The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) Combined Project Information Documents / Integrated Safeguards Datasheet (PID/ISDS) Appraisal Stage | Date Prepared/Updated: 21-Oct-2020 | Report No: PIDISDSA30575 Oct 20, 2020 Page 1 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) St. Lucia P174797 Second Additional P166783 Financing to the Saint Lucia Health System Strengthening Project Parent Project Name Region Estimated Appraisal Date Estimated Board Date Saint Lucia Health System LATIN AMERICA AND 30-Oct-2020 10-Nov-2020 Strengthening Project CARIBBEAN Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Ministry of Finance, Ministry of Health and Financing Economic Growth, Job Wellness, Saint Lucia Creation, and External Affairs Proposed Development Objective(s) Parent The development objective is to improve the accessibility, efficiency, and responsiveness of key health services. Components Component 1: Design and Implementation of an Essential Health Services Package Component 2: Strengthening Service Delivery in Support of the Essential Package of Health Services Component 3: Institutional Capacity Building, Project Management and Coordination Component 4: Contingent Emergency Response Component PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 0.94 Total Financing 0.94 of which IBRD/IDA 0.00 Financing Gap 0.00 DETAILS -NewFinEnh1 Non-World Bank Group Financing Oct 20, 2020 Page 2 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) Trust Funds 0.94 Pandemic Emergency Financing Facility 0.94 Environmental Assessment Category B-Partial Assessment OPS_TABLE_SAFEGUARDS_DEFERRED ‘Have the Safeguards oversight and clearance function been transferred to the Practice Manager?’ Yes Decision The review did authorize the team to appraise and negotiate Other Decision (as needed) B. Introduction and Context Country Context 1. Saint Lucia is an upper-middle income country which has seen economic growth exceeding two percent since 2016, driven by tourism exports. The country has a population of 178,696, nearly 30 percent of which reside in Castries Quarter, where the capital (also called Castries) is located. The country is a mountainous island with a tropical, humid climate and ranks high on the United Nations Development Programme’s (UNDP) Human Development Index (HDI). Gross National Income (GNI) per capita is US$10,803, life expectancy at birth is 76 years, and the Infant Mortality Rate is 14.9 per 1,000 live births; health outcomes are slightly better than the Caribbean small states average (World Development Indicators 2018). The country is politically stable, and the 2016 national elections resulted in a peaceful transition in political power. 2. Unemployment rates have been declining since 2015 and was 20.2 percent in 2018. Recent poverty estimates are not available, but a poverty assessment conducted in 2005 found that almost 29 percent of the population live in poverty. Among the employed, 57 percent earn less than EC$1,500 (US$555) per month while nearly half of the population is classified as not having decent work. There is a large share of employment in the informal sector, mainly in small and microbusinesses.1 3. An outbreak of COVID-19 caused by the 2019 novel coronavirus (SARS-CoV-2) has been spreading rapidly across the world with over 35 million confirmed cases and over 1 million deaths reported in more than 200 countries and territories (as of October 8, 2020). On March 11, 2020, the World Health Organization (WHO) declared a global pandemic. This situation is particularly devastating for small island states, given the travel restrictions and impact on tourism. 1 1 The Private Sector Baseline Survey (2009) estimated that about 40 percent of enterprises were considered informal. Oct 20, 2020 Page 3 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) 4. Saint Lucia, with a population of 178,696, has reported 36 confirmed cases of COVID-19 with no deaths (as of October 20, 2020). The first case of COVID-19 was reported on March 13, and schools were closed beginning March 14. Cancelations of mass gatherings were effective from 6 pm, March 20, 2020 from 6 pm. The Prime Minister declared a State of Emergency effective March 23, 2020 (National Gazette Vol. 189; issue #10) in accordance with the National Emergency and Disaster Management Act, 2006 which implemented an overnight curfew period, shutdown of nonessential services, protocols on physical distancing, residential confinement, and restrictions on international travel (including closure of all ports of entry), social activities, visitation and road traffic. In addition, a 24-hour curfew, with some exemptions for minimarts and community shops, was declared from April 1 to April 7, 2020. Following the end of the State of Emergency on September 30, 2020, the COVID-19 Prevention and Control Act to regulate the containment of the spread of COVID-19 in the interests of public safety, public order and public health was passed by Parliament on October 2. A phased reopening is in progress.2 Sectoral and Institutional Context 5. Saint Lucia’s health sector has been affected by new and emerging diseases, which have highlighted gaps in public health preparedness and response. The country saw the first case of Chikungunya in 2014 and the first case of Zika in 2016. By the end of 2017, there were two cases of congenital microcephaly. Meanwhile, conditions such as dengue and leptospirosis remain endemic. An assessment on preparedness by the Caribbean Regional Public Health Agency (CARPHA) following the West Africa Ebola outbreak in 2015 found mixed results for Saint Lucia, though in general the country scored above the regional average. Areas assessed included risk communication, preparedness, points of entry, transportation, health system, general infection prevention and control and laboratory services. A follow-up assessment the World Bank conducted in the wake of the country’s 2017 Zika outbreak found that the same gaps in preparedness persisted two years later, and cited shortcomings in response and research. In the context of COVID-19, an emergency contingency plan for COVID-19 was prepared by the Government of Saint Lucia (Ministry of Health and Wellness) before first cases were confirmed in-country. 6. Following the onset of the COVID-19 pandemic, the Government of Saint Lucia requested an activation of the CERC. The World Bank responded swiftly to review and approve the respective requests with the supporting documentation. This early financing is expected to support the purchase of critical medical equipment and supplies, including personal protective equipment (PPE), laboratory supplies, and equipment for the respiratory hospital. Activities under the CERC are expected to be completed by December 2021. C. Proposed Development Objective(s) Original PDO The development objective is to improve the accessibility, efficiency, and responsiveness of key health services. Current PDO The development objective is to improve the accessibility, efficiency, and responsiveness of key health services, and provide a response in the event of eligible crises or emergencies. 2 Emergency Powers (Disasters) (COVID 19) (Curfew) (No. 7) Order. Statutory Instrument, 2020, No. 74. Oct 20, 2020 Page 4 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) Key Results The following key results will be monitored throughout the Project. (i) Number of people registered under the National Health Scheme (Accessibility) (ii) Percent of diabetic/hypertensive patients > 18 years at primary care facilities managed according to national protocols (disaggregated by gender) (Efficiency) (iii) Compliance with 2005 International Health Regulations (IHR) by maintaining a trained Rapid Response Team (RRT) to respond to events that may constitute a public health emergency (Yes/No) (Responsiveness) (iv) Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents (Responsiveness) D. Project Description 7. This AF will finance the cost over-run of the CERC (Component 4) to ensure an adequate response to the COVID-19 crisis. Component 4 of the project aims to contribute to the achievement of the PDO focusing on support in the event of eligible crises or emergencies. Given the considerable requirements needed to ensure an effective and sustained COVID-19 response and the increase in prices for essential items such as personal protective equipment, the project has incurred a cost over-run under this Component. 8. Project and components: The project will keep the same four components as follows: Component 1. Design and Implementation of an Essential Package of Health Services (US$5.5 million). Component 1 focuses on the demand side and includes the review of the design and implementation of the Essential Package of Health Services (EPHS), including administration, purchasing and contracting arrangements, regulations surrounding the scheme, and potential sources of additional revenue for expanding health service coverage. The Project supports the analytics for the design of the package and the roll-out of information technology and systems platforms to enable the implementation of the package. The consultancy on the design of the EPHS is close to completion, with training sessions on the actuarial model conducted virtually and a draft of the final report recently delivered. A Public Expenditure Review of the health sector has recently been completed, and analytical work focused on the development of National Health Accounts has recently been tendered. Public funds will finance the provision of the EPHS. Component 2. Strengthening Service Delivery in Support of the Essential Package of Health Services (US$13 million). This component aims to ensure the supply of key health services outlined in the EPHS and includes subcomponents on performance-based financing (PBF) focusing on diabetes and hypertension at the primary care level, strengthening the supply of health care services, and public health emergency preparedness and response. The PBF scheme is expected to roll out by the end of the year, and a Health Facility Assessment consultancy has been contracted to ensure primary healthcare facilities have the equipment and supplies to deliver the EPHS. The National Health Care Waste Management Plan will be updated to include measures for how to manage COVID-19-related waste and equipment distribution and installation in the case of a disease outbreak. Oct 20, 2020 Page 5 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) Component 3: Institutional Capacity Building, Project Management and Coordination (US$1.5 million). This component primarily finances operational costs, and covers project management, fiduciary tasks, and monitoring and evaluation. The Ministry of Health and Wellness Project Implementation Unit (MOHW-PIU) is largely responsible for project implementation and has been in place in December 2019 following the hiring of the Project Coordinator, Financial Management (FM) Specialist, and Procurement Analyst. Hiring of the MOHW-PIU is now complete, and includes a Monitoring and Evaluation Specialist, Performance-Based Financing Coordinator, and an international procurement expert. Component 4: Contingent Emergency Response Component (CERC) (US$5 million). The CERC was included in accordance with paragraph 12 Section III of the Bank’s Policy “Investment Project Financing� related to Situations of Urgent Need of Assistance or Capacity Constraints. The CERC was activated on April 27, 2020 in the amount of US$5 million to support the COVID-19 response through procurement of essential goods, such as medical equipment and consumables, and almost half of its amount has been disbursed. E. Implementation Institutional and Implementation Arrangements No change is made to the implementation arrangements of the Project through this Additional Financing, nor fiduciary or safeguards. . F. Project location and Salient physical characteristics relevant to the safeguard analysis (if known) Under the parent project, Component 2 would include improvements and refurbishments of up to 34 selected primary health facilities including equipment inventory, procedures provided, and infrastructure, based on a survey to be conducted during implementation. Refurbishment works may take place at existing facilities anywhere on the island of Saint Lucia. The type of refurbishments envisioned could include minimal infrastructure adjustments such as establishing partitions in existing structures, improving lighting, and painting. The magnitude of such refurbishments is minor as potential adverse environmental impacts due to these interventions potentially involving dry-wall installation, installation of new lighting fixtures, and properly disposing of unused paint. It is also possible that additions, expansions, or annexes might also be rehabilitated or constructed. Under the project, the national Healthcare Waste Management System (HWMS) and associated plans will be updated for activities that include the minor refurbishments and the proper disposal of medical equipment. This may involve improvements to wastewater disposal systems and/or medical waste storage facilities. The second AF will be used to replenish funds used by the CERC to respond to COVID-19 urgent needs. The second AF will focus on procurement of goods and services. The risks for these activities are addressed by CERC-ESMF which complements the parent project ESMF. Oct 20, 2020 Page 6 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) G. Environmental and Social Safeguards Specialists on the Team Shakil Ahmed Ferdausi, Environmental Specialist Erika Piber, Social Specialist Michael J. Darr, Environmental Specialist SAFEGUARD POLICIES THAT MIGHT APPLY SAFEGUARD _TBL Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/BP 4.01 Yes Performance Standards for Private Sector No Activities OP/BP 4.03 Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources OP/BP 4.11 No Indigenous Peoples OP/BP 4.10 No Involuntary Resettlement OP/BP 4.12 No Safety of Dams OP/BP 4.37 No Projects on International Waterways No OP/BP 7.50 Projects in Disputed Areas OP/BP 7.60 No KEY SAFEGUARD POLICY ISSUES AND THEIR MANAGEMENT OPS_SAFEGUARD_SUMMARY_TBL A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: This additional financing will not trigger any additional safeguard policy and will maintain the same environmental risk of the parent project. The parent project is considered as environmental risk Category B, given that the proposed Project is not likely to result in significant negative, irreversible and/or large-scale impacts on human populations and/or the environment. The Environment and Social risk rating was considered Moderate. The potential negative impacts of the parent project were grouped into two categories: those associated with typical small civil works during refurbishment, and those associated with medical waste management during operation. The Oct 20, 2020 Page 7 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) former are minor and short-term, and are addressed within the Environmental and Social Management Framework (ESMF) by the provision of a generic Environmental and Social Management Plan (ESMP) with Best Management Practices (BMPs) and standard contract clauses for small civil works, and a pre-design screening to identify any special conditions requiring additional mitigation measures. It may be noted that these activities will not require any physical or economic displacement, or restriction of access to natural resources and any land acquisition/resettlement and according the OP/BP 4.12 has not been triggered. The latter are addressed by provision of study to develop a Health Care Waste Management System (HWMS) during the early stages of implementation. The mitigation of the exogenous risk posed by the COVID pandemic is captured in the CERC – ESMF which was prepared when the CERC was activated, and more broadly by a range of measure put in place by the Government, such as curfews, social distancing, hotlines, expanded testing, and a plan for phased reopening. The CERC-ESMF also includes safety measures and protocols for COVID-19. The second AF will focus on procurement of goods and equipment, and thus the AF activities are covered by the instruments that have already been prepared, reviewed, and disclosed. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Improved access and quality to health care will result in long-term benefits to the population. Improved waste management may result in long-term benefits to the environment, to health care workers, and to the surrounding communities. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. Alternatives was considered as part of the design of each potential improvement or action under the parent project. The ESMF includes screening formats and criteria to ensure that refurbishments, rehabilitations, or improvements do not inadvertently result in impacts to physical cultural resources, natural habitats, acquire lands or affect assets or access. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. Capacity is currently sufficient to manage safeguards. The MOHW, where the implementing unit is based, has made progress in implementation, has capacity and personnel to independently implement the safeguards instruments, given that the activities now focus on procurement of equipment and supplies. The PIU will require additional safeguards support once the facilities inventory is completed and clinic rehabilitation/upgrade needs are identified, but this will be undertaken through the parent project. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Stakeholders include the staff of the Ministry of Health and other governmental entities working in the health sector and, more importantly, the end user of health services who will benefit from the implementation of the Essential Package of Health Services(EPHS) and the improvements to be introduced to the supply of health services outlines in the EPHS. Moreover, citizen engagement mechanisms that collect patient feedback on their perception of the quality of health services and patient satisfaction, and take actions in response to the patient feedback (closing the feedback loop) are included under the parent Project and will continue to apply to the AF. The ESMF for the parent project was consulted on and disclosed on the MOHW and WBG websites in June 2018. It was revised and redisclosed to include a Grievance Mechanism in July 2019, and again in May 2020 to include the CERC-ESMF addendum for COVID-19 safety measures. Oct 20, 2020 Page 8 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) The ESMF includes a grievance redress/feedback mechanism which has been established which will also be the GRM for the OECS Regional Health Project in St Lucia. The project level GRM will be strengthened under this second AF with procedures to receive, address, and refer complaints linked to sexual exploitation, abuse and harassment (SEAH). OPS_SAFEGUARD_DISCLOSURE_TBL B. Disclosure Requirements (N.B. The sections below appear only if corresponding safeguard policy is triggered) OPS_EA_DISCLOSURE_TABLE Environmental Assessment/Audit/Management Plan/Other For category A projects, date of Date of receipt by the Bank Date of submission for disclosure distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure OPS_COMPLIANCE_INDICATOR_TBL C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) (N.B. The sections below appear only if corresponding safeguard policy is triggered) OPS_EA_COMP_TABLE OPS_ PDI_ COMP_TAB LE OPS_ALL_COMP_TABLE CONTACT POINT World Bank Neesha Harnam Health Specialist Borrower/Client/Recipient Oct 20, 2020 Page 9 of 10 The World Bank Second Additional Financing to the Saint Lucia Health System Strengthening Project (P174797) Ministry of Finance, Economic Growth, Job Creation, and External Affairs Cointha Thomas Permanent Secretary cointha.thomas@govt.lc Implementing Agencies Ministry of Health and Wellness, Saint Lucia Felix St. Hill Permanent Secretary fsthill@gosl.gov.lc FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Task Team Leader(s): Neesha Harnam Approved By Safeguards Advisor: Marco Antonio Zambrano Chavez 29-Oct-2020 Practice Manager/Manager: Michele Gragnolati 29-Oct-2020 Country Director: Oct 20, 2020 Page 10 of 10