COMBINED PROJECT INFORMATION DOCUMENTS / INTEGRATED SAFEGUARDS DATA SHEET (PID/ISDS) ADDITIONAL FINANCING Report No.: PIDISDSA17758 Date Prepared/Updated: 19-May-2016 I. BASIC INFORMATION A. Basic Project Data Country: Malawi Project ID: P156129 Parent P125237 Project ID (if any): Project Name: Additional Financing to Nutrition and HIV/AIDS Project (P156129) Parent Project Malawi Nutrition and HIV/AIDS Project (P125237) Name: Region: AFRICA Estimated 16-May-2016 Estimated 20-Jun-2016 Appraisal Date: Board Date: Practice Area Health, Nutrition & Population Lending Investment Project Financing (Lead): Instrument: Sector(s): Health (100%) Theme(s): Nutrition and food security (50%), Health system performance (50%) Borrower(s): NAC (NATL AIDS COMMISSION) Implementing DNHA (PART 1)CR5068-MW Agency: Financing (in USD Million) Financing Source Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 22.60 Japan Policy and Human Resources Development Fund 1.08 Total Project Cost 23.68 Environmental B - Partial Assessment Category: Appraisal The review did authorize the team to appraise and negotiate Review Decision (from Decision Note): Other Decision: Is this a No Page 1 of 8 Repeater project? B. Introduction and Context Country Context Malawi is a very poor country with high population growth: Malawi➢❨ s population has quadrupled in the last 50 years, and the fertility rate remains high (5.47 births per woman in 2012). Gross Domestic Product (GDP) growth averaged 4 percent during 2012➢❨ 15 and significantly below the 7 percent targeted under Malawi➢❨ s Growth and Development Strategy. According to the International Monetary Fund➢❨ s (IMF➢❨ s) 2015 Article IV consultation with Malawi, high inflation is hampering real GDP growth, and the economic outlook remains difficult, reflecting the negative impact of weather-related shocks, and the ongoing suspension of budget support by development partners. All these factors have shrunk job opportunities and resulted in Malawi now being the world➢❨ s poorest country with the lowest GDP per capita in the world in 2014. Sectoral and institutional Context Disease burden primarily includes HIV, TB and malnutrition. In Malawi, HIV/AIDS, TB and other communicable diseases, along with malnutrition and neonatal condition, account for around two thirds of the burden of disease. HIV prevalence is one of the highest in the world, with 10.0 percent (1.1 million) of the population living with HIV. The national HIV epidemic varies greatly across the country, with HIV prevalence in Southern regions of Malawi twice as high as Northern and Central regions. Preliminary data from the recent TB prevalence study shows that 300 per 100,000 population ages 15 years and older are infected. The current case finding rate is 52%, and of these, only 50% patients are being treated. Malawi has one of the highest prevalence of malnutrition with 47.1 percent of under five children are stunted despite the country being food surpluses in recent years. Malnutrition is the single biggest contributor to child mortality as it predisposes children to repeated infection and disease. Furthermore, malnutrition has negative consequences on education outcomes, productivity and growth. Health sector delivery constraints. Malawi faces a number of significant challenges to quality health service delivery: (i) there are not enough health care workers to cope with the demand for services (vacancy rates of about 70%), which is leading to ➢❨ down-shifting➢❨ responsibility for service delivery to untrained and volunteer providers; (ii) physical infrastructure is overburdened resulting in services being provided in sub-optimal, sometimes open-air conditions; and (iii) despite the creation of parallel delivery systems and the ongoing reforms of the Central Medical Stores Trust (CMST), stock outs of essential commodities are not uncommon. Furthermore, Malawi➢❨ s US$37.8 per capita annual health expenditure is far below the World Health Organization➢❨ s estimate of US$54 per capita (expressed in 2005 US$ terms) for low income countries to have a fully functioning health system covering a basic package of health services. Progress achieved in health outcomes. Despite these constraints, Malawi has made progress in expanding access to health services and human development outcomes have improved (mainly through targeted, donor-funded, vertical interventions): (i) neonatal tetanus and polio have been eliminated through immunization programs; (ii) estimated annual new HIV infections have been reduced by half from 85,000 in 2004 to 42,000 in 2014; (iii) coverage of insecticide treated bed Page 2 of 8 nets (ITN) to tackle malaria rapidly increased from 8% of pregnant women sleeping under an ITN in 2006 to 56% in 2012 (which contributed to a 30% reduction in infant mortality); and (iv) TB cure rates of over 70% have been maintained despite the high mortality rate fueled by AIDS. Malawi achieved two of the three Millennium Development Goals related to health: reducing child mortality, and combating HIV and AIDS, malaria and other diseases. C. Proposed Development Objective(s) Original Project Development Objective(s) - Parent The project development objective is to increase access to, and utilization of, selected services known to contribute to the reduction of child stunting, maternal and child anemia, and the prevention of HIV and AIDS in children and sexually active adults. Proposed Project Development Objective(s) - Additional Financing To increase coverage of selected nutrition and HIV/AIDS services and strengthen disease outbreak preparedness in project areas. Key Results D. Project Description The Nutrition and HIV/AIDS Project tackles the most significant causes of disease burden in Malawi by focusing on (i) implementing and scaling up ? through public sector and community delivery systems ? the most cost-effective nutrition and HIV prevention interventions, and (ii) supporting the implementation of an emergency disease outbreak preparedness plan. Since the 2014 Government corruption scandal involving the misuse of donor funds, the Bank has been providing fiduciary guidance and continuing to contribute to the HIV pooled fund which supports HIV service delivery and coordination costs associated with the National AIDS Commission (NAC). The HIV Pool was established in 2003 after the NAC was created, and previously co- financed by the Bank, CIDA, NORAD, DFID and the Global Fund. Furthermore, the Project remains as a major source of financing and technical assistance to: (i) implement Malawi?s Voluntary Medical Male Circumcision (VMMC) action plan ? a proven and cost-effective approach to prevent HIV; (ii) strengthen national capacity in multisectoral nutrition planning, coordination, implementation, monitoring and evaluation capacity; and (iii) build national capacity to tackle sudden outbreak of infectious diseases including Ebola. Component Name Component A: Nutritional Improvement Comments (optional) An additional financing of US$12.27 million to Component A (Support for nutritional improvement) will be added to provide support for the Integrated Management of Acute Malnutrition (IMAM) in the 14 drought affected Districts (Mzimba, Rumphi, Nkhotakota, Mchinji, Ntcheu, Zomba, Mwanza, Chiradzulu, Blantyre, Mulanje, Mangochi, Thyolo, Ntchisi, and Manchinga) and to finance eligible expenditures under the NHAP. Component Name Component B: Support for the National HIV/AIDS Strategic Plan (NSP) Page 3 of 8 Comments (optional) An additional financing of US$11.41 to Component B will be added to the finance eligible expenditures under the original project and strengthen health sector M&E Platform. Component Name Component C: Support for Ebola and Disease Outbreak Preparedness Comments (optional) The proposed AF will not finance any of the activities under Component C. E. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project will support services throughout Malawi with HIV and AIDS interventions (including clinical activities) taking place in district hospitals in all Districts, and in a limited number of health centers and mobile clinics in some Districts. Nutrition interventions will target at least 14 Districts (i.e. roughly half of all Districts nationally, namely: Mzimba, Rumphi, Nkhotakota, Mchinji, Ntcheu, Zomba, Mwanza, Chiradzulu, Blantyre, Mulanje, Mangochi, Thyolo, Ntchisi, and Manchinga). F. Environmental and Social Safeguards Specialists II. Implementation Institutional and Implementation Arrangements The institutional and implementation arrangements do not change as a result of the proposed additional financing. The two implementing agencies for the project will be the Department of Nutrition HIV and AIDS (DNHA) for Component A and the NAC for Components B and C. The implementation of the Component A - Nutritional Improvement - is coordinated by the DNHA, which is a semi-autonomous entity reports to the Ministry of Health (MOH). The implementation of the Component B - Support for the National HIV/AIDS Strategic Plan (NSP) - and Component C - Support for Ebola and Disease Outbreak Preparedness is ensured by the NAC, a semi-autonomous agency created for the implementation of the mainly donor-funded HIV/AIDS interventions. Project oversight will be provided by the National Principal Secretaries Steering Committee on Nutrition, HIV and AIDS. III.Safeguard Policies that might apply Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment Yes The storage and disposal of medical waste generated OP/BP 4.01 by the clinical activities is the key environmental issue under Component B and C in the project. To address impacts due to project activities, a Health Care Waste Management Plan (HCWMP) was prepared for the project and re-disclosed on May 10, 2016. Page 4 of 8 Under Component C, the main impacts are associated with minor civil works for the construction of seven Ebola treatment centers with prefabricated materials as well as the operational activities. The potential environmental impacts include clearance of trees on sites, dust emissions, disruption of healthcare services, safety of workers and access of patients and community to services. Poor management of infectious medical waste and improper occupational practices and unsafe handling of infectious waste has the potential to expose health care workers, patients and communities to infections or diseases. Open and uncontrolled slow burning of mixed waste which includes plastic waste produces emissions, such as dioxins and furans, which can be potentially hazardous and carcinogenic. The HCWMP will be implemented across all the districts where this project is operating and site- specific Environment and Social management Plans (ESMPs) have been developed and disclosed for the construction and operation of the infectious control centers under the Ebola component. The new AF does not require any additional safeguards instruments; however more attention will be paid to improving implementation of the HCWMP across all the districts. Natural Habitats OP/BP 4.04 No Project activities will not intrude into new or sensitive areas with natural habitats. Forests OP/BP 4.36 No Project activities will not intrude into new or sensitive areas which are designated forest zones. Pest Management OP 4.09 No Project activities will not procure or utilize harmful pesticides or insecticides. Physical Cultural Resources No Project activities will not be undertaken on new land OP/BP 4.11 where there is possibility of presence of PCR. Indigenous Peoples OP/BP No Project area does not include areas with indigenous 4.10 people. Involuntary Resettlement OP/ No Project activities does not cause any involuntary BP 4.12 resettlement. Safety of Dams OP/BP 4.37 No Not applicable. Projects on International No Project activities will not be undertaken on Waterways OP/BP 7.50 International Waterways. Projects in Disputed Areas OP/ No Project activities will not be undertaken in Disputed BP 7.60 Areas. IV. Key Safeguard Policy Issues and Their Management Page 5 of 8 A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: This AF is not changing any project activities which are expected to increase environmental impacts. The AF will also not include any new projects, so no new safeguard polices will be triggered. However, over the implementation of the project➢❨ s Ebola treatment center component, it has been identified that environment and social due diligence activities have not been well managed. As such, the current AF will emphasize better operational and institutional procedures to ensure implementation of environmental and social implementation measures identified in the site specific ESMPs and the HCWMP. Moreover, the HCWMP will be implemented across all the districts where this project is operating and updates on the status of that implementation will be included in quarterly reports to the Bank. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: There are no potential indirect and/or long term impacts anticipated from future activities in the project area. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. No project alternatives have been considered for this project considering the level environmental risk. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. The borrower is developing site-specific ESMPs to provide measures to minimize adverse effects on the biophysical and socio-economic environment during both construction and operation of the Ebola treatment centers. The borrower has the capacity to implement the safeguard measures identified within those ESMPs as well as the HCWMP. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The HCWMP was disclosed in 2012 and re-disclosed in May 2016. The site specific ESMPs for the 7 proposed Ebola Treatment Centers were disclosed in country as well as through InfoShop on May 18, 2016. B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 18-May-2016 Date of submission to InfoShop 18-May-2016 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure Malawi 18-May-2016 Comments: If the project triggers the Pest Management and/or Physical Cultural Resources policies, the Page 6 of 8 respective issues are to be addressed and disclosed as part of the Environmental Assessment/ Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) Yes [ ] No [ ] NA [ ] report? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the Yes [ ] No [ ] NA [ ] World Bank's Infoshop? Have relevant documents been disclosed in-country in a public Yes [ ] No [ ] NA [ ] place in a form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional Yes [ ] No [ ] NA [ ] responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included Yes [ ] No [ ] NA [ ] in the project cost? Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] with the borrower and the same been adequately reflected in the project legal documents? V. Contact point World Bank Contact: Ziauddin Hyder Title: Sr Nutrition Spec. Borrower/Client/Recipient Name: NAC (NATL AIDS COMMISSION) Contact: Davie Kalomba Title: Acting DG Email: kalombad@aidsmalawi.org.mw Implementing Agencies Name: DNHA (PART 1)CR5068-MW Contact: Felix Phiri Title: Director Email: felixphiri8@gmail.com Page 7 of 8 VI. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop VII. Approval Task Team Leader(s): Name: Ziauddin Hyder Approved By Safeguards Advisor: Name: Nathalie S. Munzberg (SA) Date: 19-May-2016 Practice Manager/ Name: Magnus Lindelow (PMGR) Date: 19-May-2016 Manager: Country Director: Name: Preeti Arora (CD) Date: 19-May-2016 Page 8 of 8