Page 1 INTEGRATED SAFEGUARDS DATASHEET APPRAISAL STAGE I. Basic Information Date prepared/updated: 08/06/2009 Report No.: 49936 1. Basic Project Data Country: Dominican Republic Project ID: P106619 Project Name: Health Sector Reform Second Phase APL (PARSS 2) Task Team Leader: Fernando Montenegro Torres Estimated Appraisal Date: June 17, 2009 Estimated Board Date: September 17, 2009 Managing Unit: LCSHH Lending Instrument: Adaptable Program Loan Sector: Health (100%) Theme: Health system performance (100%) IBRD Amount (US$m.): 30.50 IDA Amount (US$m.): 0.00 GEF Amount (US$m.): 0.00 PCF Amount (US$m.): 0.00 Other financing amounts by source: Borrower 13.74 13.74 Environmental Category: C - Not Required Simplified Processing Simple [] Repeater [] Is this project processed under OP 8.50 (Emergency Recovery) or OP 8.00 (Rapid Response to Crises and Emergencies) Yes [ ] No [X] 2. Project Objectives The proposed second phase of this APL is designed within the framework of the overarching objectives of the APL (Adaptable Program Loan) approved by the Board in 2003: (i) improved mother and child health and reduction of poverty; (ii) implementation of new health sector reform laws (42-01 and 87-02), including strengthening the stewardship role of the MOH; (iii) consolidating universal health insurance as the public stewardship organization for the health sector; (iv) development of regional health care networks; and (v) health insurance mechanisms. The Project's Development Objectives are to: (i) improve the capacity of RHSs to deliver, in a timely fashion, quality services known to improve the health of mothers, children and people with chronic conditions by public providers at the first level of care; (ii) improve health system responsiveness, defined here as the institutional capacity of public sector health organizations to conduct strategic purchasing of health care services and goods, and to respond to public health emergencies. 3. Project Description The proposed project is the second phase of an APL (Adaptable Program Loan). It is consistent with the objectives and agreements of the APL, which called for three Page 2 consecutive loans. The first phase -following a restructuring- focused on strengthening health care infrastructure, reorganization of regional health systems, strengthening multiannual financial planning, and supporting expansion of enrollment of the poor in the SR (Subsidized Regime). The project consists of four components: Component 1: Introducing results-based mechanism for the first level of care in Regional Health Services (US$21.49 million - Bank financing US$14.52 million).The component would introduce results-adjusted capitation mechanisms to better align incentives to improve delivery of health services at the first level of care. Component 2: Strengthening the capacity of the MOH to improve health system responsiveness while fostering transparency and accountability (US$10.00 million - Bank financing US$7.00 million). This component's objectives are to strengthen MOH capacity to deliver public health goods and services while fostering transparency and accountability, and to strengthen existing information systems for the adequate functioning of results-adjusted capitations - Subcomponent 2.1. Strengthening the strategic planning and evaluation capacity of the MOH to improve transparency and accountability with an emphasis on improving health system responsiveness. - Subcomponent 2.2. Strengthening monitoring, information and evaluation systems for results-based financing Component 3: Improving quality of public spending on health care goods and services (US$12.57 million - Bank financing US$8.80 million). The objective of this component would be to strengthen coordination and institutional capacity of public sector organizations for more sustainable financing, planning and purchasing of health services and other key inputs needed to improve the quality of health services with an emphasis on primary health care. This component would include three subcomponents. - Subcomponent 3.1. Strengthening public sector planning, procurement and distribution of medicines and medical inputs - Subcomponent 3.2. Strengthening institutional capacity to expand and enhance social protection in health for the poor - Subcomponent 3.3. Overall project coordination and operational costs for implementation of components 1 and 3 Component 4: Support for Public Health Emergencies (US$0.10 million - Bank Financing US$0.10 million). The objective of this component is to support the MOH in coordinating and implementing activities for a swifter and better response to public health emergencies. This component would finance consulting and non-consulting services, technical assistance and goods including medicines, laboratory and protective equipment, laboratory reagents and other medical supplies, development and dissemination of materials for information campaigns, training for emergency preparedness and Page 3 incremental operational costs related to the health sector response to public health emergencies of local or international nature. 4. Project Location and salient physical characteristics relevant to the safeguard analysis The project is national in scope, but will focus on prioritized areas to increase access to primary health services and improved delivery of primary health care services. 5. Environmental and Social Safeguards Specialists Mr Gunars H. Platais (LCSEN) Ms Amy Faust (LCSDE) 6. Safeguard Policies Triggered Yes No Environmental Assessment (OP/BP 4.01) X Natural Habitats (OP/BP 4.04) X Forests (OP/BP 4.36) X Pest Management (OP 4.09) X Physical Cultural Resources (OP/BP 4.11) X Indigenous Peoples (OP/BP 4.10) X Involuntary Resettlement (OP/BP 4.12) X Safety of Dams (OP/BP 4.37) X Projects on International Waterways (OP/BP 7.50) X Projects in Disputed Areas (OP/BP 7.60) X II. 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 project was originally classified as a Category B at the PCN stage, but as project preparation progressed the team found that a Category C would be more appropriate given that the project activities would cause no adverse environmental impacts and no civil works would be financed. OP 4.01 (Environmental Assessment) is the only safeguard policy triggered, which reflects that technical assistance related to environmental aspects will be supported during project implementation. The Bank will work with the client to develop a strategic approach to address biomedical waste management in the health sector, which will capitalize on past analytical work from APL1 and other projects, as well as the approval of recent legislation specific to biomedical waste management (see 4 below). The aim is to have a positive impact on public health, worker safety, and link the notion of improved environmental management to quality health service delivery. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Substandard biomedical waste management is a persistent issue in the Dominican Republic. If managed improperly, the wastes produced by health establishments pose Page 4 health risks for the public and personnel as well as environmental contamination. Past projects have included measures related to biomedical waste management, and while discrete advancements have been noted there is a clear need for macro-level engagement on the issue to support long-term improvements on a national scale. Though the types of risks posed by improper waste management are indirectly related to the proposed project's actual activities, the project is well-placed to provide technical assistance in support of better practices at a strategic level, framing the issue as not only environmental but as one facet of improving the quality of health care. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. N/A 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. Several studies and programs to improve biomedical waste management have been initiated in the past through World Bank projects and by other donors. These have achieved notable results in the short term and in localized areas, but widespread improvements have not been sustained in the long term. Under APL1, an evaluation of biomedical waste management in the Dominican Republic was conducted in 2007. This included a review of the waste management procedures for a sample of health facilities. The evaluation found that the majority of health facilities included in the study was not compliant with relevant laws, most facilities did not have set procedures for biomedical waste, and that personnel were often untrained or did not have the resources for proper waste management. A regulation to the General Health Law was passed in February 2009, which establishes clear procedures and an institutional framework specifically for biomedical waste management. Soon after the regulation was passed the client prepared a manual for healthcare waste management, which included detailed procedures for health centers to create internal institutional structures for waste management (as mandated by the regulation) as well as actual procedures for waste management. The manual requires further strengthening, but is a positive step in addressing both institutional and practical aspects of this issue. Given the foundation of past analytical work (supported by the Bank and other donors) on practices for biomedical waste management in the Dominican Republic combined with the momentum of new legislation, PARSS2 is well-positioned to build capacity within the MOH to implement these procedures. Under the proposed project the client would build on previous work to apply lessons learned from past experiences and develop a strategy to implement measures from the new regulation. The implementing agency currently has low capacity to implement biomedical waste management procedures, lacking staff, capabilities to monitor health facilities' waste management practices and enforce standards, and coordination between other Government actors associated with these issues (e.g. environmental, solid waste, and Page 5 regional health authorities). Authorities are supportive of capacity building activities and have in the past undertaken a limited initiative on training health care professionals on the proper care of biomedical waste management under the auspices of the Japanese aid agency JICA. The government has expressed interest in pursuing a more strategic approach to adopting safeguard measures in its health sector and has asked the Bank to provide technical assistance. Rather than limit the initiative to specific activities of the proposed project, the planned strategy would apply more broadly to the health sector. Terms of reference have been prepared by the client for a consultancy that would include the design of a personnel training program, an environmental management plan, and create educational materials for health workers. The Bank will work closely with the client as the consultancy is carried out, as part of an ongoing strategic engagement with the health sector. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. An initial strategy workshop is planned with the MOH, which will bring together other relevant authorities linked to environmental issues and the health sector. A consultation with outside stakeholders (e.g. NGOs, academia, public health organizations) would take place after the consultancy is underway. B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: Was the document disclosed prior to appraisal? N/A Date of receipt by the Bank 02/19/2009 Date of "in-country" disclosure 02/19/2009 Date of submission to InfoShop 06/19/2009 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Resettlement Action Plan/Framework/Policy Process: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Indigenous Peoples Plan/Planning Framework: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Pest Management Plan: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Page 6 * If the project triggers the Pest Management and/or Physical Cultural Resources, 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: EA disclosure is not applicable. C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? No If yes, then did the Regional Environment Unit or Sector Manager (SM) review and approve the EA report? N/A Are the cost and the accountabilities for the EMP incorporated in the credit/loan? N/A The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank's Infoshop? No Have relevant documents been disclosed in-country in a public place in a form and language that are understandable and accessible to project-affected groups and local NGOs? No All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of measures related to safeguard policies? Yes Have costs related to safeguard policy measures been included in the project cost? Yes Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures related to safeguard policies? No Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? Yes Page 7 D. Approvals Signed and submitted by: Name Date Task Team Leader: Mr Fernando Montenegro Torres 08/05/2009 Environmental Specialist: Mr Gunars H. Platais 06/12/2009 Social Development Specialist Additional Environmental and/or Social Development Specialist(s): Approved by: Sector Manager: Mr Keith E. Hansen 08/04/2009 Comments: