Hainan Health Sector Reform Project Environmental and Social Management Framework WORLD BANK FINANCED HAINAN HEALTH SECTOR REFORM PROJECT (P171064) ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK (ESMF) Hainan Provincial Health Commission January 2020 I Hainan Health Sector Reform Project Environmental and Social Management Framework Table of Contents Executive Summary .................................................................................................... I Abbreviation and Acronyms ...................................................................................... III 1 Introduction ............................................................................................................ 1 1.1 PROJECT BACKGROUND ............................................................................................................ 1 1.2 PROJECT DESCRIPTION .............................................................................................................. 1 1.3 IMPLEMENTATION ARRANGEMENTS ......................................................................................... 3 1.4 PURPOSE AND SCOPE OF THE FRAMEWORK ............................................................................. 5 2 Applicable Environmental and Social Policy Framework .......................................... 7 2.1 WORLD BANK’S ENVIRONMENTAL AND SOCIAL FRAMEWORK (ESF) .................................. 7 2.2 ASSESSMENT OF NATIONAL ENVIRONMENTAL MANAGEMENT SYSTEM ............................... 10 2.3 ASSESSMENT OF NATIONAL SOCIAL MANAGEMENT SYSTEM................................................ 13 3 Environmental and Social Impact and Risk Screening ............................................ 17 ENVIRONMENTAL RISK ANALYSIS: ................................................................................................ 17 SOCIAL RISK ANALYSIS: ................................................................................................................. 19 4 Environmental and Social Baseline ........................................................................ 24 4.1 GENERAL .................................................................................................................................. 24 4.2 ENVIRONMENTAL QUALITY BASELINE..................................................................................... 24 4.3 SOCIO-ECONOMIC CONDITIONS ............................................................................................ 24 4.4 PUBLIC HEALTH CARE SYSTEM IN HAINAN ............................................................................ 25 5. Environmental and Social Management Procedures............................................... 28 5.1 SUBPROJECT SCREENING ......................................................................................................... 28 5.2 SUBPROJECT PREPARATION .................................................................................................... 29 5.3 SUB-PROJECT APPRAISAL AND APPROVAL ............................................................................ 29 5.4 SUBPROJECT IMPLEMENTATION AND MONITORING .............................................................. 29 5.5 SUB-PROJECT COMPLETION AND EVALUATION ..................................................................... 30 5.6 STAKEHOLDER ENGAGEMENT.................................................................................................. 30 6 Environmental and Social Impacts and Mitigation Measures .................................. 31 6.1 ENVIRONMENTAL IMPACT ASSESSMENT AND MITIGATION MEASURES ................................ 31 6.2 SOCIAL RISK ASSESSMENT AND MITIGATION MEASURES ...................................................... 35 7 Institutional Arrangements and Capacity Development Program ............................ 39 7.1 ENVIRONMENTAL AND SOCIAL MANAGEMENT ORGANIZATION OF THE PROJECT ............... 39 7.2 ENVIRONMENTAL AND SOCIAL MANAGEMENT CAPACITY BUILDING PLAN .......................... 41 8 Monitoring, Reviewing and Reporting ................................................................... 46 8.1 INTERNAL MONITORING ......................................................................................................... 46 8.2 EXTERNAL MONITORING ......................................................................................................... 46 8.3 REPORTING SYSTEM ................................................................................................................ 46 9 Information Disclosure and Public Consultation ..................................................... 48 9.1 IDENTIFICATION OF KEY STAKEHOLDERS ................................................................................ 48 9.2 STAKEHOLDER CONSULTATION FROM ENVIRONMENTAL PERSPECTIVES ............................... 48 9.3 STAKEHOLDER ENGAGEMENT FROM SOCIAL PERSPECTIVES................................................... 50 9.4 GRIEVANCE AND COMPLAINT MECHANISM ........................................................................... 51 9.5 INFORMATION DISCLOSURE .................................................................................................... 52 10 Budget ................................................................................................................ 54 II Hainan Health Sector Reform Project Environmental and Social Management Framework Annex 1 Guidance on Environmental and Social (E&S) risk classification for subprojects .............................................................................................................. 55 Annex 2 E&S Screening Checklist ............................................................................ 56 Annex 3 Environmental, Health, and Safety Guideline for Primary Health Care Facilities .................................................................................................................. 59 Annex 4 Stakeholder Engagement Plan ..................................................................... 73 III Hainan Health Sector Reform Project Environmental and Social Management Framework Executive Summary China has made remarkable gains in reducing poverty and enhancing overall health outcomes in the last three decades, fueled by consistently high rates of growth. However, China’s economy has slowed more recently, reinforcing the push towards building human capital especially by supporting population health and productivity. A major round of health reforms was initiated in 2009. While turning around the hospital-centric, fragmented and volume-driven health system to a people-centered integrated care (PCIC) based system, China’s health system is still facing a series of emerging challenges, including a rapidly aging population, a high and increasing burden of non-communicable diseases (NCDs), and insufficient coordination among institutional actors. In such contexts, the Government of China has been collaborating with the World Bank Group (WBG) to respond to these challenges and to leverage the most up-to-date global experience. The World Bank-financed Hainan Health Sector Reform Project (HHSRP) is thus proposed as part of these efforts to strengthen the quality of Primary Health Care (PHC) services and efficiency of the health system in Hainan Province. The project investment is estimated at RMB 1.54billion RMB (USD 220million), including USD 200million from the World Bank loan. The project consists of five components, namely: a) Component 1: Reforming Institutions and Strengthening Stewardship for People-Centered Integrated Care (US$21.15M); b) Component 2: Strengthening PHC service delivery ($82.55M); c) Component 3: Strengthening Healthcare Information System ($59.23M); d) Component 4: Strategic purchasing for quality services (US$43.07M); and e) Component 5: Technical Assistance and Project Management (US$14M). All investments are proposed for existing PHC facilities without expansion, focusing on equipment purchase and deeper institutional, financing, human resource and informational technology reform actions and involved no civil works. Thus, the project activities are not expected with any direct and significant negative E&S impacts. However, considering lack of experience and capacity for the Borrower on E&S management of the World Bank-supported project, the project’s E&S risks is rated Substantial under the WBG’s Environmental and Social Framework (ESF). Specific project activities will be identified until project implementation, therefore, an Environmental and Social Management Framework (ESMF) was developed as the instrument to manage the project-related E&S risks based on the findings of E&S assessment conducted during project preparation. The ESMF describes the general approach to be followed to avoid or mitigate any negative harms resulting from the implementation of project activities on the environment and the people, which includes: - Brief description of project background, activities and implementation arrangements, also the purpose and scope of the ESMF (Chapter 1); - Review of Chinese existing regulatory framework and their enforcement related to E&S management of health sector, in comparison with Good International Industry Practice (GIIP) currently available (Chapter 2); - Justification of project-related E&S risk screening following the ESF requirements (Chapter 3); I Hainan Health Sector Reform Project Environmental and Social Management Framework - Description of environmental and socio-economic baselines in Hainan Province (Chapter 4); - Principles, rules, guidelines and procedures for the screening, assessment, management and monitoring of E&S impacts of sub-projects during project implementation, including E&S eligibility criteria/exclusion list for subproject screening (Chapter 5); - Key findings and recommendations from E&S assessment conducted for the project on impact analysis and mitigation measures (Chapter 6); - Review of existing institutional capacity of the Borrower on E&S management and the project-specific capacity building plan proposed (Chapter 7); - Requirements on monitoring, reviewing and reporting during project implementation (Chapter 8); - Approaches and key findings of information disclosure and public consultation conducted for the ESMF preparation (Chapter 9); and - Budget for E&S management (Chapter 10). In addition, the ESMF is also attached with three annexes as the guidance to support the ESMF implementation, namely: - Guidance on Environmental and Social (E&S) risk classification for subprojects (Annex 1); - E&S screening checklist to be used for subproject screening during project implementation (Annex 2); - A set of Environmental, Health and Safety Guidelines (EHSGs) developed for project-supported PHC facilities in Hainan Province, incorporating requirements on OHS management for health care workforce and chemical/waste management with reference to existing Good International Industry Practice (GIIP) (Annex 3); - A project-tailored Stakeholder Engagement Plan (SEP) to enable meaningful stakeholder engagement and effective Grievance Redress Mechanism (GRM), particularly for ethnic groups and other vulnerable groups (Annex 4). II Hainan Health Sector Reform Project Environmental and Social Management Framework Abbreviation and Acronyms DLI Disbursement Linked Indicators E&S Environmental and Social EIA Environmental Impact Assessment ESF Environmental and Social Framework ESMF Environmental and Social Management Framework EHSG Environmental, Health and Safety Guidelines EMEF Ethnic Minority Engagement Framework EMDP Ethnic Minority Development Plan GIIP Good International Industrial Practice GAP Gender Action Plan GRM Grievance Redress Mechanism HHSRP Hainan Health Sector Reform Project HPHC Hainan Provincial Health Commission HPMO Hainan Project Management Office IA Implementation Agency M&E Monitoring and Evaluation NCD Non-communicable diseases PHC Primary Health Care PHSA Provincial Health Security Agency PIU Project Implementation Units PMO Project Management Office PSC Project Steering Committee SAP Social Action Plan SEP Stakeholders Engagement Plan TA Technical Assistance ToRs Terms of References USD United State Dollar WBG World Bank Group WHO World Health Organization III Hainan Health Sector Reform Project Environmental and Social Management Framework 1 Introduction 1.1 Project Background With the rapid social and economic development in China, the health system has been facing a new series of challenges, including rapid population aging, fragmented healthcare service, high and increasing burden of non-communicable diseases (NCDs), insufficient coordination among institutional actors, decentralized medical financing, limited capacity of Primary Health Care (PHC) facilities to provide quality resources and lack of PHC information accessible to the public, etc. The Government of China is keen to respond to these challenges and to leverage the most advanced international experience. In 2016, a Flagship Health Sector Study, entitled “Deepening Health Reform in China: Building High-Quality and Value-Based Service Delivery”, was undertaken jointly by the WB, the Government of China and the World Health Organization (WHO). Informed by the Study and guided by the 2015 national strategy known as “Healthy China”, China embarked on a new phase of national health reforms, as articulated in the Healthy China 2030 Plan, the 13th Five-Year Health Sector Development Plan and the Health Reform Plan. In April 2018, the State Council issued the Instructions on Supporting Hainan's Deepened Reform and Opening-up at a Comprehensive Scale, which endowed Hainan with a special status as a pilot city which can take a free and innovative reform. As the continuous supports of the WBG in China’s health sector based on the experience and lessons learned from previous WBG-financed projects, the Hainan Health Sector Reform Project (HHSRP) was proposed to improve the service quality of PHC facilities in Hainan and to promote the health and wellbeing of the general population of the province. 1.2 Project Description The overall goal of the Hainan Health Sector Reform Project (HHSRP) is to contribute to improving the quality of primary health care (PHC) services and efficiency of the health system in Hainan Province. Focusing on PHC services (the foundation for people-centered integrated care), the project takes a systematic approach to deliver improved health outcomes for the people of Hainan, which consists of five components with a total estimated investment of RMB 1.54 billion (USD 220million), including USD200 million from the World Bank loan. The project will be implemented within Hainan at a provincial level wideness, covering totally 18 prefectures/counties. More details of project activities are provided in the table below. 1 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 1-1 List of Project Activities Estimated Comp Estimated Implementation Cost onent Name and Description of Component Cost (USD Agency (RMB No. million) million) Reforming Institutions and Strengthening Hainan 148.05 21.15 Stewardship for People-Centered Integrated Provincial Care (PCIC): Health - Reducing institutional fragmentation Commission in primary care services (HPHC) and - Increasing coordination between Provincial 1 HPHC and HPHSA Healthcare - Developing a collaborative approach Security in which providers and patients work Administration together to improve the (HPHSA) self-management of health and, eventually, health outcomes Strengthening Primary Health Service HPHC and 577.85 82.55 Delivery with appropriate support system: Prefecture and to strengthen Family Doctor Team (FDT) County Health performance through a mix of approaches Commissions 2 involving a) capacity building, b) strengthened performance management and targeted incentives and c) supportive demand and supply side measures. HPHC and 414.61 59.23 3 Strengthening Healthcare Information System HPHSA Supporting the Provincial Health Commission HPHC 322.21 46.03 IT capacity: - Strengthening IT governance and 3A stewardship - Support the building of an interconnected Provincial Health Information System Supporting the Provincial Health Security PHSA 91.14 13.02 Agency IT Capacity: - Improve management and upgrade of current HPHSA information services; - Participate in data security and 3B privacy subsystem development; - Enhance operational efficiency by, for example, integrating PHC patient’s identification check, insurance fee receipt information with e-medical insurance platform through issuing 2 Hainan Health Sector Reform Project Environmental and Social Management Framework Estimated Comp Estimated Implementation Cost onent Name and Description of Component Cost (USD Agency (RMB No. million) million) devices and desktop solutions. Strategic purchasing for quality services: PHSA 301.49 43.07 - Progressive improvement in the generosity of the benefit package for 4 outpatient services - Support for PHSA to become a strategic purchaser by introducing performance-based payment to FDTs Technical Assistance (TA) and Project HPMO 98.00 14.00 Management: - Financing key TA that supports the research, development, design and monitoring of specific Project 5 activities - Support for the HPHC and HPHSA to play a strong stewardship role in the health sector - Support for project management Total 1540 220 1.3 Implementation Arrangements Considering the project’s features of wide geographical coverage, large investment and diverse activities, the Hainan Provincial People's Government has established a Project Steering Committee (PSC)/Project Guidance Leading Group to provide guidance on project implementation and support the management of implementation risks. Under the leadership of Vice Governor (in charge of health), and Deputy Sectary-General of the provincial government, the PSC consists of the Provincial Development and Reform Commission (DRC), Provincial Department of Finance (DoF), Provincial Health Commission (HPHC) and Provincial Health Security Agency (PHSA). The PSC will also include representatives from the National Health Commission Reform Office and the National Health Security Administration. 3 Hainan Health Sector Reform Project Environmental and Social Management Framework Figure 1-1 Project Institutional Arrangements HPHC will be the lead implementation agency supported closely by the HPHSA. Drawing on representation from both these entities a Project Management Office (PMO) will be established within the HPHC. The PMO will be headed by the Deputy Director-General of the HPHC, with the Director for Health Reform and the Director of the HPHSA as the two Executive Deputy Directors of PMO. The PMO will be responsible for day-to-day management of the project activities, including carrying out regular supervision missions, monitoring progress on the results framework and preparing progress reports. Expert panels will be constituted as necessary to support the PMO on technical issues cutting across key areas such as health institutional issues, health financing, human resources in health and health information technology. The PMO will also have specialist skills on project management, safeguards and financing. The key Project Implementing Units (PIU) will include the HPHC (together with the centers responsible for specific activities) at the provincial level and prefectural/county levels, the HPHSA and the Social Security Bureaus in the prefectures and counties. The PMO and the PIUs will include a mix of technical, project management and implementation specialists including those skilled in procurement, financial management and safeguards. Some of the key mandates of the three units are outlined below: - Project Management Office/HPHC PIU will provide overall leadership for Project implementation and tracking of Project results and six-monthly reporting, provide technical support and advice for the various Project components and carry out, as needed, the procurement tasks as related to Component 1, 2 and Component 5. - Provincial Center PIU will lead the implementation of Components 1, 2 and 3 A including technical design, planning, implementation, procurement and reporting for these components. The Centers at the provincial level include: a) 4 Hainan Health Sector Reform Project Environmental and Social Management Framework the Center for Disease Control and Prevention; b) the Center for Health Information and Technology; c) the Center for Health Education and Behavior Promotion; d) the Center for Medical Research and Academic Exchange; and e) the Center for Health Services and Management Supervision. Each PIU will develop clear annual task plans, implement the corresponding social and environmental safeguards plans, and at their very core ensure sound finance management and procurement activities where mandated. - Prefecture/County Health Commission PIU: As the frontline agency, the Prefecture/County Health Commission will be responsible for the implementation of Component 2. It will lead the hiring of technical support, capacity building activities, supervision, behavior change and community mobilization and periodic reporting on performance. It will sign a tripartite “service agreement” along with Prefectural/County Social Security Bureaus PIU and THC/CHCs for a set of key priority services and activities to be delivered through FDTs, the service standards expected and supervision arrangements. - The HPHSA PIU will lead the design, planning and rollout out of performance-based payment of the project, overall strategic purchasing capacity building and the advancement of IT linkages (component 3 B) between the HPHSA and HPHC. - Prefectural/County Social Security Bureaus PIU will sign the tripartite service agreements along with the Prefecture County Health Commission PIU and THCs/CHCs for a set of key priority services and activities to be delivered through FDTs, the service standards expected and the performance payments that will be triggered when the results are achieved and results counter-verified by HPHSA. 1.4 Purpose and Scope of the Framework While the project is designed to bring overall Environmental and Social (E&S) benefits by targeting at the improvement of quality and efficiency of Primary Health Care (PHC) services in Hainan, an Environmental and Social Management Framework (ESMF) was developed as the instrument to manage the E&S risks identified based on the E&S impact assessment conducted during project preparation since the details of these activities remains to be determined during implementation. The ESMF will apply to all sub-project activities to be implemented in 18 prefectures and counties of Hainan Province. Following applicable domestic regulatory framework and the World Bank’s Environmental and Social Framework (ESF), this ESMF is designed to improve and enable effective and informed decision-making during project implementation in an environmentally sound and sustainable manner, while encouraging meaningful stakeholder consultation and enhancing social wellbeing. The specific objectives of the ESMF are to: - Establish procedures for screening all proposed sub-projects/investments and identifying the initial environmental and social risks; - Specify measures to manage, mitigate and monitor environmental and social impacts throughout sub-projects’ execution; 5 Hainan Health Sector Reform Project Environmental and Social Management Framework - Develop a project-tailored capacity building plan based on the assessment of existing institutional capacity on environmental and social management; - Develop a project-tailored Stakeholder Engagement Plan (SEP) in compliance with the World Bank’s ESF requirements, particularly the strategy for meaningful and effective engagement of ethnic groups (Ethnic Minority Engagement Framework, EMEF) if relevant to the subproject activities during project implementation. 6 Hainan Health Sector Reform Project Environmental and Social Management Framework 2 Applicable Environmental and Social Policy Framework This chapter summarizes China’s existing legislation on environmental and social management most relevant to the project and how they are aligned with the World Bank’s Environmental and Social Framework (ESF). If there is any revision of national environmental or social laws and regulations applicable to this project during implementation, the ESMF will be updated accordingly. HPMO will supervise the subprojects’ compliance with the regulatory provisions in the ESMF and require the subproject PIUs to comply with environmental and social management requirements in the ESMF. 2.1 World Bank’s Environmental and Social Framework (ESF) The World Bank’s ESF is applicable to this project, under which the relevance of environmental and social standards in the context of this project is summarized in Table 2-1. Table 2-1 Relevance of the World Bank’s Environmental and Social Standards (ESSs) Name of Environmental Relevant No. Remarks and Social or not Standard The project targets at improving quality and efficiency of PHC services in Hainan through deeper institutional, financing, human resource and informational technology reform actions, which will not involve any civil works. No significant adverse environmental and social impacts are anticipated with proposed activities based on the assessment conducted during project preparation. However, considering ESS1: lack of previous experience working with Bank policies and Assessment and the proposed provincial-wide sector reform activities management of involved, the overall environmental and social risk rating is 1 Yes environmental considered substantial for the project. and social risks The project has been prepared under the World Bank’s ESF and impacts policy with an Environmental and Social Management Framework (ESMF) developed for risk management, which also comprises other management instruments applicable to the project including the Poverty and Social Impact Assessment, the Environmental, Health and Safety (EHS) Guidelines for PHC Facilities, the Stakeholder Engagement Plan (SEP) and the Ethnic Minority Engagement Framework (EMEF, part of SEP). ESS2 is relevant to the project. Given the civil works will be not supported under this project therefore there will be no construction workers and community workers involved. The social risk and impact on labor management is low and minor. Doctors involved in the primary healthcare system are not ESS2: Labor considered “direct workers”, and they are following the 2 and working Yes government civil servant management system, which is fully conditions compliance with the national labor management regulations. Therefore, ESS2 is not relevant for such government civil servant except for the provisions on occupational health and safety under ESS2, and the EHS guidelines for PHC facilities was developed as part of the ESMF following WBG EHSGs and other available GIIP. 3 ESS3: Yes In the ESMF, the EHS guidelines provides guidance on the 7 Hainan Health Sector Reform Project Environmental and Social Management Framework Name of Environmental Relevant No. Remarks and Social or not Standard Resource management of wastewater and waste for PHC facilities and efficiency and the control of exposure to infection and radiation, which pollution integrated the requirements of WBG EHSGs and other prevention and applicable GIIP. management Without involving civil works, the project is not expected with labor influx and will not bring any construction nuisance ESS4: to nearby communities. The EHS guidelines for PHC facilities Community 4 Yes developed for the project have incorporated necessary health and measures to avoid and minimize environmental and safety safety risks when health care services are provided in the vicinity of communities. The project investment actives do not involve any direct physical investments, such as extension of primary healthcare center and new disposal sites etc. No civil works is identified based on the FSR and it will be excluded from the project ESS5: Land components through the E&S screening tool as defined in the acquisition, ESMF. However, there may be some subprojects involving restrictions on 5 Yes associated facilities that already exist or are under land use and construction, such as install IT system in the existing new involuntary buildings which will require to submit asocial/resettlement resettlement due diligence report to HPMO for clearance before the subproject is approved. Therefore, ESS5 is considered relevant for the project to apply for the due diligence work to avoid the potential risk of using existing land. Based on current design, the project will neither finance any civil works, nor involve activities with potential risks or impacts associated with natural resources. In addition, as part ESS6: of the sub-project exclusion list, any activity with potential Biodiversity impacts on biodiversity or natural habitat will be excluded conservation from project financing during sub-project screening. 6 and sustainable Yes However, ESS6 is considered relevant as a precaution against management of potential ecological impacts of any "associated facilities" to be living natural identified during project implementation, and the ESMF has resources included measures to ensure that waste management systems of participating Primary Health Care facilities do not impact natural resource. ESS7 is relevant due to high percentage of the population in Hainan is ethnic minorities. A rapid PSIA is prepared during the preparation stage. PSIA conducted baseline study and ESS7: initial stakeholder consultation with project affected people Indigenous especially focused on vulnerable groups and ethnic minorities. peoples It assessed the risk of exclusion of vulnerable groups from /sub-Saharan access to project benefits and proposed measures to provide 7 African Yes meaningful engagement with vulnerable groups and ethnic historically minorities as part of ESMF. To better contribute the project underserved objectives, an Ethnic Monitory Engagement Framework traditional local (EMEF) has also been developed by following ESS7 during communities the project preparation to ensure minority people are engaged at different stages to express their needs and suggestions and has proposed necessary plans and activities, so as to ensure cultural appropriate access and sharing the project benefits by 8 Hainan Health Sector Reform Project Environmental and Social Management Framework Name of Environmental Relevant No. Remarks and Social or not Standard meaningful engagement with the ethnic minority groups throughout the project lifecycle. According to current design, the project will neither fund any ESS8: Cultural 8 No civil works nor involve potential risks or impacts associated heritage with cultural heritage. ESS9: FIs are not involved in this project. This standard is not 9 Financial No applied. intermediaries During project preparation, a stakeholder engagement plan (SEP) including an Ethnic Minority Engagement Framework ESS10: was prepared prior to appraisal to enable the equal Stakeholder improvement of PHC services quality and efficiency for poor 10 engagement Yes and ethnic minorities groups. Following the SEP, the and information Borrower will engage all stakeholders throughout the project disclosure life cycle, paying attention to inclusion of vulnerable and ethnic minorities groups, to provide stakeholders with timely, relevant, understandable, and accessible information. In addition, two EHS guidelines of the World Bank Group1 are considered applicable to the project, namely: - Environmental, Health and Safety (EHS) Guidelines: General EHS Guidelines; - Environmental, Health and Safety (EHS) Guidelines for Health Care Facilities. 1 www.ifc.org/ifcext/enviro.nsf/Content/EnvironmentalGuidelines 9 Hainan Health Sector Reform Project Environmental and Social Management Framework 2.2 Assessment of National Environmental Management System Since the promulgation of its first Environmental Protection Law in 1979, China has gradually established a comprehensive environmental management legal framework. At the national level, there are more than 80 laws, 120 regulations and over 1,000 standards and technical guidelines formulated in relation to environmental quality control, pollution control, natural resource and ecological protection. Meanwhile, many environmental regulations have been issued at the provincial and local levels, whose requirements are even stricter than the corresponding national ones. In the context of proposed project, the following environmental laws and regulations are deemed applicable. Table 2-2 Applicable Domestic Laws and Regulations on Environmental Management No. Name Version Relevance Analysis 1. General Legal Document on Environmental Protection and Pollution Control China’s fundamental and the most “stringent” environmental protection Law of the People’s Republic of China on statute, which lays out general 1 2015-01-01 Environmental Protection principles for environmental protection and describes key instruments for environmental management. Environmental impact assessment is required for construction project to analyze, predict and evaluate potential Law of the People’s Republic of China on environmental impacts caused by 2 2018-12-29 Environmental Impact Assessment project implementation, and to propose mitigation measures to prevent or mitigate adverse environmental impacts. National statute for water pollution prevention and control, which also Law of the People’s Republic of China on 3 2018-10-26 applies to the management of medical Water Pollution Prevention and Control wastewater from the operation of PHC facilities. The impact of medical waste on the Law of the People's Republic of China on environment need to be analyzed, 4 Prevention and Control of Environmental 2018-12-29 predicted and evaluated, and mitigation Pollution by Solid Waste measures need to be developed in accordance with the Law. OHS risks and public risks in relation Law of the People's Republic of China on to medical radiation need to be Prevention and Control of radioactive 5 2003-10-01 analyzed, predicted and evaluated, and pollution mitigation measures need to be . developed in accordance with the Law. Medical waste is categorized as hazardous waste and should be treated National Catalogue of Hazardous Waste 6 2016-08-01 and disposed in compliance with national laws and regulations for hazardous waste. Medical waste is categorized as Management Measures for Hazardous hazardous waste, and its transfer should 7 Waste Transfer Vouchers 1999-10-01 comply with the requirements in the management measures. 2. Protection from Radiation and Medical Waste 8 Medical Waste Management Regulations 2011-01-08 Medical waste is categorized as 9 Management Measures for Medical Waste 2003-10-15 hazardous waste, and shall be managed, 10 Hainan Health Sector Reform Project Environmental and Social Management Framework No. Name Version Relevance Analysis in Medical and Health Institution transported and disposed according to Classification Catalogue of Medical relevant laws, regulations and technical 10 2003-10-10 Waste(Care and Health [2003]287) specifications for medical waste and Technical Specification for Centralized hazardous waste. 11 Incineration Disposal of Medical Waste 2005-05-24 (HJ/T 177-2005) Technical Requirements for Medical Waste 12 2003-06-30 Transfer Vehicles (GB 19217-2003) Management Regulations on Medical Waste 13 of Health Care Facilities in Hainan 2015-03-01 Province (Trial) Opinions of the General Office of the People's Government of Hainan Province on Strengthening the Prevention and 14 2018-05-06 Control of Pollution of Hazardous Waste (Qiongfuban [2018] No. 31) Guidelines for Environmental Supervision 2017-06-0 15 of Hazardous Wastes in Hainan Province 8 Regulations for the Safety and Protection 16 2005-12-01 The medical devices with radio action from Radioisotopes and Radiation Devices risks shall be managed, transported and Specification of Radiation Shielding for 17 2007-04-01 disposed according to relevant laws, Medical X-Ray CT Room (GBZ/T180-2006) regulations and technical specifications. Regulations for the Safety and Prevention of 18 2015-12-01 Radioisotopes and Radiation Devices Technical Specifications for Hospital 19 Sewage Treatment Engineering 2013-07-01 Medical wastewater shall be treated (HJ2029-2013) and disposed in accordance with the Discharge standard of medical waste water technical specifications of the 20 2006-01-01 (GB18466-2005) Technical Specifications for Hospital Technical guidelines for medical waste Wastewater Treatment Engineering 21 water（HF [2003] No. 197） 2004-01-01 (HJ2029-2013). Since the project involves hospitals, the infectious diseases should be controlled Law of the People's Republic of China on to meet the requirements in the Law of 22 Infectious Disease Prevention and 2013-06-29 the People's Republic of China on Treatment Infectious Disease Prevention and Treatment. These measures are applicable to medical and healthcare institutions, Measures for the Administration of disinfection service institutions, and the 23 Disinfection (2016 Amendment PKULAW 2016-01-19 units and individuals engaged in the Version) production and operation of disinfection products. 3．Occupational Health and Safety (OHS) management Labor Law of the People's Republic of 24 2018-12-29 China Contract Law of The People's Republic of General requirements on OHS risk 25 1999-10-01 China management, including clarification of Law of the People’s Republic of China on roles and responsibilities, management 26 2014-12-01 Safe Production process and penalties in case of Law of The People's Republic of China on non-compliance. 27 Prevention and Control of Occupational 2017-11-05 Diseases Guidelines for Prevention and Control of 29 2010-08-01 Methodology and technical guidance Occupational Diseases in Employers on OHS risk management in China. 30 Occupational Health and Safety 2018-03-12 11 Hainan Health Sector Reform Project Environmental and Social Management Framework No. Name Version Relevance Analysis Management System Requirements and User Guide Measures for Application of Projects with 31 2012-06-01 Occupational Risk Classification of Hazard Degree of 32 2010-11-01 Occupational Exposure to Toxicant Occupational Exposure Limits for 33 Hazardous Factors in The Workplace - 2007-11-01 Chemical Hazardous Factors Occupational Exposure Limits for 34 Hazardous Factors in The Workplace - 2007-11-01 Physical Factors Management Measures for Emergency 35 Prepareness Plan of Production Safety 2009-05-01 Accidents Regulations on Reporting, Investigation and 36 2007-06-01 Handling of Production Safety Accidents 4. Environmental Impact Assessment EIA should be conducted for Law of Environmental Impact Assessment of construction projects/development 37 2017-01-01 the People’s Republic of China activities with potential environmental impacts. The public is encouraged to participate in the EIA process. Three rounds of Measures for Public Participation in the information disclosure (initial project 38 2019-01-01 Environmental Impact Assessment information, draft EIA report, final EIA and Statement of Public Consultation) are required. Being introduced into China in the 1970’s, the Environmental Impact Assessment (EIA) has gradually evolved and developed into a legal statute for environmental management of construction projects with a complete set of technical guidelines to support its enforcement. However, following the latest Chinese law and regulations on EIA management, particularly the national Categorized Directory for Environmental Management of Construction Projects2, the current project will involve no subproject requiring EIA process since it will not include any construction activities, but only provide supports to equipment purchase, technical assistance and capacity building in the PHC system of Hainan Province. On the other hand, Chinese existing regulations/policies, standards and specification set a generally sound framework for environment and safety management of health care sector in China, which are enforced through the Ministry of Ecology and Environment (MEE) and its local bureaus at provincial and prefecture/county levels in Hainan. With the amendment of the 2015 Environmental Protection Law, the national-wide inspection against environmental non-compliance has been significantly strengthened in the past few years. A series of institutional reforms have been put in place to enhance the environmental enforcement, e.g. vertical management of environmental monitoring and supervision under the provincial Departments of Environmental Protection (DEPs) along with national-wide 2 The Directory provide detailed criteria for EIA category classification for various sectors. The latest version of 2018 specifies classifications for 192 types of projects in 50 sectors, i.e. provide detailed thresholds for three categories, i.e. EIA Report, EIA Form and EIA Registration (roughly equivalent to category A, B and C of the World Bank OP4.01). 12 Hainan Health Sector Reform Project Environmental and Social Management Framework environmental enforcement supervision campaign by the MEE since 2015 by sending central supervision teams to various regions to supervise the environmental compliance and enforcement of local governments every year. In May 2019, the State Council issued the Implementation Plan for the National Ecological Civilization Pilot Zone (Hainan), which means that the most stringent environmental protection regulations are now being implemented in Hainan to safeguard its excellent environmental quality while exploring the value realization mechanism of ecological products. In general, the existing environmental laws and regulations relevant to this project are deemed adequate and comparable to the World Bank’s ESF requirements. The project’s ESMF has been designed to ensure unified implementation, cross-department coordination and continuous capacity building on environmental management. Regarding Occupation, Health and Safety (OHS) management, OHSAS18001 was adopted as the national standard (GB/T28001-2001 occupational health and safety management system specification) in 2002 after China's accession to the WTO. At the same time, China has also formulated a series of laws, regulations, standards and guidelines on occupational risk management which has formed a relatively complete management system consistent with existing GIIPs, including the applicable EHS guidelines of the World Bank Group. However, the OHS risk assessment is not required as part of EIA, but part of the feasibility study to be reviewed by the health departments when applicable. In addition, Chinese existing regulations on OHS management provide only general rules and principles, instead of sector-specific guidance. To fill these gaps, current ESMF has considered the downstream OHS risk of existing PHC facilities in relation to the project (Section 6.1) and based on the EIA findings, the sector-specific Environmental, Health and Safety (EHS) guidelines for PHC facilities have been developed as one annex of the ESMF to support the capacity building activities under the project during implementation. 2.3 Assessment of National Social Management System Sound social safeguard management systems have been established for Chinese investment projects, mainly including a management system for project social risks, and a social management system for land acquisition and house demolishment, and labor management. The management system for project social risks requires that the project must meet the ultimate needs of most people, and a social stability risk evaluation must be conducted for major fixed asset investment projects. China has established institutional arrangements for project social stability risk assessment. The project developer shall be responsible for preparing or entrusting consulting institutions to prepare social stability risk assessment and analysis reports; The people's government of project location shall review and appraise the social stability risk analysis made by the project developer and propose the social stability risk evaluation report. For the development of minority areas, the PRC has promulgated the Law of the PRC on Regional Ethnic Autonomy, Regulations on the Administrative Work of Ethnic Minority Townships in the PRC, 13th Five-year Plan for Ethnic Minority Programs, etc. The objectives are to respect the dignity, rights, economy and culture of ethnic minorities, promote their equality and development, and pay special attention in their 13 Hainan Health Sector Reform Project Environmental and Social Management Framework economic, social and cultural development to protect their rights and interests, and improve their social and economic status. In terms of the Labor management, the staff of provincial, municipal and county Health Commission and Health Security Bureaus belong to the state public servants, who are appointed in accordance with the law of the People's Republic of China on civil servants (Amended in 2018), the administrative provisions on the appointment system for civil servants (trial) (September 2017) and the pilot work plan of Hainan province on the appointment system for civil servants in accordance with the principle of " openness, equality, competition and meritocracy ".When appointing a civil servant/staff, an organ shall, in accordance with the principle of equality, accountability and consensus through consultation, conclude a written contract of appointment with the civil servant to determine the rights and obligations of both parties. These are subject to the China’s Labor Law (amended in 2018) and Labor Contract Law (amended in 2012). Wage standards, working hours, labor protection, and labor disputes are regulated in these laws, and forced labor and/or child labor are prohibited, which are fully in conformance with relevant requirements under ESS2. The risk of forced labor and child labor regarding project workers is low considering project nature and China’s comprehensive regulations on labor protection and increasingly strengthened labor inspection by local authority. Considering the relevance of social standards in the context of this project, the following Social laws/regulations or policies are deemed applicable. Table 2-3 Applicable Domestic Laws and Regulations on Social Management. No. Name Version Relevance Analysis 1. General Legal Document on Social risks Management A social stability risk evaluation includes: 1) if any major matter is scientific, meets ultimate needs of most people (including minority areas), is financially affordable, and is understood and supported by most people (especially Social Stability Risk minority areas); 2) if any major matter has been subject to Evaluation for Major rigorous research and demonstration to fully consider 1 2012 Fixed Asset Investment various restraints; if the program is detailed and specific, Projects and if supporting measures are sound; 3) if there is any strong objection to the project among local people, if any major event of public security and stability will occur, and if there is any contingency plan; and 4) potential major issues affecting social stability. 2. Legal document on ethnic minority development In addressing special issues concerning local ethnic groups, authorities of ethnic minority autonomous regions must Regional Ethnic effect since conduct extensive consultations with their representatives Autonomy Law of the 2 October 1, and respect their views. These authorities shall ensure that People's Republic of 1984 members of all local ethnic groups enjoy citizen rights as China specified in the Constitution and shall educate them to fulfill their due obligations When performing their functions, people’s governments of ethnic monitories shall use local languages. preferential Regulations of People’s policies in terms of teachers, expenses and teaching Republic of China on issued on facilities shall be implemented to support development of 3 Administrative Work in September education in ethnic minority townships; ethnic minority Ethnic Minority 15, 1993 townships shall be assisted in building radio stations, Townships cultural centers (stations) and other cultural facilities to enrich cultural life of all ethnic groups and in protecting and inheriting cultural heritages of ethnic minority 14 Hainan Health Sector Reform Project Environmental and Social Management Framework No. Name Version Relevance Analysis characteristics; measures shall be taken to strengthen training and assignment of ethnic minority leaders and introduce talented people to participate in local development 3. Legal document on labor management The distribution of wages shall follow the principle of distribution according to the nature of work and equal pay for equal work. Provisions of the State Council on Working hours of Workers and Staff, duration of work will not exceed 44 Amended in hours per weeks or eight hours per day on average. Labor Law of PRC 2018 In case of specific circumstances, the extended working 4 Labor Contract Law of Amended in hours will not exceed 3 hours per day and 36 hours in total PRC 2012 per month. The juvenile workers (16-18 years old) should not be involved in overtime working. The well-developed mediation system covers labor disputes through an enterprise committee under the official trade union system. Workers may also directly lodge a complaint through the labor bureau. The administration of public servants shall follow the principles of openness, equality, competition and meritocracy, and shall be conducted in accordance with The law of the People's Amended in statutory authority, conditions, standards and procedures. Republic of China on 5 2018 According to the requirements of their job duties or position civil servants and the need to improve the capacity of civil servants, the government carries out kinds of training for them The salary of civil servants includes basic salary, allowance, subsidy and bonus When appointing a civil servant, an organ shall, in The administrative accordance with the principle of equality, countability and provisions on the consensus through consultation, conclude a written contract appointment system for of appointment with the civil servant to determine the rights Issued in civil servants (trial) and obligations of both parties. 6 September2 Pilot work plan of The employment contract shall contain such clauses as 017 Hainan province on the contract term, position and duty requirements, working appointment system for conditions, wages, benefits and insurance benefits, civil servants termination of employment contract, liability for breach of contract and so on. The social risk management system for Chinese investment projects is consistent with that of the Bank, namely to realize the project objective sand mitigate social risks, but there are some differences.  Chinese policies require that a social stability risk evaluation is conducted, and more attention is paid to measures that affect social stability without stressing measures that promote social fairness and inclusiveness.  Although Chinese policies require that measures be taken to ensure that affected minority residents receive social and economic benefits suited to their cultural customs, and minimize potential negative impacts on minority residents, preparing an EMDP/EMDF is not required.  M&E on the SAP, and EMDP is not required at the implementation stage. To strengthen social management, realize the social objectives of the Project, promote social fairness, inclusiveness, and sustainability, and improve PMO’s social management capacity, PMO promises to act on the Bank’s social safeguard policies. The following measures are proposed:  A social assessment will be conducted to identify and address social risks, poor population, gender development, and people’s well-being in the poverty and 15 Hainan Health Sector Reform Project Environmental and Social Management Framework ethnic minority counties, if necessary, a SAP and GAP will be prepared to enhance the project benefits and mitigate the social risks.  An EMDP/EMDF should be prepared and implemented in the area of minority habitat involved.  EMEF should be implemented to ensure the meaning engagement and consultation for the ethnic minority people and communities in the project areas.  M&E on the SAP, and EMDP /EMDF should be conducted at the implementation stage. 16 Hainan Health Sector Reform Project Environmental and Social Management Framework 3 Environmental and Social Impact and Risk Screening The environmental and social (E&S) screening is conducted based on (i) information collected from Hainan Provincial Health Commission (PHC) and Hainan Provincial Health care Security Administration (PHSA) on its E&S risk management approach; (ii) initial interviews with relevant provincial departments including Hainan Ecology and Environment Department, Hainan Ethnic Minority Committee, Hainan PHC and Hainan PHSA; (iii) consultation with health specialists from Hainan Medical University; and (iv) Information from field investigation and public consultation on environmental and social issues, covering 31 PHC facilities (including two medical waste disposal centers) and 88 identified key stakeholders in 9 representative prefectures/counties, namely, Haikou, Sanya, Chengmai, Wuzhishan, Qiongzhong, Lingshui, Changjiang, Danzhou and Baoting. The project targets at the improvement of quality and efficiency of Primary Health Care (PHC) services in Hainan Province through the investments on deeper institutional, financing, human resource and informational technology reform actions. The project activities include the following four categories: (A) Technical studies (B) Capacity building through training, workshops, study tours, etc. (C) Equipment procurement (D) Personnel allowance Environmental Risk Analysis: These activities will bring overall environmental and social benefits by improving the accessibility, quality and efficiency of PHC services and thus the public health and well-being in the province. Meanwhile, the project implementation is not anticipated with any direct and significant environmental and social impact since it will only support sector financial reform, equipment procurement, capacity building and technical assistance activities without involving any civil works. However, potential environmental risks/impacts are only anticipated with the operation of project-supported PHC facilities at county/town/villages levels. Based on the relevance of ESSs as described in Chapter 2, potential environmental risks/impacts associated with the project is presented in the following table. Table 3-1 Environmental Risk Analysis Potential Env. Risk Analysis based on Current Management & Mitigation Tools Risks Considered Project Design/Context Pollution due to - The project will be implemented on - As part of this ESMF, a set of inappropriate existing PHC facilities without any Environmental, Health and management of expansion and thus will not lead to Safety Guidelines (EHSGs) medical wastewater the increase of wastewater/waste were developed for and waste at PHC generation from PHC facilities in project-supported PHC facilities facilities (ESS3 and Hainan. in the Province, incorporating ESS4) - Wastewater/waste infrastructure for requirements on PHC facilities is being improved wastewater/waste management during standardized reconstruction of with reference to existing Good PHC facilities financed by Hainan International Industry Practice government. However, the filed (GIIP). investigation found that there were - The project-supported capacity still gaps on the awareness and building activities for PHC enforcement of appropriate medical facilities are designed to support waste management for PHC the enhancement of 17 Hainan Health Sector Reform Project Environmental and Social Management Framework Potential Env. Risk Analysis based on Current Management & Mitigation Tools Risks Considered Project Design/Context facilities, particularly for environmental awareness town/township clinics. among healthcare workforce. - Two licensed medical waste disposal companies are currently responsible for final disposal of all medical waste of the province, which are being operated at full load with overall environmental compliance. The Construction Plan of Hazardous Waste Centralized Disposal Facilities in Hainan (2018-2022) has proposed the upgrading and expansion of existing medical waste incineration facilities and the co-incineration with Municipal Solid Waste to increase the province’s treatment capacity for medical waste by 2022. - Overall, the project will not have direct or significant negative impacts on wastewater/waste management at PHC facilities and is designed to support the capacity building activities to fill existing gaps on wastewater/water management. OHS Risk for - The field visits to various hospitals - A set of Environmental, Health medical personnel and clinics during ESMF preparation and Safety Guidelines (Annex and personnel found that all PHC facilities had well 3) were developed for responsible for established OHS-related work project-supported PHC facilities medical waste procedures, covering disinfection, based on the review of current collection and infectious disease prevention, practice and with reference to transportation due to emergency response and reporting, the available GIIP. exposure to medical waste management, fire - OHS training and awareness hazardous waste and prevention and emergency, radiation campaign could be included in radiation (ESS2) exposure protection and so on. the Project to improve current However, some medical personnel practice of OHS management in working in town/township clinics PHC facilities in Hainan. were noticed with behaviors not compliant with good OHS practice. - More advanced and energy-efficient equipment will be preferred in the procurement to support better management of PHC facilities. - The project will support the capacity building activities to improve the quality and efficiency of PHC system in Hainan province which provides opportunities for further improvements of OHS management performance. In summary, the project will not involve any civil works and thus will not result in any direct and significant environmental impact. Key environmental risks and impacts 18 Hainan Health Sector Reform Project Environmental and Social Management Framework associated with project activities are downstream environmental management issues during the operation of project-supported PHC facilities at county/town/village levels, mainly related to better enforcement of existing regulatory system and further enhancement of the Borrower’s capacity to comply with the ESF requirements. The project design has incorporated more modern equipment and technology, more efficient processes, more targeted awareness campaign and better management system to minimize negative environmental impacts during the operation of enhanced PHC facilities. Therefore, the project’s environmental risk is deemed moderate. Social Risk Analysis: The project is designed to enhance the Primary Health Care (PHC) services in all 18 counties of the main island, which will include the national-level poverty counties and autonomous counties. There is no civil work involved and no land take is expected to be required according to current project component and design. Therefore, there is no negative social impacts due to project activities. No community workers will be used and no significant risk on labor management are envisaged due to the nature of the project. The potential social risks include: Exclusion of vulnerable groups from equal access to project benefits. Considering the large scale of project coverage in whole Hainan province, all residents living in Hainan are identified as the “project affected people”, including vulnerable groups, women and ethnic minorities. According to National Health Service Survey (2018) the poor disproportionately utilize the primary care services with 18.3 percent of them seeking care in the past two weeks and 78.2 percent of which were at the primary care level. If not managed well, such large scope of investment activity could contribute to existing inequalities rather than remove them. For instance, improving the quality of primary care service may attract other users from upper income groups and induce to a situation of paying users would receive priority over more vulnerable users. Therefore, it is critical to tailor the project design to pay attention to the vulnerable groups and ethnic minorities. The rapid poverty and social impact assessment indicate that Hainan had 33,000 poor households with 122,600 persons in 2017. They rely more on PHC and will benefit directly from the improved PHC service level. Currently, registered poor residents in Hainan have the priority channel for seeing doctors, the percentage of reimbursement of medical expenses is over 90%, and have the full coverage of basic medical insurance, critical illness insurance and supplementary insurance for major diseases With the upgrading of PHC resources and the expansion of medical capacity after project completion, medical care costs of ordinary residents (including traffic and time costs) who prefer county and provincial hospitals to PHC providers will be reduced greatly. The building of IT systems, medical alliances and rural doctor teams will improve the operating efficiency of PHC providers, reduce personal medical financial burden, and alleviate poverty due to diseases. After project implementation, poor people will continue to enjoy health poverty alleviation policies and preferences. In summary, that vulnerable groups will not be excluded from access to project benefits, whilst they will benefit from accessing better quality of local primary healthcare centers/hospitals. (Full analyses see the rapid Poverty and Social Impact Assessment Report) Lack of appropriate participation and consultation in poor and Ethnic minority areas. The Project would have a provincial wide coverage in Hainan province and 6 autonomous counties with a higher composition of ethnic minorities will be 19 Hainan Health Sector Reform Project Environmental and Social Management Framework potentially involved inter alia. According to the 2018 statistics, 18.2% of the population belong to minority groups, including Li (16.5%), Miao (0.87%), Zhuang (0.44%) and other 45 ethnic minorities in small numbers live scattered in Hainan. Civil works and land taken is exclude in the project component therefore no displacement impact and direct adverse impact on ethnic minorities is identified. The project nature and coverage indicate that the project benefit is not sole to ethnic minorities. Considering the large scale of project coverage in whole Hainan provide, ethnic minorities are identified as key project affected people as part of the whole Hainan people. The initial screening indicated high percentage of ethnic minorities in Hainan and ethnic minority areas are relatively in poor infrastructure condition which tend to result in unbalanced primary healthcare services. Therefore, it is critical to tailor the project design to pay attention to the vulnerable groups and ethnic minorities throughout the effective stakeholder engagement approach to achieve the equal improvement in the poor and ethnic minorities areas. PSIA conducted initial consultation with the provincial and local EACs, agencies in ethnic minority areas, and minority residents to collect their concerns, needs and suggestions. Based on the consultation, local minority residents show no significant difference from Han residents in medical care and have no special need for doctor gender and ethnic group. However, some rural minority people are superstitious in medical care. Additionally, language is also a concern identified for some rural minority people, especially for some old minority people. The PSIA baseline survey indicated that in Hainan minority and Han residents are highly integrated in living habits, and Mandarin is very popular among minority residents. Minority residents have no taboo in doctor gender and are similar to Han residents in health status and diseases. In Wuzhishan City, Li and Miao residents have a higher incidence of thalassemia for genetic reasons, and patients are mostly from poor families with a weak sense of antepartum examination. In addition, some minority residents like drinking, and have a higher incidence of liver cirrhosis than Han residents. There are Li and Miao doctors in minority areas, and some rural minority residents are superstitious in medical care. In addition, although some minority people cannot speak the Hainan dialect or Mandarin, there are many doctors and nurses of young generation speaking the Li language in rural primary healthcare teams, so the medical care is not significantly affected in ethnic minority areas due to language barriers. To better contribute the project objectives, an Ethnic Monitory Engagement Framework (EMEF) has also been developed by following ESS7 during the project preparation. The EMEF concludes that i) the ethnic minorities will share the benefits of the expansion of medical resource capacity at the same level as Han people in Hainan, and the minority poor residents will benefit more with the improvement of PHC services as well as descent of healthcare cost. And, the Project will solve the difficulty of minority residents in receiving medical care by measures such as overcoming the language barrier with setting up language help desks. ii) the Project will be focusing on technical design, service transformation, and primary healthcare improvement, and will involve no construction, no land acquisition, and no materially adverse impact on local communities and minorities; therefore, the Project has no adverse economic and physical impacts, no crowding out effect to the ethnic minorities people. Given the high percentage of the population in Hainan of ethnic minorities, a Stakeholder Engagement Plan (SEP) has been developed by setting out mechanisms of stakeholder identification, engagement needs assessment or interests & concerns analysis, engagement approach assessment and engagement planning. The 20 Hainan Health Sector Reform Project Environmental and Social Management Framework SEP aims to achieve the meaningfully engagement throughout the Project to maximize the local benefits of the Project. Impacts on working condition and OHS in the health care system. According to the rapid social assessment, by the end of 2017, there were 77,652 health workers in Hainan, including 60,578 health technicians. The labor included in the project includes: i) the staff of provincial, municipal and county-level Health Commission, Health Security Bureaus and other government departments of Hainan province, who are national public servants and enjoy the treatment of civil servants; ii) the medical personnel of the township health institutions within the scope of the project shall be the establishment or contract workers of public institutions; iii) most of the village-level doctors within the scope of the project are part-time doctors who are both farmers and doctors. Given the civil works will be not supported under this project therefore there will be no construction workers and community workers involved. The social risk and impact on labor management is low and minor. Doctors involved in the primary healthcare system are not considered “direct workers”, and they are following the government civil servant management system, which is fully compliance with the national labor management regulations. Therefore, ESS2 is not applied for such government civil servant except for the provisions on occupational health and safety under ESS2, and the EHS guidelines for PHC facilities was developed as part of the ESMF following WBG EHSGs and other available GIIP. (Annex 3). The main contractors involved in the project will be likely IT service company and consultancy service. Considering the professional and high technology nature of the qualified contractors, it is unlikely on using of child labor and force labor and no primary supplier is identified under the project. Therefore, the social risk and impact on labor management is low and minor. Regarding borrower capacity and commitment. From the perspective of implementation capacity, this is the first human development operation in Hainan and the first operation to be implemented by the HPHC and local divisions. Although HPHC and implementation agencies have experience in tackling health reform challenges in the past few years government officials at both the provincial and prefecture levels have no prior experience of using the World Bank’s lending instrument. The project risk rating on technical design is High and the project result will bring the widely change for all PHCs’ operation in whole Hainan Province covering more than 9 million people. Considering project nature of social development, high risk on technical design and the limited Bank experience of PMOs and PIUs, the overall social risk rating is considered substantial at this stage. In summary, there is minor negative social impacts from the project activities, considering the project natural and broadly coverage in Hainan Province, the overall social risk rating is considered Substantial. The specific project activities and the potential environmental and social risks are shown in Table 3-2. 21 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 3-2 Screening of Potential Environmental and Social Risks or Impacts Four types of activities under the Project: (A) Technical studies (B) Capacity building (C) Equipment procurement (D) Personnel allowance Type of Relevant Applicabl Project components Activities Potential environmental risks / impacts Potential social risks / impacts Activities ESSs E&S tools - Reducing institutional fragmentation in primary care Component 1: Anticipated with positive environmental services Reforming impacts with more standardized, efficient Exclusion of vulnerable groups from - Increasing coordination between Institutions and and systematic management system for equal opportunities to enjoy the benefits ESMF HPHC and HPHSA Strengthening PHC facilities, and no negative of the project, ESS1 SA - Developing a collaborative AB D Stewardship for environmental impacts. Lack of appropriate consultation with ESS7 EMEF/EM approach in which providers and People-Centered The outcomes of technical studies on policy minority groups, women's participation ESS10 SEP patients work together to Integrated Care development may have downstream and the poor, improve the self-management of (PCIC) environmental and social implications. health and, eventually, health outcomes Training of FDT and local service providers could bring environmental benefits as EHS awareness campaign is included to improve - To strengthen Family Doctor current practice of environmental and OHS Exclusion of vulnerable groups from Team (FDT) performance management in PHC facilities. equal opportunities to enjoy the benefits Component 2: through a mix of approaches ESMF More advanced and energy efficient of the project, ESS1 Strengthening involving a) capacity building, b) SA equipment will be preferred in the Lack of appropriate stakeholder ESS2 Primary Health strengthened performance EMEF/EM AB C D procurement. participation and consultation, especially ESS7 Service Delivery with management and targeted SEP During project implementation, the among ethnic groups, women and the ESS10 appropriate support incentives and c) supportive EHSG for environmental risks/impacts of identified poor. system demand and supply side PHC facil Associated Facilities (if any) should also be Impact of work environment and safety measures including equipment considered. on health care system workers. upgrading and technical studies. The outcomes of technical studies on policy development may have downstream environmental and social implications. Component 3: 3A: Provincial Health Commission Based on current design, the proposed Lack of appropriate stakeholder Strengthen IT capacity: information system will be installed in participation and consultation, especially SEP C ESS10 Information - Strengthening IT governance and existing buildings. No negative among ethnic groups, women and the EMEF Technology stewardship environmental impact is expected. poor. 22 Hainan Health Sector Reform Project Environmental and Social Management Framework Type of Relevant Applicabl Project components Activities Potential environmental risks / impacts Potential social risks / impacts Activities ESSs E&S tools - Support the building of an interconnected Provincial Health Information System 3B: Provincial Health Security Agency IT Capacity: - Improve management and upgrade of current HPHSA information services; - Participate in data security and privacy subsystem development; - Enhance operational efficiency by, for example, integrating PHC patient’s identification check, insurance fee receipt information with e-medical insurance platform through issuing devices and desktop solutions. - Progressive improvement in the generosity of the benefit Component 4: Lack of appropriate stakeholder package for outpatient services ESMF Strategic purchasing participation and consultation, especially ESS1 - Support for PHSA to become a D No potential environmental risk. SEP for quality services among ethnic groups, women and the ESS10 strategic purchaser by EMEF poor. introducing performance-based payment to FDTs - Financing key TAs that support the research, development, design and monitoring of Component 5: specific Project activities The outcomes of technical studies on policy ESMF Technical Assistance ESS1 - Support for the HPHC and AB development may have downstream No potential social risks SEP (TA) and Project ESS10 HPHSA to play a strong environmental and social implications. EMEF Management stewardship role in the health sector - Support for project management 23 Hainan Health Sector Reform Project Environmental and Social Management Framework 4 Environmental and Social Baseline 4.1 General Hainan Province, consisting of the main Hainan Island (97% of the total area) and various small islands, is the southernmost province of China. Its provincial capital is Haikou. Hainan Province is China's special economic zone and free trade pilot zone (port). It is located in South China, bordering Guangdong with the Qiongzhou Strait in the north, adjacent to the North Bay in the west, across the sea from Guangxi and Vietnam, facing Taiwan with the south sea in the east, adjacent to the Philippines, Brunei and Malaysia in the South China Sea. The contour of Hainan Island is like an oval large pear. Hainan Province has a total area of 35,400km 2, including 33,900 km2 of the Hainan Island and a sea area of 2 million km2. It has high mountains in the middle known as Wuzhishan Mountain and Yingge Ridge and the topology gradually descends to the periphery, presenting as dome mountain. It is composed of mountains, hills, terraces and plains. Hainan is featured by the tropical maritime monsoon climate with warm and hot rainfall throughout the year. Hainan Province governs a total of 19 prefectures and counties, including 4 prefectural-level cities, 5 county-level cities, 4 counties, and 6 autonomous counties, of which 18 (except Sansha Prefecture) will be supported by the project. By the end of 2018, it has a permanent resident population of 9,343,200, with a regional GDP of 483,205 million yuan and the per capita GDP of 52,000 yuan. 4.2 Environmental Quality Baseline With relatively rich land resources in tropical zone, Hainan’s economy is predominantly agricultural, and the province’s industrial development has largely been limited to the processing of its mineral and agricultural products. The province’s continuous efforts on afforestation and ecological restoration in last decades has increased its forest coverage to a level of 62.1% with the top quality of air, water, soil and ecological resources in China. The 2018 statistic data show that the excellence ratio3 of its surface water quality was up to 94.4%, and the number of days with excellent air quality4 takes up 98.4% of the whole year. In 2018, the Ecological Index5 of 18 prefectures/counties in Hainan (excluding Sansha) ranged from 71.44 to 93.55, with an average index of 81.42. In May 2019, the State Council issued the Implementation Plan for the National Ecological Civilization Pilot Zone (Hainan), which represents the most stringent environmental protection regulations being implemented at the provincial level to safeguard its excellent environmental quality while exploring the value realization mechanism of ecological products. 4.3 Socio-economic Conditions Hainan is a tropical island in southern China, with a tropical monsoon climate, rich rainfall, and distinct dry and rainy seasons. According to the 2018 Statistical Yearbook 3 Following Chinese current statistic approach, the surface water with the quality of Class I-III according to GB3838-2002 (Environmental quality standards for surface water) is defined as “Excellent” surface water. 4 Air quality at Grade 1 and Grade 2 according to the national standard of “Ambient Air Quality Standard” (GB3095-2012). 5 A comprehensive index currently used by Chinese Government to evaluate the status of regional ecological environment. The ecological environment quality of a region is deemed excellent when EI is over 75. 24 Hainan Health Sector Reform Project Environmental and Social Management Framework of Hainan Province, Hainan has 27 cities, counties and districts, including 6 autonomous counties, 8 districts and 218 townships (including sub-districts), and a resident population6 of 9.2576 million, in which male population accounts for 52.41% and urban population for 58.04%. About 8.14% of residents are aged 65 years or above, below the national average by over 3%. Hainan attracts a large migrant population from other provinces for wintering due to its tropical climate. From October 1, 2017 to April 30, 2018, the migrant population wintering in Hainan was as large as 1.65 million, in which retirees aged 60 years or above accounted for 56%. Hainan has a minority population of 1.6574 million, accounting for 18.2%, in which Li population accounts for about 16%, followed by Miao, Zhuang, Hui, etc. The minority population is distributed mainly in Sanya and Wuzhishan Cities, and Baoting, Qiongzhong, Lingshui, Baisha and Changjiang Counties. As for poverty, the Three-year Action Plan for Poverty Alleviation of Hainan Province issued by the Hainan Provincial Government in September 2018 indicates that there are 33,000 poor households with 122,600 persons, 83 poor villages (including 35 deeply poor villages), and 5 poor counties (cities) in Hainan, with a poverty incidence of 2.2%. Hainan’s average healthy life expectancy is 76.0 years (67.8 years), lower than the national average 76.2 years (68.0 years), its death rate of pregnant and lying-in women is higher than the national average, while its death rate of children below 5 years, infants and newborns is lower than the national average. Almost all children are covered by vaccination. The Hainan health system is medium in China. In 2017, Hainan had 5,177 PHC providers, including 25 centers for disease control, 24 maternity and child care centers, 15 specialized disease prevention and treatment institutions, 175 community health service institutions, and 299 township health centers, with 42,000 sickbeds and 60,600 health workers in total, including 20,900 medical practitioners (assistants), 28,500 registered nurses and 3,000 pharmacists. However, only 33.7% of doctors and assistant doctors, and 25.9% of registered nurses work at PHC providers. There are only 1.22 general practitioners (GPs) per 10,000 people, just 2/3 of the national average, and only 4.53 sickbeds per 1,000 people, also below the national average (5.72). 4.4 Public Health Care System in Hainan 4.4.1 General In general, people in Hainan have good access to primary care facilities. There are 5,298 health care facilities in total, including 255 hospitals, 476 town/township and community clinics, 2,716 village clinics, 1,787 private clinics, 3 first-aid facilities, and 61 other health care facilities. The specialized public health care facilities include 24 maternal and child health hospitals (clinics, stations), 18 specialized disease prevention and treatment centers (offices, stations), 27 disease prevention and control institutions, 24 health supervision offices, 1 health education office, 3 first-aid stations, 4 blood supply institutions and 18 family planning services institutions. However, the PHC system is still weak and underutilized, and the outpatient visits are concentrated around certain locations such as capitals towns or more developed areas. To further improve the PHC services, a provincial-wide program of standardized reconstruction for PHC facilities (covering town/township clinics, community clinics and village 6 Resident population means population resident in an area (more than half a year). 25 Hainan Health Sector Reform Project Environmental and Social Management Framework clinics) has been implemented since 2018, which plans to complete infrastructure upgrading for all town/township clinics by 2020. It was noticed that environmental requirements had been incorporated into standardized reconstruction specifications for PHC facilities, including site selection with environmental considerations, availability of wastewater treatment and solid waste collection and temporary storage facilities, energy-efficient design, compliance with applicable national and local wastewater discharge and medical waste management standards. According to the latest statistics, there are currently 82,597 medical staff in Hainan, including 18,726 licensed doctors, 3,589 licensed assistant doctors, 29,955 registered nurses, 3,086 pharmacists, 2,394 lab technicians, 994 imaging technicians, 2,647 village doctors and 21,206 other personnel (including technicians, management personnel and logistics personnel and so on). Although various medical training programs have been initiated since 2010 in general, the quality of training programs remain inadequate and hence the passing rate of the national licensure examination for licensed assistant doctors is low. There are regulations and procedures of labor management and safe workplace management established and 4.4.2 Medical Waste Management Medical waste is categorized and disposed as hazardous waste in China. According to the Construction Plan of Hazardous Waste Centralized Disposal Facilities in Hainan (2018-2022) provided by the provincial Department of Ecology and Environment, the generated medical waste in the province has increased from 4089t/y to 5600t/y during 2012-2017 and is expected to remain a stable growth rate until to a level of 7600t/y in 2022. Table 4-1: Generation of Medical Waste in Hainan Province (2012-2017) Year 2012 2013 2014 2015 2016 2017 Generation of medical 4089 4435 4580 5085 5470 5600 waste (tons) Growth / 8.5% 3.3% 11.0% 7.6% 2.4% Rate Following Chinese applicable laws and regulations, there has been established system for the management of medical waste in Hainan Province, where medical waste is separate, collected and temporarily stored in the health care facilities before being transferred, treated and disposed by two licensed medical waste disposal companies, respectively, Hainan Yifengda Medical Hygiene Products Co., Ltd. (simplified as “Yifengda” below) in Haikou serving the northern region and Sanya Baoqilai Medical Waste Disposal Co., Ltd. (simplified as “Baoqilai”) serving the southern region. All 18 project-supported prefectures/counties are covered by their services. The 2018 annual generation of medical waste was about 7123.52tons (theoretical estimation based on the number of beds in existing health care institutions), of which 82.7% (5892.28 tons) was properly collected and disposed by Yifengda and Baoqilai through pyrolysis process, as presented in the table below. 26 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 4-2: 2018 Statistics of Medical Waste Disposal in Hainan Province Name of Disposal Service Collected Disposed Way of Remarks Company Scope Amount Amount Disposal (tons) (tons) Hainan Yifengda 9 prefectures 4314.28 4087.76 Pyrolysis 226.52t was Medical Hygiene /counties of transferred to Products Co., Ltd. north Hainan Baoqilai for disposal. Sanya Baoqilai 9 prefectures 1578 1804.52 Pyrolysis Medical Waste /counties of Disposal Co., Ltd. south Hainan Total 5892.28 5892.28 The field investigation found that both Yifengda and Baoqilai are currently being operated at full load. The environmental performance of both companies is regularly monitored and disclosed to the public following the national regulatory requirements (including quality of discharged wastewater, dioxin content in flue gas emission, slag and soil samples and noise level around the sites). The 2018-2019 monitoring reports showed overall environmental compliance of Yifengda and Baoqilai except occasional non-compliance of dioxin content in flue gas emission. To enable proper treatment and disposal of 7600t/y medical waste anticipated in 2022, the Construction Plan of Hazardous Waste Centralized Disposal Facilities in Hainan (2018-2022) has considered the upgrading and expansion of Yifengda and Baoqilai and the co-incineration with Municipal Solid Waste (MSW) at MSW incineration plants in Haikou, Sanya, Qionghai and Danzhou, through which the province’s treatment capacity for medical waste is expected to increase to a total of 8400t/y by 2022. On the other hand, it was also noticed during the filed investigation that there was still gaps on the awareness and enforcement of appropriate management of medical waste for PHC facilities, particularly for town/township clinics. A few town, township and village clinics were not yet covered by the network for medical waste collection; and medical waste collected from small healthcare facilities, such as clinics and community hospitals, was sometimes mingled with 25% general waste, which unnecessarily increased the work load of medical waste disposal facilities. In response to these identified issues, the project will include training sessions to enhance the environmental awareness of PHC staff and a set of Environmental, Health and Safety (EHS) guidelines has been developed as the supporting materials. 27 Hainan Health Sector Reform Project Environmental and Social Management Framework 5. Environmental and Social Management Procedures This section describes the environmental and social management procedure for the project. The following guidance shall serve to ensure that potential environmental and social impacts are identified, and practical mitigation measures are prepared early in the planning and development of subprojects, in order to avoid or mitigate potential adverse impacts that may be generated by subprojects to be financed under the project. Subproject Management Steps E&S Risk Management Activities Subproject screening - Application of exclusion list - Sub-project E&S risk screening Subproject preparation - E&S documents preparation Subproject appraisal and - E&S documents appraisal and clearance approval Subproject implementation and monitoring - E&S performance monitoring and reporting Subproject completion and - E&S performance evaluation evaluation Figure 5-1 Subproject Environmental and Social Management Procedures 5.1 Subproject Screening Though the project is not designed to support any civil works, there is still possibility that some project-supported activities (equipment procurement) to be determined during project implementation will be linked to the physical investments of “Associated Facilities” as defined under the World Bank’s ESF. Also, it is possible that some sector-wide technical/policy studies will lead to downstream adverse environmental and social impacts. Therefore, the E&S screening should be conducted to ensure the E&S eligibility and preparedness of selected subprojects. More specifically, at this stage, the PMO, with the supports of their external environmental and social experts, should complete the E&S Screening Checklist (Annex 2 of this ESMF) for the following purposes:  To determine the E&S eligibility of proposed subprojects based on the developed Exclusion List (Part 1 of the screening checklist) and exclude the ineligible activities from project financing; 28 Hainan Health Sector Reform Project Environmental and Social Management Framework  To categorize the E&S risk level of eligible subprojects and confirm the applicable E&S instruments following the Guidance on Environmental and Social (E&S) risk classification (Annex 1 of this ESMF). If the subproject is rated with high risk, the subproject will be deemed ineligible. For subproject rated with substantial E&S risk, ESIA, ESMP and EMDP need to be prepared. The Environmental and Social (E&S) risk screening forms should be filed and sent to the Bank for records and spot-check. The risk rating results needs to be endorsed by Hainan provincial Project Management Office (HPMO) and their external experts. 5.2 Subproject Preparation Based on results of E&S risk screening described above, subprojects not requiring additional measures/instrument will follow domestic laws and regulations on environmental and social management. Otherwise, as specified in the Guidance on Environmental and Social (E&S) risk classification, additional project-specific E&S management instruments, as appropriate, shall be prepared before the subproject implementation by qualified consultants in accordance with applicable ESSs under the World Bank’s ESF, including the EMDP for subprojects in ethnic minority autonomous counties and the Terms of References (ToRs) for sector-wide policy/strategy studies with significant downstream E&S implications which should be submitted to the HPMO and the Bank for review. 5.3 Sub-project Appraisal and Approval For this step, the compliance and completeness of environmental and social documentations shall be confirmed by being checked by the PMO and their external E&S experts against applicable domestic E&S approval procedure and the World Bank’s ESF policies, more specifically:  For all subprojects, the PMO need to make sure the E&S documents are approved in compliance with national regulations;  For subprojects with substantial risk, the PMO should also submit the E&S documents to the Bank for prior review and approval until it is established that adequate capacity exists on the part of the Borrower.  Whenever any subproject is classified as High Risk and the PMO decides to proceed with detailed investigation and further preparation, the PMO shall inform the World Bank for prior agreement. 5.4 Subproject Implementation and Monitoring After subproject approval, continuous monitoring of E&S management performance shall be conducted by the PMO as an integral part of subproject monitoring. Specific requirements include:  For subprojects to be financed by the World Bank, the project management should include review and assessment of E&S performance of the subprojects. The PMO and subproject owners should assess the performance against national laws/regulations and the World Bank ESF requirements applicable to the subprojects.  For subprojects with substantial E&S risk, the PMO and project owners shall strengthen monitoring and supervision. 29 Hainan Health Sector Reform Project Environmental and Social Management Framework  To enhance its capacity, the PMO needs to recruit independent third-parties to conduct external monitoring of E&S performance of the subprojects and report to the Bank on a semi-annual basis.  During implementation, for those subprojects identified with increasing E&S risks, the PMO should document the findings and inform the World Bank. Following national regulations and the World Bank ESF requirements, mitigation measures should be developed and implemented, which should also be documented in the monitoring reports to be submitted to the World Bank. 5.5 Sub-project Completion and Evaluation As part of the project completion evaluation, the E&S performance of subprojects will be reviewed and evaluated upon completion. 5.6 Stakeholder Engagement In addition to the environmental and social risk management activities described above, the PMO and PIUs should ensure meaningful stakeholder engagement and information disclosure throughout the project lifecycle following the Stakeholder Engagement Plan (SEP) developed as part of this ESMF (See Annex 4 for details). The grievance redress mechanism (GRM) applicable to all subprojects is also included there. 30 Hainan Health Sector Reform Project Environmental and Social Management Framework 6 Environmental and Social Impacts and Mitigation Measures 6.1 Environmental Impact Assessment and Mitigation Measures The project will mainly focus on the investments on equipment purchase and deeper institutional, financing, human resource and informational technology reform actions, but involve no civil works. Therefore, the project activities are anticipated with moderate environmental risks considering the downstream environmental and social management issues during the operation of project-supported PHC facilities at the county/town/village levels, as elaborated in the sections below. The mitigation measures to address existing environmental issues have been incorporated into the Environmental, Health and Safety (EHS) guidelines for project-supported PHC facilities (Annex 3). 6.1.1 Waste Management at PHC Facilities Based on current design, the project will be implemented on existing PHC facilities without any expansion. Therefore, the project activities will not lead to the increase of waste generation from PHC facilities in Hainan, that is, the project will not have direct or significant negative impacts on waste management at PHC facilities. On the other hand, though there are already regulations and procedures established and implemented for waste management of health care sector in the province, the enforcement in the PHC facilities was found not satisfactory according to the field investigation conducted during the preparation of current ESMF. Thus, the project implementation could improve the performance of waste management in Hainan’s PHC system if the project-supported capacity building activities for PHC facilities can be designed to support the enhancement of environmental awareness among healthcare workforce, particularly in relation to the following issues identified during field investigation: 1) Mingling of municipal solid waste with transferred medical waste: Due to lack of environmental awareness, some bins used for collection of infectious waste were noticed collecting general waste during the visits to some town/village clinics. During the field interview, the management of Yifengda also indicated that around 25% of the transferred medical waste could be domestic solid waste, which has increased the cost and work load of medical waste disposal companies. 2) Incomplete registration and record filing during transfer of medical waste: According to existing regulations and procedures on hazardous waste management, PHC facilities are obliged to properly fill in and keep the records of medical waste transferred to the medical waste disposal companies. However, it was noticed that about 10% of PHC facilities failed to report the exact weight of transferred medical waste, which may pose potential risks of medical waste loss and thus environmental pollution. 3) “Long” temporary storage of medical waste at PHC facilities: The investigation showed that only 59.52% of the healthcare facilities in Hainan maintained a temporary storage of medical waste less than 2 days before transfer for final disposal, which is in compliant with the applicable “Medical Waste Management Regulations”. Another 22.96% would keep medical waste 31 Hainan Health Sector Reform Project Environmental and Social Management Framework within their own facilities for 3-4 days; 13.6% for 5-10 days; and the other 3.93% would even keep the temporary storage of medical waste for more than 10 days, particularly for village clinics in remote mountainous areas. Such long-time storage of medical waste in the PHC facilities will apparently induce environmental risks. 4) Inadequate incineration capacity for medical waste: based on the statistics presented in Chapter 4, the annual provincial medical waste generation has increased from 4089 tons to 5600 tons from 2012 to 2017. The theoretically estimated annual production of medical waste in 2018 was about 7123.52 tons, of which 82.7% (5892.28 tons) was properly collected and disposed by Yifengda and Baoqilai already being operating at their full capacity. Given that the quantity of medical waste is estimated to steadily grow to 7600t/y in 2022, there is likely to be nearly 2,000 tons of medical waste exceeding the current incineration capacity. To address this forecast inadequacy in medical waste incineration capacity, the Construction Plan of Hazardous Waste Centralized Disposal Facilities in Hainan (2018-2022) has proposed the upgrading and expansion of Yifengda and Baoqilai and the co-incineration with Municipal Solid Waste (MSW) at MSW incineration plants in Haikou, Sanya, Qionghai and Danzhou, through which the province’s treatment capacity for medical waste is expected to increase to a total of 8400t/y by 2022. Mitigation Measures  Avoid mingling of medical wastes with general waste to minimize the cost of medical waste transport and disposal;  Improve the enforcement of established rules and regulations for medical waste management, including emergency response plan, internal self-inspection mechanism and personnel performance evaluation system;  Improve the waste treatment capacity of PHC facilities when implementing standardized reconstruction for town/township, village and community clinics, and equip the remote village clinics with refrigerators for temporary storage of medical waste;  Enhance the environmental awareness of healthcare personnel working for PHC facilities with the provision of regular environmental training; and  Strengthen the supervision over the management of medical waste, covering the registration and record-filing during transfer. 6.1.2 Wastewater Management at PHC Facilities To be implemented on existing PHC facilities without expansion, the project activities will not lead to the increase of waste generation from PHC facilities in Hainan. The investigation conducted during ESMF preparation found that all county hospitals in Hainan were equipped with wastewater treatment system; however, some town/township hospitals don’t have wastewater treatment facilities installed or well-functioning since they only provide outpatient services with limited generation of wastewater. The wastewater infrastructure for local clinics is being improved with the implementation of the ongoing standardized clinics reconstruction financed by 32 Hainan Health Sector Reform Project Environmental and Social Management Framework Hainan government; meanwhile, the project-supported capacity building activities can help to enhance the environmental awareness among healthcare workforce. Mitigation Measures  Enhance and better enforce the established rules and regulations for medical waste management, covering emergency response plan and internal self-inspection mechanism and personnel performance evaluation system;  Strengthen the training of wastewater management personnel;  Strengthen the supervision over wastewater management. 6.1.3 Occupational Health and Safety (OHS) Management for PHC staff Since the project is designed to improve the quality and efficiency of PHC system in Hainan province, it is the minimum requirement to ensure that the well-being of their employees. Recognizing that healthcare employees are exposed to a wide array of work-related safety and health risks. The field visits to various hospitals and clinics during ESMF preparation found that all PHC facilities had well established OHS-related work procedures, along with institutional arrangements for implementation, by following national and local regulations. These work procedures cover the aspects of disinfection, infectious disease prevention, emergency response and reporting, medical waste management, fire prevention and emergency, radiation exposure protection and so on. However, the lack of awareness was still found in some clinics at town/township clinics. Thus, a set of Environmental, Health and Safety Guidelines were developed for project-supported PHC facilities based on the review of current practice and with reference to the available GIIP (Annex 3 of current ESMF), which would be part of supporting materials for project-financed capacity building activities targeting at the identified risks. Further elaboration on risk of exposure to medical waste and radiation is provided below. Risk of exposure to medical waste  Medical waste collectors: Due to the high turnover rate, the staff responsible for medical waste collection often has limited knowledge on infection risks, inadequate training, and low self-protection awareness. When collecting medical waste, the collectors do not follow the requirements to wear necessary personal protection equipment such as protective clothing, rubber gloves, rubber apron, high-top rubber shoes, etc.  Mistaken segregation of medical waste: With high work load, some medical personnel do not pay much attention to appropriate segregation of medical waste following the requirements. Different types of medical are mixed with each other. Especially when the damaging waste is thrown into the yellow plastic bags containing infectious waste, the staff collecting the waste may easily get hurt and infected. In addition, the medical waste container is too full that the wastes exceed 3/4 of the maximum volume. The wastes may leak when staff carry the container, which increases the staff’s exposure to occupational safety risks.  Lack of health protection for full-time personnel: With the outsourcing of hospital logistics management services, regular medical examinations for 33 Hainan Health Sector Reform Project Environmental and Social Management Framework full-time personnel cannot be guaranteed, so their health status cannot be understood timely. Mitigation measures  The logistics department should strengthen procurement management of waste containers and make sure that the containers are procured from reliable sources and meet the national standards;  Provide regular training to staff on medical waste management requirements;  Ensure the availability of personal protection equipment and improve staff’s self-protection awareness;  Unless refrigerated storage is possible, waste storage time should not exceed 48 hours;  Strengthen the routine disinfection of waste containers and waste transfer vehicle;  Establish the emergency response procedures and reporting mechanism in case of occupational exposure;  Strengthen the supervision of medical waste management by Infection Control Division;  Provide regular medical examinations to staff with potential exposure to medical wastes and maintain a record of occupational accidents and diseases. Medical Radiation Exposure Risk All PHC facilities with radioactive devices have established and implemented radiation safety rules and regulations with the installation of standard radiation-proof equipment as required. All medical personnel working in the radiation division are provided with pre-employment training and regular training organized by the health and environmental protection departments to obtain and maintain radioactive work permits. They are also required to use radiation measurement accumulative cards for regular working environment monitoring. However, during the field visit, it was noticed that a small number of radiologists did not carry the radiation measurement accumulative card and didn’t pay enough attention to the risk in their daily work. In general, the radiation risk management is in place and adequate, while staff training could be further strengthened. Mitigation Measures  Strengthen regular and targeted training to staff on radiation safety;  Establish radiation accident accountability system to strengthen the supervision of radiation safety compliance. Other impacts and mitigation measures on occupational health and safety could be found in Annex 3. 6.1.4 Community Health and Safety Located in the vicinity of residential areas for better provision of PHC services, the PHC facilities could also pose potential health and safety risks to nearby neighborhood if without appropriate management. The investigation showed that the management of PHC clinics is general adequate and effective. Emergency response plan is available for all PHC facilities. One thing to notice could be the transfer of 34 Hainan Health Sector Reform Project Environmental and Social Management Framework medical waste from the PHC facilities, whose leakage during transportation could expose nearby residents along the road to the impacts of medical waste. Mitigation Measures  Medical wastes should be transported in sealed and leakage-proof container by dedicated vehicle. 6.1.5 Ecological Impacts and Mitigation Measures The project does not involve civil works, so there are no ecological impacts directly caused by the project. Any activities that may cause adverse impacts on nature reserves (existing or planned), critical natural habitat, scenic areas, forest parks, protected water sources, or areas with high ecological value will be excluded from project financing at the subproject screening stage. If any subproject implementation (or identified “Associated Facilities”) is anticipated with impacts on non-critical natural habitats, environmental impacts assessment shall be performed to identify the type and significance of such impacts and mitigation measures shall be proposed to mitigate negative impacts to an acceptable level following both World Bank and national requirements. Relevant requirements are integrated into the subproject screening procedure. 6.1.5 Impacts and Mitigation Measures on Endemic Disease Prevention Dengue fever is a kind of typical endemic disease in tropical Hainan, which is currently well controlled with few cases identified in 2019. Dengue fever is transmitted in the crowd through mosquito bites. Education campaign on Dengue prevention are still being conducted all over the province by the provincial government, which is deemed efficient and effective based on the visits of PHC facilities and interviews with the provincial health commission and the provincial center of disease control. 6.2 Social Risk Assessment and Mitigation Measures As per the rapid social assessment, the project implementation is not anticipated with any direct social impact since it will only support sector financial reform, equipment procurement, capacity building and technical assistance activities without involving any civil works. Therefore, there is no displacement impact and direct adverse impact on local communities and ethnic minorities. No community workers will be used and no significant risk on labor and working conditions are envisaged considering the natural of the project. However, considering the large scale of project coverage in whole Hainan provide, ethnic minorities are identified as key vulnerable groups as part of project affected people in Hainan. To ensure that minority communities and poor communities in the project area benefit equally from the project in a cultural appropriate way, social risk of the subproject will be categorized as substantial when the subprojects are located in minority counties as well as in poor counties at the national or provincial level. Accordingly, social assessment for the saying subproject is needed, and findings of the social assessment will be the basis for determining which instruments should be used for risk management. The social assessment framework and ethnic minority development framework are prepared as below to guide the social assessment conduction and ethnic minority engagement or development plan preparation. 35 Hainan Health Sector Reform Project Environmental and Social Management Framework 6.2.1 Social Assessment Framework The purpose of SA is to avoid/reduce adverse impacts, improve the project design and implementation through extensive participation and consultation so that individuals and groups that may be affected by project activities, especially women, the poor and other vulnerable groups participate in and support the Project, social risks are avoided or reduced, and the project objectives are fulfilled. SEP is prepared as Annex 4. Methodology Qualitative methods such as literature review, interview and Focused Group Discussion, and quantitative methods such as sampling questionnaire survey and structured interview are usually used in SA.  Literature review: collecting socioeconomic data, relevant policies, LA and HD compensation rates, ethnic annals, etc.  Questionnaire survey: designing a questionnaire based on the project scope, and conducting a survey on Affected Persons  FGD: involving primary stakeholders, such as APs, vulnerable groups, and government officials, to learn their attitudes to, needs for and suggestions on the Project, and ability and willingness to pay  In-depth interview: interviewing APs in a semi-structured manner to learn their attitudes to, needs for and suggestions on the Project  Key informant interview: interviewing government and village officials to learn their attitudes to and comments on the Project, and provide inputs into the SA Contents of SA As necessary, the SA Report will include the following:  Stakeholder analysis: identifying primary stakeholders, and analyzing their needs for and attitudes to the Project, especially women and the poor  Information disclosure and public participation: disclosing the project design and information, the Bank’s social safeguard policies, state and local compensation and employment policies, grievance redress mechanism, scope and modes of participation, attitudes to and suggestions on policies and plans, especially how vulnerable groups participate in and benefit from the Project  Social gender impacts: learning local women’s attitudes to and comments on the Project, potential impacts of the Project on women, women’s employment and social security, needs for suitable jobs, women’s perceptions of the Project, special measures, and monitoring indicators  Social impact analysis: analyzing potential positive and negative social impacts of the Project on different stakeholders, thereby identifying and managing (avoiding/reducing) social risks effectively. Preparation and Implementation of the SAP (including the GAP) A feasible SAP (including the GAP, can be a section of SAP) is to be developed when a subproject is categorized as substantial, following the E&S screening process. Based on the identified social risks, specific measures, implementation time, agencies, budgets, funding sources and monitoring indicators (at least one social gender indicator) will be specified. Sensitivity to social gender should be considered in SAP. 36 Hainan Health Sector Reform Project Environmental and Social Management Framework The SAP specifies agencies responsible for social actions, which should participate in SAP preparation, and learn their duties and funding sources. 6.2.2 Ethnic Minority Engagement Framework (EMEF) This EMEF has been prepared in accordance with the applicable PRC laws and regulations, and ESS7 to ensure that affected minority residents receive social and economic benefits suited to their cultural customs, and measures are taken to avoid, minimize or compensate for negative impacts on minority residents. Social Assessment (SA) (factors to be included in SA in minority areas) If, based on the screening, PMO Social consultant concludes that the subproject is located in an ethnic minority autonomous area, the social risk of the subproject will be categorized as substantial, and the subproject enterprise will undertake a social assessment to evaluate the project’s potential positive and adverse effects on the ethnic minority communities, and SAP (including GAP) will be applied. When the subproject is not located in ethnic minority autonomous county but located in areas/communities involving ethnic minority people, Ethnic minority engagement framework (EMEF) will be implemented; when the subproject is located in any ethnic minority autonomous counties, ethnic minority development plan (EMDP) should be prepared. The SA should also examine project alternatives where adverse impacts may be significant. The breadth, depth, and type of analysis in the social assessment are proportional to the nature and scale of the proposed project’s potential impacts on the ethnic minority communities, whether such impacts are positive or adverse.  Reviewing the legal and institutional framework suited to minority residents on a scale appropriate to the Project;  Collecting baseline information on the population, social, cultural and political features of affected minority communities, land and estates traditionally owned, used or occupied by them, and natural resources on which they rely;  Identifying primary stakeholders, and drafting a detailed and culturally appropriate ethnic minority consultation procedure for all stages on the basis of the review results and the baseline information;  Evaluating the Project’s potential positive and negative impacts on the basis of free, prior and informed consultation with affected minority residents, and analyzing their relative vulnerability and potential risks;  Determining and evaluating measures to avoid or minimize negative impacts based on free, prior and informed consultation with affected minority residents, and ensuring that minority residents benefit from the Project in a culturally suited manner Consultation and Participation If the subproject affects the ethnic minority, the subproject should conduct meaningful consultation with them. To ensure such consultation, subproject need to: a) Develop appropriate gender-inclusive and intergeneration-inclusive frameworks to provide opportunities for consultation between borrowers, affected minority communities, minority organizations (if any) and other civil society organizations recognized by affected minority communities at all stages of project preparation and implementation; b) Adopt consultative methods, which are in line with the social and cultural values of the affected minority communities and local conditions, c) Pay a special attention to minority women, youth and children and their access to and benefits from development projects when designing these methods; d) Provide information about all relevant projects to ethnic minority communities in a manner consistent with their cultural habits at all stages of project preparation and 37 Hainan Health Sector Reform Project Environmental and Social Management Framework implementation (including the assessment of potential negative impacts of projects on affected ethnic minority communities). The ethnic minority engagement framework is prepared under SEP (see annex 4) EMDP preparation As mentioned above, if the subproject is located at an ethnic minority autonomous county, the subproject is categorized as substantial, following the E&S screening process. The subproject enterprise will conduct social assessment to evaluate the potential positive and negative impacts on such ethnic minority and prepare an EMDP for affected ethnic minorities. The World Bank will determine whether the affected minority communities are willing to provide extensive support to the subproject based on SA. If such support is available, the subproject PMO/IAs should prepare an EMDP. As necessary, the EMDP will include the following:  An information summary: reviewing a legal and institutional framework suited to minority residents on a scale appropriate to the Project; collecting baseline information on the population, social, cultural and political features of affected minority communities, land and estates traditionally owned, used or occupied by them, and natural resources on which they rely;  A summary of meaningful consultation: conducting such consultation at the preparation stage in the particular minority communities for extensive community support;  A framework document that ensures that meaningful consultation is conducted with affected minority communities at the implementation stage;  An action plan to ensure that minority residents receive culturally appropriate social and economic benefits, including measures to improve the capacity of the IAs if necessary;  An appropriate action plan to avoid, minimize or compensate for potential negative impacts on minority residents;  Budget and financing plan of the EMDP;  An appropriate and understandable grievance redress mechanism for minority communities, established by reference to common local judicial recourse and dispute settlement mechanisms;  An appropriate EMDP implementation M&E and reporting mechanism, including arrangements made for meaningful consultation with affected minority communities. 38 Hainan Health Sector Reform Project Environmental and Social Management Framework 7 Institutional Arrangements and Capacity Development Program 7.1 Environmental and Social Management Organization of the Project The organizational structure of the project is shown in Figure 7-1. Figure 7-1 Organization Structure of Environmental and Social Management Roles and Responsibilities World Bank (WB): 1) Guide the preparation and implementation of ESMF; 2) Provide relevant training and capacity building to the HPMO and relevant subproject implementation agencies; 3) Supervise and spot-check the implementation of ESMF; 4) Spot-check the E&S documents of the sub-projects supported by the WB loan. Provincial Project Steering Committee (PSC): 1) Guide the preparation and implementation of the ESMF; 2) Provide relevant training and capacity building to HPMO and relevant subproject implementation agencies; 3) Supervise and spot-check the implementation of ESMF; 4) Record or spot-check the environmental and social documents of the sub-projects supported by the World Bank loan. Hainan Provincial Project Management Office (HPMO) will: 1) Assign at least one dedicated staff to be responsible for the coordination of environmental and social management (ESMF implementation) during project implementation and recruit at least one external environmental expert and one 39 Hainan Health Sector Reform Project Environmental and Social Management Framework external social expert to provide consulting services on environmental and social management of the project. 2) Conduct capacity building of the sub-project implementation agencies on environmental and social management following ESMF requirements; 3) Guide and supervise the implementation agencies to implement the environmental and social management of the sub-project in accordance with ESMF; 4) With the assistance of the external expert group, review and confirm the screening results of environmental and social risks, review the environmental and social documents, and submit them to the World Bank for spot checks and record; 5) Supervise the implementation of environmental and social documents as applicable (environmental management plan, social action plan, ethnic minority development plan, etc.) and submit them to the World Bank for spot checks and record. Assess and manage environmental and social risks during the preparation and implementation of subprojects. 6) During project implementation, carry out environmental and social management of the sub-project in accordance with the ESMF, and engage external environmental and social monitoring consultants to conduct external monitoring of environmental and social management of the project, prepare external monitoring reports on the project’s performance on environmental and social management, and report to the WB every six months. External environmental and social expert group will: 1) Be established to include competent and experience environmental and social experts as external technical consultants. 2) Guide and assist the HPMO in complying with the environmental and social management requirements of the subprojects during preparation and implementation; 3) Assist the provincial project management office in building capacity of sub-borrowers on environmental and social management of subprojects; 4) Review the screening results of environmental and social risks and provide comments; 5) Review applicable environmental and social documents for subprojects and provide comments. Sub-project Implementation Agencies will: 1) Perform the environmental and social management for their subprojects following the ESMF requirements with the assistance of their consultants (if any); 2) Fill in the environmental and social screening form following the ESMF requirements; 3) Prepare applicable environmental and social documents for subprojects, and report to the HPMO for review and approval; 4) Conduct information disclosure and stakeholder engagement for the subproject following the ESMF and SEP requirements; 5) Supervise the implementation of environmental and social management plans as applicable to subprojects, and submit sub-project progress reports to HPMO on a regular basis; 40 Hainan Health Sector Reform Project Environmental and Social Management Framework Sub-project environmental assessment, social assessment and resettlement planning consulting service units will: Entrusted by the sub-project implementation agencies, according to the national and WB requirements, prepare applicable environmental and social documents, such as environmental impact assessment report, social assessment reports, ethnic minority development plan (if any) and other instruments applicable. External environmental monitoring consultants will: Be entrusted by the HPMO to monitor and evaluate the progress and effectiveness of the implementation of ESMF and submit an external monitoring report on environmental management to the HPMO on a regular basis (every six months). External social monitoring consultants will: Be entrusted by the HPMO to conduct monitoring and evaluation of the social management action plan or ethnic minority development plan (if any) and submit external monitoring reports to the HPMO on a regular basis (every six months). The consultants and/or qualified consulting agencies will conduct social and resettlement training for the sub-project implementation agencies, relevant communities and the project implementation management agency. 7.2 Environmental and Social Management Capacity Building Plan 7.2.1 Internal Capability Assessment The leading groups and implementation agencies involved in the project mainly include the Project Steering Committee (PSC), Hainan Provincial Project Management Office (HPMO), local PHC facilities and local ecology and environmental protection agencies. The project steering committee (PSC) is headed by the Governor of Hainan Provincial People's Government, and the deputy head is the deputy governor of Hainan Provincial People's Government. The leading group has 19 members, mainly including the Provincial Development and Reform Commission, the Provincial Department of Finance, and the Provincial Legal Affairs Office. They are responsible for formulating policies and measures for environmental and social management throughout the province, and coordinating major issues in environmental and social management in the province. Most of the organization’s members do not have professional knowledge of environmental and social management. Therefore, it is necessary to strengthen the training on environmental and social management and improve the organizational capabilities. The Provincial Project Management Office (located in the HPHC) will undertake the daily work of the leading group. The head of the office is the director of the Hainan Provincial Health Commission (HPHC), and the deputy head is the deputy director of HPHC. The Development Planning and Information Technology, Department and the System Reform Office, the Medical and Hospital Administration, the Provincial Health Care Bureau, the Primary Health Department, the Disease Prevention and Control Office and the Occupational Health Division each appoints one person to join the project management office, so there are totally nine people. The Provincial Project Management Office is responsible for the guidance and supervision of the sub-project’s environmental and social management, and will involve in the project’s 41 Hainan Health Sector Reform Project Environmental and Social Management Framework environmental and social management, but it has only professionals in occupational health and safety but no environmental and social management experts. In addition to recruit one environmental expert and one social expert, the existing personnel should also be trained to improve the capability of environmental and social management, guidance and supervision. Health care facilities and environmental protection agencies are the implementation agencies of the project. The relevant personnel do not have prior project experience, but they need to prepare documents related to environmental and social management in accordance with the requirements of the ESMF and are responsible for implementation, supervision and reporting. Therefore, the person in charge of the sub-project implementation is required to be trained prior to the project implementation, and environmental and social consulting and monitoring agencies need to be procured. 7.2.2 External Team Building Plan The provincial project management office will have full-time environmental and social management staff as liaison person to the World Bank and carry out sub-project environmental and social management. At the same time, the provincial project management office will hire external environmental and social experts to carry out sub-project environmental and social management and risk control, carry out review and provide technical guidance to the provincial project management office and the sub-project implementation agencies on environmental and social management work. The qualification requirements and main responsibilities of external experts are shown in Table 7-1. Table 7-1 Qualification Requirements and Main Responsibilities of External Environmental and Social Management Experts Provincial Environmental expert Social expert Project Qualification requirements: Qualification requirements: Management (1) Have deep knowledge in this profession (1) Have deep knowledge in this profession Office or industry, familiar with the domestic and or industry, familiar with the domestic and External international situations and dynamics of this international situations and dynamics of this expert group profession or industry; profession or industry; (2) Familiar with the relevant laws, (2) Familiar with the relevant laws, regulations and policies of China and the regulations and policies of China and the World Bank, and master the technical World Bank, and master the technical specifications and requirements for specifications and requirements for social environmental impact assessment; impact assessment; (3) Have a senior professional technical (3) Have a senior professional technical title and have worked in related title and have worked in related professional fields for 10 years or more. professional fields for 10 years or more. Main duties: Main duties: (1) Assist the provincial project (1) Assist the provincial project management office to guide the management office to guide the social environmental management of the management of the subprojects in subprojects in accordance with the accordance with the approved 42 Hainan Health Sector Reform Project Environmental and Social Management Framework approved environmental and social environmental and social management management framework; framework; (2) Assist the provincial project (2) Assist the provincial project management office to build capacity on management office to build capacity on environmental management of the social management of the sub-borrower; sub-borrower; (3) Establish and update the ESMF, (3) Establish and update the ESMF, including sub-project social screening including sub-project environmental criteria, social risk identification, etc.; screening criteria, environmental risk (4) Assist in reviewing the social grading, etc.; documents (including external monitoring (4) Assist in reviewing the environmental reports) of the subprojects and provide documents (including external monitoring comments; reports) of the subprojects and provide (5) Instruct the sub-borrowers to prepare comments; social documents, and carry out relevant (5) Instruct the sub-borrowers to prepare capacity training for provincial project environmental documents, and carry out management office staff and sub-borrowers; relevant capacity training for the provincial (6) Track the latest social management project management office staff and policies and requirements of China and sub-project implementation agencies; international financial institutions such as (6) Track the latest environmental the World Bank. management policies and requirements of China and international financial institutions such as the World Bank. 7.2.3 Staffing The staffing of the Project Steering Committee (PSC) and the Provincial Project Management Office (HPMO) could be adjusted later according to the demand of the project. However, at least one dedicated staff should be assigned in HPMO and each subproject implementation agency for the coordination of environmental and social management following the ESMF requirements. 7.2.4 Capacity Building Plan An external expert group will be established, including environmental and social experts. External experts and World Bank experts will provide ESMF-related routine and specific training for relevant personnel of the sub-project implementation agencies to learn how to implement ESMF throughout the life of the sub-project. The environmental and social management capacity building will utilize the provincial project management office's own funds and institutional capacity development funds supported by World Bank loans. The phased plan for capacity building for environmental and social management is as follows: 43 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 7-2: Training Plan for Environmental and Social Management Capacity Building Training Resource/trai Number of Duration Main training content Objectives Form Frequency participants ner Participants (days) Explanation on the project’s Environment and Social Management Framework (ESMF), including: 1. Purpose of ESMF; 2. Policy and regulatory requirements; At project 3. Relevant environmental protection and social launch and at management measures and requirements; Strengthen the capacity World Bank least once a HPMO 2~4 Lecture 0.5 4. Screening of potential environmental and social of HPMO on ESMF experts year during issues; implementation. implementatio 5. Implementation of SEP. n 6. The role of the resettlement policy framework and the ethnic minority development framework (including the participation framework). Upon Classroom mobilization Training and at least External E&S Strengthen the 2 Workshop 2 twice a year Experts with experts, knowledge and capacity (Advance during Understand the World Bank's Environmental and experience in external E&S of external experts on d) implementatio Social Framework (ESF) World Bank monitoring environmental and n projects team social management. External expert 2 advisory services 44 Hainan Health Sector Reform Project Environmental and Social Management Framework Training Resource/trai Number of Duration Main training content Objectives Form Frequency participants ner Participants (days) Explanation on the project’s environment and social management framework (ESMF), including: Strengthen the 1. Roles and purpose of ESMF; sub-project units and 2. Policies and regulations; their environmental and External At least twice 3. Related environmental protection and social social management environmental Subproject a year during management measures and requirements; staff’s capability in and social implementati 10~20 Lecture 2 project 4. Screening of potential environmental and social ESMF implementation, experts, other on agencies implementatio security issues; environmental and national/intern n 5. Implementation of SEP; social management, and ational experts 6. Role of resettlement policy framework and ethnic occupational health and minority development framework (including safety management. participation framework). 1.Good operational practice on medical waste/wastewater separation, collection, storage, Introduction of good External transfer and disposal. medical At least twice environmental Project-suppo 2.Occupational Health and Safety (OHS) training, waste/wastewater On the a year during and social rted PHC covering the aspects of disinfection, infectious management and OHS 20-40 job/Works 2 project experts, other facilities disease prevention, emergency response and management practice hop implementatio national/intern reporting, medical waste management, fire following available n ational experts prevention and emergency, radiation exposure GIIPs protection and so on 45 Hainan Health Sector Reform Project Environmental and Social Management Framework 8 Monitoring, Reviewing and Reporting 8.1 Internal Monitoring Internal monitoring is carried out by the borrower. HPMO should appoint a full-time environmental and social management staff to be responsible for collecting and sorting out information related to environmental and social management in a timely manner. The internal monitoring reporting is conducted twice a year. The HPMO analyzes the internal monitoring results semi-annually and checks the implementation progress of the environmental management plan, environmental and social commitment plan, social management plan and ethnic minority development plan (if any). The subproject implementing agencies prepares a progress report semi-annually (deadlines: August 31st and February 28th of each year) and submits it to the HPMO. HPMO summarizes the report and submit the progress report to the World Bank (deadlines: September 30th and March 31st of each year). Before the completion of sub-project supported by the World Bank, the sub-project implementing agencies shall prepare the ethnic minority development and social development completion report (if applicable) which should be submitted to the HPMO for review and then submitted by the HPMO to the World Bank for review and record. 8.2 External Monitoring Borrower entrusts independent agencies through public bidding to perform external monitoring and evaluation on the environmental and social management of the whole project until all the subprojects supported the World Bank have been accomplished. Independent institutions or individuals could be academic or institutional organizations, non-governmental organizations (NGOs), or independent consulting firms, which have qualified and experienced staffs. The external monitoring units shall prepare the monitoring report on the implementation of ESMF and other applicable E&S instruments such as environmental management plan, ethnic minority development plan, social action plan (including gender development plan) (if any) semi-annually and submit them to the HPMO and the World Bank on 30th September and 31st March of each year. 8.3 Reporting System Subproject implementation agencies should prepare the subprojects’ external environmental and social monitoring reports during the implementation of environmental management plan, poverty and social action plan (including gender development plan) (if any) as part of the semi-annual progress report and submit them to the HPMO on the 31th July and the 31th January of each year. After review, the HPMO should submit them to World Bank on the 31st August and the 28th February of each year. The external monitoring report mainly includes the external environmental management report, the resettlement monitoring report (if any), ethnic minority development and social development report (including implementation of gender development plan monitoring report) (if any). Before the loan closing date, the subproject implementation agencies should prepare completion report, which includes the reports on the implementation of environmental 46 Hainan Health Sector Reform Project Environmental and Social Management Framework management plan, the resettlement report, ethnic minority development and social development report, and submit them to HPMO and the World Bank for review and record. 47 Hainan Health Sector Reform Project Environmental and Social Management Framework 9 Information Disclosure and Public Consultation 9.1 Identification of Key Stakeholders The key stakeholders of the Project are identified as following: i) Rural and urban residents, and migrant population, including 9.2576 million local rural and urban residents, and a migrant population of 1.31 million; ii) Vulnerable groups, including 4.4 million women, 70,000 poor residents and 165,742 minority residents in 27 cities, counties and districts in Hainan Province; iii) 9,724 (in 2017) PHC practitioners (rural and family doctors) in Hainan Province; iv) PHC providers: 5,177 PHC providers in Hainan Province, including 25 centers for disease control, 24 maternity and child care centers, 15 specialized disease prevention and treatment institutions, 175 community health service institutions, 299 township health centers, 51 community health centers, and 1,312 village clinics; v) Hainan Provincial Health Commission (HPHC, including information center) and Hainan Healthcare Security Administration (HHSA, Hainan PMO) vi) Medical alliances, mainly including county / city top three hospitals, such as Hainan General Hospital, Hainan Nongken General Hospital, Affiliated Hospital of Hainan Medical University, and central hospitals 9.2 Stakeholder Consultation from Environmental Perspectives (1) Consultation Meeting The Hainan Provincial Health Commission, with the support of its environmental and social consultants, conducted two stakeholder consultations in July 2019. The meetings were held in Haikou, Hainan Province. The main stakeholders in the meeting included relevant departments of Hainan Provincial Health Commission, external environmental and social experts, and relevant commissions of Hainan Province. Figure 9-1 Environmental and Social Government Department and Sector Experts Consultation Meeting The meeting determined that the main scope of this health sector reform project is to improve the primary medical software, and the major contents are to improve resource utilization efficiency, reduce pollution waste, improve personnel skills as well as improve the institutional system. Environmental management mainly includes two aspects: 48 Hainan Health Sector Reform Project Environmental and Social Management Framework 1) Improve the technical, health and safety management of primary health care personnel by compiling the environmental safety and health manuals and providing awareness training for patients and medical personnel on their own safety and health; 2) Assess the medical waste management capability and increase the efficiency of waste collection and treatment through daily management improvement. (2) Field Investigation and Stakeholder Consultation  First round of field investigation On August 15-16, typical PHC facilities in Chengmai County were visited, persons in charge of pollutant management were interviewed, questionnaire surveys of medical personnel were conducted, and waste storage and wastewater treatment were inspected. The purpose of the field visit is to understand (1) the institutional environmental management capabilities and environmental management awareness of primary health care personnel; (2) the management process of medical waste, wastewater, and radioactive pollution control; (3) the existing environmental risks in the project. The survey results show that the risk associated with medical radiation is low because the physicians have high awareness of safety protection and are physically protected; in terms of medical wastewater, all hospitals at county level have treatment facilities but hospitals at village or township level do not have facilities for proper wastewater treatment; in terms of medical waste, the primary health care facilities in Hainan have relatively good facilities, including sub-packaging, temporary storage, transfer, and disposal facilities, but the staff have weak awareness of waste management, resulting in overtime storage. Figure 9-2 Photos of the First Field Investigation  Second round of field investigation Based on the first round of investigation, a large-scale survey was carried out targeting the medical waste regarding transfer system, storage time, treatment costs, disinfection methods and compliance status, and the medical radiation regarding personnel medical examination and environmental monitoring report. 18 related institutions were visited, including Sanya Baoqilai Waste Disposal Co., Ltd., five health care facilities and a garbage transfer station in Wuzhishan, three health care facilities in Qiongzhong, two health care facilities in Lingshui, three health care facilities and a garbage transfer station in Changjiang, two health care facilities in Zhangzhou. The survey results show that in terms of medical wastewater, the hospitals at village and township level have inadequate treatment facilities or do not treat wastewater properly; and in terms of medical wastes, there are problems including weak personnel awareness, inadequate supervision, unstandardized storage room and overtime storage. 49 Hainan Health Sector Reform Project Environmental and Social Management Framework Figure 9-3 Photos of the Second Field Investigation (3) Online Investigation and Stakeholder Consultation Based on the field investigation, questionnaire was developed and distributed to various health care facilities to conduct investigations on the environmental protection facilities and radiation protection and conduct research on the personnel’s waste management knowledge. The questionnaire for the status of pollutant management in health care facilities can be found at: https://www.wjx.cn/jq/45110450.aspx.The questionnaire for environmental safety awareness of medical staff in health care facilities can be found at https://www.wjx.cn /jq/45113667.aspx. The results show: In terms of medical waste, there are 59.52% of health care facilities which have its medical wastes temporarily stored for less than 2 days, 22.96% of the health care facilities with a storage time of 3-4d , 13.6% of the health care facilities with a storage time of 5-10d, and 3.93% of the health care facilities with a storage time of above ten days. The frequency of medical waste collection for county-level public health care facilities in Hainan is at least once per 2 days, while the frequency of medical waste collection for township hospitals and urban private clinics is once per 2 ~ 3 days. Except for public health care facilities above the secondary level, the medical waste generated by most health care facilities has a temporary storage time of more than 2 days. Primary health care facilities have the characteristics of small amount of business, scattered distribution, and long transport distances. Therefore, the centralized disposal units have extended the interval for medical waste collection given economic consideration and limitations of capability. The phenomena that medical waste is not safely disposed, and the existing disposal capacity is not fully utilized coexist. There are risks of medical waste leakage and environmental pollution. The survey found that only 89.05% of the waste was weighed during transfer for charging purpose. Only 9.67% of the health care facilities are charged according to the quantity of waste. There is no incentive for specifying the amount of waste at the time of transfer. Regarding wastewater treatment methods adopted by various health care facilities, 30.82% of medical units use chlorine dioxide for disinfection; 27.79% of medical units use chlorine for disinfection; 6.34% of health care facilities use ozone treatment; 4.53 % of the units are treated with UV disinfection and 30.51% are treated with other methods. A survey of medical waste management personnel in health care facilities found that some health care facilities outsourced sewage treatment, but personnel working for the outsourced institution have an uneven age and education level. Some small health care facilities only operated and maintained equipment by electricians. 9.3 Stakeholder Engagement from Social Perspectives Such methods as key informant interview focus group discussion (FGD) and field investigation were used from social perspective. During September and October 2019, the task force visited Baoting Li-Miao Autonomous County (no longer a poor county 50 Hainan Health Sector Reform Project Environmental and Social Management Framework in 2019), Wuzhishan City (poor area, gathering of minority residents), Sanya City (gathering of migrant population) and Haikou City (gathering of migrant population). Among these cities / counties, minority population accounts for 69.5% and 73.3% in Baoting County and Wuzhishan City, respectively. Baoting County was no longer a poor county in 2019, and Wuzhishan City is still a poor area, where minority and poor populations highly overlap. Therefore, these two cities / counties are most typical in stakeholder needs (especially vulnerable groups) and rural medical care; Haikou and Sanya Cities have largest migrant populations and are more economically developed, so they are most typical in urban primary healthcare and migrant population needs. During the fieldwork, the task force held FGDs with health commissions (HCs), ethnic affairs commissions (EACs), women’s federations (WFs), and poverty alleviation offices (PAOs) in Hainan Province and the sample cities / counties, and conducted in-depth interviews with PHC provider staff and residents to learn the basic information of PHC providers, the use of PHC services by local residents, migrants, poor people, minority residents, women and other vulnerable groups. During the fieldwork, 15 FGDs were held with 160 persons, and 88 key informant interviews conducted. The social survey found that some local residents tend to receive medical care at county level or above hospitals for some common chronic diseases, resulting in expensive and difficult medical care. The Project aims to improve the medical service level of primary hospitals, and increase the utilization rate of PHC, thereby benefiting 5.56 million rural residents in the province, especially 70,000 poor rural residents. After project completion, public health resources will be allocated more evenly between urban and rural areas, enabling rural residents, especially poor rural residents, to receive medical care more conveniently, and increasing the utilization rate of PHC providers. The building of IT systems, medical alliances and rural doctor teams will improve the operating efficiency of PHC providers, reduce personal medical financial burden, and alleviate poverty due to diseases. In 2017, the outpatient expense per man-time at general hospitals in Hainan Province was 263.6 yuan, and the inpatient expense per man-time was 10,603.7 yuan. Township health centers often cannot treat major diseases due to the shortage of medical staff and equipment, while county hospitals are usually crowded. Rural residents need to pay travel expenses and accommodation fees due to the long distance, so it is expensive and hard to see a doctor in county hospital, especially for poor rural residents. At FGDs, all stakeholders highly support the Project, and consider it beneficial to the public and have no negative impact. 9.4 Grievance and Complaint Mechanism The grievance mechanism will be consistent with the nature, size, potential risks and impacts of the subprojects. Its purpose is to quickly resolve related issues, adopt a process that is understandable and transparent, provide timely feedback to the parties in the language they understand, without any penalty, and operate in an independent and objective manner. The grievance mechanism can make use of existing grievance mechanisms as follows: The first stage: If the affected people in the project area are dissatisfied with the implementation of the project, they can submit an oral or written appeal to the village committee/community or implementation agency of the project; if it is a verbal complaint, it must be handled and recorded by the village committee/community or project implementation agency. The village committee/community or project 51 Hainan Health Sector Reform Project Environmental and Social Management Framework implementation agency should resolve within 2 weeks, or call the complaint hotline 12345 directly; The second stage: If the affected people in the project area are still dissatisfied with the decision of stage 1, they can appeal to the street/township and related institutions (the Letters and Calls Bureau). After receiving the decision, the management agency should make a dealing decision within 2 weeks; The third stage: If the decision of stage 2 is still not satisfactory, after receiving the decision, they can appeal to the administrative agency with jurisdiction for arbitration, according to the Administrative Procedure Law of the People's Republic of China. The fourth stage: If you are still dissatisfied with the arbitration decision, you can file a suit in a civil court in accordance with the Civil Procedure Law after receiving the arbitration decision. In addition to the above appeal procedures, affected people can appeal directly to the provincial project management office. Before the project is officially implemented, the provincial project management office will publicize the relevant contacts and their contact information. Before the implementation of each sub-project, each sub-borrower needs to inform the affected people and communities of the contacts of complaints, contact information, complaint channels, complaints registration forms (including complaints, time, receptionists, processing results, etc.). Affected people can sue for any aspect of project construction. The above appeal channels will be notified to the affected people in the project area through meetings and other means, so that the affected people can fully understand their right to appeal. At the same time, media tools will be used to strengthen publicity and reporting, while the right opinions and suggestions of all parties will be compiled into information provisions. In addition, in minority areas, bilingual staff will serve at all stages. At the same time, the telephone number and address of the staff in charge of complaint will be publicized. 9.5 Information Disclosure Two rounds of information disclosure were conducted during ESMF preparation. The Chinese documents were disclosed on the official website of the Hainan Provincial Health Commission (http://wst.hainan.gov.cn/swjw/ywdt/tzgg/201911/t20191112_2703040.html ) respectively on Nov. 12, 2019 (first draft) and Dec. 18, 2019 (draft final). No feedback was received during disclosure. The English documents will be disclosed on the external website of the World Bank in January 2020. 52 Hainan Health Sector Reform Project Environmental and Social Management Framework 53 Hainan Health Sector Reform Project Environmental and Social Management Framework 10 Budget The total budget for the project’s E&S management is estimated RMB 5,880,000 in rough, including two parts: part 1 is for preparation of related E&S documents when required; part 2 and 3 is for capacity strengthening of the PMO and PIUs. See Table 10-1 for details. Table 10-1 Budget for E&S Management of the Project No. Areas Budget (RMB) Source of financing 1 E&S documents 400,000 Domestic fund preparation 2 External Environment 1,000,000 Bank loan and social experts 3 Environmental and OHS 4,000,000 Bank loan Training 4 Stakeholder Engagement 480,000 Bank loan Total 5,880,000 / 54 Hainan Health Sector Reform Project Environmental and Social Management Framework Annex 1 Guidance on Environmental and Social (E&S) risk classification for subprojects The proposed subprojects will be screened with the Exclusion List as indicated in Annex 2. If the subproject is deemed eligible, the subproject, especially infrastructure subproject, subproject identified with associated infrastructure facilities or TA providing advice on the development of sector policies/strategies, should be screened using the E&S screening checklist to determine potential E&S risks and categorization. The E&S screening checklist provides a series of questions related to Environmental and Social Standards (ESSs) under the Bank’s Environmental and Social Framework (ESF). Upon risk classification, additional E&S management instruments/measures, if any, will be identified for preparation under the subproject. The risk rating results needs to be endorsed by Hainan provincial Project Management Office (HPMO) and their external experts. The Environmental and Social (E&S) risk screening forms should be filed and sent to the Bank for records and spot-check. Definition Typical subprojects Applicable E&S E&S Risk instruments Category High The project is likely to generate a Subprojects that are in the exclusion / wide range of significant adverse list. risks and impacts on human populations or the environment, and some of these impacts cannot be mitigated or specific mitigation measures require complex and/or unproven mitigation, compensatory measures or technology. Substantial Some E&S impacts of the project Subprojects required to prepare full ESIA, ESMP, may be significant, but mitigatory EIA report according to China’s SEP and/or compensatory measures may Directory for EIA Categorized be designed more readily and be Management of Construction ESIA, ESMP, more reliable than those of High Risk Projects (2018); SEP and EMEF projects. Subprojects located in national or or EMDP provincial poverty counties or districts; Subprojects located in ethnic ToRs minority areas; integrating E&S TA on sector policies/strategies considerations with potentially significant downstream E&S impacts Moderate Potential adverse E&S risks and Subprojects that need to prepare ESMP, SEP impacts are not likely to be EIA form as required in significant and can be easily Categorized Directory for EIA mitigated in a predictable manner. Categorized Management of Construction Projects. Low Potential adverse E&S risks and Physical subprojects requiring only SEP impacts are likely to be minimal or registration according to China’s negligible. Directory for EIA Categorized Management of Construction Projects; Subprojects located in neither national or provincial poverty counties nor ethnic minority areas. 55 Hainan Health Sector Reform Project Environmental and Social Management Framework Annex 2 E&S Screening Checklist During the implementation of Hainan Health Section Reform Project, this screening checklist shall be filled by Hainan PMO with the supports of external environmental and social experts at the subproject screening stage, and the completed sheets for candidate subprojects shall be sent to the World Bank for review. Name of Subproject: ________________________________ Type: (A) Technical studies (B) Equipment procurement (C) Capacity building through training, workshops, study tours, etc. (D) Personnel allowance (E) Others, to specify Implementation Unit: Location： Cost estimate： Implementation duration： Relevance Criteria Remarks/Actions Yes No Exclusion List 1. Will the subproject implementation cause any negative impacts on nature reserves (existing or planned), critical natural habitat, scenic areas, forest parks, protected water sources, or areas with high ecological value? 2. Will the subproject produce, or trade of any production deemed illegal under host country laws or regulations or international conventions and agreements, or restricted by international injunctions such as pharmaceuticals, pesticides/herbicides, ozone-depleting substances, polychlorinated biphenyls, wildlife or CITES regulated products? If yes, the subproject will not be supported. 3. Will the subproject produce or trade alcoholic beverages (excluding beer and wine)? 4. Will the subproject produce or trade the unbounded asbestos fibers? This does not apply to the purchase and use of asbestos-cement slabs with asbestos content below 20%. 5. Will the subproject require land acquisition or physical displacement? 56 Hainan Health Sector Reform Project Environmental and Social Management Framework Relevance Criteria Remarks/Actions Yes No 6. Will the subproject involve any form of forced labor and/or child labor? 7. Does the subproject have irreversible adverse environmental and social impacts even mitigation measures are taken? 8. Is the subproject forbidden by national and local laws and regulations? Environmental and Social Risks If yes, then the same safeguards requirements for the subproject will 1. Is there “associated facilities1” involved in the subproject? apply to the “associated facilities”. 2. Will the subproject implementation lead to impacts on non-critical natural habitat? If yes, the sub-project shall require an environmental impact assessment and environmental management plan. 3. Is there known archeological, historical, or cultural heritage site in the area of influence of the If yes, a cultural heritage management plan needs to be prepared to subproject? explain the specific operation. 4. Will the subproject bring significant community health and safety risk? If yes, the subproject shall require an environmental impact assessment and mitigation measures. 5. Will the subproject cause significant labor safety and health risks? If yes, OHS management should be implemented following the guidelines in Annex 3. 6. Are there any potential significant adverse environmental impacts associated with the If yes, the subproject must be rated S or H. The sub-project shall sub-project; and if yes, are the impacts considered sensitive, multiple and unprecedented? require an environmental impact assessment and environmental management plan. 7. Is there any likelihood that the environmental impacts are beyond the site boundary, or the If yes, the subproject must be rated S or H. The sub-project shall impacts occurring during project implementation are beyond the planning area? require an environmental impact assessment and environmental management plan. 1 “Associated Facilities” means facilities or activities that are not funded as part of the project and, in the judgment of the Bank, are: (a) directly and significantly related to the project; and (b) carried out, or planned to be carried out, contemporaneously with the project; and (c) necessary for the project to be viable and would not have been constructed, expanded or conducted if the project did not exist. 57 Hainan Health Sector Reform Project Environmental and Social Management Framework Relevance Criteria Remarks/Actions Yes No If yes, the subproject must be rated S or H, and: 1. Social impact assessment and mitigation measures should be required. 2. Ethnic minority engagement framework (EMEF) will be 8. Is the subproject area located in ethnic minority areas? implemented when the subproject is not located in any ethnic minority autonomous county but located in areas/communities involving ethnic minority people. 3. Ethnic minority development plan (EMDP) should be prepared when the subproject is in any ethnic minority autonomous counties. Overall environmental and social risk: “High” risk subprojects are not eligible for financing under the Project, until agreed by the World Bank and meeting the requirements (Overall risk shall be determined based on the highest rating of all above questions) of relevant ESSs. Note: In case “High” risk subprojects are to be funded under the Project, HPMO shall obtain the prior approval of the World Bank in the risk screening stage. Meanwhile, the World Bank will upgrade the overall project risk level to “High” following the requirement of ESF. HPMO will review and adjust, in a manner acceptable to the World Bank, the ESMF when the environmental and social risk profile is changed to High. Following the updated ESMF, the high-risk subprojects should be assessed, prepared and implemented to meet the relevant requirements of the ESSs that are applied. Completed by: ___________________________ Date: _______________ 58 Hainan Health Sector Reform Project Environmental and Social Management Framework Annex 3 Environmental, Health, and Safety Guideline for Primary Health Care Facilities 59 Hainan Health Sector Reform Project Environmental and Social Management Framework 1. 背景及适用范围（Background and Scope of application） 本《环境、健康与安全指南》是针对世行贷款海南重构以健康为中心的医疗卫生服务体系项目而编 制的，旨在确保基层医疗机构为其员工、病人以及周边社区构建安全、健康而且环境友好的工作环境。 指南根据现行中国法规以及国际良好行业实践（GIIP）编制，包括适用世行集团和世界卫生组织的环境 健康安全指南，适用于本项目所支持的海南省境内所有县级及以下的基层医疗服务机构,包括县级公立 医院、乡镇卫生院及村卫生室。 The Environmental, Health, and Safety Guideline (EHSG) were developed under the World Bank-financed Hainan Health Sector Reform Project (HHSRP), which is designed to secure a safe, healthy and environmentally friendly work environment in the Primary Health Care Facilities (PHCF) for their employees, patients and nearby communities. These guidelines were developed based on existing national legislation and Good International Industry Practice (GIIP), such as applicable EHSG of the World Bank Group (WBG) and the World Health Organization7. In the context of HHSRP, the guidelines are applicable to various project-supported PHC facilities at county/town/village/community levels in Hainan Province, including county hospitals, town/township clinics and community/village clinics. 2. 通则 General The leadership and commitment from management is essential in establishing a safe and healthy workplace. Management of PHC facilities should: 管理层的领导和承诺对于建立一个安全和健康的工作场所至关重要。管理基层医疗机构应该：  Support compliance with existing legislation of the country and the province as applicable;  Establish and implement the facility’s Environment, Health and Safety (EHS) management policies suitable to the nature and scale of its EHS risks with reference to the EHSG;  Prepare and implement comprehensive and realistic action plans so that acceptable conditions are achieved and maintained;  Promote awareness and build capabilities among all employees on EHS management.  遵守国家和海南省的现行法律；  建立并执行与 EHSG 有关的机构环境、健康和安全（EHS）管理政策，以适应其 EHS 风险的 性质和规模；  制定并执行全面和现实的行动计划，以便达到和保持可接受的状态；  提高所有雇员对 EHS 管理的认识和能力。 Health-care settings are environments with a high prevalence of infectious disease agents. Patients, staff, carers and neighbors of the PHCF would face unacceptable risks of infection if without adequate risk management measures. The following table summarizes key health risks related to environmental health in PHCF. 医疗机构属于传染病流行率高的环境。如果没有适当的风险管理措施，基层医疗机构的病人、工作人员、 护理人员和周围社区将面临不可接受的感染风险。下表概述了基层医疗机构中与环境健康有关的关键风险。 Table 1 Health Risks and Preventive Measures in Primary Health Care Facilities (PHCF) 表1 基层医疗机构的健康风险和预防措施 Health Risk 健康风险 Preventive Measures 预防措施 7 Applicable ESHG of the WBG (available at www.ifc.org/ifcext/enviro.nsf/Content/EnvironmentalGuidelines ) include the General Guidelines and the EHSG for Health Care Facilities; reference was also made to the Essential Environmental Health Standards in Health Care by the WHO. 适用世界银行环境、健康和安全指南（可查阅 www.ifc.org/ifcext/enviro.nsf/Content/Environmental Guidelines）包括《通用指南》和《医疗服务 机构的环境、健康与安全指南》；还参考了世界卫生组织的《医疗服务机构基本环境健康标准》。 60 Hainan Health Sector Reform Project Environmental and Social Management Framework Health Risk 健康风险 Preventive Measures 预防措施 - Ventilation Airborne Infections (e.g. Legionella, avian - Space available per patient influenza, SARS, tuberculosis) - Spacing of beds 空气传播感染（例如：军团菌、禽流感、非 - Use of separate rooms for highly vulnerable or infectious patients 典、肺结核） - Use of masks and correct incineration of wastes - 通风 - 每个病人可用的空间 - 床间距 - 为极易感染或感染的病人提供单独的房间 - 使用口罩和正确焚烧废物 - Water supply (quality and access) Water-, food- or hand-borne infection (e.g. - Excreta disposal HEV, diarrhea) - Hygiene facilities 水、食物或手传感染（例如：戊型肝炎病毒、 - Food hygiene 痢疾） - Hand hygiene - 供水（水质及获取） - 排泄物处置 - 卫生设施 - 食物卫生 - 手卫生 - Use of single-use medical devices and dressings Infection of wounds/surgical incisions from - Pre-disinfection contaminated water, medical devices and - Cleaning and sterilization of instruments and dressings dressings (e.g. sepsis) - Water supply (quality and access) 受伤口/手术切口污染的水、医疗设备和敷料 - Asepsis in surgical or dressings procedures 感染（例如：脓毒疾） - 一次性医疗器械和敷料的使用 - 预消毒 - 器械和敷料的清洗和灭菌 - 供水（水质及获取） - 外科或敷料手术中的无菌性 - Health-care waste management and use of single-use needles and syringes Bloodborne infections due to contaminated - Safe blood transfusion needles and syringes, unsafe blood transfusion - 医疗废物管理和使用一次性针头和注射器 (e.g. HBV, HCV and HIV) - 安全输血 由受污染的针头和注射器引起的血液传播感 染和不安全的输血（例如乙型肝炎病毒、丙 型肝炎病毒和艾滋病毒） Heat- and cold-related stress and discomfort Heating, ventilation, air-conditioning (HVAC) and insulation (e.g. higher fever) 供暖、通风、空调和隔热 与热和冷有关的压力和不适（例如：高烧） 61 Hainan Health Sector Reform Project Environmental and Social Management Framework Health Risk 健康风险 Preventive Measures 预防措施 - Control of disease vectors in and around buildings Vector-borne disease transmission (e.g. malaria, - Protection of patients dengue, leishmaniasis) - Protection of infrastructure 媒介传播疾病（例如：疟疾、登革热、利什 - 控制建筑物内和周围的病媒 曼病） - 保护病人 - 保护基础设施 - Installation of radiation-proof equipment and wearing of personal Radiological hazards protection equipment. 放射性危害 - Regular awareness campaign - 安装防辐射设备和佩戴个人防护设备 - 定期开展提高认知的活动 - Safe use and handling of hazardous chemicals; Chemical-resulting toxic responses on human - Appropriate management and disposal of chemical waste. body, from mild irritations to potentially serious - Regular awareness campaign among medical personnel or even fatal damage to body tissues and organs - 安全使用和处理危险化学品 由化学引起的对人体的毒性反应，从轻微的 - 适当管理和处置化学废物 刺激到对身体组织和器官的潜在、严重甚至 - 定期在医务人员中开展提高认知的活动 致命的损害 3. 废弃物管理（Waste Management） 基层医疗服务机构（PHCF）产生的废弃物可分为两类：第一类是行政、内务清洁和维护职能部 门 产生的一般性废弃物， 成分与生活废弃物相似。第二类是各类危险的医疗废弃物。 Waste from health care facilities (HCF) can be divided into two separate groups. The first consists of general waste, similar in composition to domestic waste, generated during administrative, housekeeping, and maintenance functions. The second group consists of specific categories of hazardous health care waste. 医疗服务机构应建立、 执行和保持与业务活动和已确定危害之规模及类型相适应的医疗废弃物 管理系统（HWMS） 。医疗服务机构经营者应定期对废弃物的产生数量及类别进行评估，以促进废弃物 管理规划，并不断设法最大限度减少废弃物。具体应包括以下内容： Health care facilities should establish, operate and maintain a health care waste management system (HWMS) adequate for the scale and type of activities and identified hazards. Facility operators should undertake regular assessment of waste generation quantities and categories to facilitate waste management planning, and investigate opportunities for waste minimization on a continuous basis. The HWMS should include the following components: 3.1 废弃物的减少、再利用和循环（Waste Minimization, Reuse, and Recycling） 医疗服务机构应在不牺牲患者的卫生和安全条件的前提下，考虑采用最大限度减少产生废弃物的 做法和规程，包括： Facilities should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations, including: 3.1.1 减少废弃物来源的措施（Source reduction measures）  进行产品 /材料的替代，避免产品内包含导致产品必须作为危险或特殊废弃物进行处置的 62 Hainan Health Sector Reform Project Environmental and Social Management Framework ，在功能相同的前提下，选择同类产品中包装较少或重量轻巧 危险物质（例如汞或气雾罐） 的产品；  在不影响消毒和符合卫生及患者安全标准的前提下，尽可能采用物理清洁方法来代替化学 清洁方法（例如使用微纤维拖把和抹布）。  Consider options for product / material substitution to avoid products containing hazardous materials that require the product to be disposed as hazardous or special waste (e.g. mercury or aerosol cans), and preferring products with less packaging or products that weigh less than comparable products that perform the same function  Use of physical rather than chemical cleaning practices (e.g. using microfiber mops and cloths), where such practices do not affect disinfection and meet relevant standards for hygiene and patient safety 3.1.2 降低废弃物毒性的措施（Waste toxicity reduction measures）  进行产品 /材料的替代：包含汞或其他危险物质的器械；丢弃后可能成为危险废弃物的产 品；聚氯乙烯（PVC）制品；卤代化合物；释放挥发性有机化合物（VOC）的产品，或包含 持久性、生物蓄积性和毒性（PBT）化合物的产品；包含属于致癌毒素、致突变毒素或生殖 毒素（CMR）之物质的产品。  Consider options for product / material substitution for equipment containing mercury or other hazardous chemicals; products that may become hazardous waste when disposed; products made of polyvinyl chloride (PVC); halogenated compounds; products that off-gas volatile organic compounds (VOCs), or products that contain persistent, bio-accumulative and toxic (PBT) compounds; products that contain substances which are carcinogenic, mutagenic or reproductive toxins (CMR). 3.1.3 对库存进行高效率的管理和监督（例如对化学品及药品的库存）（Use of efficient stock management practices and monitoring (e.g. for chemical and pharmaceutical stocks)）  对于迅速变质的产品采取少量多次订货的做法，并严格监督失效日期；  用完原有的产品存货之后，再使用新进货的产品；  最大限度地利用安全的可重复使用的医疗设备，包括：器械再利用之前须灭菌消毒（例如 。 锐器收集箱）  Small / frequent orders for products that spoil quickly and strict monitoring of expiry dates.  Complete use of old product before new stock is used.  Maximization of safe equipment reuse practices, including: Reuse of equipment following 63 Hainan Health Sector Reform Project Environmental and Social Management Framework sterilization and disinfection (e.g. sharps containers). 3.2 废弃物隔离方法（Waste Segregation Strategies） 在废弃物的产生点，应对废弃物进行鉴别和隔离。无危险废弃物，例如纸张和纸板、玻璃、铝和 塑料，应单独收集和回收；食品废弃物应分离开来作堆肥处理；对于感染性和（或）危险 废弃物，应 采用色彩代码系统进行识别和分类隔离。如果不同类型废弃物意外混合在一起，应作为危险废弃物处 理。其他隔离措施包括： At the point of generation, waste should be identified and segregated. Non-hazardous waste, such as paper and cardboard, glass, aluminum and plastic, should be collected separately and recycled. Food waste should be segregated and composted. Infectious and / or hazardous wastes should be identified and segregated according to its category using a color-coded system. If different types of waste are mixed accidentally, waste should be treated as hazardous. Other segregation considerations include the following:  避免一般性医疗废弃物与危险医疗废弃物相混合，以降低处置成本；  Avoid mixing general health care waste with hazardous health care waste to reduce disposal costs;  含汞废弃物须隔离作特殊处置。对于含汞产品及相关废弃物，应制定管理计划，安排在隔离及清理 方面受过专门培训的人员来管理；  Segregate waste containing mercury for special disposal. Management of mercury containing products and associated waste should be conducted as part of a plan involving specific personnel training in segregation and clean up procedures;  对重金属（例如镉、铊、砷、铅）含量高的废弃物应进行隔离，以避免进入废水；  Segregate waste with a high content of heavy metals (e.g. cadmium, thallium, arsenic, lead) to avoid entry into wastewater streams;  清空容器中残留的化学品，放入适当的处置容器，以减少污染废水的产生量。不应混合不同类型的 危险化学品；  Separate residual chemicals from containers and remove to proper disposal containers to reduce generation of contaminated wastewater. Different types of hazardous chemicals should not be mixed;  对于接受基因毒性药物治疗患者的尿液、粪便、血液、呕吐物和其他废弃物，建立单独的收集规程 和机制。该等废弃物是危险废弃物，应按相关规定进行处理；  Establish procedures and mechanisms to provide for separate collection of urine, feces, blood, vomits, and other wastes from patients treated with genotoxic drugs. Such wastes are hazardous and should be treated accordingly 64 Hainan Health Sector Reform Project Environmental and Social Management Framework  对气雾罐和其他气体容器应采取隔离措施，避免焚烧处置法及相关的爆炸危害；  Aerosol cans and other gas containers should be segregated to avoid disposal via incineration and related explosion hazard  隔离包含 PVC 的医疗产品，避免进行焚烧（见下文“大气排放物”）或填埋处置。  Segregate health care products containing PVC to avoid disposal via incineration (see Air Emissions below) or in landfills. 3.3 现场处理、收集、运输和储存（On-site Handling, Collection, Transport and Storage）  废弃物口袋和容器大约装满四分之三时，密封后进行更换。口袋和容器装满后应立即更换；  Seal and replace waste bags and containers when they are approximately three quarters full. Full bags and containers should be replaced immediately;  在移走废弃物口袋和容器之前，须加以鉴别并设置标签；  Identify and label waste bags and containers properly prior to removal  使用专用的手推车/拖车将废弃物运往储存区，手推车/拖车应定期清洗和消毒；  Transport waste to storage areas on designated trolleys / carts, which should be cleaned and disinfected regularly  废弃物储存区应位于医疗设置内部，规模与废弃物产生量相适应，并且在设计上作以下考虑：  Waste storage areas should be located within the facility and sized to the quantities of waste generated, with the following design considerations:  地面硬化、不可渗透，带有排水系统，并且可使用现有的水源进行清洗 /消毒；  可上锁限制出入；  仅限获许可的清洁人员及车辆进入和定期进行清洁；  防止日照，动物/啮齿类动物无法进入；  配备适当的照明和通风；  与食品供应及准备区隔离开来；  配备防护服和备用的口袋/容器。  除非可以进行冷冻储存，否则废弃物从产生到处理的储存时间不应超过：寒冷季节 48 小时，炎热 季节 24 小时。  Hard, impermeable floor with drainage, and designed for cleaning / disinfection with available water supply  Secured by locks with restricted access 65 Hainan Health Sector Reform Project Environmental and Social Management Framework  Designed for access and regular cleaning by authorized cleaning staff and vehicles  Protected from sun, and inaccessible to animals /rodents  Equipped with appropriate lighting and ventilation  Segregated from food supplies and preparation areas  Equipped with supplies of protective clothing, and spare bags / containers  Unless refrigerated storage is possible, storage times between generation and treatment of waste should not exceed the following: Warm climate: 48 hours during cool season, 24 hours during hot season  汞放在密封和不可渗透的容器内，单独储存于安全的地点；  Store mercury separately in sealed and impermeable containers in a secure location  细胞毒性废弃物与其他废弃物隔离开，单独储存于安全的地点；  Store cytotoxic waste separately from other waste in a secure location  放射性废弃物置于容器内，储存在铅屏蔽板后。  Store radioactive waste in containers to limit dispersion, and secure behind lead shields 3.4 运往外部设施（Transport to External Facilities）及处理处置要求（Treatment and Disposal Options）  感染性废弃物的运输包装应包括金属或塑料材质的防水内包装，并采用防泄漏密封。根据废弃物的 具体类型和体积，外包装应具有足够的强度和容量；  Transport packaging for infectious waste should include an inner, watertight layer of metal or plastic with a leak-proof seal. Outer packaging should be of adequate strength and capacity for the specific type and volume of waste.  锐器包装容器应具有防刺穿功能；  Packaging containers for sharps should be puncture-proof  废弃物应设置适当的标签，标明物质分级、包装标准（例如感染性废弃物、放射性废弃物）、废弃 物类别、质量/体积、医院内部的来源地和最终目的地；  Waste should be labeled appropriately, noting the substance class, packaging symbol (e.g. infectious waste, radioactive waste), waste category, mass / volume, place of origin within hospital, and final destination  应采用专用的废弃物运输车辆，并且装载废弃物的车厢有密封措施。  Transport vehicles should be dedicated to waste and the vehicle compartments carrying waste sealed.  项目范围内的医疗服务机构所产生的医疗废弃物均运往现场以外的焚烧设施进行处理。焚烧炉应取 得处理医疗废弃物的许可证，并正确运转和维护。  The waste will be transported to an off-site incineration facility. Incinerators should have permits to accept 66 Hainan Health Sector Reform Project Environmental and Social Management Framework health care waste and be properly operated and maintained. 4. 废水收集、处理与排放（Wastewater collection, treatment and emission） 4.1 来源及收集（Source and collection） 医疗服务机构产生的废水，其质量往往与城市废水相似。可能排放被污染废水的来源有病房和手 术室 （例如体液和分泌物、 解剖废弃物）、实验室（例如微生物培养液、储存的传染原）、药房和化 ；以及 X 光洗印室。此外，处理和处置技术和手段，例 学试剂库；清洁活动（例如清扫废弃物储藏室） 如压力蒸汽灭菌、微波辐射、化学灭菌和焚烧（例如使用湿法洗涤器处理可能包含固体悬浮物、汞、 ，也会产生废水。 其他重金属、氯化物和硫酸盐的烟道气） Wastewater from HCFs often has a quality similar to urban wastewater. Contaminated wastewater may result from discharges from medical wards and operating theaters (e.g. body fluids and excreta, anatomical waste), laboratories (e.g. microbiological cultures, stocks of infectious agents), pharmaceutical and chemical stores; cleaning activities (e.g. waste storage rooms), and x-ray development facilities. Wastewater may also result from treatment disposal technologies and techniques, including autoclaving, microwave irradiation, chemical disinfection, and incineration (e.g. treatment of flue gas using wet scrubbers which may contain suspended solids, mercury, other heavy metals, chlorides, and sulfates). 根据危险废弃物管理做法的效能（特别是上述废弃物隔离策略的效能），危险医疗废弃物可能会进 入废水系统，包括微生物病原体（肠道病原体含量高的废水，包括细菌、病毒和寄生蠕虫/寄生虫）、 危险化学品、药品和放射性同位素。为了最大限度减少废水的产生，污染预防措施包括： Depending on the effectiveness of hazardous waste management practices (in particular waste segregation strategies described above), hazardous health care wastes may enter the wastewater stream, including microbiological pathogens (wastewater with a high content of enteric pathogens, including bacteria, viruses, and helminthes / parasitic worms), hazardous chemicals, pharmaceuticals, and radioactive isotopes. Pollution prevention measures to minimize the generation of wastewater include the following:  对于接受基因毒性药物治疗患者的尿液、粪便、血液和呕吐物， 建立单独的收集规程和机 制，避免其进入废水系统（见上文有关隔离危险废弃物等废弃物的内容）；  Procedures and mechanisms for separate collection of urine, feces, blood, and vomit from patients treated with genotoxic drugs to avoid their entry into the wastewater stream (as described above under waste segregation for hazardous and other wastes)  对数量大的废弃药品，单独处理或返回给制造商。少量药性温和的液体药品，除抗生素或细 胞毒性药物外，可排入水流量大的污水系统。 67 Hainan Health Sector Reform Project Environmental and Social Management Framework  Collection of large quantities of pharmaceuticals for separate treatment or return to manufacturer. Small quantities of mild, liquid pharmaceuticals, excluding antibiotics or cytotoxic drugs, may be discharged to sewer systems with a large water flow. 4.2 处理与排放（Treatment and Emission） 医疗服务机构如果向市政污水处理系统排放废水，应确保废水的指标符合所有相关的排放规定，并 且市政设施有能力处理所排放类型的废水。如果医疗服务机构不向市政污水系统排放废水，则应确保除 氯气消毒之外，在现场对废水进行一级和二级处理。 If wastewater is discharged to sanitary sewage treatment systems, the HCF should ensure that wastewater characteristics are in compliance with all applicable permits, and that the municipal facility is capable of handling the type of effluent discharged. In cases where wastewater is not discharged to sanitary sewage systems, HCF operators should ensure that wastewater receives on-site primary and secondary treatment, in addition to chlorine disinfection. 医疗服务行业的废水处理手段包括：通过隔离废水来源和预处理，去除/回收特定的污染物，例如 放射性同位素、汞等；采用撇油器或油水来分离可漂浮的固体；过滤分离可过滤固体；流量及负荷调节； 使用澄清池，通过沉淀来减少固体悬浮物；生物处理，一般是好氧处理，以减少可溶性有机质（BOD）； 去除化学或生物养料，以减少氮磷含量；需要消毒时，对废水进行氯化消毒；残留物脱水后，作为危险 /感染性废弃物进行处置。可能需要采取其他工程控制措施， 以去除活性成分（抗生素和各种药品，以 及其他危险成分），以及围阻和处理废水处理系统各单元操作所产生的挥发性成分和气溶胶。 Techniques for treating wastewater in this sector include source segregation and pretreatment for removal / recovery of specific contaminants such as radio isotopes, mercury, etc.; skimmers or oil water separators for separation of floatable solids; filtration for separation of filterable solids; flow and load equalization; sedimentation for suspended solids reduction using clarifiers; biological treatment, typically aerobic treatment, for reduction of soluble organic matter (BOD); biological or chemical nutrient removal for reduction in nitrogen and phosphorus; chlorination of effluent when disinfection is required; dewatering and disposal of residuals as hazardous medical / infectious waste. Additional engineering controls may be required for removal of active ingredients (antibiotics and miscellaneous pharmaceutical products, among other hazardous constituents), and containment and treatment of volatile constituents and aerosols stripped from various unit operations in the wastewater treatment system. 5. 职业健康与安全（Occupational Health and Safety） 68 Hainan Health Sector Reform Project Environmental and Social Management Framework 医疗服务机构的健康与安全危害可能影响到医护人员、清洁及维护人员和参与废弃物管理的工人 （包括搬运、处理和处置）。行业特有的危害包括： 接触传染病和疾病及接触辐射。 HCF health and safety hazards may affect health care providers, cleaning and maintenance personnel, and workers involved in waste management handling, treatment, and disposal. Industry specific hazards include the following: Exposure to infections and diseases, Exposure to radiation. 5.1 接触传染病/疾病（Exposure to Infections / Diseases） 医护人员和其他工作人员在护理和治疗的过程中，以及收集、 搬运、处理和处置医疗废弃物的过 程中，可能会接触到一般性的传染病、血源性病原体和其他潜在感染性材料（OPIM）。 Health care providers and personnel may be exposed to general infections, blood-borne pathogens, and other potential infectious materials (OPIM) during care and treatment, as well as during collection, handling, treatment, and disposal of health care waste. 建议采取以下措施来降低医护人员感染传染性疾病的风险： The following measures are recommended to reduce the risk of transferring infectious diseases to health care providers:  制定血源性病原体的接触控制方案；  Formulate an exposure control plan for blood-borne pathogens  向工作人员和访客提供感染控制政策及规程方面的信息；  Provide staff members and visitors with information on infection control policies and procedures  建立通用/标准防范措施，采用适当的防范措施来处理血液和所有其他潜在感染性材料，包括 ：  Establish Universal / Standard Precautions to treat all blood and other potentially infectious materials with appropriate precautions, including:  对工作人员进行必要的免疫（例如接种乙型肝炎病毒疫苗）；  使用手套、口罩和罩衣；  提供充足的洗手设施；  针对脏寝具和被污染衣物的处理以及食物的准备和处理，制定相关制度，并提供设施；  医疗服务场所建立适当的清洁及废弃物处置制度。  Immunization for staff members as necessary (e.g. vaccination for hepatitis B virus)  Use of gloves, masks, and gowns  Adequate facilities for hand washing 69 Hainan Health Sector Reform Project Environmental and Social Management Framework  Procedures and facilities for handling dirty linen and contaminated clothing, and preparing and handling food  Appropriate cleaning and waste disposal practices for the health care workplace  使用和处理针头/锐器时应遵循以下建议：（ The following recommendations should be implemented when using and handling of needles / sharps:）  使用较安全的针具和无针器械，以减少针刺或接触其他锐器的风险；  不得弯折、 重复使用或去除被污染的针头和其他锐器；  切勿剪断或折断被污染的锐器；  针具容器摆放在靠近针具可能的放置地点附近；  被污染的锐器立即丢弃，或尽快放入适当的容器内；  用过的一次性剃刀应视作被污染的废弃物，须放入适当的锐器容器内进行处置。  Use safer needle devices and needleless devices to decrease needle stick or other sharps exposures  Do not bend, recap, or remove contaminated needles and other sharps  Do not shear or break contaminated sharps  Have needle containers available near areas where needles may be found  Discard contaminated sharps immediately or as soon as feasible into appropriate containers  Used disposable razors should be considered contaminated waste and disposed of in appropriate sharps containers  制定禁止动物进入医疗服务机构的政策。  Establish policies to exclude animals from facility property. 除上述建议外，还须对参与废弃物管理的人员采取下列措施，以减少传染性疾病的传播风险： In addition to the above recommendations, the following measures are applicable to personnel involved in waste management to reduce the risk of transferring infectious diseases:  对工作人员进行必要的免疫（例如接种乙型肝炎病毒疫苗、破伤风免疫）；  为参与废弃物管理的人员提供足够的个人防护装备，包括：必要的全身防护服/工业 围裙、护腿、 重载手套、头盔、面罩和护眼装备（特别是清理危险物质溢漏时）及呼吸器（如果溢漏物或废弃物 涉及有毒的粉尘或焚烧残渣）；  提供个人卫生用途的清洗设施，特别是在废弃物储存地点。 70 Hainan Health Sector Reform Project Environmental and Social Management Framework  Implement immunization for staff members, as necessary (e.g. vaccination for hepatitis B virus, tetanus immunization);  Provide adequate supplies of PPE for personnel involved in waste management including: overalls / industrial aprons, leg protectors, boots, heavy duty gloves, helmets, visors / face masks and eye protection (especially for cleaning of hazardous spills), and respirators (for spills or waste involving toxic dust or incinerator residue) as necessary;  Provide washing facilities for personal hygiene, particularly at waste storage locations. 5.2 辐射（Radiation） 发射 X 光和伽玛射线的设备（例如 CT 扫描仪）、放射治疗机和核医学设备可能造成职业性辐射接 触。医疗服务机构的经营者应征求受影响员工的意见，制定综合性的辐射接触控制计划。在可能的范围 内，应根据实际的辐射接触情况，尽快细化和修改该计划，并设计和实施相应的辐射控制措施。 Occupational radiation exposure may result from equipment emitting X-rays and gamma rays (e.g. CT scanners), radiotherapy machines, and equipment for nuclear medicine activities. HCF operators should develop a comprehensive plan to control radiation exposure in consultation with the affected workforce. This plan should be refined and revised as soon as practicable on the basis of assessments of actual radiation exposure conditions, and radiation control measures should be designed and implemented accordingly. 5.3 社区健康与安全（Community Health and Safety） 本项目医疗服务机构运营阶段的社区健康与安全问题与大多数工业设施是类似的，见 IFC 的《通用 EHS 指南》。与危险医疗废弃物有关的危害，需要使公众充分了解医疗服务机构内部和相关废弃物处置场所（例 如焚烧场）的潜在传染危害。有关社区疾病传播的指南，参见《通用 EHS 指南》。 Community health and safety issues during the operations of HCFs are generally common to those of most industrial facilities, and are discussed in the General EHS Guidelines. Community hazards associated with health care facility environments, particularly related to hazardous health care waste, necessitate that members of the public receive adequate information regarding potential infection hazards within the facility, and at associated waste disposal sites (e.g. incineration site). Guidance on community disease transmission is provided in the General EHS Guidelines. 6. 环境监测/职业健康与安全监测（Environmental Monitoring / Occupational Health and Safety Monitoring） 6.1 环境监测（Community Health and Safety） 本行业的环境监测制度应针对所有被确定为可能对环境造成重大影响的活动（包括在正常 操作条件 。环境监测活动的对象应当是具体子项目在废气、废水及资源使用方面的直接 下和受干扰条件下的情况） 或间接指标。监测的频率应当足以提供所监测参数的有代表性数据。监测应由受过训练的人员进行，应 71 Hainan Health Sector Reform Project Environmental and Social Management Framework 遵循监测和记录规范，并采用正确校准和维护的设备。监测数据应定期加以分析和审查，并与操作标准 加以比较，以便采取必要的纠正行动。 Environmental monitoring programs for this sector should be implemented to address all activities that have been identified to have potentially significant impacts on the environment, during normal operations and upset conditions. Environmental monitoring activities should be based on direct or indirect indicators of emissions, effluents, and resource use applicable to the particular project. Monitoring frequency should be sufficient to provide representative data for the parameter being monitored. Monitoring should be conducted by trained individuals following monitoring and record-keeping procedures and using properly calibrated and maintained equipment. Monitoring data should be analyzed and reviewed at regular intervals and compared with the operating standards so that any necessary corrective actions can be taken. 6.2 职业健康与安全监测（Community Health and Safety） 应当针对具体的子项目监测工作环境的职业危险。监测工作应当由获得认证的专业人员进行设计和 执行，并作为职业健康与安全监测制度的组成部分。工作场所还应保持职业事故与职业疾病、危险时间 和事故的记录。 The working environment should be monitored for occupational hazards relevant to the specific project. Monitoring should be designed and implemented by accredited professionals as part of an occupational health and safety monitoring program. Facilities should also maintain a record of occupational accidents and diseases and dangerous occurrences and accidents. 72 Hainan Health Sector Reform Project Environmental and Social Management Framework Annex 4 Stakeholder Engagement Plan 73 Hainan Health Sector Reform Project Environmental and Social Management Framework World Bank-financed Hainan Health Sector Reform Project (P171064) Stakeholder Engagement Plan (SEP) Hainan Provincial Health Commission (HPHC) December 2019 Hainan Health Sector Reform Project Environmental and Social Management Framework Contents 1 Project Introduction .................................................................................. …….1 1.1 PROJECT BACKGROUND .............................................................................................. 1 1.2 PURPOSE, SCOPE AND IMPLEMENTATION PATH....................................................... 1 2 Stakeholder Analysis ........................................................................................ 3 2.1 STAKEHOLDER IDENTIFICATION ..................................................................... 3 2.2 OVERALL ATTITUDE OF STAKEHOLDERS TO THE PROJECT .............................. 4 2.3 STAKEHOLDER DEMAND ANALYSIS ................................................................ 4 2.4 VULNERABLE GROUPS .................................................................................. 4 2.4.1 IDENTIFICATION OF VULNERABLE GROUPS ........................................ 4 2.4.2 DEMAND ANALYSIS OF VULNERABLE GROUPS ................................. 5 3 Stakeholders Engagement ............................................................................... 9 3.1 STARTED INFORMATION DISCLOSURE ACTIVITIES ........................................... 9 3.2 INFORMATION DISCLOSURE ACTIVITIES TO BE STARTED................................ 10 3.3 STARTED PUBLIC CONSULTATION ACTIVITIES............................................... 11 3.4 PUBLIC CONSULTATION ACTIVITIES TO BE STARTED ..................................... 11 4 Grievance Mechanism .................................................................................... 17 4.1 FOR RESIDENTS.......................................................................................... 17 4.2 FOR PRIMARY MEDICAL INSTITUTIONS ......................................................... 17 5 Resources and Responsibilities .................................................................... 18 6 Monitoring and Reporting............................................................................... 18 Appendix 1 List of FGDs ....................................................................................... 19 Appendix 2 Ethnic Minority Engagement Framework ......................................... 20 Appendix 3 Summary of First Round of Public Consultation ............................. 27 Appendix 4 Implementation and Operation Stages ............................................. 32 Appendix 5 Field work Photos .............................................................................. 38 Hainan Health Sector Reform Project Environmental and Social Management Framework Abbreviations EAC - Ethnic Affairs Commission FDT - Family Doctor Team FGD - Focus Group Discussion HC - Health Commission HHDRC - Hainan Health Development Research Center HHSA - Hainan Healthcare Security Administration HPHC - Hainan Provincial Health Commission HSA - Healthcare Security Administration PAO - Poverty Alleviation Office PHC - Primary Healthcare PMO - Project Management Office SEP - Stakeholder Engagement Plan WF - Women’s Federation Units Currency unit = Yuan (CNY) USD1.00 = CNY6 1 hectare = 15 mu Hainan Health Sector Reform Project Environmental and Social Management Framework 1 Project Introduction 1.1 Project Background The overall goal of the Hainan Health Sector Reform Project (HHSRP) is to strengthen the quality of primary health care (PHC) services and efficiency of the health system. Focusing on primary health care (the foundation for people-centered integrated care), the Project takes an integrated health system approach to deliver improved health outcomes for the people of Hainan. Recognizing that there is no silver bullet to achieve this goal, the project adopts a two-pronged approach: 1） The project supports the strengthening of primary care delivery system to address several key gaps that plague the health system in Hainan, including: a) poor preventive and promotive care, particularly in the context of the rising incidence of NCDs and an ageing population; b) the routine bypassing of PHC facilities in favor of hospital care; c) the declining quality of PHC, largely due to a lack of rigorously applied standards of service quality and shortage of appropriately qualified human resources; and d) inefficiencies in financing that disproportionately affect service utilization and health outcomes of the poor and most vulnerable. The central focus for PHC strengthening will be (i) to build health sector stewardship of People Centered Integrated Care (PCIC) through better integration of different levels of care and alignment of public health functions such as disease surveillance and emergency response with PHC service delivery; and (ii) to improve the performance of Family Doctor Teams (FDTs) operating in township health clinics, village clinics and community health centers through targeted strengthening of front-line service delivery , rigorous measurement of performance outputs and outcomes, supportive supervision and targeted incentives driving forward a strong/high capacity PHC system that is delivered through team-based approaches and responds efficiently to population health needs. 2） This is supported with deeper institutional, human resource, and information technology reform to create a sustainable and efficient service delivery system. At the operational level this will mean providing technical and financial support for strategic and results-oriented planning and management, evidence-based decision-making and adoption of e-governance platforms for greater coordination and efficiency. The Project will also streamline strategic purchasing of services through insurance programs in order to drive the system towards the Project goals of improving quality of primary care and efficiency of the health system. At the individual provider level, the Project will leverage incentives to change provider-level behavior and improve care for the growing burden of NCDs. Component 1: Reforming Institutions and Strengthening Stewardship for People-Centered Integrated Care (PCIC): • Reducing institutional fragmentation in primary care services • Increasing coordination between HPHC and HPHSA • Developing a collaborative approach in which providers and patients work together to improve the self-management of health and, eventually, health outcomes Component 2: Strengthening Primary Health Service Delivery with appropriate support system: • to strengthen Family Doctor Team (FDT) performance through a mix of approaches involving a) capacity building, b) strengthened performance management and targeted incentives and c) supportive demand and supply side measures. Component 3: Strengthening Information Technology • Supporting the Provincial Health Commission IT Capacity • Supporting the Provincial Health Security Agency IT Capacity Component 4: Strategic purchasing for quality services Component 4: Technical Assistance and Project Management 1.2 Purpose, Scope and Implementation Path 1.2.1 Purpose This SEP aims to ensure that stakeholder consultation, communication and engagement is conducted continuously and effectively throughout the Project, and relevant design and measures are optimized and improved continually by collecting reasonable comments and suggestions from A4-1 Hainan Health Sector Reform Project Environmental and Social Management Framework stakeholders, thereby benefiting all stakeholders to the greatest extent. In addition, since the Project involves some minority areas, this SEP includes a special Ethnic Minority Engagement Framework (EMEF) to ensure that minority residents are engaged throughout the Project to maximize the local benefits of the Project. Specifically, this includes:  Establishing and maintaining constructive relationships among all stakeholders;  Considering opinions of stakeholders in project design, and environmental and social management;  Maintaining adequate, equal and effective engagement at the implementation and operation stages to control project impacts and risks, and adjust and optimize relevant measures timely;  Ensuring timely and accessible information disclosure to stakeholders, including appropriate project information on environmental and social risks and impacts; and  Providing appropriate and inclusive ways to stakeholders, so that opinions, issues and appeals of stakeholders (especially vulnerable groups and ethnic minorities) are collective and handled effectively. 1.2.2 Scope This SEP applies to the 4 components, and the project area is the entity of Hainan Province. 1.2.3 Basic path This SEP will identify stakeholders, analyze interest correlations and engagement needs, and draft an engagement mechanism and plan across the design, implementation and operation stages. Since the Project was at the preparation stage when this SEP was prepared, and project activities at the implementation and operation stages may be further adjusted, detailed stakeholder identification and demand analysis is not fully carried out at this stage. This SEP is an ongoing living document, it will analyze stakeholder engagement activities started and to be started at the preparation stage and plan such activities for the implementation and operation stages, focusing on mechanism set up, design and monitor, thereby to ensure that all stakeholders are engaged as in a good manner. This will be further tracked by monitoring. A4-2 Hainan Health Sector Reform Project Environmental and Social Management Framework 2 Stakeholder Analysis 2.1 Stakeholder Identification According to the Feasibility Study Report, the Project has 4 components, which involve different stakeholders. Therefore, stakeholders should be identified for each component, and their duties and interests learned. Stakeholders are identified and analyzed in two dimensions – impacts by the Project (positive: degree of benefiting; negative: potential environmental impacts, etc.), and influence on the Project. See Figure 2-1. Figure 2-1 Distribution of stakeholders Note: Other departments include without limitation women’s federations (WFs), ERACs (ERACs), poverty reduction offices, ecology and environment bureaus, and county and township levelgovernments It shows that based on the degree of impact by the Project, the primary stakeholders include: 1) Rural and urban residents, and migrant population, including 9.2576 million local rural and urban residents, and a migrant population of 1.31 million 2) Vulnerable groups, including 4.4 million women, 70,000 poor residents and 165,742 minority residents in 27 cities, counties and districts in Hainan Province 3) 9,724 (in 2017) PHC (primary healthcare) practitioners (rural and family doctors) in Hainan Province; 4) 5,177 PHC providers in Hainan Province, including 25 centers for disease control, 24 maternity and child care centers, 15 specialized disease prevention and treatment institutions, 175 community health service institutions, 299 township health centers, 51 community health centers, 1,312 village clinics, HPHC and Hainan Healthcare Security Administration (HHSA, Hainan PMO) Medical alliance, mainly including county / city 3A hospitals, such as Hainan General Hospital, Hainan Nongken General Hospital, Affiliated Hospital of Hainan Medical University, and central hospitals The secondary stakeholders include: 1) Hainan Provincial Development and Reform Commission (responsible for project approval), and Hainan Provincial Finance Department (responsible for financial management); 2) County (district) health commissions (HCs) and healthcare security administrations (HSAs) 3) Design agency, competent authorities, and information system operation and maintenance contractors; 4) Local WFs, ethnic affairs commissions (EACs), and poverty alleviation offices (PAOs) in 218 townships (21 Xiangs, 175 towns and 22 sub-district offices) in 5 county-level cities, 4 counties, 6 autonomous counties and 8 districts in 4 prefecture-level cities A3-3 Hainan Health Sector Reform Project Environmental and Social Management Framework 2.2 Overall Attitude of Stakeholders to the Project Different stakeholders have different attitudes to the Project. Most government agencies support the Project, including HPHC, PHC providers and their staff, as well as residents, who think that the Project will improve their livelihoods greatly to improve the PHC quality and reduce the financial burden. Table 2-1 analyzes their general roles in and attitudes to the Project. Table 2-1 Stakeholder Analysis Attitude to Direct stakeholder Rights and duties remarks the Project HPHC (including information center) and Project coordination, regulation and Positive HHSA implementation management Hainan Provincial Development and Research Project assessment and approval Supporting Reform Commission tasks Hainan Provincial Finance Department Financial management Supporting Information Protecting and managing the systems WFs Supporting interests of women Institutional Protecting and managing the capacity EACs Supporting interests of minority residents building Protecting and managing the PAOs Supporting interests of poor people Design agency Project design and research Positive Research PHC providers (township health centers Project implementation Positive tasks / community health centers and clinics) Information Providing advanced medical systems Medical alliances technologies and staff for two-way Positive Institutional diagnosis and treatment capacity Improving their own medical level, PHC practitioners Positive building and increasing training opportunities Enjoying better medical services at Rural residents Positive the village level Community Enjoying better medical services at Local residents Positive residents the community level Enjoying better medical services in Migrant population Positive their locations Research Enjoying better medical assistance tasks Women for gynecological diseases at the Positive Information primary level systems Enjoying such medical services as Vulnerable groups Poor people healthy diagnosis and treatment, and Positive a green channel Enjoying medical treatment that is Minority residents Positive identical to or better than Han people 2.3 Stakeholder Demand Analysis Different project activities often involve different stakeholder, and the same stakeholder may have different attitudes to different project activities. For example, residents in a village may highly support the Project in general, because they don’t have to go to remote hospitals, and spend more money and time for ordinary chronic diseases, thereby reducing their medical costs and improving their medical efficiency; however, on the other hand, the improper disposal of medical waste may have negative impacts on them, so they may hold a prudent attitude. Therefore, engagement needs of stakeholders should be analyzed based on project activities, as shown in Table 2-2. 2.4 Vulnerable Groups 2.4.1 Identification of Vulnerable Groups Vulnerable groups / individuals have relatively weak affordability, and are more likely to suffer disproportionate losses and be excluded from the engagement process. Therefore, appropriate measures should be taken to ensure that they are fully engaged in the Project. Vulnerable groups A3-4 Hainan Health Sector Reform Project Environmental and Social Management Framework include women, poor people and minority residents. In Hainan Province, Han, Li, Miao and Hui are local resident ethnic groups, while other ethnic groups moved Hainan island after 1949 and are lived in Hainan. The Li, Miao and Hui people mostly live in central and southern Hainan, while the Han people mostly in northeast and north Hainan, and coastal areas. The Project will affect minority residents greatly. See Appendix 2 “Ethnic Minority Engagement Framework”. 2.4.2 Demand Analysis of Vulnerable Groups The survey shows that vulnerable groups affected by the Project have generally the same interests as ordinary local residents, and have the following 3 features: 1) Local poor people enjoy good primary healthcare benefits, have access to priority channel offered by all PHC providers, and receive medical care almost free of charge under the provincial health poverty alleviation project. 2) Local women receive a subsidy for childbirth, and receive free cervical and breast cancer screening. They think that the Project will provide them with more benefits, such as breastfeeding rooms at PHC providers. 3) Some minority residents have difficulty in communicating in Mandarin and expect a language assistance platform. It can be seen that preferential measures for vulnerable groups are in place under the primary healthcare system. Table 2-3 summarizes key features and potential needs of vulnerable groups. Table 2-3: Engagement Demand Analysis of Vulnerable Groups / Individuals Stakehold Type Key feature Interest Need for engagement er About 70,000, having not 1) The same as local 1) Paying special received higher education, residents (see Table 2-2); attention to the Poor people entitled to healthcare poverty 2) Ensuring that vulnerable interests of poor alleviation and a green groups and minority people, women and channel residents are engaged minority residents, and Vulnerable 47.51% of gross population, equally, and that primary communicating in the groups having not received higher doctors speak both Hainan dialect and Women education, mostly Mandarin and dialects minority languages; housewives (Hainan dialect, Li and Miao 2) Needing Having not received higher languages, etc.) non-holiday, Minority education, no difference from non-weekend and child residents Han people care consultation A3-5 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 2-4 Stakeholder Engagement Demand Analysis Component Output / activity Stakeholder Interests Engagement demand analysis Improving 1. Reducing institutional HCs (including Preparing a scientific and rational project design to HCs and HSAs conduct an in-depth survey and Primary fragmentation in primary care information center), reach the expected objectives consultation with all stakeholders at the Health Care services HSAs preparation stage to receive useful information. Performance 2. Addressing the human Local residents,  Chronic disease prevention and treatment 1. Rural and family doctors maintain close ； Strategic resource gaps especially chronic  Treatment of ordinary diseases and drug routine communications on disease prevention purchasing 3. The project will target a set disease patients purchase and treatment with local residents at the for quality of results areas that will aim to  Learning the situation of primary doctors, and implementation and operation stages. services further the outcomes achieved selecting suitable / satisfactory ones 2. Township hospitals communicate with rural for key Non-Communicable  Higher percentage of reimbursement and family doctors and ordinary residents on Diseases  Public health needs, e.g., preventive injection relevant issues within their jurisdiction regularly 4. Upgrading PHC  Environmental pollution impact management at the implementation and operation stages, infrastructure  Health publicity and education such as medical quality, reimbursement, drug 5. Progressively improve the Primary doctors: rural  Learning the health status of local residents supply, public health management and medical generosity of benefit package and family doctors  Health publicity and education environment management. for outpatient services  Leaving a good impression to local residents 3. County hospitals or medical alliances and receiving good performance evaluation communicate with township hospitals and village results to increase income clinics on relevant issues regularly at the  Receiving support from superior authorities, implementation and operation stages, including especially technical support from general equipment, technical support, talent training and practitioners and specialists performance evaluation. PHC providers:  Learning the health status of local residents township hospitals /  Health publicity and education village clinics  Obtaining better equipment and talents  Receiving support from superior authorities, especially technical support from general practitioners and specialists County hospitals or  Allocating resources to meet needs of primary medical alliances hospitals Vulnerable groups and See the “Vulnerable groups” section of Chapter 2 and Appendix 2:“Ethnic Minority Engagement minority residents Framework“. Other administrative  Implementing work in relevant fields The monitoring agency consults with competent units practically, e.g., women health protection and authorities regularly to track relevant issues at medical support for poor people the implementation and operation stages. Migrant population  Some common problems can be solved at primary hospitals.  Major hospitals should not be too crowded.  Non-local security settlement A3-6 Hainan Health Sector Reform Project Environmental and Social Management Framework Building leadership for quality Local residents,  Scope, role, charges, etc. of healthcare Rural and family doctors communicate routinely in primary care services especially old people services with local residents on healthcare issues at the implementation and operation stages. PHC/QAC integrated  Learning primary healthcare in depth, and PHC management teams communicate with management teams discovering and solving issues quickly primary institutions and doctors regularly at the implementation and operation stages. 1.County/Prefecture HCs and HSAs  Establishing an effective primary healthcare 1) HCs and HSAs conduct an in-depth survey management teams will lead quality regulation system and design at the preparation stage. the service delivery Quality monitoring  Collecting primary healthcare quality 2) Quality monitoring teams collect medical strengthening effort, and build teams information accurately and timely quality information of local residents and doctors quality monitoring teams Local residents  Convenient access to medical quality through the proposed information system at the 2. Support PHSA to become a information; convenient reporting of medical implementation and operation stages. strategic purchaser by problems 3) Quality monitoring teams provide transparent introducing Primary doctors  Transparent medical quality monitoring medical quality information with primary doctors performance-based payment system that allows doctors to file appeals to the public at the implementation and operation to FDTs stages. 3. A key responsibility for the 4) Quality monitoring teams establish an appeal County/Prefecture will be to and feedback mechanism for primary doctors at implement a “Performance the implementation and operation stages. Enhancement Program” (PEP) for the FDT Technical Public service subsystem HCs and HSAs  Designing projects suited to primary needs 1) HCs and HSAs conduct a survey on PHC Assistance ； providing IT services PHC providers:  Mastering technical requirements for relevant providers, doctors and community residents at Improving township hospitals / services the preparation stage. Primary village clinics  Learning relevant service policies, such as 2) HCs and HSAs organize training for PHC Health Care Primary doctors: rural reimbursement providers and their staff at the implementation Performance and family doctors and operation stages. Local residents  Learning relevant service policies, such as 3) PHC providers and doctors explain relevant reimbursement service policies to local residents at the implementation and operation stages. Addressing the human HCs and HSAs  Designing and organizing rational skills 1) HCs and HSAs conduct a survey on PHC resource gaps training courses to improve the skill level of providers, doctors and community residents at primary doctors the preparation stage. PHC providers:  Learning skills training types, policies, etc. 2) HCs and HSAs organize training for PHC township hospitals / providers and their staff at the implementation village clinics and operation stages. Primary doctors: rural 3) PHC providers and doctors explain relevant and family doctors service policies to local residents at the A3-7 Hainan Health Sector Reform Project Environmental and Social Management Framework implementation and operation stages. 1. Building an Interconnected HCs and HSAs  Designing a scientific and reliable integrated 1) HCs and HSAs conduct a survey on PHC Provincial Health Information information system; providers, doctors and community residents at System  Adjusting the system to practical needs the preparation stage. 2. Strengthening IT efficiently and continually 2) HCs and HSAs organize training for PHC Governance and Stewardship  Improving treatment effects using big data and providers and their staff at the implementation other high techs and operation stages, so that PHC providers and  Building a provincial health database on PHC their staff master relevant skills. providers and doctors using the information 3) Primary healthcare staff explains how to use system for scientific investment and the relevant app to local residents at the management implementation and operation stages.  Establishing a result-oriented primary 4) Information system authorities set up a hotline healthcare incentive mechanism based on or forum to collect information on system data system operation from primary healthcare staff and PHC providers:  Improving treatment effects using big data and residents through PHC providers at the township hospitals / other high techs implementation and operation stages. village clinics Primary doctors: rural  Improving treatment effects using big data and and family doctors other high techs; transparent medical quality monitoring system that allows doctors to file appeals Local residents  Convenient access to medical quality information; convenient reporting of medical problems Information system  Collecting issues on system operation timely authorities for upgrading and improvement Technical 1.Financing key TA activities HCs  Purchasing demand for relevant techs Government agencies communicate regularly at Assistance 2.Support for the HPHC and HSAs  Financial support for relevant diseases the implementation and operation stages. PHSA to play a strong Finance bureaus  Making unified funding arrangements stewardship role in the health sector 3.Support for project management through specific activities A3-8 3 Stakeholders Engagement This SEP is based on the stakeholder in the previous chapter, especially stakeholder engagement demand analysis. Different stakeholders’ needs are described for the preparation, implementation and operation stages, while those at the implementation and operation stages are largely identical. At the preparation stage (or feasibility study stage), many stakeholder engagement activities were conducted under the leadership and coordination of HPHC to collect their opinions on the project design. Since the Project was at the preparation stage when this SEP was prepared, and project activities at the implementation and operation stages may be further adjusted, detailed stakeholder identification and demand analysis is not fully carried out at this stage.. This SEP will plan stakeholder engagement activities for the implementation and operation stages, focusing on mechanism set up, design and monitor, thereby to ensure that all stakeholders are engaged as planned. This will be tracked by monitoring. 3.1 Started Information Disclosure Activities In December 2018 at preparation stage, the National Development and Reform Commission, and Word Bank Team conducted a healthcare survey in Hainan Province. During December 10-13, the Department of Foreign Capital and Overseas Investment of the National Development and Reform Commission organized Bank experts to conduct a healthcare survey in Hainan Province, and organized Bank experts, China Medical Board, National Health Commission, Hainan Provincial Development and Reform Commission, Finance Department, HPHC, etc. to hold seminars and FGDs. During this period, project information was disclosed. See Table 3-1. A3-9 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 3-1 Summary of First Round of Information Disclosure Time Venue Stakeholders / participants Key points Method National Development and Learning the current Reform Commission, Bank District / county situation of the Field investigation, 2018.12 mission, Hainan Provincial PHC providers healthcare industry of online disclosure Development and Reform Hainan Province Commission, HCs Bank representative, Duke Kunshan University, Chronic Discussing the project Disease and Aging Office of HPHC meeting lifecycle and the current 2019.7 Chinese Center for Disease Seminar room situation of primary Control and Prevention, Project healthcare Regulation Center of the National Health Commission Current situation and District / county Field investigation, 2019.8 HPHC, EIA agency, SA agency issues of PHC providers PHC providers FGD, interview in Hainan Province School of Medicine of Tsinghua Current situation of District / county 2019.8 University, professor of Sichuan primary healthcare in Field investigation PHC providers University Hainan for reference District / county Environmental issues of 2019.8 HPHC, EIA agency Field investigation PHC providers PHC providers HPHC meeting 2019.8 Bank experts Project discussion Seminar room 3.2 Information Disclosure Activities to be Started In order to make stakeholders further aware of the Project’s risks, impacts and potential opportunities, HPHC should disclose project information at different stages, especially the Project’s potential local risks and impacts, suggestions to alleviate such risks and impacts, potential risks that may further disadvantage vulnerable groups, measures to avoid and alleviate such risks and impacts, in order to make adequate preparations for incorporating public opinions. At the implementation stage, HPHC will ensure that information on environmental and social issues (whether positive or negative) is disclosed to the APs and other stakeholders (including the public and NGOs) at appropriate places, and in understandable forms and languages timely. See Table 3-2. Information disclosed and disclosure modes at different stages should be based on local conditions, as shown in Table 3-3. Table 3-2 Times and channels of information disclosure Stage Time Time and channel First round: Sep. First round: Sep. 2019; 2019 Second round: Sep. – Dec. 2019; Feasibility study Second round: Information disclosure and feedback channels: HPHC website; PHC Sep. – Dec. 2019 provider bulletin board; village bulletin board; health day publicity Each December during the implementation stage; Information disclosure and feedback channels: HPHC website; PHC Implementation Each December provider bulletin board; county / district public account; village bulletin board; village committee notice; health day publicity Each December; Information disclosure and feedback channels: HPHC website; PHC Operation Each December provider bulletin board; county / district public account; village bulletin board; village committee notice; health day publicity A3-10 Hainan Health Sector Reform Project Environmental and Social Management Framework 3.4 Started Public Consultation Activities To date, HPHC and HHSA have conducted a series of public consultation activities with the Hainan Provincial Finance Department, Development and Reform Commission, and other departments of the provincial government to discuss the Project’s current portfolio, overall environmental and social risks, alleviation measures and suggestions, etc. In August and September 2019, HPHC, and the EIA and SA agencies conducted the first round of stakeholder consultation by means of organizational interview, FGD, key informant interview and field investigation. The findings are as follows:  All agencies in Hainan Province support the Project, and are willing to support its preparation and implementation.  Township health centers are short of talents and techniques, and do not have an effective incentive mechanism to attract and retain talents.  In addition, township health centers also have an urgent need for advanced IT systems, and technical and talent exchanges with 3A hospitals. Since rural doctors have very few patients in a daily basis (2-3 persons per day), they expect to improve their medical skills through training to meet public healthcare needs.  Community health centers have operating difficulties due to fund shortage and the small population served. They should have the drug dispensing function for the convenience of old people.  With the implementation of the targeted poverty alleviation program, the difficulty of poor people in medical care has been largely solved; the utilization rate of PHC providers is still low, and both men and women would go to 3A hospitals; there are Li and Miao doctors in minority areas.  In addition, ordinary residents spend much money and time on healthcare, even more than the middle class, because they would see a doctor when diseases develop to a certain extent and prefer doctors who prescribe drastic drugs. See Table 3-4 and Appendix 3. 3.5 Public Consultation Activities to be Started Stakeholder consultation is a two-way process that should run through the whole project lifecycle. First, initial opinions on the Project should be collected from the early stage of project planning; second, stakeholders should be encouraged to give feedback as a means of project design, stakeholder engagement, and the alleviation of environmental and social risks; relevant, transparent, objective, meaningful and accessible information should be disclosed and communicated in advance in order to conduct meaningful consultation with stakeholders in a culturally compatible manner, the local language and an understandable form to support active and extensive engagement. Stakeholder consultation covers the preparation, implementation and operation stages. See Table 3-5. Stakeholder engagement during project implementation and operation is detailed in Appendix 4. A3-11 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 3-3 Proposed Information Disclosure Measures Stage Information to be disclosed Proposed mode Venue / date Target stakeholders Persons responsible HPHC contact First round of information Internet; HPHC website, bulletin Local residents, PHC Township officials (HCs, WFs, disclosure: project information Bulletin board; boards of PHC providers practitioners, government PAOs, ERACs, etc.) (mainly including purpose, nature, Village official notice; and village committees / agencies, vulnerable Village / community officials scale, duration, etc.), SEP Public account notice Sep. 2019 groups, etc. Component agencies Preparation HPHC contact Internet; HPHC website, bulletin Local residents, PHC Second round of information Township officials (HCs, WFs, Bulletin board; boards of PHC providers practitioners, government disclosure: ESMF, SEP (including PAOs, ERACs, etc.) Village official notice; and village committees / agencies, vulnerable EMEF) Village / community officials Public account notice Oct. – Dec. 2019 groups, etc. Component agencies Internet; HPHC contact HPHC website, bulletin Local residents, PHC Bulletin board; Township officials (HCs, WFs, Time and scope of boards of PHC providers practitioners, government Implementation Village official notice; PAOs, ERACs, etc.) implementation, etc. and village committees, agencies, vulnerable Village congress; Village / community officials project area / 2020-2025 groups, etc. Public account notice Component agencies Internet; HPHC contact HPHC website, bulletin Local residents, PHC Bulletin board; Township officials (HCs, WFs, boards of PHC providers practitioners, government Operation Project operation Village official notice; PAOs, ERACs, etc.) and village committees, agencies, vulnerable Village congress; Village / community officials project area / 2025 groups, etc. Public account notice Component agencies A3-12 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 3-4 Opinions of First Round of Public Consultation Time Venue Stakeholder Key points Method used Findings 1) Current situation and issues 1) All agencies support the Project actively. of PHC providers in Hainan, 2) All local ethnic minorities are highly assimilated to Han and solutions people, and there is no preferential medical policy for ethnic Provincial 2) Roles and responsibilities of minorities; there is no special healthcare need, e.g., doctor authorities (HPHC, Organizational 2019.8-9 HC offices all agencies gender. Their healthcare awareness may be improved in HHSA, WF, PAO, interview, FGD 3) Current situation of women, conjunction with minority festivals. EAC, etc.) minority residents and poor 3) EACs and WFs will participate in project publicity. people in all cities, counties and districts 1) Project introduction 1) Township health centers are short of talents and Xiangshui Town 2) Basic information of techniques, and do not have an effective incentive Health Center, Township township health centers FGD, key informant mechanism to attract and retain talents. Hainan No.2 2019.8-9 health 3) Opinions and suggestions on interview, field 2) Doctors think they have no development opportunity at People’s Hospital, centers the Project investigation the township level and are poorly paid. Maoyang Town 3) An advanced information system should be established. Health Center 4) Talents should be introduced. 1) Project introduction 1) Rural doctors have very few patients in a daily basis (2-3 2) Basic information of village persons per day), and can only treat minor diseases, so Hekou and clinics FGD, key informant they expect more training opportunities. Village 2019.8-9 Maojian Village 3) Opinions and suggestions on interview, field 2) Patients are mostly old people and children. clinics Clinics the Project investigation 3) Villagers usually receive medical advice and treatment at village clinics for free. 4) Many rural doctors are contracted and regularly trained. 1) Project introduction 1) Outpatients include many local residents and migrants. 2) Basic information of 2) The center is not running at full capacity. community health centers 3) Residents think that doctors make detailed inquiries, but 3) Opinions and suggestions on are not skilled enough. Fenghuang, the Project 4) Family doctors contract with local residents, with a Community Sanyawan, Haiken FGD, key informant contracting rate of 30%. 2019.8-9 health and Binya interview, field 5) A medical alliance has been established with 3 hospitals centers Community Health investigation for medical care at different levels. Centers 6) It operates with difficulties, because it serves a small population and is short of funds. 7) Community health centers should have the drug dispensing function for the convenience of old people. Village / Villagers of Hekou 1) Project introduction FGD, key informant 1) Many poor old people would go to village clinics for minor 2019.8-9 community and Maogui 2) Village conditions and interview diseases. A3-13 Hainan Health Sector Reform Project Environmental and Social Management Framework committees Villages, residents medical situation 2) Villagers prefer more expensive but more efficacious of Fenghuang 3) Opinions and suggestions on urban hospitals. Community the Project 1) Project introduction 1) Poor families contract with family doctors, and usually go 2) Situation of poor people and to township hospitals. medical care FGD, key informant 2) Poor families are entitled to a green channel. Poor people 3) Opinions and suggestions on interview 3) Poor families can reimburse most medical expenses the Project under health poverty alleviation and new-type rural medical insurance. 1) Project introduction 1) Women usually go to major hospitals for childbirth. 2) Situation of women and 2) There is a fixed subsidy for childbirth. FGD, key informant Women medical care 3) Women receive free cervical and breast cancer screening interview 3) Opinions and suggestions on the Project 1) Project introduction 1) Rural minority residents are superstitious in medical care. 2) Situation of minority 2) There are Li and Miao doctors in minority areas. FGD, key informant Minority residents residents and medical care 3) There are language barriers for minority residents, and interview 3) Opinions and suggestions on language help desks are expected. the Project A3-14 Hainan Health Sector Reform Project Environmental and Social Management Framework Table 3-5 Proposed Modes of Public Consultation Stage Key topic Method Venue / date Target stakeholder Organizer FGD, key informant Local residents (including Different groups’ suggestions Township governments, HCs interview, questionnaire, villagers, community on and expectations for the village committees Township heads “12345” and “12306” residents, migrant Project Sep. – Dec. 2019 Village / community heads hotlines population) Medical safety, PHC providers FGD, key informant HCs PHC practitioners; and staff, vulnerable groups’ interview, questionnaire, PHC providers Customer service staff of PHC vulnerable groups; local suggestions on and health day consultation, Sep. – Dec. 2019 providers residents expectations for the Project public satisfaction survey Doctors FGD, key informant PAOs, poor people’s needs interview, questionnaire, HCs PAOs for, suggestions on and “12345” and “12306” Poor people; PAOs PAO heads Sep. – Dec. 2019 Preparation attitudes to the Project hotlines, annual inspection Village / community heads of PAOs FGD, key informant ERACs, minority residents’ Village committees, HCs interview, Minority residents; needs for, suggestions on and meeting rooms of ERACs ERAC heads “12345” and “12306” ERACs attitudes to the Project Sep. – Dec. 2019 Village / community heads hotlines WFs, women’s needs for, FGD, key informant Meeting rooms of WFs HCs suggestions on and attitudes interview, “12345” and Women; WFs Sep. – Dec. 2019 WF heads to the Project “12306” hotlines Identification of emission Meeting rooms of HCs Provincial authorities; standards for production FGD HCs, government agencies Sep. – Dec. 2019 PHC providers wastewater and medical waste HCs Local media / medical Every month during Project publicity Local residents Village / community heads extension 2020-2024 PHC providers Meeting rooms of PHC Local residents HCs Environmental pollution FGD providers PHC providers Heads of PHC providers 2020-2024Each December Implementati Offices of HCs and HSAs Consultation on medical Local residents HCs and HSAs on Key informant interview Every month during quality, reimbursement, etc. PHC providers Heads of PHC providers 2020-2024 “12345” and “12306” Every month during Local residents Grievances and appeals HCs hotlines 2020-2024 PHC providers and staff Meeting rooms of PHC HCs Talent training, remuneration, FGD providers PHC practitioners Customer service staff of PHC doctor performance rating, etc. Questionnaire survey Every month during providers A3-15 Hainan Health Sector Reform Project Environmental and Social Management Framework 2020-2024 PHC providers HCs Operation and issues of the Every month during Medical alliances FGD Information system O&M medical information system 2020-2024 Information system O&M contractor contractor HC offices HCs Implementation of work on Vulnerable groups FGD Every month during Other administrative units vulnerable groups Other administrative units 2020-2024 (WFs, EACs, etc.) HCs Local media / medical Every month during Project publicity Local residents Village / community heads extension 2025-2044 PHC providers Meeting rooms of PHC Local residents HCs Environmental pollution FGD providers PHC providers Heads of PHC providers 2025-2044Each December Offices of HCs and HSAs Consultation on medical Local residents HCs and HSAs Key informant interview Every month during quality, reimbursement, etc. PHC providers Heads of PHC providers 2025-2044 “12345” and “12306” Every month during Local residents Grievances and appeals HCs hotlines 2025-2044 PHC providers and staff Meeting rooms of PHC Operation HCs Talent training, remuneration, FGD providers PHC practitioners Customer service staff of PHC doctor performance rating, etc. Questionnaire survey Every month during providers 2025-2044 PHC providers HCs Operation and issues of the Every month during Medical alliances FGD Information system O&M medical information system 2020-2024 Information system O&M contractor contractor Public satisfaction survey after Every month during Local residents, PHC Customer service staff of PHC Public scoring PHC provider reform 2025-2044 providers providers HC offices HCs Implementation of work on Vulnerable groups FGD Every month during Other administrative units vulnerable groups Other administrative units 2020-2024 (WFs, EACs, etc.) A3-16 4 Grievance Mechanism In order to respond to concerns and grievances about environmental and social performance, a special grievance redress mechanism (GRM) has been established for the Project: For subjects of primary healthcare services, namely residents, a collection, handling and feedback mechanism for relevant concerns and appeals that may be received at the implementation stage will be established; For primary healthcare staff, a collection, handling and feedback mechanism for relevant issues at the implementation stage will be established. 4.1 For Residents At HPHC and HHSA, any appeal or issue related directly to the Project will be handled through the following procedure. This GRM will also be disclosed on the websites of HPHC and HHSA. All appeal records and related dispositions will be saved through the annual environmental and social monitoring mechanism and reported to the Bank. Stage 1: An AP or stakeholder may ask questions to the opinion handling department (customer service department of the hospital) under the township/community medical institutions. The opinion handling department will record on site and deal with it within 10-15 working days, and give a reply or resolution to the AP. Stage 2: If AP have any objection to the treatment results of the township/community medical institutions, they can put forward relevant opinions to the county and city medical institutions/county and city health and health commission departments. The relevant departments will make records and consult with them, and provide the AP with replies or solutions within 10 working days. Stage 3: If the AP have objections to the results of the county mentioned in Stage 2, they can respond directly to the provincial health and fitness commission, or file a lawsuit directly to the court. HPHC and HHSA may be reached in the following manner. See Table 4-1. Table 4-1 Contact Information Method Time of response e-mail / 48 hours “12345” and “12306” hotlines Real time; or 48 hours Telephone Hotlines of HCs, health supervision offices, etc. for messages Letter / 15 days Appeal handling agencies / One week Online compliant / 15 days Customer service staff of PHC / One week providers Public satisfaction survey Public scoring Monthly 4.2 For Primary Medical Institutions In addition, HPHC and HHSA have established a sound internal appeal channel for PHC provider staff, and such channel is embedded into the existing labor management system. Staff may file appeals through the staff organization, customer service department, general administration department, etc., or resort to the arbitration procedure or judicial system. A4-17 6 Resources and Responsibilities The Hainan PMO (composed of HPHC and HHSA) promises to appoint a coordinator to implement this SEP, and provide a sufficient budget for stakeholder engagement. This coordinator should be familiar with the requirements of this SEP, and work closely with the relevant implementing agencies to ensure that this SEP is implemented practically. 7 Monitoring and Reporting The Hainan PMO (composed of HPHC and HHSA) will keep records of all stakeholder engagement and information disclosure activities, and appeals and dispositions to be included in annual environmental and social monitoring reports. 8 Budget According to the actual situation of the project and the upcoming activities, the budget is estimated, as shown in Table 8-1. Table 8-1 Budget of SEP County Activities Budget (RMB) Source of financing Haikou, Sanya, FGD 5000 (per county) Bank loan Wuzhishan, Health day publicity tour 5000 (per county) Bank loan Wenchang, Public satisfaction 5000 (per county) Bank loan Qionghai, Wanning, survey Ding’an, Tunchang, Medical education 10000 (per county) Bank loan Chengmai, Lingao, animation video Danzhou, Dongfang promotion 12 counties Total 25000 (per county) Bank loan Ledong, FGD 5000 (per county) Bank loan Qiongzhong, Health day publicity tour 5000 (per county) Bank loan Baoting, Lingshui, Public satisfaction 5000 (per county) Bank loan Baisha, Changjiang survey Medical education 10000 (per county) Bank loan animation video promotion The healthy entry of 5000 (per county) Bank loan ethnic minorities into the countryside 6 Counties Total 30000 (per county) Bank loan Total / 480000 Bank loan A4-18 Appendix 1 List of FGDs City / Participants Venue Key points county 1 HC office 1) Project introduction (current situation Xiangshui Town Health of primary healthcare, women, minority 2 Center residents and poor people in Baoting Baoting County HC, 3 County) PAO, ERAC and WF; Hekou Village Clinic 2) Public consultation: public opinions head of the Xiangshui Baoting and suggestions on primary healthcare; Town Health Center; County opinions of heads and staff of PHC rural doctors in Hekou A villager’s home in providers (rural doctors, etc.); opinions 4 Village; villagers of Hekou Village of minority poor people and women Hekou Village 3) Organizational consultation: opinions of WFs, PAOs, EACs, etc. on primary healthcare and the Project Wuzhishan Municipal 1) Project introduction (current situation 5 HC of primary healthcare, women, minority Wuzhishan Municipal Hainan No.2 People’s residents and poor people in Wuzhishan 6 HC, PAO and ERAC; Hospital City) contact of Hainan No.2 Maogui Village 2) Public consultation: public opinions 7 People’s Hospital; Wuzhishan Committee and suggestions on primary healthcare; villagers of Maogui City Maoyang Town Health opinions of heads and staff of PHC 8 Village; head of the Center providers (rural doctors, etc.); opinions Maoyang Town Health of minority residents and women Center; Maojian Village 3) Organizational consultation: opinions 9 Clinic rural doctors Maojian Village Clinic of WFs, PAOs, EACs, etc. on primary healthcare and the Project 10 Sanya Municipal HC 1) Project introduction (current situation Fenghuang Community of primary healthcare, women, minority 11 Sanya Municipal HC, Health Center residents and poor people in Sanya City) PAO, ERAC and WF; 2) Public consultation: public opinions head of the Fenghuang and suggestions on primary healthcare; Sanya City Community Health opinions of heads and staff of PHC Center; staff of the Sanyawan Community providers (rural doctors, etc.); opinions 12 Sanyawan Community Health Center of minority residents and women Health Center 3) Organizational consultation: opinions of WFs, PAOs, EACs, etc. on primary healthcare and the Project Haiken Community 1) Project introduction (current situation 13 Health Center of primary healthcare, women, minority Binya Community residents and poor people in Haikou 14 Longhua District HC; Health Center City) head of the Haiken 2) Public consultation: public opinions Community Health Haikou and suggestions on primary healthcare; Center; head and staff City opinions of heads and staff of PHC of the Binya providers (rural doctors, etc.); opinions 15 Community Health HPHC office of minority women Center 3) Organizational consultation: opinions of WFs, PAOs, EACs, etc. on primary healthcare and the Project A4-19 Appendix 2 Ethnic Minority Engagement Framework A2.1. Basic information of minority population in Hainan Province According to the 2018 Statistical Yearbook of Hainan Province, at the end of 2017, Hainan had a minority population of 1,657,423, accounting for 18.2% of gross population, including 1,502,415 Li people, accounting for 90.65%; 79,515 Miao people, accounting for 4.8%; 40,218 Zhuang people, accounting for 2.43%; 13,225 Hui people, accounting for 0.8%; and 22,050 people of other ethnic minorities, accounting for 1.33%, distributed mainly in Sanya and Wuzhishan Cities, and Baoting, Qiongzhong, Lingshui, Baisha and Changjiang Counties. There are over 30 ethnic minorities in Hainan, in which Han, Li, Miao and Hui are resident ethnic groups, while other ethnic groups have moved in after 1949 and are scattered. The Li, Miao and Hui people mostly live in central and southern Hainan, while the Han people mostly in northeast and north Hainan, and coastal areas. According to the Constitution of the People’s Republic of China, and the Law on Regional Ethnic Autonomy, a township in which minority population accounts for over 30% of gross population may become a minority township. See Table 1: Table A2-1 Distribution of Minority Population in Hainan Province Percentage of minority Division Han Li Miao Zhuang Hui Other population (%) Hainan Province 7446704 1502415 79515 40218 13225 22050 18.2 Sanya City 339626 233934 4074 2280 9710 2582 42.7 Wuzhishan City 28217 70718 5975 351 109 428 73.3 Ledong County 328792 203067 3096 1903 36 507 38.8 Lingshui County 162633 216529 866 727 30 474 69.5 Qiongzhong County 79472 112969 15460 6680 79 1499 63.2 Baoting County 51104 104461 7457 3856 61 877 69.5 Baisha County 66106 122610 2078 3058 14 1180 66.1 Changjiang County 148926 103123 299 888 723 566 41.5 The dialects spoken in Hainan include: 1) Hainan dialect, which is the dialect most spoken in Hainan by over 5 million residents; 2) Li language, which is spoken by all Li people; 3) Lingao dialect, which is close to the Zhuang language and is spoken by about 500,000 residents; and 4) Miao language, which is spoken by about 50,000 Miao people. In the 4 sample cities / counties, almost all minority residents can speak the Hainan dialect or Mandarin, except some old people aged above 75 years or those leading a secluded life in mountains. In Hainan, minority and Han residents are highly integrated in living habits, and Mandarin is very popular among minority residents. Minority residents have no taboo in doctor gender and are similar to Han residents in health status and diseases. In Wuzhishan City, Li and Miao residents have a higher incidence of thalassemia for genetic reasons, and patients are mostly from poor families with a weak sense of antepartum examination. In addition, some minority residents like drinking, and have a higher incidence of liver cirrhosis than Han residents. There are Li and Miao doctors in minority areas, and some rural minority residents are superstitious in medical care. In addition, although some minority residents cannot speak the Hainan dialect or Mandarin, there are many doctors and nurses speaking the Li language in rural primary healthcare teams, so their medical care is not affected. See Table 2. A4-20 Table A2-2 Distribution of Minority PHC Providers Village Community health Township health City / county Ethnic minority clinics centers centers Sanya City Li, Hui 85 23 4 Wuzhishan City Li, Miao 4 0 9 Ledong County Li 176 2 13 Lingshui County Li 0 0 1 Qiongzhong County Li, Miao 6 1 15 Baoting County Li, Miao 47 0 9 Baisha County Li 60 1 11 Changjiang County Li 67 2 11 A2.2. Impacts on minority residents 1) Positive impacts The Project will improve the overall primary healthcare level of Hainan, so local minority residents will benefit from more medical resources, and higher primary healthcare quality and efficiency, especially poor minority residents. On the whole, Hainan's ethnic minorities are no different from the han in terms of health status, medical treatment tendency, medical treatment procedures and health poverty alleviation policies. Baoting county, Wuzhishan city and other cities and counties where the population of ethnic minorities accounts for more than 40% have consistent medical treatment policies. Therefore, after the implementation of the project, the minorities will share the benefits of the expansion of medical resource capacity at the same level, the improvement of the quality and efficiency of primary medical treatment, and the minority poor residents will benefit more. In addition, the Project will solve the difficulty of minority residents in receiving medical care, and overcome the language barrier by setting up language help desks. 2) Negative impacts The investment in the Project will be focused on technical design, service transformation, and primary healthcare improvement. The Project will involve no construction, no land acquisition, and no materially adverse impact on local communities and minorities. Based on a rapid social assessment, the Project has no crowding out effect and no negatively affected population. A2.3. Application of EMEF or EMDP Ethnic minority engagement framework (EMEF) will be implemented when the subproject is not located in any ethnic minority autonomous counties but located in areas/communities involving ethnic minority people. Ethnic minority development plan (EMDP) should be prepared when the subproject is in any ethnic minority autonomous counties. A2.4 Minority engagement A2.4.1 Information disclosure to minority residents 1) Started information disclosure activities Since local minority and Han residents are highly integrated, information disclosure activities for minority residents are similar to those for Han residents. See Table 3. Table A2-3 Started Information Disclosure Activities for Minority Residents Time Venue Stakeholders / participants Key points Method National Development and Field Learning the current District / county Reform Commission, Bank investigation, 2018.12 situation of the healthcare PHC providers mission, Hainan Provincial online industry of Hainan Province Development and Reform disclosure A4-21 Commission, HCs, EACs Current situation and issues of PHC providers in Hainan; Field HPHC, EIA agency, SA District / county project awareness, and investigation, 2019.8 agency, municipal / county PHC providers frequency and willingness FGD, EACs to use PHC providers of interview minority residents School of Medicine of Tsinghua University, Current situation of PHC District / county Field 2019.8 professor of Sichuan providers in Hainan PHC providers investigation University, municipal / county (including minority areas) EACs Environmental issues of District / county HPHC, EIA agency, municipal Field 2019.8 PHC providers in minority PHC providers / county EACs investigation areas 2) Information disclosure activities about to be started Since local minority residents have their own spoken languages, and some old people cannot speak Mandarin, local dialects and minority languages should be used as appropriate in future information disclosure activities. See Table 4. A2.4.2 Public consultation for minority residents 1) Started public consultation activities The SA agency has conducted consultation with the provincial and local EACs, agencies concerned in minority areas, and minority residents to collect suggestions and needs. Based on the first round of consultation, local minority residents show no significant difference from Han residents in medical care, and have no special need for doctor gender and ethnic group. However, some rural minority residents are superstitious in medical care. In addition, language is also a main concern, especially for some old minority residents. See Table 5. 2) Public consultation activities about to be started In order to ensure that minority residents are engaged at different stages to express their needs and suggestions, an ethnic minority engagement plan has been developed. See Table 6. A4-22 Table A2-4 Information Disclosure Activities about to be Started for Minority Residents Stage Information to be disclosed Proposed mode Venue / date Persons responsible Remarks First round of information HPHC website, bulletin HPHC contact Use minority languages Internet; disclosure: project information boards of PHC Township officials (HCs, in oral communication, Bulletin board; (mainly including purpose, providers and village WFs, PAOs, ERACs, etc.) and provide dialect Village official notice; nature, scale, duration, etc.), committees / Village / community officials interpretation when Public account notice SEP Sep. 2019 Component agencies necessary. Preparation HPHC website, bulletin HPHC contact Internet; Second round of information boards of PHC Township officials (HCs, Bulletin board; disclosure: ESMF, SEP providers and village WFs, PAOs, ERACs, etc.) Village official notice; (including EMEF) committees / Oct. – Village / community officials Public account notice Dec. 2019 Component agencies Internet; HPHC website, bulletin HPHC contact Ensure that a certain Bulletin board; boards of PHC Township officials (HCs, percentage of village Time and scope of Implementation Village official notice; providers and village WFs, PAOs, ERACs, etc.) congress attendees are implementation, etc. Village congress; committees, project Village / community officials minority residents; use Public account notice area / 2020-2025 Component agencies minority languages in Internet; HPHC website, bulletin HPHC contact oral communication, Bulletin board; boards of PHC Township officials (HCs, and provide dialect Operation Project operation Village official notice; providers and village WFs, PAOs, ERACs, etc.) interpretation when Village congress; committees, project Village / community officials necessary. Public account notice area / 2025 Component agencies A4-23 Table A2-5 Started Public Consultation Activities for Minority Residents Time Venue Stakeholder Key points Method used Findings 1) Current situation and 1) All local ethnic minorities are highly assimilated to Han people, and issues of PHC providers in there is no preferential medical policy for ethnic minorities; there is no Provincial Hainan, and solutions special healthcare need, e.g., doctor gender. Their healthcare authorities Organizational 2) Roles and responsibilities awareness may be improved in conjunction with minority festivals. 2019.8-9 HC offices (HPHC, HHSA, interview, of all agencies 2) EACs and WFs will participate in project publicity. WF, PAO, EAC, FGD 3) Current situation of etc.) minority residents in all cities, counties and districts 1) Project introduction Findings: 2) current situation of primary 1) The main ethnic minority of Baoting County is Li. There is no healthcare and minority preferential medical policy for ethnic minorities; there is no special Baoting County Baoting residents in Baoting County; Organizational healthcare need, e.g., doctor gender. 2019.8-9 HC, PAO and County 3) Opinions and suggestions interview Suggestions: ERAC of agencies on primary 1) Local minority residents’ healthcare awareness may be improved in healthcare conjunction with minority festivals. 2) EACs will participate in project publicity. Villagers of 1) Project introduction Findings: A villager’s Hekou Village 2) Basic information of 1) Rural minority residents are superstitious in medical care. home in (incl. women, personal healthcare Key informant 2) Many poor old people would go to village clinics for minor diseases. 2019.8-9 Hekou poor people and 3) Opinions and suggestions interview Suggestions: Village minority on the Project 1) Rural doctors should be able to treat more diseases. residents) 2) There should be breastfeeding and kid playing spaces at hospitals. 1) Project introduction Findings: 2) Basic information of 1) There are Li and Miao doctors in minority areas. Maogui Villagers and Maogui Village 2) Villagers prefer more expensive but more efficacious urban hospitals. 2019.8-9 Village women’s director 3) Opinions and suggestions FGD Suggestions: Committee of Maogui Village on the Project 1) Provide more investment in township hospitals 2) More capable doctors should be introduced. 3) Technical gaps of township health centers should be made up. 1) Project introduction Findings: Meeting 2) current situation of primary 1) Minority residents have the same medical care habits as ordinary room of Sanya Municipal healthcare and minority residents, but sometimes need language support. Organizational 2019.8-9 Sanya HC, EAC, PAO residents in Sanya City; Suggestions: interview Municipal and WF 3) Opinions and suggestions 1) Relevant jobs should be first made available to minority and local HC on the Project residents. 2) Language help desks should be set up as appropriate. A4-24 Table A2-6 Ethnic Minority Engagement Framework Form Other (filing, disclosure, Component Stakeholder Interests Activity Organizer (channel/time) monitoring) Improving Minority  Thalassemia prevention 1) Rural and family doctors rural and  Village clinics  Recorded by organizer, Primary Health residents and treatment maintain close routine family doctors  Follow-up and always available for Care (especially  Treatment of ordinary communications on disease public access Performance ； thalassemia) diseases and drug prevention and treatment  Open to third party access Strategic purchase with minority residents at (e.g., monitoring agency) purchasing for  Learning the situation of the implementation and  Number of participants: 5 quality services primary doctors, and operation stages.  Dialect interpretation selecting suitable / 2) Township hospitals Township  Village clinics  Recorded by organizer, satisfactory ones communicate with rural and hospitals  Township and available online or  Building a language family doctors and ordinary hospitals physically for public service platform residents on relevant  Specified time access  Public health needs, e.g., issues within their  Open to third party access preventive injection jurisdiction regularly at the (e.g., monitoring agency)  Environmental pollution implementation and  Frequency and number of impact management operation stages, such as participants: monthly, 10 medical quality, at a time reimbursement, drug  Dialect interpretation supply, public health management and medical environment management. 3) County hospitals or County  Fixed place  Recorded by organizer, medical alliances hospitals or and time and available online or communicate with township medical  Or online physically for public hospitals and village clinics alliances follow-up access on relevant issues regularly  Open to third party access at the implementation and (e.g., monitoring agency) operation stages, including  Frequency: monthly, 15 at equipment, technical a time support, talent training and  Dialect interpretation performance evaluation. Minority primary  Learning the health status PHC providers maintain PHC providers  Village clinics  Recorded by organizer, doctors: rural of minority residents close routine  Township and always available for and family  Leaving a good communication on skills, hospitals public access doctors impression to minority training and salary needs of  Specified time  Open to third party access residents, and gaining minority rural and family (e.g., monitoring agency) performance and doctors at the  Dialect interpretation A4-25 popularity to increase implementation and income operation stages.  Receiving support from superior authorities, especially technical support from general practitioners and specialists PHC providers:  Learning the health status HCs learn needs of PHC HCs  PHC providers  Recorded by organizer, township of minority residents providers for technical  Fixed place and always available for hospitals /  Obtaining better equipment and talents and time public access village clinics equipment and talents through regular  Online  Open to third party access  Receiving support from communication via certain follow-up (e.g., monitoring agency) superior authorities, channels at the especially technical implementation and support from general operation stages. practitioners and specialists EACs Implementing work in relevant The monitoring agency Monitoring  Through  Recorded by organizer, fields practically consults with competent agency external and available online or authorities regularly to track monitoring physically for public relevant issues at the mechanism access implementation and  Consistent with  Open to third party access operation stages. external (e.g., monitoring agency) monitoring in time Technical Minority  Learning relevant service Primary healthcare staff PHC providers  Village clinics  Recorded by organizer, Assistance residents policies, such as explains how to use the  Follow-up and always available for reimbursement relevant app to local public access  Convenient access to residents at the  Open to third party access medical quality implementation and (e.g., monitoring agency) information operation stages.  Reflecting medical issues conveniently Technical EACs  Implementing work in Government agencies HCs  Fixed place  Recorded by organizer, Assistance relevant fields practically communicate regularly at and time and always available for the implementation and  Working public access operation stages. meeting A4-26 Appendix 3 Summary of First Round of Public Consultation Time Venue Stakeholder Key points Method used Findings 2019.8-9 HPHC office Provincial authorities 1) Current situation and issues Organizational All agencies support the Project actively. (HPHC, HHSA, etc.) of PHC providers in Hainan, interview and solutions 2) Roles and responsibilities of all agencies 2019.8-9 Days Inn Hot Baoting County HC, 1) Project introduction Organizational Findings: Spring Baoting PAO, ERAC and WF 2) Current situation of primary interview 1) The main ethnic minority of Baoting County is Li. There is healthcare, women, minority no preferential medical policy for ethnic minorities; there is no residents and poor people in special healthcare need, e.g., doctor gender. Baoting County 3) Baoting County has a high incidence of thalassemia, and 3) Opinions and suggestions of special measures are in place. agencies on primary 4) In Baoting County, health poverty alleviation is for rural healthcare areas only. 5) In Baoting County, women receive a fixed childbirth subsidy of 800 yuan. Suggestions: 1) Local minority residents’ healthcare awareness may be improved in conjunction with minority festivals. 2) EACs and WFs will participate in project publicity. 2019.8-9 Xiangshui Town Head of the 1) Project introduction Key informant Findings: Health Center Xiangshui Town 2) Basic information of interview 1) The health center has only two doctors. Health Center Xiangshui Town Health Center 2) The health center’s capacity is not fully utilized (50%). 3) Opinions and suggestions 3) The outpatient utilization rate of the health center is low. on the Project 4) The self-paid consultation rate of migrants is only 3.6%. Suggestions: 1) The doctors should receive more training to improve their skills. 2) An advanced information system should be established. 2019.8-9 Hekou Village Doctors and health 1) Project introduction Key informant Findings: Clinic workers of Hekou 2) Basic information of Hekou interview 1) Rural doctors have few patients in a daily basis, and can Village Clinic, Village Clinic only treat minor diseases. women’s director of 3) Opinions and suggestions 2) Patients are mostly old people and children. Hekou Village on the Project 3) The income of rural doctors is average. 4) Villagers usually receive medical care at village clinics for A4-27 free. Suggestions: 5) Poor families contract with family doctors. Suggestions: 1) Training opportunities are expected. 2019.8-9 A villager’s home Villagers of Hekou 1) Project introduction Key informant Findings: in Hekou Village Village (incl. women, 2) Basic information of interview 1) Poor families contract with family doctors, and usually go to poor people and personal healthcare township hospitals. minority residents) 3) Opinions and suggestions 2) Rural minority residents are superstitious in medical care. on the Project 3) Many poor old people would go to village clinics for minor diseases. Suggestions: 1) Rural doctors should be able to treat more diseases. 2) There should be breastfeeding and kid playing spaces at hospitals. 2019.8-9 Meeting room of Wuzhishan Municipal 1) Project introduction Organizational Findings: the Wuzhishan HC, PAO and ERAC 2) Current situation of primary interview 1) Patients of village clinics are mostly old people and Municipal HC healthcare, women, minority children; most residents go to Hainan No.2 People’s Hospital. residents and poor people in 2) The utilization rate of township health centers is only Wuzhishan City 30%-50%. 3) Opinions and suggestions of Suggestions: agencies on primary 1) Strengthen manpower and equipment. healthcare 2) Increase the number of doctors and improve medical quality. 3) Increase the turnover rate of hospitals. 4) Design capacity based on resident population and in consideration of migrant population. 5) Set up language help desks for old minority people. 2019.8-9 Hainan No.2 Contact of Hainan 1) Project introduction Key informant Findings: People’s No.2 People’s 2) Basic information of Hainan interview 1) Poor families are entitled to a green channel. Hospital Hospital, pediatrics No.2 People’s Hospital 2) The hospital is not running at full capacity. outpatient doctors, 3) Opinions and suggestions 3) The hospital is short of manpower. service head, on the Project 4) The hospital is about to establish a medical alliance for patients hierarchical and two-way diagnosis and treatment. 5) Some patients need to communicate in the Hainan dialect. 6) The hospital handles patient appeals through its customer A4-28 service department and the 12345 platform. Suggestions: 1) Talents should be introduced. 2) Introducing advanced equipment 2019.8-9 Maogui Village Villagers and 1) Project introduction FGD Findings: Committee women’s director of 2) Basic information of Maogui 1) Rural doctors are not resident, and are contacted by Maogui Village Village telephone when necessary. 3) Opinions and suggestions 2) This village is close to the town, and most villagers go to the on the Project town for medical care. 3) There are Li and Miao doctors in minority areas. 4) Villagers prefer more expensive but more efficacious urban hospitals. Suggestions: 1) Investing heavily in township hospitals 2) More capable doctors should be introduced. 3) Technical gaps of township health centers should be made up. 2019.8-9 Maoyang Town Head of the Maoyang 1) Project introduction Key informant Findings: Health Center Town Health Center 2) Basic information of interview 1) Patients are mostly old people and children. Maoyang Town Health Center 2) There is only one competent middle-rank doctor, and there 3) Opinions and suggestions is no incentive mechanism. on the Project Suggestions: 1) Talents should be introduced under a sound incentive mechanism. 2) Doctors should be trained externally. 2019.8-9 Maojian Village Maojian Village Clinic 1) Project introduction Key informant Findings: Clinic rural doctors 2) Basic information of Maojian interview 1) The rural doctors’ salary is higher than average. Village Clinic 2) Many rural doctors are contracted. 3) Opinions and suggestions 3) Rural doctors are trained regularly. on the Project 2019.8-9 Meeting room of Sanya Municipal HC, 1) Project introduction Organizational Findings: the Sanya EAC, PAO and WF 2) Current situation of primary interview 1) Sanya City has many migrant people, who mostly go to 3A Municipal HC healthcare, women, minority hospitals. residents and poor people in 2) There are already medical alliances in Sanya City. Sanya City 3) Community health centers are understaffed, especially in 3) Opinions and suggestions winter. A4-29 on the Project 4) Village clinics cannot attract and retain talents. 5) Minority residents have the same medical care habits as ordinary residents, but sometimes need language support. 6) Healthcare for poor people is still available after the completion of the poverty alleviation program. Suggestions: 1) Talents should be introduced. 2) A remuneration reform and primary standardization should be conducted. 3) Major hospitals should be established in rural areas. 4) Relevant jobs should be first made available to minority and local residents. 5) Language help desks should be set up as appropriate. 2019.8-9 Fenghuang Residents (including 1) Project introduction Key informant Findings: Community migrants and poor 2) Basic information of interview 1) Outpatients include many local residents and migrants. Health Center people); head of the Fenghuang Community Health 2) The center is not running at full capacity. Fenghuang Center 3) Residents go to the health center for minor diseases. Community Health 3) Opinions and suggestions 4) Residents think that doctors make detailed inquiries, but Center on the Project are not skilled enough. 2019.8-9 Sanyawan Head 1) Project introduction Key informant Findings: Community 2) Basic information of interview 1) The migrant population visiting the service center Health Center Sanyawan Community Health decreases year by year. Center 2) Equality for migrant population should be realized. 3) Opinions and suggestions on the Project 2019.8-9 Crowne Plaza Sanya Municipal HC; 1) Project introduction FGD Suggestions: Sanya Bay EIA agency; SA 2) Opinions and suggestions 1) A sound organizational structure with clear duties should be agency on the Project established. 2) The scope of the Project should be defined. 2019.8-9 Haiken Longhua District HC; 1) Project introduction Key informant Findings: Community head of the 2) Basic information of Haiken interview 1) The health center has many female staff members, and Health Center community health Community Health Center about half of its staff members are minority residents, center; HPHC 3) Opinions and suggestions especially Li residents. on the Project 2) The outpatient utilization rate of the health center is only 50%. 3) Patients are mostly low residents. A4-30 4) Family doctors contract with local residents, with a contracting rate of 30%. 5) A medical alliance has been established with the Second Affiliated Hospital of Hainan Medical University for medical care at different levels. 6) It operates with difficulties, because it serves a small population and is short of funds. 2019.8-9 Binya Longhua District HC; 1) Project introduction Key informant Findings: Community head and staff of the 2) Basic information of Binya interview 1) The outpatient utilization rate of the health center is only Health Center service center; Community Health Center 40%. HPHC 3) Opinions and suggestions 2) Medical expenses here cannot be reimbursed. on the Project 3) The health center conducts volunteer medical consultation every week, mainly for special diseases, such as diabetes and hypertension. 4) The contracting rate of family doctors is about 45%. 5) A medical alliance has been established with the provincial hospital. Suggestions: 1) Community health centers should have the drug dispensing function for the convenience of old people. A4-31 Appendix 4 Implementation and Operation Stages At the implementation and operation stages, a certain stakeholder engagement mechanism should be established based on project activities and engagement needs to ensure that stakeholders are engaged effectively. Such mechanism may be adjusted flexibly to local conditions, but should include the following basic factors: 1) Subjects: Who organizes each engagement activity? Who are subjects of communication? 2) Form: modes and times of communication, such as face-to-face, telephone and online communication 3) Scope: What is the scope of communication? 4) Filing and disclosure: How to keep and save records, and how is information disclosed? 5) Monitoring: How to conduct monitoring? The stakeholder engagement mechanism of the implementation and operations under the above framework is shown in Table A4-0-1. A4-32 Table A4-0-1 Stakeholder Engagement Plan of the Implementation and Operation Stages Form Other (filing, disclosure, Component Stakeholder Interests Activity Organizer (channel/time) monitoring) Improving Local residents, • Chronic disease prevention 1) Rural and family doctors Rural and • Village clinics • Recorded by organizer, and Primary especially and treatment maintain close routine family doctors • Follow-up always available for public Health Care chronic disease • Treatment of ordinary communications on disease access Performance patients diseases and drug purchase prevention and treatment with • Open to third party access ；Strategic • Learning the situation of local residents at the (e.g., monitoring agency) purchasing primary doctors, and implementation and operation • Number of participants: 5 for quality selecting suitable / stages. (incl. women and minority services satisfactory ones residents) • Higher percentage of • Dialect interpretation reimbursement 2) Township hospitals Township • Village clinics • Recorded by organizer, and • Public health needs, e.g., communicate with rural and family hospitals • Township available online or physically preventive injection doctors and ordinary residents on hospitals for public access • Environmental pollution relevant issues within their • Specified time • Open to third party access impact management jurisdiction regularly at the (e.g., monitoring agency) implementation and operation • Frequency and number of stages, such as medical quality, participants: monthly, 10 at a reimbursement, drug supply, time (incl. women and public health management and minority residents) medical environment • Dialect interpretation management. 3) County hospitals or medical County • Fixed place • Recorded by organizer, and alliances communicate with hospitals or and time available online or physically township hospitals and village medical • Or online for public access clinics on relevant issues regularly alliances follow-up • Open to third party access at the implementation and (e.g., monitoring agency) operation stages, including • Frequency: monthly, 15 at a equipment, technical support, time (incl. women and talent training and performance minority residents) evaluation. Primary doctors: • Learning the health status of PHC providers maintain close PHC • Village clinics • Recorded by organizer, and rural and family local residents routine communication on skills, providers • Township always available for public doctors • Leaving a good impression to training and salary needs of hospitals access local residents and receiving minority rural and family doctors • Specified time • Open to third party access good performance evaluation at the implementation and (e.g., monitoring agency) results to increase income operation stages. • Receiving support from A4-33 superior authorities, especially technical support from general practitioners and specialists PHC providers: • Learning the health status of HCs learn needs of PHC HCs • PHC • Recorded by organizer, and township local residents providers for technical equipment providers always available for public hospitals / village • Obtaining better equipment and talents through regular • Fixed place access clinics and talents communication via certain and time • Open to third party access • Receiving support from channels at the implementation • Online (e.g., monitoring agency) superior authorities, and operation stages. follow-up especially technical support from general practitioners and specialists County hospitals • Allocating resources to meet County hospitals or medical County • Fixed place • Recorded by organizer, and or medical needs of primary hospitals alliances conduct regular hospitals or and time available online or physically alliances communication and resource medical • for public access allocation for primary schools at alliances the implementation and operation stages. Other • Implementing work in The monitoring agency consults Monitoring • Through • Recorded by organizer, and administrative relevant fields practically, with competent authorities agency external available online or physically units e.g., women health regularly to track relevant issues monitoring for public access protection and medical at the implementation and mechanism support for poor people operation stages. • Consistent with external monitoring in time Migrant • Some common problems can Rural and family doctors maintain Rural and • Village clinics • Recorded by organizer, and population be solved at primary close routine communications on family doctors • Follow-up always available for public hospitals. disease prevention and treatment access • Major hospitals should not be with migrant population at the • Open to third party access too crowded. implementation and operation (e.g., monitoring agency) stages. • Number of participants: 5 Local residents, • Scope, role, charges, etc. of Rural and family doctors Rural and • Village clinics • Recorded by organizer, and especially old healthcare services communicate routinely with local family doctors • Follow-up always available for public people residents on healthcare issues at access the implementation and operation • Open to third party access stages. (e.g., monitoring agency) • Number of participants: 5 A4-34 (incl. women and minority residents) • Dialect interpretation PHC integrated • Learning primary healthcare PHC management teams PHC • Fixed place • Recorded by organizer, and management in depth, and discovering and communicate with primary management and time available online or physically teams solving issues quickly institutions and doctors regularly teams • Or online for public access at the implementation and follow-up • Open to third party access operation stages. (e.g., monitoring agency) • Frequency: monthly Quality • Establishing an effective 1) Quality monitoring teams Quality • Village clinics • Recorded by organizer, and monitoring teams primary healthcare quality collect medical quality information monitoring • Follow-up always available for public regulation system of local residents and doctors teams access through the proposed information • Open to third party access system at the implementation and (e.g., monitoring agency) operation stages. • Dialect interpretation • Collecting primary healthcare 2) Quality monitoring teams Quality • Fixed place • Recorded by organizer, and quality information accurately provide transparent medical monitoring and time available online or physically and timely quality information with primary teams • Or online for public access doctors to the public at the follow-up • Open to third party access implementation and operation (e.g., monitoring agency) stages. • Frequency: monthly Local residents • Convenient access to 3) Quality monitoring teams Quality • Fixed place • Recorded by organizer, and medical quality information; establish an appeal and feedback monitoring and time available online or physically convenient reporting of mechanism for primary doctors at teams • Or online for public access medical problems the implementation and operation follow-up • Open to third party access stages. (e.g., monitoring agency) Primary doctors • Transparent medical quality Primary doctors file appeals Quality • Fixed place • Recorded by organizer, and monitoring system that through the appeal and feedback monitoring and time available online or physically allows doctors to file appeals mechanism at the implementation teams • Or online for public access and operation stages. follow-up • Open to third party access (e.g., monitoring agency) Technical PHC providers: • Mastering technical HCs and HSAs organize training HCs and • Fixed place • Recorded by organizer, and Assistance； township requirements for relevant for PHC providers and their staff HSAs and time available online or physically Improving hospitals / village services at the implementation and • Or online for public access Primary clinics • Learning relevant service operation stages. follow-up • Open to third party access Health Care policies, such as (e.g., monitoring agency) Performance reimbursement • Frequency: monthly 2) PHC providers and doctors PHC • Village clinics • Recorded by organizer, and Primary doctors: explain relevant service policies to providers and • Follow-up always available for public A4-35 rural and family local residents at the doctors access doctors implementation and operation • Open to third party access Local residents • Learning relevant service stages. (e.g., monitoring agency) policies, such as • Dialect interpretation reimbursement PHC providers: • Learning skills training types, 1) HCs and HSAs organize HCs and • Fixed place • Recorded by organizer, and township policies, etc. training for PHC providers and HSAs and time available online or physically hospitals / village their staff at the implementation • Or online for public access clinics and operation stages. • Open to third party access (e.g., monitoring agency) • Frequency: monthly 2) PHC providers and doctors PHC • Village clinics • Recorded by organizer, and Primary doctors: explain relevant service policies to providers and • Follow-up always available for public rural and family local residents at the doctors access doctors implementation and operation • Open to third party access stages. (e.g., monitoring agency) • Dialect interpretation HCs and HSAs • Designing a scientific and 1) HCs and HSAs organize HCs and • Fixed place • Recorded by organizer, and reliable integrated training for PHC providers and HSAs and time available online or physically information system; their staff at the implementation • Or online for public access • Adjusting the system to and operation stages, so that • Open to third party access practical needs efficiently PHC providers and their staff (e.g., monitoring agency) and continually master relevant skills. • Frequency: monthly • Improving treatment effects 2) Primary healthcare staff Primary • Village clinics • Recorded by organizer, and using big data and other high explains how to use the relevant healthcare • Follow-up always available for public techs app to local residents at the staff access • Building a provincial health implementation and operation • Open to third party access database on PHC providers stages. (e.g., monitoring agency) and doctors using the • Dialect interpretation information system for 3) Information system authorities Information • Hotline or • Recorded by organizer, and scientific investment and set up a hotline or forum to collect system forum always available for public management information on system operation authorities • Anytime access • Establishing a result-oriented from primary healthcare staff and • Open to third party access primary healthcare incentive residents through PHC providers (e.g., monitoring agency) mechanism based on data at the implementation and system operation stages. PHC providers: • Improving treatment effects township using big data and other high hospitals / village techs A4-36 clinics Primary doctors: • Improving treatment effects • Hotline or rural and family using big data and other high forum doctors techs; transparent medical • Anytime quality monitoring system that allows doctors to file appeals Local residents • Convenient access to medical quality information; convenient reporting of medical problems Information • Collecting issues on system • Anytime system operation timely for authorities upgrading and improvement Technical HCs (incl. • Purchasing demand for Government agencies HCs • Fixed place • Recorded by organizer, and Assistance information relevant techs communicate regularly at the and time always available for public center) implementation and operation • Working access HSAs • Financial support for relevant stages. HSAs meeting diseases Finance bureaus • Making unified funding Finance arrangements bureaus A4-37 Appendix 5 Field work Photos September 18, 2019: interview at the Xiangshui Health bulletin board of the Xiangshui Town Town Health Center Health Center September 18, 2019: interview at the Hekou September 18, 2019: interview with villagers of Village Clinic Hekou Village (women and minority residents) September 18, 2019: interview with villagers of September 18, 2019: organizational FGD in Hekou Village (poor and old people) Baoting County A4-38 September 19, 2019: interview with medical September 19, 2019: interview at the customer staff of Hainan No.2 People’s Hospital service department of Hainan No.2 People’s Hospital September 19, 2019: FGD with villagers of September 19, 2019: interview with head of Maogui Village the Maoyang Town Health Center September 19, 2019: interview with a rural September 19, 2019: organizational interview doctor in Wuzhishan City A4-39 September 20, 2019: FGD with residents of September 20, 2019: organizational FGD in Fenghuang Community Health Center in Sanya Sanya City City September 22, 2019: interview with head of the September 22, 2019: interview with medical Haiken Community Health Center staff of the Binya Community Health Center Health bulletin board of the Haiken Community Health bulletin board of the Sanyawan Health Center Community Health Center A4-40