The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) For Official Use Only Date Prepared/Updated: 05/09/2024 | Report No: ESRSA03417 Jun 18, 2024 Page 1 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) I. BASIC INFORMATION A. Basic Operation Data Operation ID Product Operation Acronym Approval Fiscal Year P504281 Investment Project Financing (IPF) INSPIRER 2025 Operation Name Innovative Systems to Promote Integrated, Resilient and Enhanced Responses to Women and Girls’ Health Country/Region Code Beneficiary country/countries Region Practice Area (Lead) (borrower, recipient) Ethiopia Ethiopia EASTERN AND Health, Nutrition & SOUTHERN AFRICA Population Borrower(s) Implementing Agency(ies) Estimated Appraisal Date Estimated Board Date Ministry of Finance Ministry of Health 08-Apr-2024 14-Dec-2024 For Official Use Only Estimated Decision Total Project Cost Review Date 05-Apr-2024 120,000,000.00 Proposed Development Objective To improve women and girls’ health outcomes through strengthening resilient and innovative health systems in climate- stressed and conflict-affected areas. 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 [Description imported from the PAD Data Sheet in the Portal providing information about the key aspects and components/sub-components of the project] The project aims to contribute to the improvement of the coverage and quality of women and girls’ healthcare services. This goal will be achieved through the implementation of selected climate-resilient and innovative health systems strengthening initiatives focusing on low-performing and climate affected geographical areas in Ethiopia. The project Jun 18, 2024 Page 2 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) will prioritize interventions addressing what to do about the people, providers, places, and partners: (ii) people: the project will target women in childbearing age with their infants and girls aged between 5 and 17 years living in climate sensitive areas; (ii) providers: the project will aim to improve the knowledge and skills of health services providers. The project strategically chose to concentrate on the HEWs, who are the main interface between the household and the health care system in Ethiopia, especially in rural areas; (iii) spaces: the project will aim at transforming spaces through rebuilding a climate resilient and technology-enhanced service delivery infrastructure to ensure the continuity of service provision and establish a health facility that is safe and attractive for the client and patients, and (iv) partnerships: the project will forge a collaborative, multi-sectoral approach by bringing together various stakeholders, including government agencies from multiple sectors, digital health developers, health sector development partners, and philanthropies. Taking a context-tailored systems approach can ensure that breakpoints in care are addressed in more holistic, transformative ways to address persistent challenges as well as leapfrog systems. This is needed to better address the health needs of women and girls today and contain any system shocks of tomorrow. Given the foundations already in place in Ethiopia, a strategic, systems-based innovation agenda can accelerate the shift to more people- centered, high-quality, integrated, and sustainable health systems and health service delivery. In this context, the proposed operation proposes a systems innovation agenda for increased access to high-quality services through to the last mile through a focus on key enablers that can holistically improve women and girls’ experience of the full continuum of care in Ethiopia. As part of an integrated primary health care package of services, maternal and Newborn Health and HPV will be used as the ‘leading edge’ around which systemic innovations will be designed, implemented, and evaluated. The proposed operation has three areas of focus where system and point of care innovations can be adapted and scaled for better quality, efficiency and reach of the health system and health service delivery: For Official Use Only Strengthening organizational capacity: this is to ensure that people are receiving the right care, from the right providers, at the right time. The investment will focus on rationalizing the platforms for service delivery by shifting the place of care for key services to more accessible points, ensuring adequate linkages between points of care, and ensuring adequate utilization of provided services by women and girls. The investment will also address needed inputs and linkages for quality care. The inputs will include infrastructure strengthening, commodity procurement and the introduction of service provision equipment that will maximize health worker efficiency. It will also include capacity strengthening for health workers to improve care quality. The linkages agenda will ensure effective emergency referrals from community to higher levels of care. Integrating systems and services: this will involve the integration of the community level into the broader health system structure, i.e., quality, connected care for women and girls in rural areas through harnessing key systems opportunities for strengthening the linkages between the lowest levels of care and higher centers. This will be done principally through the strengthening of existing and new digital data platforms for interoperability, care continuity and data utilization. Promoting sustainability: A climate-smart approach will be employed by implementing interventions that ensure the continuous availability of key services in the face of climate- related system shocks like flooding. Additionally, system inputs that contribute to lower GHG emissions in the process of healthcare service delivery, e.g., solar rather than diesel-generator electricity backup systems, will be deployed as part of the operation. Key Project Results: - % of 9–14-year-old girls in school and out of school who receive HPV vaccination - Number of eligible women who are screened for cervical cancer at health centers. - Number of health facilities supported with climate resilient and digital technologies to provide women and girls health services. Project Components: Component 1: : Expand access to quality interventions for women and girls, including through tech- enabled care. Component 2: Improved service delivery through innovative interventions in climate stressed & conflict affected areas. Component 3: Strengthen data systems and reinforce decision-making to ensure high quality care. Component 4: Project Implementation and Monitoring. Jun 18, 2024 Page 3 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) D. Environmental and Social Overview D.1 Overview of Environmental and Social Project Settings [Description of key features relevant to the operation’s environmental and social risks and opportunities (e.g., whether the project is nationwide or regional in scope, urban/rural, in an FCV context, presence of Indigenous Peoples or other minorities, involves associated facilities, high-biodiversity settings, etc.) – Max. character limit 10,000] Ethiopia, characterized by complex topography with variations in terrain, rainfall, and climate, is highly vulnerable to environmental degradation. The country faces numerous environmental issues, including soil erosion, land degradation, deforestation, water scarcity, biodiversity loss, and water, soil, and air pollution. Poorly planned development and mismanagement of natural resources have exacerbated past economic, environmental, and social challenges. There are also major challenges related to healthcare waste management in Ethiopia. Primary challenges include a lack of awareness among healthcare staff, inadequate waste management utilities, and insufficient enforcement from regulatory bodies. Social issues such as rural/urban poverty, unemployment, and gender inequality are prevalent. The increased displacement of the population due to fragility, conflict, and violence, including social unrest, has further disrupted access to basic social services. Cultural norms and economic conditions make women particularly vulnerable to Gender-Based Violence, with 28 percent of women reporting having experienced intimate partner violence. D.2 Overview of Borrower’s Institutional Capacity for Managing Environmental and Social Risks and Impacts [Description of Borrower’s capacity (i.e., prior performance under the Safeguard Policies or ESF, experience applying E&S policies of IFIs, Environmental and social unit/staff already in place) and willingness to manage risks and impacts and of For Official Use Only provisions planned or required to have capabilities in place, along with the needs for enhanced support to the Borrower – Max. character limit 10,000] The Government of Ethiopia and the Ministry of Health (MoH) have some experience and track record in managing environmental and social risks associated with bank projects, adhering to the banks' operational policies and the environmental and social framework (ESF). The MoH manages and coordinates multiple World Bank-financed projects in the health sector, such as the Sustainable Development Goal Program for Results (P123531), the Ethiopia component of the Africa CDC Regional Investment Project (P167916), the Ethiopia Program for Results (Hybrid) for Strengthening Primary Health Care Services (P175167), and the Ethiopia COVID-19 Emergency Response (P173750). These projects have thus far demonstrated good performance in terms of environmental and social risk management. To ensure the successful implementation of this project, the MoH-Ethiopia will maintain the existing environmental and social development specialists who have been required for the Ethiopia COVID-19 Emergency Response Project. This is reflected in the environmental and social commitment plan. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate A.1 Environmental Risk Rating Moderate [Summary of key factors contributing to risk rating, in accordance with the ES Directive and the Technical Note on Screening and Risk Classification under the ESF – Max. character limit 4,000] Jun 18, 2024 Page 4 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) Both HPV advocacy work that is designed to increase vaccination by the government and healthcare energy supply or WASH facility renovation/equipping (Component 1&2) carry potential risks to the environment, health, and safety (EHS). Renovation generates hazardous and non-hazardous waste, including debris, sharps, adhesives, and paint cans. Noise, dust, and infection risks are significant during healthcare facility renovations, which can introduce contaminants and increase healthcare-associated infections. Other risks include infectious waste, pharmaceutical waste, chemical waste, and general healthcare waste. Proper storage, distribution, administration, and disposal of vaccines are essential to avoid EHS risks. The disposal of compromised or expired vaccines must follow hazardous waste management guidelines. Mishandling or administration by unqualified staff can compromise vaccine potency and beneficiary health. There are also potential community health risks if HIV/STI prevention and control activities are not properly implemented. Solar power energy (Component 2) may use rechargeable batteries like lithium-ion, nickel metal hydride, nickel cadmium, and lead acid batteries. Batteries, specifically nickel cadmium and lead acid batteries, have the potential to cause environmental and health impacts due to the presence of chemicals and heavy metals. Proper handling during transportation, storage, and disassembly/recycling is crucial due to potential environmental and health risks from chemicals and heavy metals. Water and raw material consumption during renovation is expected to be minimal. No new healthcare facility construction is involved, minimizing risks to biodiversity and habitats. The procurement, use, and management of incinerators under sub-component 2C must adhere to the World Bank Environmental, Health, and Safety Guidelines for Health Care Facilities. To comply with international emission standards for dioxins and furans, it is essential to procure and use modern incinerators. These incinerates should operate at temperatures ranging from 850 °C to 1100°C and must be fitted/ equipped with advanced gas-cleaning technology. Overall, the environmental risk is rated as moderate at this stage. For Official Use Only A.2 Social Risk Rating Moderate [Summary of key factors contributing to risk rating, in accordance with the ES Directive and the Technical Note on Screening and Risk Classification under the ESF – Max. character limit 4,000] The project's social risks are expected to be Moderate. These mainly refer to: (i) community health and safety risks, especially those involved in renovating, rehabilitating, and installing sewage treatment facilities in existing healthcare and schools, and those related to road safety; (ii) safety risks to project workers and on-project implementation and monitoring in some regions experiencing conflict; (iii) If the project advocacy work resulted in the increasing availability and distribution of the HPV vaccine, the administration of the HPV vaccine by unqualified staff, which could compromise the potency and affect people’s health, as well as risks associated with who provides consent for the administration of the vaccine .; (iv) potential exclusion of vulnerable groups, such as historically underserved communities, during project implementation, if a targeted approach and consultations with them are not properly implemented; and (v) potential criticism from some civil society stakeholders to the measures to be supported, or not supported, by the Project, particularly considering the social sensitivity of the topics. The project does not finance new construction, so no impacts on land acquisition and resettlement are expected. Potential security-related risks will be identified and mitigated as part of the Contractor's Environmental and Social Management Plan(C-ESMP). [Summary of key factors contributing to risk rating. This attribute is only for the internal version of the download document and not a part of the disclosable version – Max. character limit 8,000] B. Environment and Social Standards (ESS) that Apply to the Activities Being Considered Jun 18, 2024 Page 5 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) B.1 Relevance of Environmental and Social Standards ESS1 - Assessment and Management of Environmental and Social Risks and Impacts Relevant [Explanation - Max. character limit 10,000] The project activities will generate hazardous and non-hazardous waste, including debris, sharps, adhesives, and paint cans; risks include infectious, pharmaceutical, chemical, and general healthcare waste. Proper storage, distribution, administration, and disposal of vaccines are crucial to avoid EHS risks. Mishandling or administration by unqualified staff can compromise vaccine potency and raise health concerns. Risks to community health and safety include road safety and the emission of pollutants, particulate matter, noise, and odors. There is also a possibility of excluding vulnerable groups during project implementation. Conflicts in some regions may pose safety risks to project workers and on-project implementation and monitoring. Sexual exploitation, abuse, and SEA/SH/GBV among project staff have been identified as project risks as well. The MoH will adopt the existing ESMF and LMP, which were prepared for the COVID-19 project. ESCP and SEP have been prepared prior to appraisal. ESS10 - Stakeholder Engagement and Information Disclosure Relevant [Explanation - Max. character limit 10,000] Key Project stakeholders are expected to include relevant government departments and ministries; staff from health service institutions; health care workers, nurses, health extension workers, first responders, and For Official Use Only academics/universities/research centers; nongovernmental organizations and civil society organizations at both the national and regional level working on Health care; and individuals seeking medical services, including potentially vulnerable individuals. Prior to appraisal, the Ministry of Health has prepared and disclosure Stakeholder Engagement Plan (SEP), and carry out stakeholder engagement activities with the key stakeholders identified, to inform the project design and the preparation of its E&S risk management instruments. ESS2 - Labor and Working Conditions Relevant [Explanation - Max. character limit 10,000] The project labor-related risks include (i) Lack of compliance with national employment and labor and occupational health and safety laws and regulations; and (ii) Unsafe and unhealthy working conditions and the workers involved in renovation activities in the project. Key labor requirements including OHS risk management has been included in the LMP for COVID-19 project which will be adopted for this project. It includes: (i) written contracts of employment; (ii) protection of wages including fair treatment, non-discrimination and equal opportunity of project workers; (iii) occupational, health and safety to all project workers; and (vi) grievance mechanism for workers with accessible means to raise workplace concerns. Although the risk of child labor specifically related to this project may be minimal, there have been reports of forced labor risks linked to the suppliers of solar panels and solar components, which need to be addressed through appropriate precautionary measures. ESS3 - Resource Efficiency and Pollution Prevention and Management Relevant Jun 18, 2024 Page 6 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) [Explanation - Max. character limit 10,000] Healthcare and WASH facility renovation activities can generate both hazardous and non-hazardous waste. Dust and infection risks can be significant during healthcare facility renovations. Other potential risks from operation of healthcare facilities include : a) infectious waste; b) pharmaceutical wastes; c) chemical waste; d) general healthcare waste; e) contamination of surface or ground water and e) used solar batteries. Compromised or expired vaccines used vials and ampoules or syringes must be collected and disposed of according to hazardous waste management guidelines. There are also potential EHS risks if proper storage, distribution, administration, and disposal of vaccines are not followed. Although water and other raw materials are necessary for the renovation process and WASH facilities, their consumption is not expected to be significant. The project activities are not anticipated to generate any significant greenhouse gases. ESS4 - Community Health and Safety Relevant [Explanation - Max. character limit 10,000] Community health and safety risks include (i) the possibility of excluding vulnerable groups from the project benefits, (ii) risks related to gender, GBV/SEA/SH, and (iii) the transmission and spread of HIV/AIDS and other communicable diseases. Health and safety risks may arise from the inappropriate use and disposal of hazardous & other healthcare waste and other pollutants during construction. (iv) Safety and security risks, including road traffic safety, may also be a concern for project beneficiaries and workers, which will be addressed through the Contractor Environment and For Official Use Only Social Management Plan (C-ESMP). (v) downstream mishandling or improper administration of vaccinations by unqualified staff can compromise the vaccine's potency and pose concerns about the health of the beneficiaries and healthcare workers. There should be protocols in place to ensure parental consent for the vaccination of school girls, as it may result in creating conflict between the project and the community. ESS5 - Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant [Explanation - Max. character limit 10,000] The main goal of this project is to provide financial assistance for the limited physical infrastructure in conflict- affected areas, with a particular emphasis on the rehabilitation and renovation of health facilities. All civil work activities will take place on public land within pre-existing medical facilities owned by the government. The Ethiopian COVID-19 Response Project Environmental and Social Management Framework (ESMF) will be adopted for the project, and it will serve as a screening tool to assess any potential impact on the land. No impacts associated with ESS 5 are expected as a result of this project. ESS6 - Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources [Explanation - Max. character limit 10,000] ESS6 is not relevant at this stage as the project will not finance any activity that will lead to conversion of habitats and loss of biodiversity. All rehabilitation activities will be undertaken within exiting healthcare facilities. Jun 18, 2024 Page 7 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) ESS7 - Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Relevant Local Communities [Explanation - Max. character limit 10,000] It is anticipated that the project's country-wide implementation will impact individuals who may meet the criteria of ESS7. There are risks associated with unequal access to project benefits, particularly in areas where vulnerable people reside due to low capacity and inadequate infrastructure. Furthermore, cultural and linguistic differences may lead to gaps in identifying appropriate risk and benefit communication and community engagement activities, such as developing health messages. Therefore, project preparation must involve understanding the physical and socio- economic challenges that prevent the group from accessing project benefits. The MOH will conduct effective and culturally appropriate consultation and engagement among different socio-cultural groups. ESS8 - Cultural Heritage Not Currently Relevant [Explanation - Max. character limit 10,000] The proposed project will not involve any significant physical interventions that could impact cultural heritage. This includes objects, sites, structures, cultural practices, and natural features or landscapes of historical, archaeological, paleontological, religious, aesthetic, or other cultural significance. A Chance Finds procedure will be part of the adopted Environmental and Social Management Framework (ESMF). Contractors working on the project will be required to halt construction if any cultural heritage is discovered. They must follow the procedures outlined in the For Official Use Only contract. ESS9 - Financial Intermediaries Not Currently Relevant [Explanation - Max. character limit 10,000] No FI will be engaged 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 No [Explanation including areas where “Use of Borrower Framework” is being considered - Max. character limit 10,000] No part of the borrower's E&S framework will be used. Jun 18, 2024 Page 8 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) Use of Common Approach No [Explanation including list of possible financing partners – Max. character limit 4,000] None B.4 Summary of Assessment of Environmental and Social Risks and Impacts [Description provided will not be disclosed but will flow as a one time flow to the Appraisal Stage PID and PAD – Max. character limit 10,000] The HPV vaccination and the renovation/equipping of healthcare facilities (Component 1&2 of the project) can pose potential risks to the environment, health, and safety (EHS). Renovation activities often generate both hazardous and non-hazardous waste, including debris, broken sharps, adhesives, paint cans. Noise or other disturbance, dust and infection risks can be significant during healthcare facility renovations. Renovation activities can introduce contaminants into clinical spaces, increasing the risk healthcare-associated infections. Other potential risks from operation of healthcare facilities include a) infectious waste such as waste suspected to contain pathogens; b) pharmaceutical wastes such as expired, unused, spoiled, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer needed, including containers and other potentially contaminated materials (e.g. drug bottles vials, tubing etc.); c) chemical waste which may be toxic, corrosive, flammable, reactive, and genotoxic properties and could be generated through use of chemicals during diagnostic work, cleaning, housekeeping, and disinfection; and d) general healthcare waste. Although water and other raw materials are necessary for the renovation process, their consumption is not For Official Use Only expected to be significant. The project activities do not involve the construction of new healthcare facilities, so there is no anticipated risk to biodiversity and habitats. The project's social risks are expected to be Moderate. These mainly refer to: (i) community health and safety risks, especially those involved in renovating, rehabilitating, and installing sewage treatment facilities in existing healthcare facilities and those related to road safety; (ii) safety risks to project workers and on-project implementation and monitoring in some regions experiencing conflict; (iii) If the project advocacy work resulted in the increasing availability and distribution of the HPV vaccine, the administration of the HPV vaccine by unqualified staff, which could compromise the potency and affect people’s health, as well as risks associated with who provides consent for the administration of the vaccine .; (iv) potential exclusion of vulnerable groups, such as historically underserved communities, during project implementation, if a targeted approach and consultations with them are not properly implemented; and (v) potential criticism from some civil society stakeholders to the measures to be supported, or not supported, by the Project, particularly considering the social sensitivity of the topics. The project does not finance new construction, so no impacts on land acquisition and resettlement are expected. The project SEA/SH risk is rated as Substantial. The project involves risks of sexual exploitation, abuse, and violence, particularly due to the worsening of existing insecurity and conflict in some project areas and the lack of SEA/SH management protocol in the health sector. Sexual harassment among project staff is also likely to be experienced as part of the implementation of the Project. Jun 18, 2024 Page 9 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) 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? [Description of expectations in terms of documents to be prepared to assess and manage the project’s environmental and social risks and by when (i.e., prior to Effectiveness, or during implementation), highlighted features of ESA documents, other project documents where environmental and social measures are to be included, and the related due diligence process planned to be carried out by the World Bank, including sources of information for the due diligence - Max. character limit 10,000] The following E&S instruments have been prepared or will be adopted for the project implementation: Stakeholder Engagement Plan (SEP). A plan for engaging stakeholders has been developed. This plan includes a grievance mechanism and a process for addressing social and environmental issues. The plan outlines meaningful, timely, and easy access to information. This includes individuals who speak different languages and come from diverse cultural backgrounds, as well as those who face challenges due to illiteracy or disabilities. An Environmental and Social Commitment Plan (ESCP) was developed. Adopt the Environmental and Social Management Framework (ESMF), which was prepared for the Ethiopia COVID-19 project and includes procedures for identifying, screening, preparing instruments, managing, and monitoring For Official Use Only environmental and social risks and impacts. The MoH will also adopt the LMP prepared for the COVID-19 project. SEA/SH action plan: along with other measures, like SEA/SH provisions in the codes of conduct, contractual provisions, training and awareness activities, and grievance mechanisms prepared to receive and process SEA/SH complaints. During the Project’s implementation stage, subprojects will also have E&S risk management instruments and plans (e.g., ESMPs, including security risk identification and management ) to be prepared and disclosed before the commencement of subproject activities. III. CONTACT POINT World Bank Task Team Leader: Enias Baganizi Title: Senior Health Specialist Email: ebaganizi@worldbank.org TTL Contact: Roman Tesfaye Job Title: Senior Operations Officer Email: rtesfaye@worldbank.org Jun 18, 2024 Page 10 of 11 The World Bank Innovative Systems To Promote Integrated, Resilient And Enhanced Responses To Women And Girls’ Health (P504281) 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): Enias Baganizi, Roman Tesfaye ADM Environmental Specialist: Tamru Demsis Temam ADM Social Specialist: Aynalem Getachew Gashaw For Official Use Only Jun 18, 2024 Page 11 of 11