Public Disclosure Copy COMBINED PROJECT INFORMATION DOCUMENTS / INTEGRATED SAFEGUARDS DATA SHEET (PID/ISDS) APPRAISAL STAGE Report No.: PIDISDSA17597 Date Prepared/Updated: 16-May-2016 I. BASIC INFORMATION A. Basic Project Data Country: Belarus Project ID: P156778 Parent Project ID (if any): Project Name: Belarus Health System Modernization Project (P156778) Region: EUROPE AND CENTRAL ASIA Estimated 16-May-2016 Estimated 25-Oct-2016 Appraisal Date: Board Date: Practice Area Health, Nutrition & Population Lending Investment Project Financing (Lead): Instrument: Sector(s): Health (100%) Theme(s): Health system performance (50%), Injuries and non-communicable diseases (30%), e-Government (20%) Borrower(s): Republic of Belarus Implementing Ministry of Health Public Disclosure Copy Agency: Financing (in USD Million) Financing Source Amount Borrower 0.00 International Bank for Reconstruction and Development 125.00 Financing Gap 0.00 Total Project Cost 125.00 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 Repeater project? Page 1 of 11 Public Disclosure Copy B. Introduction and Context Country Context Belarus is an upper middle-income country with a population of 9.5 million, similar in size to many central and eastern European countries and strategically located between the European Union (EU) and Russian Federation. Up until 2008, Belarus was economically strong, with an average gross domestic product (GDP) growth rate of 8.3 percent during 2001–2008, exceeding the rates for the Europe and Central Asia region at 5.7 percent and the Commonwealth of Independent States (CIS) at 7.1 percent. However, since the onset of the global financial crisis in 2008, Belarus has experienced significant economic instability. Growth slowed down substantially and the country has gone through recurring macroeconomic turmoil. A weak external environment, accumulated macroeconomic imbalances, and delays in structural reforms have put Belarus on a low growth path. Although real GDP grew modestly in 2013–14, the macroeconomic situation remained fragile. In 2013, real GDP growth slowed to 1 percent, slightly accelerating to 1.6 percent in 2014. The modest growth, however, was accompanied by monetary expansion, leading to double- digit annual inflation of around 16 percent in 2013 and 2014. From the beginning of 2015, real output has been contracting for the first time in two decades. From January to August 2015, real GDP dropped by 3.5 percent year-on-year due to weaker demand from Russia and Ukraine. Overall, the economic outlook for the future shows significant challenges ahead, if global conditions remain weak, domestic macroeconomic vulnerability continues, and structural reforms are delayed. Equity and social welfare are the key principles of the country’s economic model. In 2010, poverty rates according to the international poverty lines of US$2.50 and US$5 per day were 0.1 percent and 4 percent (the latest available data), respectively, far below the Europe and Central Asia regional averages of 5.8 and 18.8 percent, respectively. In the first half of 2015, the Public Disclosure Copy estimated poverty rate remained unchanged at 3.5 percent compared to the same period in 2014. Sectoral and institutional Context The current Belarussian health care system is based on a hierarchical and nationally controlled system staffed by state employees. Incremental change, rather than radical reform, has been the landmark of the health care policy. The Ministry of Health (MoH) has overall responsibility for the health care system, although the funding and purchasing of primary and secondary care is devolved to the regional level, which includes six regions including the capital city of Minsk. Highly specialized tertiary care hospitals are funded directly from the MoH budget. There are very few privately owned service providers in the country. Planning for capital investments has been based on legal minimum requirements that have focused on the required inputs. However, per capita budgeting has been introduced for primary care, which has led to some shift toward planning infrastructure according to demographic needs. The MoH is responsible for planning and management functions which are largely integrated. The MoH plays the main regulatory role at all levels of the health system, although regional and district governments are also key stakeholders given that they are responsible for financing the system at their level. Life expectancy at birth has not changed substantially in this period (72 in 2013 compared to 71 in 1990 for both sexes), although there have been some improvements more recently. Average life expectancy for women is now higher than it was before independence (77.9 years in 2013), though lower than the average of 79 years for the WHO European region and disability-adjusted Page 2 of 11 Public Disclosure Copy life expectancy of only 66 years. Average life expectancy for men has improved (65.8 years in 2013), but it still has yet to recover pre-independence levels and is below the European average of 72 years. Both tobacco and alcohol consumption are key factors for this gender gap. Regional disparities are also observed. The existing training capacity is not sufficient to catch up in the short term. The rollout of general practice is destined to stagnate if the necessary large number of new GPs cannot be recruited and retrained. The recommended rollout of general-practice-based PHC requires a mix of measures, including (a) investments in financial and human resources; (b) expansion of GP education and training; (c) improvement of medical information; (c) assessment of the responsibilities and tasks of GPs and nurses; and (d) more efficient health care management at all levels. 1. Integrated Health Information System. There is great opportunity to improve quality of care through e-health according to the population health trends. In order to improve quality of care and better manage health care delivery, information must be readily made available to all health care workers and citizens who need it. Current paper based format makes difficult access to information. E-Health can improve quality of care, through a variety of means including: - Reducing delays or duplication of services, due to medical records not being accessible between different sites; - Collecting information about performance of different providers, polyclinics and hospitals and holding them accountable for achieving quality of care; - Prompting healthcare providers on the latest clinical best practices are (i.e., drug use, tests or other services); - Reducing medical errors due to certain issues such as illegible handwriting; and - Keeping patients informed about their care so they can be part of the decision-making. There is also unfinished agenda of infrastructure modernization. The structural dimension of Public Disclosure Copy quality refers to the environment in which health care is provided and characteristics of the facility where services are delivered. In this regard, through years of economic growth, Belarus has made considerable investment to upgrade infrastructure and equipment capacity at all levels of care. The state programs aim to trigger strategic health care delivery improvements. The most recent priorities have been maternity services, building capacity for cardio surgery, and orthopedic care (endo-prosthesis). Meanwhile, the current economic hardship confronts allocation of resources for infrastructure upgrade, forcing the government to seek alternative resources, particularly for modernization of the obsolete Department of Neonatal Care at the Republican Center of Mother and Child (RCMC). C. Proposed Development Objective(s) Development Objective(s) The proposed project development objective (PDO) is to contribute to improving selected aspects of the quality of health care delivery in the Republic of Belarus. This PDO is expected to be achieved by the: (a) establishment of e-Health system and adoption of ICT-based clinical decision-support tools for quality improvement; (b) improvement of clinical competencies of health care providers in NCD management; and (c) modernization of neonatal care provision at the RCMC. Page 3 of 11 Public Disclosure Copy Key Results The following are the proposed PDO indicators: (a) Percentage of selected health facilities (PHC centers/ambulatories, polyclinics, hospitals, and diagnostic centers) that can electronically exchange patient summaries (b) Number of oblasts using e-prescription (c) Percentage of trained GPs certified to perform emergency services according to standards (certified by the Postgraduate Institute of Physicians [BelMapo] Simulation Center) (d) Percentage increase in survival rate of newborns with low birth weight admitted at the Department of Neonatal Care of the RCMC. D. Project Description The proposed Project would focus on three main areas, namely: (a) the establishment of e-Health system and the adoption of ICT-based clinical tools for quality management; (b) the improvement of clinical competencies of health care providers in NCD management; and (c) the modernization of neonatal care provision at the RCMC. Component 1: Establishment of e-Health and Clinical Decision-support Systems The objective of this component will be to support the government of Belarus in (a) establishing an integrated nationwide health information system based on the available digital information and (b) developing a framework clinical decision-support system for quality improvement, which will ensure effective and up-to-date use of medical information for each citizen and consequently guarantee high-quality health and health care services to the society. This component consists of Public Disclosure Copy two subcomponents: (a) establishment of E-Health; and (b) development of clinical decision support system for quality improvement. Sub-component 1.1 would finance: (a) civil works for rehabilitation of regional offices (oblast level) for housing IT-related infrastructure; (b) advisory support for the design of the e-Health system, standardization of health care digital data and data exchange protocols, standardization and customization of business processes, implementation of digital decision-support tools based on clinical protocols, and improvement of laws, regulations, institutions, and instructions for health information protection; (c) hardware and software, including upgrade of current EMRs and development of the CHIS; (d) training of health providers related to the e-Health system; (e) the beneficiaries satisfaction survey; and (f) study tours. Sub-component 1.2 would finance: (a) advisory support on quality indicators and practice tool development—development of tools, customization and field testing, and clarification of roles and responsibilities; (b) training of clinical staff in selected regions on the use of clinical practice tools; (c) advisory support for incorporation of the flow sheets and practice tools into the EMR; (d) advisory support for the creation of quality monitoring framework, including dashboards for each clinic in selected regions allowing decision makers to monitor a limited number of high-level indicators; (e) publishing reports with established benchmarks to highlight differences in quality between different institutions and identify the highest performers who should be emulated; and (f) development or purchase of a CDSS (the functionality and number of different CDSSs will be specified during the Page 4 of 11 Public Disclosure Copy preparation phase). Component 2: Improvement of Clinical Competencies of Health Care Providers in Noncommunicable Disease Management The objective of this component is to support GP training and improve skills and competencies of health providers in the provision of a broad range of health services conforming to international best practices. Belarus has indicated an interest in expanding the skill labs at medical universities and colleges and creating a Simulation Center at the BelMapo for training of medical professionals at all levels, including undergraduate, postgraduate, and retraining or continuing education for practicing physicians. The intent of such labs and center is to continue the shift toward practice-based skills training rather than theoretical knowledge; shorten the time for training, allowing providers to experience higher volumes of rarer or complex cases; and create a safer environment for training where skills are first learned on a mannequin, simulator, or animal parts before real patients. This component would finance : ((a) advisory support to review the curriculum and development of unified standards for training of GPs as well as specialists; (b) advisory support for the development of a certification program for verifying student/trainee skills; (c) skill labs for all 4 universities and 17 secondary colleges in Belarus; (d) simulation equipment for a high-tech simulation center at BelMapo; (e) skill labs equipment for medical universities and colleges; (f) advisory support to faculties at universities for the establishment of GP departments; (g) training of trainers; (h) civil works to house a high-tech simulation center in BelMapo and skill labs at universities and colleges; (i) software to program different cases for trainees review; (j) study tours (including conferences and workshops); and (k) beneficiary surveys. Component 3: Modernization of Neonatal Care at the Republican Center of Mother and Child (RCMC) Public Disclosure Copy The objective of this component is to support the modernization of the neonatal department at the RCMC in line with the international best practice. This will include infrastructure, equipment and medical staff capacity improvement and advancement of quality improvement measures. It is expected that the modernization of the neonatal department, creation of appropriate infrastructure conditions, provision of modern biomedical equipment, upgrading skills of personnel, and adoption of up-to-date clinical protocols and quality improvement tools will contribute to reducing hospital infection cases and death rate at the department and, as a long-term impact, the disability rate among children born with low and extremely low birth weight. This component would finance: (a) civil works; (b) provision of medical equipment and furniture; (c) provision of telemedicine and simulation equipment, didactic materials; (d) training of medical personnel; (e) study tours; and (f) advisory support to develop quality improvement tools and procedures. Component 4: Project Management, Monitoring and Evaluation The objective of this component is to support the Project Management Unit (PMU) at the national level, which will be responsible for day-to-day project implementation (fiduciary and safeguards) and technical advisory support for Components 1, 2, and 3. This component will also finance Page 5 of 11 Public Disclosure Copy financial audits. This component will sponsor complementary data collection and analytical activities for monitoring results (that is, citizen/beneficiary engagement indicators and so on). Information and data collection from the Republican Scientific and Practical Center for Medical Technologies, Informatization, Administration and Management of Health (RSPC MT) will be complemented through evidence-based data on specific areas and ad hoc household and facility surveys. In addition, the component will sponsor learning events to educate and promote better use of evidence for policy. Component Name Establishment of E-Health and clinical decision support systems Comments (optional) Component Name Improvement of clinical competencies of health care providers in NCD management Comments (optional) Component Name Modernization of neonatal care at the RCMC Comments (optional) Component Name Project Management, Monitoring and Evaluation Comments (optional) Public Disclosure Copy E. Project location and salient physical characteristics relevant to the safeguard analysis (if known) Nationwide. Key considerations for safeguard analysis include: Component 1: Small-scale civil works for the rehabilitation of regional offices (oblast level) for housing IT related infrastructure; Component 2: construction of premises for the establishment of a Simulation Center for post- graduate education of medical trainees and rehabilitation/renovation of premises of four medical universities and seventeen colleges. Component 3: Reconstruction of neonatal resuscitation department at the Republican Center of Mother and Child (located in Minsk). All civil works will be carried out within the footprint/boundaries of existing universities/colleges/medical facilities. Land acquisition and involuntary resettlement are not envisioned. The impacts will be mainly small- to medium-scale and site-specific, and will be mitigated by good housekeeping practices. F. Environmental and Social Safeguards Specialists Alexei Slenzak (GEN03) Jennifer Shkabatur (GSU03) Page 6 of 11 Public Disclosure Copy II. Implementation Institutional and Implementation Arrangements As the central government’s agency responsible for the development of health policy, the MoH would have overall responsibility for implementing the proposed Project. In this capacity, the MoH would (i) maintain a strategic link between the implementation of health sector reforms and effective delivery of the Project; (ii) coordinate Project activities implemented at the national and sub-national levels to make sure they are aligned with the PDO; (iii) liaise with the MoF and other key government agencies to enable smooth Project execution; (iv) coordinate monitoring and reporting under the Project, sending regular reports to the World Bank on progress achieved in the indicators of the Results Framework; (v) monitor Project expenditures and costs; (vi) ensure that the Project Operations Manual (POM) is followed and updated as may be necessary during implementation; and (vii) prepare and distribute consolidated progress reports and final report to the World Bank and relevant government agencies. To assist the MoH in fulfilling these requirements, including fiduciary and safeguards related tasks, the government would establish a Project Management Unit (PMU) consisting of a core team of experts (fiduciary, safeguards—environmental and social aspects-- monitoring & evaluation, and technical) upon effectiveness. An Inter-sectoral Project Implementation Working Group, supported by experts as may be needed, is already on board and will provide overall guidance during preparation and implementation on key areas of the proposed Project. III.Safeguard Policies that might apply Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment Yes The project is categorized as B. The impacts will be OP/BP 4.01 mainly small- to medium-scale and site-specific, which can be mitigated by good housekeeping practices. Because the specific sites under Component 1 will not be known and identified at the Public Disclosure Copy time of appraisal, an Environmental Management Framework (EMF) was prepared appropriate to the nature and scale of project risks and impacts, including a checklist EMP in the annex appropriate to small scale civil works. Site-specific EMPs will be prepared appropriate to the nature and scale of risks and impacts consistent with larger scale civil works/ construction under Components 2 and 3 (i.e. BelMAPO Simulation Center and RCMC). Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources Yes Some sub-projects (i.e. minor renovation works) will OP/BP 4.11 be implemented in historic buildings. Thus, OP/BP 4.11 "Physical Cultural Resources" will be triggered. However, these buildings are being currently used as functioning premises (classes, laboratories, etc.) of medical universities and colleges. Given the scope of Page 7 of 11 Public Disclosure Copy works on renovation and limited scale of potential impacts, the historic and cultural value of these buildings will not be affected as a result of project activities. Belarus legislation and regulations are sufficient to protect the cultural values. The regulations on works in historic buildings will be applied and special permits for such works will be received from the Ministry of Culture. Indigenous Peoples OP/BP No 4.10 Involuntary Resettlement OP/ No If all project-related civil works are carried out on BP 4.12 land owned by BelMAPO, RCMC and other organizations and within its current premises, the World Bank's Operational Policy on Involuntary Resettlement will not have to be triggered. Construction on this site will not require any land acquisition or physical resettlement, and will not obstruct private economic activities. The borrower has proposed sites that will not require land acquisition. A confirmation letter from the borrower will be received only after technical design of the works is ready and submitted for review by respective government officials. Safety of Dams OP/BP 4.37 No Projects on International No Waterways OP/BP 7.50 Projects in Disputed Areas OP/ No Public Disclosure Copy BP 7.60 IV. Key Safeguard Policy Issues and Their Management 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: The proposed Project would support the construction and rehabilitation of facilities. Works planned under the Project will involve new construction of two or three-storied building for the new Simulation Center at BelMAPO and renovation of the Research laboratoryof BelMAPO, construction of a new section of medical premises at the RCMC, and renovation works at four medical universities and 17 colleges for Skill Laboratories and rehabilitation of regional offices for housing IT-related infrastructure. These works are expected to have some temporary negative impacts typical for reconstruction/rehabilitation of small to medium size constructions. The potential negative impacts are perceived to be relatively minor and can be readily mitigated with standard procedures. Based on the safeguards policy and given the expected nature of the works, OP/BP 4.01 Environmental Assessment is triggered and the proposed Project is classified as Category B. An Environmental Management Framework (EMF) was disclosed (in Russian) on the website of the Page 8 of 11 Public Disclosure Copy Ministry of Health and public consultations will be carried out in a number of regions throughout the country. The final version of the EMF in Russian was disclosed on the website of the MoH, and submitted (in English) to the Bank's InfoShop before appraisal. All project works are anticipated to occur within the footprint of existing facilities. For civil works activities at BelMapo and RCMC, site-specific EMPs will be prepared, disclosed and consulted upon at a later stage (after project start). While specific sites have been identified, no environmental and design surveys have been done and the information available to the team at the time of appraisal is not sufficient for preparation of the site-specific EMPs. For renovation works at the regional offices (for housing IT equipment), medical universities and colleges (for housing skill labs) - EMP Checklists (annex to EMF) will be used. Environmental risks of these activities are expected to be modest and limited to the construction sites and to the period of construction works. Some sub-projects (i.e. minor renovation works) will be implemented in historic buildings. Thus, OP/BP 4.11 ?Physical Cultural Resources? will be triggered. However, these buildings are being currently used as functioning premises (classes, laboratories, etc.) of medical universities and colleges. Given the scope of works on renovation and limited scale of potential impacts, the historic and cultural value of these buildings will not be affected as a result of project activities. Belarus legislation and regulations are sufficient to protect the cultural values. The regulations on works in historic buildings will be applied and special permits for such works will be received from the Ministry of Culture. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: No irreversible long-term impacts are expected as a result of the proposed project activities. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. All project activities are focused on specific elements of health infrastructure and medical education facilities. Due to this focus no alternatives have been discussed for activities involving Public Disclosure Copy universities and colleges. Preparation of design for BelMAPO Simulation Center and RCMC will involve the discussion of alternative facility design options at a later stage. 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 Project Management Unit (PMU) will have one designated staff member in charge of safeguards compliance. Since the MoH has no prior experience with World Bank safeguards policies, its staff may receive guidance and on-the-job training from the Bank?s safeguards specialists in the early stages of project implementation. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Key stakeholders include population of Belarus broadly, students of medical universities, colleges, BelMAPO, and RCMC. An Environmental Management Framework (EMF) for the project have been developed. The draft documents (in Russian) were disclosed on the website of the Ministry of Health prior to appraisal start and public consultations will be carried out in project areas (districts and towns) throughout the country. The final version of the EMF in Russian will be disclosed on the website of the Ministry of Health and in English in the World Bank's InfoShop prior to completion of appraisal. During the course of project implementation, citizen engagement mechanisms will assess beneficiaries' satisfaction with the project activities and any grievances arising will be addressed at the project level. Page 9 of 11 Public Disclosure Copy B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 03-Mar-2016 Date of submission to InfoShop 15-Apr-2016 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure Comments: If the project triggers the Pest Management and/or Physical Cultural Resources policies, the 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? If yes, then did the Regional Environment Unit or Practice Yes [ ] No [ ] NA [ ] Manager (PM) review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated Yes [ ] No [ ] NA [ ] in the credit/loan? Public Disclosure Copy OP/BP 4.11 - Physical Cultural Resources Does the EA include adequate measures related to cultural Yes [ ] No [ ] NA [ ] property? Does the credit/loan incorporate mechanisms to mitigate the Yes [ ] No [ ] NA [ ] potential adverse impacts on cultural property? 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? Page 10 of 11 Public Disclosure Copy 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: Susanna Hayrapetyan Title: Lead Health Specialist Borrower/Client/Recipient Name: Republic of Belarus Contact: Title: Email: Implementing Agencies Name: Ministry of Health Contact: Vasily Ivanovich Zharko Title: Minister of Health Email: mzrb@belcmt.by VI. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Public Disclosure Copy Telephone: (202) 458-4500 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop VII. Approval Task Team Leader(s): Name: Susanna Hayrapetyan Approved By Practice Manager/ Name: Enis Baris (PMGR) Date: 16-May-2016 Manager: Country Director: Name: Young Chul Kim (CD) Date: 23-May-2016 Page 11 of 11