The World Bank Tunisia Health System Strengthening Project (P507209) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 03/02/2025 | Report No: ESRSA04001 Mar 03, 2025 Page 1 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) I. BASIC INFORMATION A. Basic Operation Data Operation ID Product Operation Acronym Approval Fiscal Year P507209 Investment Project Financing (IPF) THSSP 2025 Operation Name Tunisia Health System Strengthening Project Country/Region Code Beneficiary country/countries Region Practice Area (Lead) (borrower, recipient) Tunisia Tunisia MIDDLE EAST AND Health, Nutrition & NORTH AFRICA Population Borrower(s) Implementing Agency(ies) Estimated Appraisal Date Estimated Board Date Ministry of Economy Ministry of Health 04-Mar-2025 29-May-2025 and Planning Total Project Cost Public Disclosure 125,160,000.00 Proposed Development Objective To improve access to quality healthcare services and enhance the resilience and capacity for pandemic prevention, preparedness, and response of Tunisia’s health system B. Is the operation 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 Activities The components are financed with US$108 million of IBRD financing and US$17.16 million RETF grant from the Pandemic Fund. This covers part of the investments needed to finance the ambition and scope of health reforms envisioned by the government. Component 1: Strengthening Health System Resilience (US$24.9M, including US$17.2M RETF from the Pandemic Fund) Component 1 focuses on strengthening surveillance systems, climate change adaptation, and laboratory capacity for pandemic preparedness. It aims to enhance Tunisia's ability to effectively detect, assess, and respond to public health threats before, during, and after health events, with coordination across sectors, including human, animal, and environmental health. Key activities under this component include: 1) strengthening and Mar 03, 2025 Page 2 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) integrating data for surveillance, coordination of the preparation, response, and recovery for public health emergencies; 2) enhancing laboratory capacity and quality management for effective diagnostic networks and improved biosafety standards; 3) supporting energy efficiency systems and climate change adaptation and mitigation; and 4) improving waste management systems. Activities related to early warning systems and laboratory capacity are funded by the Pandemic Fund. Component 2: Supporting reorganization of preventive and primary health services (US$50 M) Component 2 seeks to transform primary health care services to improve the efficiency, distribution and quality of services. It will do so through three subcomponents: i) strengthening the organizational structure and governance of PHCs by developing and operationalizing a PHC service reorganization plan, developing a new governance framework, and strengthening human resources for health at the PHC level; ii) upgrading the capacity of CSBs based on the PHC service reorganization plan; and iii) supporting the deployment of a comprehensive PHC information system. Component 3: Strengthening emergency medical services ($48M) Component 3 aims to strengthen Tunisia’s emergency medical services. It will enhance all phases of emergency care including pre-hospitalization, hospitalization and discharge. This will improve the pre-hospitalization phase by improving emergency call management and ambulance dispatch systems. It will also focus on the hospitalization phase by enhancing triage systems and ensuring efficient patient transfers and address the post-hospitalization phase by establishing a referral network to connect discharged patients with primary care and intensive care services. This component will also promote environmental sustainability in emergency services by adopting green technologies and reducing energy consumption in emergency management systems. This component will update Tunisia’s emergency care strategy (La Stratégie Nationale de Développement de la Médecine d’Urgence). Component 4: Implementation Support, Training and Project Management (US$2M) This component will provide technical assistance and capacity-building support to the Ministry of Health, strengthening project management functions. It will finance technical assistance for fiduciary tasks, including audits of project financial Public Disclosure statements, procurement management, and support the implementation of environmental and social (E&S) measures to ensure alignment with the Environmental and Social Framework (ESF). MOH has designated E&S focal points from different directorates and the ES consultant would support with the coordination and reporting across the different units. Regular monitoring and reporting on project implementation will also be supported by the component. Training under this component will focus on enhancing fiduciary aspects, monitoring and evaluation, while also integrating E&S risk management into the Project implementation. This will build capacity within the MOH to identify, mitigate, and monitor environmental and social impacts throughout the project lifecycle. The component will particularly address key environmental issues such as healthcare waste management, climate resilience, and improving energy efficiency in healthcare facilities as well as social risks, including SEA/SH, exclusion risks, exposure to biohazards, and grievance management. Eligible expenditures under this component will include goods, services, ICT equipment and software, consultancies, and non-salary operating costs. D. Environmental and Social Overview D.1 Overview of Environmental and Social Project Settings Tunisia faces significant environmental and social challenges, particularly in the healthcare sector, including inadequate waste management systems, aging infrastructure, weak regulatory enforcement, and insufficient specialized training. While healthcare access has improved, significant barriers remain, especially for women, rural populations, and low- income groups, which face compounded challenges in accessing quality healthcare. Addressing these challenges requires an integrated approach that considers both environmental sustainability and healthcare system improvements. The healthcare system in Tunisia continues to grapple with high rates of non-communicable diseases (NCDs), including diabetes (23%) and hypertension (38.1%), as well as cardiovascular diseases, which have been on the rise by 27% from Mar 03, 2025 Page 3 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) 2009 to 2019. To address these pressing health concerns, the project aims to enhance healthcare infrastructure, strengthen health systems, and introduce energy-efficient, climate-resilient healthcare facilities to ensure long-term sustainability. Tunisia’s healthcare system also faces environmental challenges related to air and water pollution, poor waste management, and resource scarcity. The country grapples with the safe disposal of medical waste, leading to contamination risks for healthcare workers, patients, and surrounding communities. Industrial emissions, vehicular pollution, and inadequate wastewater treatment contribute to respiratory illnesses and waterborne diseases. Furthermore, desertification and land degradation have increased rural poverty, reducing agricultural output and food security, further straining the healthcare system. Climate change is expected to increase health risks and emergencies affecting Tunisia's most vulnerable communities, further exacerbating environmental health concerns. Tunisia’s Mediterranean location makes it highly vulnerable to climate change, with extreme weather events such as heat waves, heavy rainfall, and drought becoming more frequent. Rising sea levels are projected to impact nearly 78,700 people by 2100. Over the past Four years of, prolonged drought has significantly reduced agricultural production, increasing food insecurity and malnutrition. Water scarcity has also emerged as a critical issue, affecting not only rural communities but also healthcare facilities that depend on reliable water supply. Climate-related hazards pose high risks to 26 percent of the population (18.9 percent exposed to drought, 7.3 percent to heatwaves, and 1.3 percent to floods). Under a high emission scenario, the mean annual temperature is projected to rise by 5.3°C in 2100, causing as many as 56 deaths per 100,000 in the elderly (65+ years) by 2080, compared to the estimated baseline of 4 deaths per 100,000 annually between 1961 and 1990. Other negative health Public Disclosure impacts associated with climate change in Tunisia include the recurrence and emergence of vector-borne diseases (malaria, leishmaniasis, dengue and West Nile fever), an increase in water-borne and food-borne diseases, and the aggravation of diseases related to air pollution. Rural poor populations, as well as outside workers, women, children, the elderly are disproportionately affected by these climate-related health risks. Environmental factors such as poor air quality, water contamination, and exposure to hazardous chemicals further exacerbate the burden of NCDs. Tunisia faces significant challenges in disease surveillance, impeding its ability to efficiently detect, prevent and respond to health emergencies. Tunisia’s list of notifiable diseases includes common communicable diseases affecting both humans and animals, such as influenza, COVID-19, rabies, yellow fever, and various forms of hepatitis, as well as diseases such as leishmaniasis, meningitis, and tuberculosis. Compounding these challenges, a rise in microbial resistance due to a 38 percent increase in antibiotic consumption driven by overuse of antibiotics, which has reduced the effectiveness of treatments, particularly for vulnerable populations. Disparities exist in healthcare access and health equity for those living in peri-urban and rural versus urban centers. Regional and university hospitals are unevenly distributed; and patients in disadvantaged areas need to travel over 300 kilometers to reach essential and emergency health services. Travel times to emergency facilities shows that over 1 million people in peri-urban and rural areas (zones 6 and 8) are beyond the government's 45-minute target, compared to more accessible urban centers. In rural areas (zone 8), nearly 650,000 people (around 65 percent of the population) face travel times exceeding 45 minutes, significantly limiting their timely access to emergency care. Energy efficiency and resource sustainability are also major considerations for Tunisia’s healthcare sector. The country remains highly dependent on imported fossil fuels, making energy-intensive healthcare facilities vulnerable to supply Mar 03, 2025 Page 4 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) disruptions and high operating costs. The project will integrate renewable energy solutions and energy-efficient hospital designs to reduce the carbon footprint of healthcare infrastructure. Similarly, in peri-urban areas (zone 6), almost 395,000 people (around 40 percent of the population) fall outside the target, highlighting a stark contrast with urban centers like zone 1, where 88 percent of the population experience such delays. These disparities pose serious health equity concerns, as delayed access to emergency care increases risks for vulnerable populations. Furthermore, climate-related hazards will exacerbate these challenges, with extreme weather events such as floods disrupting roads and further prolonging travel times, disproportionately affecting those in rural and peri-urban communities. D.2 Overview of Borrower’s Institutional Capacity for Managing Environmental and Social Risks and Impacts The implementing arrangements have not yet been fully delineated in the Project Appraisal Document (PAD) and will be clarified in the appraisal meeting. As per the PAD, the PIU would be composed of the Directorate of General of Common Services DGCS (DGCS Directorate of General of Common Services) and the Directorate of General Health DGS (Directorate of General Health DGS). DGS will be responsible for is overseeing the technical aspects of the project and coordinating between the different technical directorates, while the DGCS is overseeing will oversee the fiduciary, administrative and environmental and social aspects of the project. DGCS will also coordinates the Directorate of Environment and Hygiene, as well as the financial management and procurement departments of the Ministry of Health (MOH). Public Disclosure The Directorate of Environmental Hygiene and Protection will be responsible for coordinating the implementation of environmental and social (E&S) aspects, ensuring alignment with the Environmental and Social Framework (ESF), and overseeing reporting requirements throughout the project. To effectively manage environmental, social, health, and safety (E&S) risks, the Directorate of Environmental Hygiene and Protection will establish and maintain a dedicated project team with a clear mandate, however, staffing decisions will be solidified during the appraisal meeting. As currently envisioned, focal points with expertise in environmental and social risk management have been appointed from various units of MOH including: the National Risk Assessment Agency, which assesses quality, standards, and risks related to medical equipment and devices; the Center for Technical Studies in Biomedical Maintenance, responsible for managing equipment maintenance and waste from old equipment; the Directorate of Buildings, which manages renovations and facility-related risks; the Citizens Relations Office, which addresses complaints from citizens and professionals; and Occupational Health services in hospitals, which focuses on protecting healthcare professionals and ensuring their health and well-being. The Directorate of Environmental Hygiene and Protection has appointed an E&S focal point who is currently supporting the current Tunisia COVID project and who will coordinate between the different units and report on the progress of the ESF). However, the Bank will propose that a capacity be reinforced by appointing or hiring qualified focal points for environmental, social and gender based violence (GBV) risk management as these roles will be responsible for overseeing and reporting on implementation, and guide, coordinate, and support E&S focal points at the regional levels. All E&S focal points shall also be required to receive capacity training on environmental and social risk management and monitoring, including taking the World Bank’s online ESF course. Mar 03, 2025 Page 5 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) Details of the institutional and implementation arrangements will be set out in the project operations manual (POM) but will be clarified during the appraisal meeting with MOH. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate A.1 Environmental Risk Rating Moderate The environmental risk is deemed moderate, based on the following key risks: (i) Infrastructure and Rehabilitation Activities: The project involves the establishment of health data management systems (sub-component 1.1) and the rehabilitation of Primary Health Centers (PHCs) (sub-component 2.2). These activities will take place within existing government-owned facilities, avoiding land clearing or new developments, and are unlikely to affect biodiversity or ecologically sensitive areas. However, rehabilitation and minor construction activities may lead to localized, temporary environmental impacts. These include air and noise pollution, wastewater management, solid waste generation, and occupational health and safety (OHS) risks, particularly when conducted within operational health facilities. Given the multiple project sites and varying local capacities, ensuring compliance with environmental safeguards and contractor obligations may be challenging. Mitigation measures will be incorporated into the project design to manage these risks effectively. (ii) Healthcare Waste Management: A significant environmental risk stems from healthcare waste management, which includes biomedical waste, outdated medical equipment, and e-waste. These waste types must be properly handled, segregated, and disposed of to prevent contamination risks to Public Disclosure healthcare workers, patients, and surrounding communities. Poor management of healthcare waste, especially hazardous and infectious materials, can lead to environmental pollution and public health risks. To address this, sub- component 1.5 (USD 3 million) will focus specifically on hospital waste management improvements. This will enhance national capacity for medical waste segregation, collection, transportation, treatment, and disposal in alignment with international environmental and health standards. (iii) Incineration Feasibility: Additionally, the project will evaluate the feasibility of installing incineration facilities for treating high-risk medical waste. This study will evaluate the practicality, environmental impact, and cost-effectiveness of different incineration technologies, while ensuring full regulatory compliance and adherence to best environmental and public health practices. The incineration option will only be pursued if it meets international environmental standards, including robust emission control technologies to mitigate air pollution risks. While the project presents moderate environmental risks, these risks can be effectively managed through well-designed mitigation measures, strengthened institutional capacity, and close monitoring of environmental compliance. The project’s design includes provisions for ensuring compliance with national and international environmental standards. Moderate A.2 Social Risk Rating The social risk rating is Moderate. Social risks are not expected to be significant, but they include a range of risks. These include the potential exclusion or discrimination of project beneficiaries especially among vulnerable groups; and non-inclusive and inaccessible stakeholder consultation and weak stakeholder mapping and analysis, particularly of exclusion of vulnerable groups (women, elderly, persons with disabilities, youth, etc.) in a number of assessments, evaluations, and reforms (for example: comp. 1.1 - detect, access and response to public health threats and development of early warning surveillance; developing and enhancing national intervention plans, SOPs and Mar 03, 2025 Page 6 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) emergency response guidelines; comp. 2.1 - governance framework and feedback mechanisms to improve quality of care; comp. 2 -geo-mapping exercises and climate health assessment; comp. 2.3 - PHC information systems; comp. 3 - improving access emergency services; and component 1.2 - exposure risks to pathogens to workers and patients), especially given the national scope of project design and the number of MOH units involved responsible for various activities. Another key risk is the potential for weak grievance management and a grievance mechanism (GM) that is not fit for purpose to track and address project-specific grievances, which is an issue under the ongoing Covid-19 Response Project (P173945), and that is inclusive, transparent, and accessible especially for vulnerable groups per ESS10. In addition, to address risks and incidents related to sexual exploitation and abuse/sexual harassment (SEA/SH), the GM will need capacity to develop and manage a confidential, survivor-centered, ethical, non- judgmental, and responsive incident response process with a referral pathway for psycho-social-medical and legal services. There is a risk for data privacy breaches during the digitalization of medical records. The Borrower’s policy framework for personal data protection has been evaluated with measures to be included in the legal agreement. OHS and community health risks stem from potential mismanagement of healthcare waste (component 1.4), noncompliance and monitoring with biosecurity and biosafety protocols and the safe handling of viruses and bacteria (comp. 1.2). Small construction activities are expected in existing health facilities, these activities may potentially expose the community to risks such as noise and dust pollution, disturbances from construction vibrations. These community health and safety risks will be mitigated through enforcement of health and safety protocols and strengthening of the grievance mechanisms, including on for SEA/SH, and enforcing and training Codes of Conduct. SEA/SH risks were assessed at appraisal as Substantial. Risks of SEA/SH in medical settings include opportunistic and transactional behaviors among healthcare personnel and between healthcare personnel and patients, especially related to receiving project benefits (including access to training), as well as exposure to labor during civil works. Public Disclosure While the Borrower has some experience implementing a Bank project under the ESF under the current health project, given the project's national scope, the involvement of multiple MOH units which are responsible for various activities, and the large number of healthcare facilities under the project requires that the implementing agency is adequately staffed with environmental and social risk management expertise, including SEA/SH capacity, as well as in other MoH units implementing project activities. Effective E&S coordination of activities and monitoring will be essential for successful implementation, in addition to comprehensive E&S capacity training. Technical Assistance is integrated into the project design will further address capacity gaps for effective risk mitigation. The Bank will also review TORs for evaluations, assessments, studies, etc. to ensure alignment with the ESF as per OSERC guidance. B. Environment and Social Standards (ESS) that Apply to the Activities Being Considered B.1 Relevance of Environmental and Social Standards ESS1 - Assessment and Management of Environmental and Social Risks and Impacts Relevant ESS1 is relevant due to risks from associated with medical waste management, outdated equipment, including E- waste, and potential impacts from civil works for related to infrastructure repair and rehabilitation. These risks are localized, short-term, and manageable with enhanced E&S management capacity. The project does not require land acquisition or large labor influx, as construction activities is limited to repairs and renovations of existing facilities. The key environmental and social risks identified include the handling, segregation, and safe disposal of medical waste, which could include hazardous and infectious materials. Improper management of medical waste, particularly biomedical waste and e-waste, poses significant risks to public health and the environment. If not adequately Mar 03, 2025 Page 7 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) addressed, these risks could lead to contamination of the surrounding environment, including water and soil, as well as health impacts for healthcare workers, patients, and the local community. Additionally, air pollution from the disposal of medical waste and the management of wastewater are potential risks that need to be carefully managed. The project’s civil works, limited to the repair and renovation of existing healthcare facilities, present temporary environmental and social impacts, including air and noise pollution, solid waste generation, and potential disruption to the daily operations of health facilities. However, these impacts are expected to be site-specific and short-term. Given the multiple sites involved and the varying capacities of local facilities, ensuring compliance with environmental standards and contractor obligations could present challenges. The ESMF from the current Covid health project will be updated to include guidance on mitigating risks, including management measures aligned with international best practices for the safe disposal of biomedical waste, outdated equipment, and E-waste. It will also address mitigation measures for potential E&S impacts related to infrastructure retrofitting. By strengthening institutional capacity and embedding environmental and social measures in the project design, the project aims to manage and mitigate the environmental and social risks effectively, ensuring that the benefits of improving the healthcare system are realized in a manner that protects people and the environment and promotes public health and safety. ESS10 - Stakeholder Engagement and Information Disclosure Relevant This project requires robust and regular stakeholder engagement that is inclusive, accessible, and transparent given the broad geographic scope of the project and assessment, evaluation and reform-based activities that require inputs from citizens, especially vulnerable groups (for example: component 1.1 - detect, access and response to public health threats and development of early warning surveillance for pandemics; developing and enhancing national intervention plans, SOPs and emergency response guidelines; component 2.1 - governance framework and feedback Public Disclosure mechanisms to improve quality of care; component 2 - geo-mapping exercises and climate health assessment; component 2.3 - PHC information systems). Meaningful stakeholder engagement is essential to mitigate stakeholder and exclusion risks, especially of vulnerable groups (including women, youth, elderly, persons with disabilities, etc.) and local communities who are not always meaningfully consulted on pandemic response and preparedness and emergency response systems, for example. The Stakeholder Engagement Plan (SEP) of the ongoing Tunisia COVID-19 Response Project (P173945) was modified for this project and was submitted prior to Appraisal. However, it requires revision. It will be submitted as an advanced draft and will be updated within three months of Effective Date. Among the areas to be addressed, is the need for a clear and effective grievance mechanism (GM) with multiple access channels, where grievances under the project are able to be submitted, received and addressed by the PIU. As it is envisioned that the GM of the existing project will be used, there were serious challenges in ensuring grievances related to the project reached the PIU. The Ministry of Health partnered with the Citizen Relations Office (BRC) to manage and address grievances. This model that will be strengthened to ensure it is in line with the requirements under ESS10. The GM, inclusive of an SEA/SH grievance process, is required to be operational prior to the start of project activities. ESS2 - Labor and Working Conditions Relevant The Borrower's labor framework shall be partially used. The Labor Management Procedures (LMP) for the Covid Health Project will be updated for this project. The LMP and Project Operational Manual (POM) shall include where the Borrower’s Framework shall be implemented, and any gap filling measures needed. The project will ensure labor management and working conditions of Project workers are consistent with the ESCP and with the Borrower’s labor framework, which includes, inter alia, the country's relevant policy, legal and institutional framework, including its Mar 03, 2025 Page 8 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) national, departmental, or local implementing institutions, and the applicable laws, regulations, procedures, and implementation capacity. The Borrower will also be required to notify the Bank of any changes to the Borrower’s E&S Framework that may materially adversely affect the Borrower’s ability to manage the E&S risks and impacts of the Project in line with the ESSs and the immediate measures taken or that are planned to be taken to address changes and the ensuing potential risks and impacts of the Project. If such changes adversely affect relevant ESHS risk management aspects of the Project, the will be required implement measures and actions to address them in a manner acceptable to the Bank, and will be reflected in an updated ESCP. This project involves direct, contracted, and potentially primary supply workers. The civil works are expected to be small-scale and primarily focused on upgrades and rehabilitation of existing healthcare infrastructure. As a result, a large labor influx is not anticipated, and most workers are expected to be recruited locally. Nevertheless, it is essential to ensure that labor conditions are appropriately managed, and that the rights and safety of workers, including those involved in construction and healthcare waste management, are respected. Contractors will be required to ensure their workers have signed and receive training on Codes of Conduct. This will be reported on in ES reports and in missions. The updated LMP will define the labor requirements for the project, including the terms and conditions for direct, contracted, and primary supply workers. The LMP will align with national labor laws, the World Bank's ESF, and international labor standards, ensuring the fair treatment of workers throughout the project’s lifecycle. It will also address key labor-related risks, such as OHS and ensuring that safe and hygienic working conditions are provided, especially in healthcare settings where workers may be exposed to medical and construction waste. This includes establishing protocols for the safe handling, storage, and disposal of hazardous materials, such as hazardous biological materials (pathogens, viruses and bacteria), biomedical waste and e-waste. Safe disposal and storage practices will be critical in managing risks to workers’ health, particularly in the context of handling potentially infectious waste generated from healthcare Public Disclosure services. The project will also ensure that workers receive the appropriate protective equipment (PPE) and training related to health and safety, particularly in healthcare settings and during construction activities. ESS3 - Resource Efficiency and Pollution Prevention and Management Relevant ESS3 is relevant as it addresses the increased generation of waste and potential environmental pollution due to the deployment of advanced medical, laboratory, and IT systems. These systems are essential for improving healthcare service delivery but will significantly increase waste generation, including solid and liquid hazardous waste from laboratories, e-waste resulting from IT system upgrades, and hazardous waste from decommissioned medical equipment. Additionally, the project may involve the rehabilitation of healthcare facilities and infrastructure, which may also lead to the generation of construction and demolition waste, including asbestos-containing materials in some cases. Given the potential risks associated with waste generation and the need for efficient resource management, the project will adopt due diligence procedures to assess how resources will be used efficiently to minimize waste generation and limit the potential adverse impacts on human health and the environment. To effectively manage these risks, the updated ESMF will include detailed guidelines and procedures for waste management, with a specific focus on pollution prevention and resource efficiency. A key component of the project will be the management of healthcare waste, including biomedical waste, e-waste, and hazardous materials from medical equipment and infrastructure. Waste management will follow internationally recognized standards and best practices to ensure that waste is safely handled, segregated, and disposed of in an environmentally responsible manner. For instance, the project will ensure that medical waste is properly segregated at the point of generation and disposed of according to best practices, including treatment or safe disposal of hazardous materials. The project will also include a specific focus on e-waste and outdated medical equipment, with clear protocols for their safe Mar 03, 2025 Page 9 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) management, recycling, and disposal. For E-waste management, the project will rely on the Borrower’s framework with gap-filling measures to ensure proper handling, recycling, and disposal. In terms of resource efficiency, the project will prioritize the procurement of equipment that complies with internationally recognized standards for electronics and electrical devices. This will aim to reduce the impact of the project’s activities on the environment, specifically by minimizing energy consumption and reducing the risk of harmful emissions, including radiofrequency emissions. The project will aim to reduce the environmental footprint of the new medical and IT systems and optimize the use of resources through energy-efficient technologies. To further reduce environmental risks, the updated ESMF will provide guidance on the safe handling and disposal of asbestos-containing construction waste, which may be encountered during rehabilitation or renovation activities in existing healthcare facilities. Asbestos waste is particularly hazardous, and its management will follow strict safety protocols to ensure the health and safety of workers and the surrounding community. Site-specific Environmental and Social Management Plans (ESMPs) will be developed to address any specific environmental risks identified for individual sites, including the management of construction and demolition waste, ensuring compliance with national regulations and international standards. The project will also evaluate the feasibility of installing incineration facilities for treating high-risk medical waste, especially biomedical and hazardous waste. If implemented, incineration will help address the disposal challenges associated with these types of waste, which can have significant environmental and health impacts if not properly handled. The incineration option will only be pursued if it meets international environmental standards, ensuring that the facility is equipped with robust emission control technologies to mitigate air pollution risks. The feasibility assessment will include an evaluation of the potential environmental and public health risks associated with incineration, as well as regulatory compliance and cost-effectiveness. The project will ensure that any incineration activities are aligned with international best practices and regulatory frameworks. Public Disclosure ESS4 - Community Health and Safety Relevant As construction activities are expected in existing healthcare facilities, there are several potential risks to community health and safety that need to be carefully managed throughout the project. Construction activities, particularly in health facilities that serve as community hubs, may expose the surrounding community to temporary environmental hazards and social risks, including SEA/SH due to labor. Environmental hazards include noise pollution, dust, and vibrations from construction machinery. Such disturbances could affect the daily activities of community members, particularly vulnerable groups such as the elderly, children, persons with disabilities, and people with pre-existing health conditions. Additionally, air quality could be affected, potentially leading to respiratory issues or discomfort for people living in close proximity to the construction sites. Community access to the health facilities may also be disrupted during the rehabilitation and renovation activities. These disruptions could include restricted access to certain areas of the facilities or detours around the construction sites, leading to inconvenience for local populations who rely on these facilities for medical services, especially those with reduced mobility. There could also be delays in the provision of healthcare services, further burdening already strained healthcare systems, particularly in rural or underserved areas. To mitigate these risks, the updated ESMF will include detailed guidelines for assessing and managing community health and safety risks associated with construction activities. These guidelines will include screening procedures to evaluate the potential health and safety risks for the surrounding communities before, during, and after the construction works. These procedures will be based on international standards and best practices and will include the identification of vulnerable populations that may require additional protection during construction activities. Moreover, the design of the construction projects will incorporate safety features aimed at minimizing risks to the health and well-being of community members. These features may include safety barriers Mar 03, 2025 Page 10 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) around construction sites, proper signage to warn people of potential hazards, and scheduled construction hours to reduce noise and dust disturbances, particularly during sensitive hours such as early mornings or late evenings. In cases where construction might cause prolonged disruptions to access, alternative arrangements will be made to ensure that the community continues to have access to essential health services. Risks of SEA/SH in healthcare settings include opportunistic and transactional behaviors among medical/healthcare personnel and between healthcare personnel and patients, especially related to receiving project benefits (including access to training), as well as exposure to labor during civil works. A key issue relates to the vast geographic scope of the design of the project which requires coordinated oversight over SEA/SH risk management across all health facilities involved in the project, including in rural and remote areas. As small construction activities are expected in existing health facilities, these activities may potentially expose workers and patients to SEA/SH. Workers involved in civil works will be required to sign Codes of Conduct and receive training on the same. Healthcare workers involved in training, research consultants, etc. will also be required to sign CoC. If there are frontline health workers interfacing with patients as part of the project, healthcare staff will be required to sign and receiving training on CoC. Healthcare providers are increasingly being trained to support survivors of domestic and sexual violence, but important gaps remain in implementation, including among police, prosecutors and medical providers. Socio-cultural norms and a challenging reporting environment where pressure and dissuasion among even among healthcare professionals persist. It is therefore essential to that healthcare providers are trained in providing an ethical, confidential, survivor-centered, non-judgmental, and responsive care to SEA/SH survivors. The project will develop an SEA/SH Action Plan. It will be based on the HD Action Plan template and adapted for measures from the Infrastructure Action Plan template as there are minor civil works planned. This will inform mitigation measures to be implemented and monitored. ESS5 - Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant Public Disclosure Activities that could induce physical and/or economic displacement or require voluntary land donation are not envisioned in this project ESS6 - Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources Impacts on biodiversity and living natural resources are not expected, because civil works to be supported by the project will be undertaken in areas that are already disturbed and anthropogenic alterations have been made to the natural environment, within the corridors of the existing developed areas and will be limited to the footprint of existing infrastructure. ESS7 - Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Not Currently Relevant Local Communities There are no known peoples/communities in the project area who meet the criteria of Indigenous Peoples/Sub- Saharan African Historically Underserved Traditional Local Communities (IP/SSAHUTLCs) per ESS7. ESS8 - Cultural Heritage Not Currently Relevant There are no activities which would impact physical and intangible cultural heritage. ESS9 - Financial Intermediaries Not Currently Relevant Mar 03, 2025 Page 11 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) There are no financial intermediaries in this project. B.2 Legal Operational Policies that Apply OP 7.50 Operations on International Waterways No OP 7.60 Operations in Disputed Areas No B.3 Other Salient Features Use of Borrower Framework In Part A) The project will implement the project under Labor Code (Law 66-27 of April 30, 1966). It will implement the following measures: a) Provide contracted and direct workers with information and documentation that is clear and understandable regarding their terms and conditions of employment through written contracts setting out their rights (article 6 of the Labor Code ), including, inter alia, rights related to hours of work (under 40 or 48 hours as provided by article 79 and seq of the Labor Code), allowances and benefits (as PROVIDED BY Title II of the Labor Code and determined by the Joint Agreement of the Sector), probationary period (article 6-3 of the Labor Code) overtime (article 90 of the Labor Code), and benefits, the right to annual leave with full pay (article 112 of Labor Code) as well as written notice of termination of employment (article 14 second of the Labor Code), and details of severance payments, as applicable(article 23 of Labor Code ) (and will require contractor's workers to the same); Avoid verbal contract which may complicate the negotiation process on conditions of employment and fail to adequately protect the rights of Public Disclosure affected employees and employers/contractors. This will prevent arbitrary dismissals (article 14 third of Labor Code) due to the perceived failure in performing assigned duties effectively. b) Implement occupational health and safety (including personal protective equipment, and emergency preparedness and response) measures, setting up occupational medical units or join vocational medical centers as based on the criteria provided the Labor Code(Title III of Labor Code), the General Environmental, Health and Safety Guidelines (EHSGs), the industry-specific EHSGs and other Good International Industry Practice (GIIP), as relevant; Compensation of professional diseases and accidents(Law 28-1994of February 1994 on the Compensation of Professional diseases and accidents) c) Implement measures, as applicable, to, inter alia: (i) prevent the use of all forms of forced labor and child labor (Article 58 of Labor Code); (ii) enable workers to benefit from, inter alia, access to grievance mechanisms without fear of retaliation; Resort to the Labor Inspection (articles 170-182 of the Labor Code) and ensure fair and lawful complaints procedures are followed and that employers/contractors respond to any grievance submitted by employees including before and after dismissals (article 14 third and 21) and (iii) provide effective freedom to form and join Trade Unions (Constitution July 25, 2022); or alternative mechanisms for expressing their concerns and protect their rights related to labor and working conditions including their right to strike (Constitution July 25, 2022); d) Develop a code of conduct for workers, which shall include measures to prevent and respond to sexual exploitation and abuse, and sexual harassment (SEA/SH) cases; in addition to sanctions provided by the Fundamental Law 58/2017 of August 11, 2017 on the elimination of all forms of violence against women Mar 03, 2025 Page 12 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) B) For E-waste management, the project will rely on the Borrower’s framework with gap-filling measures to ensure proper handling, recycling, and disposal. Key legal texts include Decree No. 2000-2339 of October 10, 2000; Law No. 96-41 of June 10, 1996; and Circular No. 25 of October 13, 2023. Corrective measures will be included in the Loan Agreement and Project Operation Manual (POM), as needed. Use of Common Approach No No other financing partners are included in the project. C. Overview of Required Environmental and Social Risk Management Activities C.1 What Borrower environmental and social analyses, instruments, plans and/or frameworks are planned or required by implementation? By appraisal: - an advanced draft of the Stakeholder Engagement Plan - draft ESCP Public Disclosure During implementation: - Update the ESMF of the current Health project (within three months of Effective Date), inclusive of an SEA/SH Action - The SEA/SH Action Plan (within three months of Effective Date) - Update the current Health project LMP (within three months of Effective Date) - Updated an operational Grievance Mechanism in line with ESS10, and inclusive of a SEA/SH grievance process prior to the start of project activities Due Diligence: The Bank will conduct due diligence in biannual missions, quarterly E&S reports, review of E&S instruments. III. CONTACT POINT World Bank Task Team Leader: Yassine Kalboussi Title: Health Specialist Email: ykalboussi@worldbank.org TTL Contact: Denizhan Duran Job Title: Senior Economist, Health Mar 03, 2025 Page 13 of 14 The World Bank Tunisia Health System Strengthening Project (P507209) Email: dduran1@worldbank.org TTL Contact: Fatima El Kadiri El Yamani Job Title: Senior Economist, Health Email: felkadirielyama1@worldbank.org IV. 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 V. APPROVAL Task Team Leader(s): Yassine Kalboussi, Denizhan Duran, Fatima El Kadiri El Yamani ADM Environmental Specialist: Olfa Khelifi Ep Arfaoui ADM Social Specialist: Gina Cosentino Public Disclosure Mar 03, 2025 Page 14 of 14