noise from the vehicles and equipment construction companies use to carry out civil works. These measures will be detailed in ESIAs, to be prepared later, as necessary. Waste management: The project will be involved in construction/rehabilitation of health facilities. Therefore, there will be solid waste management but likely not in large quantities. Notwithstanding this, waste coming from Public Disclosure excavation and demolition is expected. Site specific safeguards’ documents will include adequate measures to minimize waste production upstream and encourage recycling where possible. More especially regarding hazardous chemicals, medical materials and medical waste, the Borrower has prepared a Hazardous Waste Management Plan (HWMP) outlining the measures to be taken during the project implementation. ESS4 Community Health and Safety The project will finance the construction of Community Health Clinics (CHC) and accommodation for health personnel, including additional facilities. These activities may have negative effects on the health, safety, and security of the riverside communities at the work sites. The ESIAs to be developed for each of the construction sub-projects will determine whether a specific labor influx management plan is required (in the case of significant impacts) or whether (in a low risk scenario) the ESMP can include labor related clauses. For all the civil works in this proposed project, the ESMP will need to request the contractor to settle and regularly update a security system around the project sites (such as fences and security guards) and issue a code of conduct agenda to workers for the entire civil work period. Equipment and vehicles/engines will be brought together to the base building site and secured when the work is stopped to ensure both community and worker safety. Experience indicates that the influx of workers into project areas can lead to adverse social impacts on local communities, mainly in rural areas, such as SEA-SH and VAC, communicable diseases. A SEA/SH risks assessment was carried out using the SEA/SH draft Health sector risk assessment tool and expert assessment, indicating a moderate risk level of project activities. Mitigation measures will be recorded in an appropriate and proportioned action plan to ensure SEA/SH survivors have a safe and confidential venue to report cases created or exacerbated by project implementation, such as connections with local women’s Feb 04, 2021 Page 14 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) groups or centres d’écoute. The SEA-SH and VAC action plan disseminating risks will be regularly updated, and the appropriate mitigation measures will be fully reflected in the project's ESMPs and in tender documents, including measure specific to health projects, such as ensuring that end users are aware of the costs of health services and medicines and training health service providers on clinical management of GBV and referral protocols. A code of conduct covering actions to prevent SEA-SH and VAC will be prepared and included in bidding documents. The project's GM will address any project-related SEA/SH or VAC complaint. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This ESS is relevant even if it is clearly mentioned in the project document that the project proceeds will not finance land acquisition. It is anticipated that most of the planned construction in the project should take place within existing health facilities. However, some construction is expected to happen in sub-urban and rural areas, where acute land use and involuntary resettlement issues arise, leading sometimes to economic and/or physical displacement. As the specific sites of the planned construction are not yet known with any precision, the Borrower has prepared an RPF as a due diligence measure. Thereafter, wherever needed, a site-specific Resettlement Action Plan (RAP) will be prepared to properly manage potential negative impacts of involuntary resettlement operations when the precise construction sites are known based on the approved RPF's provision. The RPF will be reviewed, consulted upon, validated at a national level, approved by the Bank, and disclosed both within the country and on the World Bank's web site prior to project appraisal. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources Public Disclosure Potential impacts on biodiversity were assessed during the preparation of the ESMF and are so far negligible. The project is not anticipated to affect or involve activities with negative impacts on biodiversity or natural resources. The constructions of the project will take place in urbanized and inhabited environments where there is no biodiversity to consider. Further impacts on biodiversity or modified habitat will be assessed during the preparation of site specific ESIA/ESMPs. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard is not relevant: There are no Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities in the project area. ESS8 Cultural Heritage This Standard is relevant. It is not anticipated that the project will impact cultural heritage. However, the project will finance the investments that will involve excavation during construction and demolition during the rehabilitation of some infrastructure. The environmental and social assessment will, through consultations with the Ministry of Culture, identify any cultural heritage in project areas, and outline chance finds procedures to be carried out if any cultural heritage is come across during civil works. All construction and rehabilitation contracts will include a “Chance Find” clause, and reflect the chance finds procedures outlined in the E&S assessment, which will require contractors to stop construction/rehabilitation in the event that cultural heritage is encountered during civil works. Feb 04, 2021 Page 15 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) ESS9 Financial Intermediaries This standard is not relevant for this operation. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: This project will not use the Borrower’s Environmental and Social Framework in the assessment, nor in the development and implementation of investments. However, it will comply with relevant national legal and regulatory requirements. Public Disclosure IV. CONTACT POINTS World Bank Contact: Anthony Theophilus Seddoh Title: Senior Health Specialist Telephone No: 5269+4612 / 233-30-221-4612 Email: aseddoh@worldbank.org Contact: Mariam Noelie Hema Title: Health Specialist Telephone No: 5336+6712 / 228-225-36712 Email: nhema@worldbank.org Borrower/Client/Recipient Borrower: Office of the President Borrower: Ministère de l'Economie et des Finances Implementing Agency(ies) Implementing Agency: Ministry of Health, Public Hygiene and Universal Access to Care V. FOR MORE INFORMATION CONTACT Feb 04, 2021 Page 16 of 17 The World Bank Togo Essential Quality Health Services For Universal Health Coverage Project (P174266) 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): Anthony Theophilus Seddoh, Mariam Noelie Hema Practice Manager (ENR/Social) Nicolas Perrin Cleared on 23-Dec-2020 at 14:49:1 GMT-05:00 Public Disclosure Feb 04, 2021 Page 17 of 17