The World Bank Health System Strengthening Project (P175170) Concept Environmental and Social Review Summary Concept Stage (ESRS Concept Stage) Public Disclosure Date Prepared/Updated: 10/03/2021 | Report No: ESRSC02246 Oct 03, 2021 Page 1 of 17 The World Bank Health System Strengthening Project (P175170) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Tuvalu EAST ASIA AND PACIFIC P175170 Project Name Health System Strengthening Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 1/24/2022 3/29/2022 Population Financing Borrower(s) Implementing Agency(ies) Ministry of Finance and Ministry of Health, Social Economic Development Welfare and Gender Affairs Proposed Development Objective The Project Development Objectives (PDOs) are to increase the utilization of and strengthen the management of Public Disclosure quality essential health services provided across Tuvalu, and to provide immediate and effective response in case of an eligible crisis or emergency. Financing (in USD Million) Amount Total Project Cost 15.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The draft Tuvalu National Health Strategic Plan for 2020-2024 (NHSP) provides a point of departure to identify priority interventions, new development activities, and programs for the Tuvalu Health System Strengthening Project (HSSP). Development of the Project and its implementation will be aligned, coordinated, and planned in conjunction with engaged bilateral partners such as New Zealand and Australia, regional entities such as Secretariat of the Pacific Community (SPC), Asian Development Bank (ADB), and key technical partners, including World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF). Oct 03, 2021 Page 2 of 17 The World Bank Health System Strengthening Project (P175170) The Project Development Objectives (PDOs) are to increase the utilization of and strengthen the management of quality essential health services provided across Tuvalu, and to provide immediate and effective response in case of an eligible crisis or emergency. The proposed project will support Ministry of Health, Social Welfare and Gender Affairs (MoHSWGA) to implement elements of the NHSP and to achieve the Project Development Objectives. It will have four components, namely: Component 1: Improved quality and range of health services across Tuvalu, including: (1a) Improve the quality and availability of services at the Princess Margaret Hospital (PMH). This includes: I) demolition and construction of a new hospital wing on the site of the PMH complex, including design characteristics for energy efficiency and resilience to significant weather and climate change events and making transitional arrangements for users displaced during construction; and ii) acquisition of related medical equipment and supplies, training and support for clinical governance arrangements including for diagnosis, treatment and referral for gender-based violence. (1b): Strengthen the capacity of core public health programs. This subcomponent will build the capacity of the public health system for public health screening of the population and its environment for interventions that can be managed in Tuvalu. This includes design and undertaking of an integrated screening program of the adult population both in the capital and outer islands, including for diagnosis and risk stratification for non-communicable diseases (NCDs) such as hypertension and diabetes; and capacity building for the design and implementation of strategic public health communications in multiple contexts. (1c) Improved management of non-communicable diseases in the community and outer island clinics, including ensuring standard treatment protocols for the management and referral of hypertensive and diabetic patients at primary health care level. (1d) Strengthening infection prevention and control (IPC) and medical waste management (MWM). This includes I) upgrading of the water, sanitation and hand-hygiene Public Disclosure facilities in the outer island clinics, and associated minor physical improvements within the boundaries of the existing facilities; and ii) an assessment of current system, standard operating procedures, capacities of human resources and gaps for proper hygiene and infection control management and waste management both in Funafuti and outer islands. Component 2: Developed systems for better health service management including: (2.1) Strengthen information management for better service delivery delivering in-service trainings on outer islands associated with new ICT systems and health programs and (2.2) strengthening health planning, budgeting and implementation to ensure ongoing clinical safety and quality. Component 3: Project management, monitoring and technical support. Component 4: A contingent emergency response component (CERC) for an event that has caused, or is likely to imminently cause, a major adverse economic and/or social impact to Tuvalu associated with a natural or man-made crisis or disaster. Project financing for all goods, works and services will take into consideration existing, current, and planned investments by other external partners. The proposed health infrastructure development will be carried out taking into account environmental and social risks assessments, as well as opportunities for developing more energy efficient and climate resilient health facilities. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Oct 03, 2021 Page 3 of 17 The World Bank Health System Strengthening Project (P175170) The Republic of Tuvalu lies in the western South Pacific Ocean and is made up of a scattered archipelago of atolls approximately 3.0m to 4.0m maximum above sea level. Rain catchment and wells provide the only freshwater. The estimated population of Tuvalu in 2020 was 11,792. Funafuti atoll, where the national capital is located, is home to about half of the population. The islands consist of five coralline atolls (Nanumea, Nui, Nukufetau, Funafuti, Nukulaelae), and three table reef islands (Nanumaga, Niutao, Niulakita) with one composite (coralline atoll/ table reef) island (Vaitupu). Funafuti is a densely populated urban environment wherein the outer islands the population is generally clustered into villages. Along with changing subsistence economies and lifestyles, consumption of store-bought food has been increasing for decades. The rate of non-communicable diseases has been steadily increasing with consequent pressure on the health system from chronic disease. The lack of connectivity and suitability of public health systems to screen, monitor and manage these illnesses results in a higher stress on acute care. Tuvalu has one hospital in Funafuti, Princess Margaret Hospital (PMH), two health clinics, one south and the other north of Funafuti and eight health centers covering outer islands. These facilities are small and staffed by nurses providing primary care and preventive services. Patients needing advanced care that exceeds the hospital level are required to travel overseas hospitals through the Tuvalu Medical Treatment Scheme. PMH has 50 beds with separate wards for men, women and infants. It offers basic routine medical, surgical, obstetric and gynecologic services and there is an Intensive Care Unit, a surgery room and nurses' station, and accident and emergency services. Tuvalu is currently COVID-19 free as most of the commercial flights to and from Tuvalu have been suspended, but Public Disclosure several small repatriation flights have operated in recent months. COVID-19 testing is available at PMH. Project investments will focus on i) strengthening the capacity of core public health programs (including the design and establishment of a public health lab in the PMH, design and implementation of a health screening process for the adult population and the procurement of equipment such as laboratory equipment and reagents and vehicles as well as associated capacity building primarily located in Funafuti; ii) improved management of NCDs in the community in Funafuti and on the eight outer island clinics listed above (including technical assistance (TA) activities and the procurement of point of care diagnostic technologies and ICT equipment); iii) strengthen infection prevention and control and medical waste management including TA activities, upgrade of water, sanitation and hand-hygiene facilities in the island clinics on the eight outer islands, small infrastructure and a waste transport vehicle for use on Funafuti island; iv) strengthening information management for better services(including TA activities and the procurement of ICT equipment and software); v) strengthen health planning, budgeting and implementation (including TA activities andsurveys); and vi) a CERC that will be activated if an event has, or is likely to, cause, a major adverse economic and/or social impact to Tuvalu associated with a natural or man-made crisis or disaster such as a cyclone or pandemic. Sub-components 1b – 1d will include activities in the capital Funafuti and on all eight outer islands, Sub-component 1a will only occur on Funafuti, and Subcomponents 2-4 will be national. Civil and construction works will be completed on previously disturbed land of low biodiversity value and the Project will coordinate activities with other organizations such as the ADB, UNICEF, Taiwan, SPC and WHO who are supporting IPC and MWM projects in the area such as the installation of an incinerator and strengthening of IPC policies and guidelines. Oct 03, 2021 Page 4 of 17 The World Bank Health System Strengthening Project (P175170) D. 2. Borrower’s Institutional Capacity The Ministry of Health, Social Welfare, and Gender Affairs (MoH for short) will be the executing agency with overall implementation responsibility resting with the CEO of Health with support from technical departments, particularly the Director of Health. Given his direct role in the administration of the sector, the Director of Health will be the Project Manager and given responsibility for regular oversight. To support the MoH with its project management functions, a Project Management Unit (PMU) within the MoH will be established that will coordinate and support the implementation of the Project on a day-to-day basis, including a Project Coordinator, technical, fiduciary, and safeguard and support staff. Alongside this, the Ministry of Finance and Economic Development (MoFED) has set up a Central Project Management Office (CPMO) which is staffed with international and national consultants who are experts in project management, procurement, financial management, environment and social risk management, and monitoring and evaluation. The CPMO will provide support in setting up the PMU, training, and continuous advisory support. It is recognized that the capacity at the MoH would be stretched given its routine management functions and project responsibilities. The MoH has no previous experience executing a World Bank-financed project or any other similar multi-lateral agency development projects, though there has been some experience in providing technical input to the execution of the COVID-triggered CERC. Based on lessons learned from the CERC, the MoH has been responsive to Environmental and Social risk management requirements, however, due to low staff numbers and capacity, in-country resources are stretched and there have been delays in responding to project requirements, including inputs into safeguards instruments. However, the MoH participates in a regional project funded by the ADB related to vaccines and has an externally funded technical adviser for national strategy implementation. Public Disclosure As such, the CPMO’s project management leadership is proposed for initial procurement planning, execution, and financial management until the PMU under the MoH is established. The PMU will then take the lead in project implementation and will: (i) liaise with the CPMO in the Ministry of Finance and other key stakeholders; (ii) coordinate the project within the MoH; (iii) prepare annual work plans and budgets; (iv) facilitate the implementation of project activities; (v) perform procurement and financial management; (vii) plan and comply with the environmental and social requirements with the supervision of safeguards specialists in the CPMO; and (v) monitor and report on the project and results to the Government, the MoH, and the World Bank. The PMU will also be responsible for working with the Public Works Department (PWD) of the Ministry of Public Works, Infrastructure, Environment, Labor, Meteorology, and Disaster (MPWIELMD). The role of PWD in the Project implementation will be assessed further during preparation. While in the early stages of being staffed, the CPMO has now appointed a highly experienced international safeguards advisor with significant experience in Tuvalu to oversee and support the preparation of safeguards instruments and compliance. An E&S Specialist will be engaged to develop the E&S instruments during project preparation with support from the CPMO, PMU and PWD, ensuring that project activities are completed in compliance with the ESF, good international industry practice (GIIP), and national legislation. During the project preparation, the capacity of the implementing agencies will be assessed as part of the Preliminary Environmental and Social Management Plan (ESMP) and detailed recommendations on training and capacity building will be made. The areas of capacity strengthening for relevant ESSs will be identified and actions will be agreed in the Environmental and Social Commitment Plan (ESCP). Oct 03, 2021 Page 5 of 17 The World Bank Health System Strengthening Project (P175170) II. SCREENING OF POTENTIAL ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The Project aims to deliver significant environmental benefits through the financing of MWM and infection prevention and control (IPC) improvements. The environmental risk rating for the project has been assessed to be ‘Substantial’ as the environmental risks and impacts are not expected to be significant and will be easily mitigated in a predictable manner through the implementation of the Project’s E&S instruments. Various project activities such as equipping of the PMH and modernization of laboratory and radiology diagnostic services result in the downstream production of healthcare waste such as liquid contaminated waste (e.g. blood, other body fluids and contaminated fluid), infected materials (water used, lab solutions and reagents, syringes, bed sheets, etc.), radioactive waste and expired pharmaceuticals. Medical waste is hazardous and has the potential to be infectious to humans, or cause injury and may contaminate the environment (land, groundwater, watercourses and lagoon/ocean environments). MWM is challenging in small atoll environments and Tuvalu have some constraints with respect to medical waste management systems and infrastructure, however, this is somewhat mitigated by the relatively small volumes that will be produced by a population of less than 12,000 people and ongoing infrastructure investments (e.g. a MWM incinerator for Funafuti) and TA activities (e.g. training and the development of IPC policies and procedures) that are being supported by partners such as the ADB, UNICEF, Taiwan, SPC and WHO. Further review will be completed through the E&S assessment completed during project preparation to identify capacity gaps and Public Disclosure mitigation measures (ideally through the integration of actions into project design). Some equipment procured by the Project will also have associated occupational and community safety risks requiring specific training and procedures. Project activities will result in resource consumption during the renovation of the left-wing PMH and minor construction/renovation works in the outer island health clinics. Examples include the use of construction materials, aggregates, water, and, energy. Risks and impacts associated with demolition, renovation, construction and equipping/furnishing activities may include increased dust and noise, sedimentation, minor hydrocarbon spills and waste disposal (potentially including hazardous materials such as asbestos and e-waste) and occupational health and safety risks. Operational risks and impacts, particularly for the PMH, relate to ongoing waste generation (general, healthcare, pharmaceutical, etc.), greywater and sewage management and the equipping/furnishing of the PMH and other health facilities may generate e-waste. It is expected that there may be downstream risks and impacts such as, interisland travel and worker health and safety and waste disposal when working in remote locations. A list of potential CERC activities will be identified during project preparation and the associated risks considered in the Preliminary ESMP and included in the appraisal ESRS. Technical assistance activities may lead to both environmental benefits (e.g. improved IPC practices from the development of SOPs and capacity building activities) and environmental risks and impacts (e.g. generation of medical waste and IPC risks from the health screening process). Technical assistance activities may also be leveraged to help mitigate other project risks and impacts. Social Risk Rating Substantial The Project aims to deliver a range of social benefits in the form of improved medical services and facilities including in remote and vulnerable outer islands communities. This will benefit all citizens of the country through improved access to healthcare, facilities, diagnostic and treatment equipment and drugs supply. There are risks related to the Oct 03, 2021 Page 6 of 17 The World Bank Health System Strengthening Project (P175170) construction phase and labor influx and SEA/SH risks, along with equity in access to Project benefits. In addition the implementing agency is new to the Worlds Bank’s ESF and has limited exposure to environment and social risk management. Resettlement impacts are considered unlikely, but will be managed through preparation of resettlement plans, if necessary during the project implementation . The project includes a substantial component of procuring materials and equipment and providing associated training. There are human health risks that may result from misuse of, poor quality, and/or poorly managed medical equipment, materials and services arising from potential constrained ability to use the equipment and materials. A potential social risk related to marginalized, vulnerable or remote social groups being unable to access health screening services, and/or that screening programs are not administered in accordance with good international industry practice (GIIP) in a way that undermines the central objectives of the project. The Project is likely to have some labor influx for construction works for the new wing of the PMH and outer island health center upgrades. Tuvalu has high background rates of Gender-based Violence and SEA/SH, however the project’s SEA/SH rating is ‘low’ for civil works due to a moderate scale of construction activities, limited labor influx in Funafuti, and location of civil works in an urban area in the instance of the new wing of the PMH, and small scale and limited labor influx for the outer island health center upgrades. The project is rated ‘Substantial’ based on the health SEA/SH risk screening. The Project’s Preliminary ESMP will include a SEA/SH risk assessment and appropriate mitigation . The Environmental and Social Commitment Plan (ESCP) will commit the MoHSWGA to the implementation of a Code of Conduct for MoHSWGA staff and contracted workers including provisions for SEA/SH prevention e.g. via training curricula. While there are functional GBV & SEA/SH services operating in Funafuti (the Tuvalu Family Health Association), the Preliminary ESMP will be required to assess the availability and capacity of outer island services. Given the project description at this stage, and the nature of social impacts of the project, the overall social risk for the project is rated as “Substantial”. The risk rating Public Disclosure will be re-assessed at Appraisal stage based on additional information obtained and changes will be made if required. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: The Project will result in positive E&S impacts strengthening Tuvalu's health system including investments into IPC and MWM improvements (e.g. the upgrade of sanitation facilities in outer island clinics, review and update of procedures, capacity building and the procurement of a waste transport vehicle). Project activities present E&S and H&S risks for the project workforce, communities and the environment. The project is not expected to involve any land acquisition or involuntary resettlement and works will be completed on previously disturbed land. No large-scale labor influx is expected. Key E&S impacts and risks include: construction phase and labor influx and SEA/SH risks, equity in access to project benefits, human health risks from misuse of, poor quality, and/or poorly managed medical equipment, materials and services, the generation of medical waste and impacts from demolition and construction activities (e.g. dust and noise generation and occupational and community health and safety). Activities are comparatively small in scale and complexity, impacts are generally known, low in magnitude and site-specific, temporary, and reversible in nature Oct 03, 2021 Page 7 of 17 The World Bank Health System Strengthening Project (P175170) with management measures that are predictable and likely to be effective. Operational risks relate to equitable access, waste management and occupational and community H&S. The MoHSWGA will assess and manage E&S risks and impacts associated with proposed Project activities in a manner proportionate to their significance utilizing a mitigation hierarchy approach during Project preparation. They will prepare the following instruments: A preliminary project-wide ESMP to assess the risks and impacts associated with project activities and to develop appropriate mitigation measures. As far as possible without the completion of detailed designs, the Preliminary ESMP will identify project activities, sites, surrounding areas, environments and people affected by the Project, assess the risks and impacts, identify measures to eliminate or offset adverse E&S impacts, or to reduce them to acceptable levels and the actions needed to implement these measures, and identify any further investigations required for specific impacts and management measures to be undertaken when preparing a Comprehensive Project-wide ESMP during implementation. The Preliminary ESMP will include: an assessment of the borrower’s capacity to manage E&S risks and impacts; E&S baseline information on Tuvalu and project description (including specific project locations and any alternatives considered); key E&S vulnerabilities relevant to the project activities; an assessment of the most appropriate sources for energy, water and construction materials as well as mitigation measures to minimize the consumption of these resources; and identification of specific management plans to be prepared during implementation and integrated into the Project’s Comprehensive ESMP including an infection prevention and waste management plan (IPC&WMP), and a framework for the assessment of climate risk for the new wing of the PMH and outer island health center upgrades. Construction activities are all planned to be undertaken on Government-owned Public Disclosure or leased land, but this will be confirmed during preparation and appropriate instruments prepared as necessary. A Comprehensive ESMP will detail all site-specific impacts and measures and will be prepared during implementation on completion of design works and prior to the commencement of any works, and include site-specific annexures for key activities, including, but not limited to the new wing of the PMH. The IPC&WMP and Comprehensive ESMP will include emergency preparedness and response components for medical hazards. All requirements for the Preliminary and Comprehensive ESMP will be determined in accordance with ESS #1, and include resettlement plans if required. An addendum to the ESMP will be prepared, disclosed, consulted, and adopted prior to CERC activation, based on indicative activities and using the existing CERC ESMP for the Maritime Investment in Climate Resilient Operations (P161540) (a Tuvalu transport project which currently includes the CERC component activated in the COVID-19 Emergency Response) as a reference document. E&S mitigation action plans for the CERC, including an operational manual and governing implementation arrangements will be prepared during the project implementation. An E&S audit will be completed during project preparation to determine the nature and extent of E&S areas of concern and to identify appropriate mitigation measures and actions, estimate the cost of these measures and recommend a schedule for implementation where existing infrastructure is relied upon for project activities (e.g. wastewater discharge for sanitation facilities). The E&S Audit will be included in the Preliminary ESIA/ESMP. The IPC&WMP will contain high-level requirements, based on WHO guidance and other GIIP, for the safe operation of health facilities and associated activities and will inform the development of operational management plans. The plan will include detailed procedures for the management of e-waste, construction waste, healthcare waste, radioactive Oct 03, 2021 Page 8 of 17 The World Bank Health System Strengthening Project (P175170) waste, expired pharmaceutical supplies including an assessment of suitable waste management options and the procedures for waste management and disposal. A stakeholder engagement plan (SEP) will be developed during project preparation to outline a structured approach for community outreach and two-way engagement with stakeholders, in appropriate languages, and adopting measures to include vulnerable and disadvantaged groups (poor, disabled, elderly, isolated communities), and will be based upon meaningful consultation and disclosure of appropriate information. The SEP will include the project Grievance Redress Mechanism (GRM). Measures to minimize the risks of COVID-19 transmission will be adopted in line with national and World Bank standards. Given the COVID-19 situation and related travel restrictions, most of the consultations during preparation will be conducted in a virtual manner following the relevant interim technical note on public consultation prepared by the World Bank. A detailed strategy for communication and continued consultation will be presented in Stakeholder Engagement Plan (SEP) for the Project. This will also help address potential issues related to Universal Access to project facilities. A Labor Management Plan (LMP) will be prepared prior to appraisal (see ESS 2 below). TA activities may lead to both E&S benefits (e.g. development of SOPs and capacity building activities) and risks and impacts (e.g. generation of medical waste and IPC risks from the health screening process). TA activities may be leveraged to mitigate other project risks and impacts. E&S Specialists will (i) screen TA activities to ensure that they reflect key E&S risks and mitigation measures including ESF and relevant local legal and good international industry practice (GIIP) requirements in consultancy terms of reference (TOR) and bidding documents, and (ii) review TA Public Disclosure outputs to ensure compliance with ESF and relevant local legal and GIIP requirements. World Bank E&S Specialists will review consultancy TORs and outputs to provide a ‘No Objection’ prior to finalization to ensure compliance with ESF and relevant local legal and GIIP requirements. Contractor Environment and Social Management Plans (CESMPs) will be prepared by primary contracting companies completing demolition and civil works in compliance with both the Comprehensive ESMP and local legislation prior to the commencement of demolition or construction activities. Operational waste management plans will be developed and implemented for each supported facility and may be included under Subcomponent 1a. The development of these plans will be completed during project implementation and included as a commitment in the ESCP. Areas where “Use of Borrower Framework” is being considered: NA ESS10 Stakeholder Engagement and Information Disclosure This standard is considered relevant. The main stakeholders are: MoHSWGA, health clinics and centers at a national and local level, the health services providers (doctors, nurses, etc.) as a collective and as individuals, WHO, UNICEF, SPC, ADB, the PWD, Falekaupule and Oct 03, 2021 Page 9 of 17 The World Bank Health System Strengthening Project (P175170) Kaupule (The Falekaupule on each islands in Tuvalu is the traditional assembly of elders , Kaupule is the administrative/government arm of the Falekaupule), Tuvalu Family Health Association, and key civil-society organizations. Component 1b includes capacity building for public health communications, particularly with respect to the screening components, and based on the outcomes of this activity, the SEP may need to be updated based on target groups identified. These may include (but are not limited to): community-based organisations particularly those for women, media outlets, religious groups, health workers unions, general population receiving vaccination, communities located close to health facilities; and, vulnerable population (the poor, women, young girls, youth at risks, disables, others,) students, parents, teachers among others. There may be limitations to face to face consultation activities due to COVID-19 pandemic, such as limitations on outer island travel or stay-at-home orders. Stakeholder engagement activities will implemented in line with National requirement and relevant World Bank guidance. The borrower will prepare an SEP in a manner that is accessible and culturally appropriate, considering any specific needs of groups that may be differentially or disproportionately affected by the project. The SEP will outline a) who the key stakeholders are; b) how they are to be engaged including methods, tools, techniques, and channels such as key message dissemination through community-based organisations, radio and social media to address the gathering limitations of COVID-19 pandemic; c) how often the engagement will occur throughout the project; d) how feedback will be solicited, recorded and monitored over the project; e) who will be charged/responsible with this engagement; f) timeline for this engagement, g) resources for engagement, and so on. The SEP will be disclosed prior to appraisal and updated as relevant throughout implementation. Public Disclosure Particular attention will be given in identifying and providing tailored and culturally sensitive stakeholder engagement opportunities to vulnerable groups, disadvantaged and remote communities. This will include meaningful consultation with remote island communities, community-based organizations and religious groups. Grievance Redress Mechanisms (GRM) will be set up to address grievances and receive feedback from all stakeholders and beneficiaries in a timely manner and following due process. The GRM will be cognizant of and follow required levels of discretion, and cultural appropriateness, especially when dealing with cases of sexual harassment and GBV. The GRM will be accessible to all stakeholders, especially poor and vulnerable people. Specific worker GRMs relevant to ESS2 will also be set up. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This standard is considered relevant. Workers likely to be involved in the project include direct and contracted workers. Direct workers will include employees and consultants of the Project Technical Unit (PTU) and CPMO. Contracted workers will likely include selected private providers and construction workers. Operational health and safety risks, including potential COVID- 19 pandemic risks, will be considered for construction workers for the renovation of PMH and health infrastructures, Oct 03, 2021 Page 10 of 17 The World Bank Health System Strengthening Project (P175170) as well as in relation to the implementation of other project activities. Use of PPE and other safety measures at the medical facilities (particularly dealing with medical waste) will be included as part of post-construction and operational protocols. The LMP, to be prepared prior to appraisal, will include appropriate terms and conditions of employment, nondiscrimination and equal opportunity (which includes a safe work environment free from violence and sexual harassment), workers’ organizations, restrictions on child and forced labor, and occupational health and safety. In addition, the LMP will establish Codes of Conduct (including SEAH), and GM for worker grievances, drawing on national laws and regulations and international best practices. Individuals under the age of 18 will be prohibited from working on the Project by national laws and regulations. Construction and demolition activities may result in occupational health and safety risks and impacts which will be addressed in the Comprehensive ESMP in line with local legislation, the EHS Guidelines and GIIP. In addition, the ESCP and Comprehensive ESMP will require the development of Contractor waste and safety management plans by primary contracting companies. Component #1 addresses in-service training for technical cadres including the identification of training needs including on quality standards to safely use equipment and materials and component #2 includes technical assistance to integrate long term resources to maintain these systems. The Project will include the development of standard operating procedures and associated training for equipment and infrastructure such as laboratory and water and sanitation facilities including OHS measures during operations. The assessment will identify capacity building activities required to protect project worker safety such as IPC. The LMP will also include procedures for MoHSWGA staff involved in outer island travel, for example in providing in-service trainings for screening program delivery. Public Disclosure Emergency preparedness and response will be addressed in the IPC&WMP and Preliminary and Comprehensive ESMPs noting that emergency response plans will be developed for events such as spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, power outages, and fire in project funded facilities. ESS3 Resource Efficiency and Pollution Prevention and Management This standard is considered relevant. The renovation and rebuild of the left wing and central medical store at the PMH and the upgrading works in the outer islands will use finite resources such as construction materials, water and energy. The downstream impact of this plan will likely include an increase in the demand for construction materials as well as water and energy and this downstream impact could lead to the depletion of non-renewable resources. Downstream activities will also increase the generation of sewerage, solid waste, potentially construction waste. The construction materials such as sand, gravel and timber are mostly imported from Fiji, being the nearest readily available island. This is also due to scarcity of materials and the village/ island by-law that is in-placed that sand extraction from within islands in Tuvalu is not permitted. Oct 03, 2021 Page 11 of 17 The World Bank Health System Strengthening Project (P175170) The land and ocean transportation of construction material from sources in Fiji or the desired supplier to Funafuti and to the outer islands also have downstream impacts as dust pollution, noise pollution, fuel, chemical and hazardous material contamination. The primary source of water supply in Tuvalu is rainfall and rainwater harvesting. In the early 1980s, most families took advantage of an aid project for the provision of ferro-cement storage tanks attached to small areas of roofing sheets providing the catchment and shelter for an external kitchen area. The tank had an approximate capacity of 3.6m3 and was intended only to meet drinking water demands. Tuvalu’s power has come from electricity generation facilities that use imported diesel brought in by ships. Seven of the eight outer islands are powered by 48-80Kw each diesel generator with a total generating capacity per island averaging 176Kw. The Preliminary ESMP will include an assessment of the most appropriate energy and water supply with a focus on sustainable energy sources. Findings will be integrated into design works to ensure that building and renovation works minimize water and power use in compliance with the EHS Guidelines. Likewise, energy efficiency will be considered when sourcing hospital, health center or laboratory equipment with mitigation measures included in the Comprehensive ESMP. Due to the small- scale activities, greenhouse gas (GHG) emissions will not be significant and GHG estimations will not be required. Works to upgrade water, sanitation and hand-hygiene facilities in the outer island clinics are expected to be minor however, may rely upon existing infrastructure such as wastewater discharge points. The activities would include the upgrading of water, sanitation and hand-hygiene facilities in the outer island clinics, through improving and expanding the rain-water collection and storage facilities, functioning hand-washing stations with appropriate soaps, and functioning and environmentally appropriate latrines for men, women and disabled access. An E&S audit will be Public Disclosure completed during project preparation to determine the nature and extent of E&S areas of concern and to identify appropriate measures and actions. For Sub-Component 1.4 in improving the range and quality services provided at PMH including chronic disease management, diagnostic services in laboratory and radiology will produce healthcare waste such as liquid contaminated waste (e.g. blood, other body fluids and contaminated fluid), potential radioactive waste, infected materials (water used, lab solutions and reagents, syringes, bed sheets, etc.) and expired vaccines and other drugs. Healthcare waste poses a significant risk to nearby communities and the natural environment (land, groundwater, watercourses and lagoon/ocean environment), therefore proper treatment and disposal are important to protect both communities and the environment. The risks and impacts associated with IPC and MWM will be mitigated through both project design (e.g. the development of SOPs and capacity building and procurement of a waste transport vehicle) and implementation of the Comprehensive ESMP. For medical waste management practices in place, section 5(6) of the Tuvalu Waste Management Act 2017 states that the collection and disposal of the medical wastes is the responsibility of the Ministry of Health, which must ensure that such wastes are handled and disposed of so not to pose risks to the employees and contractors of the designated waste management operators. There are colour coded, green coloured rubbish bins for general waste and yellow coloured rubbish bins for medical or infectious waste. Waste storage areas must be kept organized and clean and locked so that pests, disease vectors and the public do not have access to these areas. All medical waste should be incinerated at a very high temperature (> 1000 degrees Celsius). According to the Tuvalu National Action Plan on Unintentional Persistent Organic Pollutant (2018) reported that health care waste (HCW) was managed through waste incineration but unfortunately the HCW incinerator was out of order and is expected to be repaired and put Oct 03, 2021 Page 12 of 17 The World Bank Health System Strengthening Project (P175170) back into operation in the future. Further review will be completed through the E&S assessment during project preparation to identify capacity gaps and mitigation measures which will ideally be addressed through the integration of actions into project design. General construction and demolition activities may generate on-site pollution such as waste (including potentially hazardous materials such as asbestos or lead paint), dust, noise sedimentation, hydrocarbon spills, etc. These construction impacts will be managed through the Comprehensive ESMP and its implementation. The Comprehensive ESMP will include mitigation measures such as dust suppression, restricted working hours and erosion and sediment control as required. The procurement of equipment for hospitals, laboratories and health facilities and enhancement of information system and connectivity may lead to the generation of e-waste. The Preliminary ESMP will include an assessment of a suitable waste management options and procedures for waste management and disposal in compliance with Tuvalu legislation and Tuvalu’s Integrated Waste Policy and Action Plan 2017- 2026 and GIIP and the IPC & WMP as well as the requirement for any operational management plans to address ongoing pollution risks such as waste management and spill response. The Tuvalu National Strategic Health Plan 2020-2024 (NHSP) has grouped broad goals and specific activities under seven key priorities areas, shaping the discussions, content and components of the proposed WB project. Development of the project and its implementation will be aligned, coordinated, and planned in conjunction with engaged bilateral partners such as New Zealand and Australia, regional entities such as SPC – The Pacific Community, ADB, and key technical partners, including WHO and UNICEF. Work to strengthen Infection Prevention and Control, and Medical Waste Management will be carefully co-ordinated with the support from (i) Taiwan for an incinerator to be used for medical waste, (ii) ADB through UNICEF on IPC & MW in conjunction with the COVID-19 vaccine deployment, and (iii) SPC (The Pacific Community) and WHO on IPC Policy and guidelines. Public Disclosure ESS4 Community Health and Safety This standard is considered relevant. The improper handling, storage and disposal of healthcare waste and improper design and operation of sanitation facilities may pose a risk to both community members and other stakeholders such as hospital staff. These risks have been addressed above under ESS3. Construction and demolition activities pose a risk to to community members through increased noise, dust and traffic and the incorrect disposal of hazardous materials. The Preliminary ESMP will assess design, demolition, construction/renovation and procurement risks to community health and safety and include the appropriate mitigation measures such as traffic management, waste management, dust control and restrictions to operating hours in the Preliminary ESMP. Waste will be managed in accordance with the IPC&WMP and will be compliant with Tuvaluan legislation, EHS Guidelines and GIIP. The design of new and refurbished health and medical facilities, if not carefully designed, has the potential to impose accessibility barriers to people with core activity or functional constraints, e.g. for people with a disability or age- related health conditions. The design of the major facilities will incorporate universal design principles and features to maximise accessibility to all. The ESMP will include design review procedures to ensure universal accessibility on Bank funded investments is achieved to GIIP. Risks as a result of misuse of, poor quality, and/or poorly managed medical equipment, vehicles, materials and services include risks to patients and staff, e.g. mis-use of radiography equipment, poor storage of pharmaceuticals, Oct 03, 2021 Page 13 of 17 The World Bank Health System Strengthening Project (P175170) incorrectly performed testing, issues with information management. While Component 1 provides training to manage these risks, the reality of frequent staff changes means a more sustained training system and SOPs will need to be prepared and implemented to ensure continuity of the skills and knowledge relating to appropriate use of equipment and resources and performance of services. These will be managed through the IPC&WMP, development of SOPs and training to be delivered under Component 1, relevant sections of the LMPs, via the Preliminary ESMP and integrated into national planning and budgeting technical assistance under component #2. According to the WHO, screening programs result in overall improvements in the societal burden of disease including: increasing choice, reducing severity of disease including less invasive treatment, reducing incidence of disease, and reducing deaths. They also identify a range of negative impacts that can result from screening programs, a) false positives can lead to psychosocial effects, such as anxiety, b) false negatives can lead to the public having decreased trust and confidence in the screening programme and reduced uptake and legal issues, c) over diagnosis where condition or problem that would never cause a person harm during their lifetime is identified, and d) over treatment where people receive more extensive or invasive treatment than is required to improve health outcomes. The Preliminary ESMP will include cross references to program guidelines and SOPs which ensure quality in design and implementation of GIIP. Emergency preparedness and response will be addressed in the IPC&WMP noting that emergency response plans will be developed for events such as spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, power outages, and fire in Project funded facilities during project implementation and prior to commissioning. Public Disclosure ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This ESS is not currently relevant. The project is not expected to require any land acquisition as works are expected to take place in the boundary of existing facilities. However, as the project will involve construction, and repair and/or refurbishment of existing structures, site-specific screening will be carried out during preparation. A land needs screening procedure will be included in the Preliminary ESMP. If land acquisition is identified as a possibility, a resettlement plan (Resettlement Action Plan (RAP) or Abbreviated Resettlement Action Plan (ARAP)) is prepared prior the commencement of works. This will be further assessed and clarified in the Appraisal ESRS. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard is not considered relevant as works will take place on previously disturbed land away from areas of high biodiversity value. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities Oct 03, 2021 Page 14 of 17 The World Bank Health System Strengthening Project (P175170) This standard is not considered relevant. There are no known groups that meet the criteria in ESS7 as the overwhelming majority of people in Tuvalu (99.1%) belong to the Tuvaluan ethnic group (including 7% with mixed Tuvaluan and i-Kiribati ethnicity), who will be the overwhelming beneficiaries for the project. ESS8 Cultural Heritage The standard is currently not relevant. However, screening for potential ESS8 risks and “chance finds” procedures will be included in the Preliminary ESMP and attention will be given to the risks and impacts of the project that may affect the intangible cultural heritage. ESS9 Financial Intermediaries The standard does not apply as the Project does not proposed to include financial intermediaries. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No Public Disclosure OP 7.60 Projects in Disputed Areas No III. WORLD BANK ENVIRONMENTAL AND SOCIAL DUE DILIGENCE A. Is a common approach being considered? No Financing Partners NA B. Proposed Measures, Actions and Timing (Borrower’s commitments) Actions to be completed prior to Bank Board Approval: Preliminary ESMP (including E&S audit and TOR of relevant E&S TA studies) to be developed, disclosed, and consulted. LMP to be developed, disclosed, and consulted. SEP to be developed, disclosed, and consulted. ESCP to be developed, disclosed, and consulted. Possible issues to be addressed in the Borrower Environmental and Social Commitment Plan (ESCP): Regular reporting. Oct 03, 2021 Page 15 of 17 The World Bank Health System Strengthening Project (P175170) Update, disclose and adopt the Comprehensive ESMP (including the IPC&WMP) prior to the commencement of works. Notification of incidents and accidents. Prepare, disclose, consult, adopt, and implement any environmental and social management plans, resettlement plans (if required), instruments or other measures as defined in the Preliminary ESMP. Prepare, disclose, consult, adopt, and implement operational waste management plans. E&S Specialists will screen TA activities and TA outputs to ensure compliance with ESF and relevant local legal and GIIP requirements. Incorporate environmental and social management plans or other instruments, ESS2 requirements, and any other required ESHS measures, into the ESHS specifications of the procurement documents and contracts with contractors and supervising firms (including a requirement for contractors to develop CESMPs. Thereafter ensure that the contractors and supervising firms comply with the ESHS specifications of their respective contracts. Engage and maintain E&S specialists in the CPMO. Training for the staff of implementing agencies on E&S issues and risk management for capacity building If the ESMP measures do not fit the type of activities and the environmental and social risks of the CERC activities, prepare, disclose, consult, and adopt an Addendum to the Comprehensive ESMP prior to CERC activation. C. Timing Tentative target date for preparing the Appraisal Stage ESRS 12-Jan-2022 Public Disclosure IV. CONTACT POINTS World Bank Contact: Kari L. Hurt Title: Senior Operations Officer Telephone No: 5740+6525 / 61-02-92356525 Email: khurt@worldbank.org Borrower/Client/Recipient Borrower: Ministry of Finance and Economic Development Implementing Agency(ies) Implementing Agency: Ministry of Health, Social Welfare and Gender Affairs V. FOR MORE INFORMATION CONTACT Oct 03, 2021 Page 16 of 17 The World Bank Health System Strengthening Project (P175170) The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Kari L. Hurt Practice Manager (ENR/Social) Ann Jeannette Glauber Recommended on 01-Sep-2021 at 10:57:48 GMT-04:00 Safeguards Advisor ESSA Nina Chee (SAESSA) Cleared on 03-Oct-2021 at 19:11:1 GMT-04:00 Public Disclosure Oct 03, 2021 Page 17 of 17