The World Bank Lebanon: Health Transformation Project (P180452) Concept Environmental and Social Review Summary Concept Stage ( ESRS Concept Stage) For Official Use Only Date Prepared/Updated: 10/24/2023 | Report No: ESRSC03820 Nov 29, 2023 Page 1 of 10 The World Bank Lebanon: Health Transformation Project (P180452) I. BASIC INFORMATION A. Basic Operation Data Operation ID Product Operation Acronym Approval Fiscal Year P180452 Investment Project Financing (IPF) Lebanon Health Reform 2025 Operation Name Lebanon: Health Transformation Project Country/Region Code Beneficiary country/countries Region Practice Area (Lead) (borrower, recipient) Lebanon Lebanon MIDDLE EAST AND Health, Nutrition & NORTH AFRICA Population Borrower(s) Implementing Agency(ies) Estimated Appraisal Date Estimated Board Date Ministry of Finance Ministry of Public Health 17-Jun-2024 30-Aug-2024 Estimated Concept Total Project Cost For Official Use Only Review Date 16-Nov-2023 150,000,000.00 Proposed Development Objective to (i) prevent the health system from collapsing and protect the coverage of essential health services for the vulnerable; and (ii) put the health sector on a reform pathway for efficiency and capacity. 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 Concept Data Sheet in the Portal providing information about the key aspects and components/sub-components of the project] The Project aims to support the Ministry of Public Health's (MoPH) key regulatory reforms and institution building; prioritize reforms in contracting health services for the uninsured, thus improving the efficiency of MoPH’s spending and the access to services; support MoPH to build efficient common platforms for purchasing of services which other public payers and development partners can utilize; and strengthen MoPH’s role as the coordinator/champion of health sector reforms. The proposed financing instrument is IPF, with the use a set of sequenced PBCs related to key strategic, Nov 29, 2023 Page 2 of 10 The World Bank Lebanon: Health Transformation Project (P180452) institutional and governance changes as the key milestones of a reform roadmap for the health sector. The Project will have two complimentary Components, with Component 1 using the PBC-based IPF approach and Component 2 using the traditional IPF instrument. Component 3 will be used for Contingent Emergency Response. Component 1: Support for Health Reforms, Regulatory Functions, Institution Building and Contracting Providers for Essential Services for the Poor (PBC-based). This Component is comprised of four sub-components supporting reforms and institution building in five respective areas: (i) health financing, (ii) pharmaceuticals, (iii) e-Health, (iv) citizen engagement, and (v) contracting service providers for the most vulnerable. Component 2: Technical Assistance, Training and Project Management (traditional IPF). This Component will support: (i) technical assistance and training required to support MoPH in achieving the PBCs in Component 1; (ii) other technical assistance in institution building; and (iii) project management (including project monitoring and evaluation), fiduciary oversight and environmental and social safeguards aspects of the Project. This Component will use the traditional IPF instrument. Component 3: Contingent Emergency Response Component (CERC) (US$0) The zero-dollar CERC will be in place to provide expedited response in case of emergency. A CERC Operational Manual will be prepared and agreed with the World Bank for use if this component is triggered. 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 2,000] This $150 million loan project ( $120 million IBRD and $30 million from trust funds) aims to prevent the health system in For Official Use Only Lebanon from collapsing and protects the coverage of essential health services for the vulnerable populations and groups nationwide; it also aims to put the health sector on a reform pathway for efficiency and capacity. The project is comprised of 3 components: 1) Support for Health Reforms, Regulatory Functions, Institution Building and Contracting Providers for Essential Services for the Poor; 2) Technical Assistance, Training and Project Management; 3) CERC . The project will be implemented nationwide, however, specific locations where the materials, equipment, and works will be executed are not yet identified - all activities will be implemented in urban as well as rural areas. Based on the available information at this level, the project area does not contain any globally important habitats or ecosystems. There are no nature reserves or other legally protected areas in the vicinity of the project or in close proximity as health care centers are generally situated in dense or semi-dense urban settings. Since 2019, Lebanon has suffered from an increasingly severe financial and economic crisis that has negatively impacted all sectors in the country. The health system has been severely affected by the lack of basic utilities such as electricity, fuel and water, in addition to the currency exchange rate. As a result, PHCCs have struggled to maintain safe, accessible operations (Lebanon Primary Health Care Network in Urgent Need of Fuel Support, March 2022). Moreover, the provision of health services is mostly private, fragmented and not well regulated. About 66%of MoPH spending has been on hospitals (mainly to finance hospital care for the uninsured) and 18% on pharmaceuticals, leaving only about 9 percent for primary health care. That being said, PHCCs are in great demand, by nationals as well as non-nationals (L’Orient Today, December 2021). 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 provisions planned or required to have capabilities in place, along with the needs for enhanced support to the Borrower – Max. character limit 2,000] Nov 29, 2023 Page 3 of 10 The World Bank Lebanon: Health Transformation Project (P180452) The Ministry of Public Health (MoPH) will be responsible for the overall implementation of the project. This is the second project for the MoPH applying the ESF. The first project, which is still waiting implementation, is the Strengthening Lebanon’s Covid-19 Response (SLCRP) (P178587), and the performance during preparation was satisfactory. In addition, the MoPH has had prior experience implementing a World Bank-financed project in the same context “Lebanon Health Resilience Project (LHRP)”, which is implemented under the Operational Policy (OP) 4.01. The current performance of the PMU in implementation of the environmental and social safeguards requirements under the safeguards policies is satisfactory and they are expected to have reasonable capacity on the World Bank Environmental and Social Framework (ESF). The MoPH has in place a project management unit under both the LHRP and the SLCRP with an E&S specialist and who may support in the preparation of the relevant E&S instruments for this new health operation. In January 2023, the World Bank team conducted awareness-raising and capacity-building session for the MoPH PMU, including the newly recruited E&S specialist,on the ESF requirements and overall ESSs. In addition to this, the MoPH E&S specialist has participated in the 5-days ESF training that was held in Beirut in May, 2023 for Lebanon- Iraq PIUs, which covered the ESF background, ESSs deep-dive, SEH/SH, GBV, reporting, supervision and monitoring, in addition to relevant case studies. Under this new project, the MoPH is advised to hire a new E&S specialist for this project who will also follow up on the implementation, monitoring, and documentation of the E&S instruments throughout the project life cycle as per the provisions of the ESCP detailed further below. II. SCREENING OF POTENTIAL ENVIRONMENTAL AND SOCIAL RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Moderate For Official Use Only 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 2,000] Overall, the project will have positive environmental and social impacts by rehabilitating health facilities, purchasing drugs and medical supplies, IT and medical equipment under component 1, in addition to reforms and redesigning of the health system in Lebanon to improve efficiency and effectiveness of MOPH’s in submitting the health services to the citizens. However, the above physical activities especially the works/rehabilitation are not confirmed yet nor the exact facilities. That being said, according to MoPH, the scale of activities will be limited and at the existing footprint of the health facilities. The potential environmental impacts and risks include: (i) consumption of energy, water, and building materials (paints, cement, steel, sand, electrical supplies, etc.) for buildings rehabilitation; (ii) the generation of solid waste domestic, demolition, hazardous waste, medical and e-waste; (iii) nuisance, related to dust generation, vibration, and noise; (iv) occupational health and safety (OHS) workforce hazards, including the increased risk of accident from inadequate working conditions at construction sites and from communicable diseases infection; (v) community health and safety (CHS) hazards from work activities particularly for residents besides proposed rehabilitation facilities; and (vi) Increasing traffic. Moreover, activities under PBC 1, 5, and 8 for Development and adoption of National Health Financing Strategy, National Health Masterplan for high-cost technology and hospital investment, and National E-health Strategy can have direct or indirect environmental and social impacts when implemented through future investments. In light of the above, and in line with the ESF Directive for E&S risk rating, the environmental risk has been determined to be Moderate. MOPH also has good experience in managing the World Bank ESF and OPs operations as explained in the borrower’s capacity section. This risk rating will be revisited during preparation. Nov 29, 2023 Page 4 of 10 The World Bank Lebanon: Health Transformation Project (P180452) 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 2,000] The social risk classification for this project is “moderate” as the risks are predictable and temporary and/or reversible; (ii) low in magnitude; (iii) site-specific, without likelihood of impacts beyond the actual footprint of the Project; and (iv) low probability of serious adverse effects to human health. The project is mostly associated with positive social impacts as it will implement reforms to improve the health sector in terms of its efficiency and capacity and it will protect healthcare coverage for the vulnerable populations including the poor Lebanese, those listed on the social assistance registry, and displaced persons including refugees. In addition, it will introduce unique health IDs and will develop and adopt a national e-health strategy which will empower citizens with access to their personal health data and information. Moreover, it will support citizen engagement and empowerment to (i) foster a social movement in health, (ii) elicit citizen feedback on service delivery and reforms and (ii) help hold policy makers and providers accountable for results. Moderate social risks may be associated with the risk of exclusion of certain vulnerable populations and groups from the project benefits if the project activities and benefits are not adequately and effectively communicated. In addition, the risk of a poorly established grievance mechanism that fails to respond in a satisfactory and timely manner to stakeholder queries and concerns may potentially result in dissatisfaction and exacerbated grievances. These risks can be effectively and readily mitigated through the establishment of a robust grievance mechanism and effective and ongoing communication of the project and its associated activities. [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 2,000] For Official Use Only B. Relevance of Standards and Policies at Concept Stage B.1 Relevance of Environmental and Social Standards ESS1 - Assessment and Management of Environmental and Social Risks and Impacts Relevant [Optional Explanation - Max. character limit 1,000] Project activities might present environmental, social, health, and safety risks for the project workforce and communities. Given the nature of how diseases spread, the environment is likely to be exposed to risks from medical wastes generated from health facilities, impacts related to air quality, water quality, waste, noise, health and workers and community safety, and nuisance and potential increase in traffic due to rehabilitation activities, though the targeted health facilities are not yet known. From a social perspective, there is the risk of vulnerable groups being excluded if effective communication of project activities is not undertaken. All environmental and social risks will be addressed through the development of site-specific ESIAs/ESMPs once the project interventions are known. MoPH will also prepare a Strategic Environmental and Social Assessment (SESA) during implementation for activities under PBC 1, 5, and 8 as per the provisions of the ESCP. ESS10 - Stakeholder Engagement and Information Disclosure Relevant [Optional Explanation - Max. character limit 1,000] Nov 29, 2023 Page 5 of 10 The World Bank Lebanon: Health Transformation Project (P180452) Project stakeholders includes beneficiaries of the project such as poor Lebanese, non-Lebanese persons including displaced persons, and those on the social assistance registry from the Emergency Social Safety Net Project (ESSN) funded by the WB. Other interested parties include the Ministry of Social Affairs, Presidency of the Council of Ministers (implementing agency for the first phase of the ESSN project), Ministry of Environment, Ministry of Displaced, Ministry of Finance, academic centers including American University of Beirut Medical Center, University of Balamand, Lebanese University, University of Saint Joseph, UNHCR, NGOs focused on environmental and social objectives and goals and CSOs. Vulnerable groups include those who do not know how to read or write, persons with physical disabilities and those who do not have access to internet as well as the elderly. The SEP will communicate various modalities for engagement, including the GM, and will be disclosed by appraisal. ESS2 - Labor and Working Conditions Relevant [Optional Explanation - Max. character limit 1,000] The project may include government civil servants at the Ministry of Public Health (MoPH) who will be members of the project implementation team. ESS2 will not apply to such government civil servants, except for the provisions of paragraphs 17 to 20 (Protecting the Work Force) and paragraphs 24 to 30 (Occupational Health and Safety. The project will include: (i) direct workers who will be comprised of the consultants of the project management unit at the Ministry of Public Health (ii) contracted workers involved in the rehabilitation of health facilities and the purchasing of drugs IT and medical equipment under component 1 as well as the contracted health workers at the PHCCs; and, iii) primary supply workers who will provide goods and materials for the construction materials essential for the project For Official Use Only on an ongoing basis. The MoPH will prepare stand-alone Labour Management Procedures (LMP) which will be cleared and disclosed during project implementation as per the ESCP. ESS3 - Resource Efficiency and Pollution Prevention and Management Relevant [Optional Explanation - Max. character limit 1,000] Potential civil works planned for the health facilities could consume raw and construction materials (paints, basalt, cement, sand, wood, iron, etc.). Rehabilitation works might have potential impacts on air, dust, land and water pollution as well. Should the project utilize raw materials for construction activities, the material will be sourced through measures specified in the EHSGs and other Good International Industry Practices (GIIPs). In keeping with ESS3, the MoPH PMU will develop and implement appropriate mitigation measures—as well as technically and financially feasible resource efficiency and pollution prevention measures—within the instruments that will be prepared prior to launching of activities in keeping with mitigation hierarchy. Medical waste management will be of importance under the project. Informal disposal, and e-waste, may lead to contamination of soil and groundwater. As per MoPH, all health facilities have contracted a specialist company to handle their waste. ESS4 - Community Health and Safety Relevant [Optional Explanation - Max. character limit 1,000] Rehabilitation activities will result in impacts on traffic routes to and from construction sites and at quarries. Site- specific environmental & social assessments that will be prepared prior to activities implementation for each subproject will outline the necessary measures to restrict community access to the construction sites during the work Nov 29, 2023 Page 6 of 10 The World Bank Lebanon: Health Transformation Project (P180452) period, and all the other measures needed to keep communities safe during construction. Site-specific instruments will make use of general and sector-specific Environment, Health, and Safety Guidelines (EHSGs) for the identified subprojects in relation to community health and safety. Works contracts will also require that contractors do not expose communities to any hazardous activities, materials or substances used in the project. A road safety assessment will be carried out, and measures to protect health of workers and communities from medical and e-waste. An SEA/SH Action Plan will also be prepared during implementation. ESS5 - Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant [Optional Explanation - Max. character limit 1,000] This ESS is not currently relevant ESS6 - Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources [Optional Explanation - Max. character limit 1,000] This ESS is not currently relevant ESS7 - Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Not Currently Relevant Local Communities For Official Use Only [Optional Explanation - Max. character limit 1,000] This ESS is not currently relevant ESS8 - Cultural Heritage Not Currently Relevant [Optional Explanation - Max. character limit 1,000] This ESS is not currently relevant ESS9 - Financial Intermediaries Not Currently Relevant [Optional Explanation - Max. character limit 1,000] This ESS is not currently relevant B.2 Legal Operational Policies that Apply OP 7.50 Operations on International Waterways No OP 7.60 Operations in Disputed Areas No Nov 29, 2023 Page 7 of 10 The World Bank Lebanon: Health Transformation Project (P180452) B.3 Other Salient Features Use of Borrower Framework No [Optional explanation – Max. character limit 1,000] No Borrower framework will be used at this stage Use of Common Approach No [Optional Explanation including list of possible financing partners – Max. character limit 1,000] No FIs are involved in the implementing of this project. 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 Concept Stage PID – Max. character limit 5,000] The potential environmental and social impacts and risks are those related to works (mainly rehabilitation of health facilities), the purchasing of IT equipment, and drugs and the potential for weak communication of project activities and benefits thus excluding beneficiaries of the project. The likelihood EHS impacts and risks could be summarized:(i) consumption of energy, water, and building materials (paints, cement, steel, sand, electrical supplies, etc.) for buildings rehabilitation; (ii) the generation of solid waste domestic, demolition, and hazardous waste; (iii) nuisance, related to dust generation, vibration, and noise; (iv) occupational health and safety (OHS) workforce hazards, including the increased For Official Use Only risk of accident from inadequate working conditions at construction sites and from covid-19 infection; (v) community health and safety (CHS) hazards results from work activities particularly for residents settle beside the proposed rehabilitation facilities; (vi) Increasing traffic jam; (vii) poor management of medical healthcare waste and e-waste. Accordingly, at this early stage of the project and until the above activities are confirmed, the environmental risk rating has been determined to be Moderate, and this will be visited during the preparation when there is more clarity on the exact activities. The social risk classification for this project is “moderate”. The project is mostly associated with positive social impacts as it will implement reforms to improve the health sector in terms of its efficiency and capacity and it will protect healthcare coverage for the vulnerable populations including the poor Lebanese, those listed on the social registry, and displaced persons including refugees. In addition, it will introduce unique health IDs and will develop and adopt a national e-health strategy which will empower citizens with access to their personal health data and information. Moreover, it will support citizen engagement and empowerment. That being said it is associated with the following adverse potential social risks i) ineffective communication of project activities and benefits and weakly functioning grievance mechanism which may result in miscommunication of project activities; (ii) exclusion of beneficiaries of project particularly the more vulnerable targeted populations; (iii) potential SEA/SH of women poor beneficiaries and amongst project workers including contracted health workers. Nov 29, 2023 Page 8 of 10 The World Bank Lebanon: Health Transformation Project (P180452) 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 Appraisal? [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 3,000] In addition to SEP, and ESCP that would be prepared by appraisal, the following actions/instruments are expected to be prepared by the borrower during project implementation and prior to commencement of project activities as per the provisions of the ESCP: 1. Preparation and Implementation of the sub-project project specific ESIAs/ESMPs in a timely manner and integration of the recommended ESMP in the bidding documents. 2. Ensuring the implementation of the SEP and LMP, grievance mechanism and their updating as needed. 3. Preparation and implementation of the SEA/SH Prevention and Response Plan; For Official Use Only 4. Ensuring that each contractor prepares and implements site specific/ design specific ESMPs. 5. Health Sector Strategic Environmental and Social Assessment (SESA) for the activities under PBC 1, 5, and 8 to inform the potential environmental and social impacts resulting from the drafting of policies, programs, plans, strategies; the SESA will be prepared under ESS1 during implementation as per the provisions of the ESCP. 6. Dedicated E&S specialist to be recruited as part of the PMU/ MoPH before commencement of project activities to ensure implementation of ESF requirements, preparation of E&S instruments, implementation of ESIA/ ESMP measures, overall monitoring of ESS implementation and identification and implementation of corrective measures where needed. III. CONTACT POINT Contact Point Task Team Leader: Ronald Eduardo Gomez Suarez Title: Senior Economist, Health Email: rgomezsuarez@worldbank.org TTL Contact: Son Nam Nguyen Job Title: Lead Health Specialist Email: Snguyen@worldbank.org Nov 29, 2023 Page 9 of 10 The World Bank Lebanon: Health Transformation Project (P180452) 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): Ronald Eduardo Gomez Suarez, Son Nam Nguyen ADM Environmental Specialist: Ahmed Hassoon Ali Al-Saedi ADM Social Specialist: Noushig Chahe Kaloustian For Official Use Only Nov 29, 2023 Page 10 of 10