89717 INTEGRATED SAFEGUARDS DATASHEET APPRAISAL STAGE I. Basic Information Date prepared/updated: July 25, 2014 1. 1. Basic Project Data Original Project ID: P102284 Original Project Name: Cambodia Second Health Sector Support Program Country: Cambodia Project ID: P150472 Project Name: Task Team Leader: Laura L Rose Estimated Appraisal Date: July 15, 2014 Estimated Board Date: N/A Managing Unit: GHNDR Lending Instrument: Investment Project Financing Sector: Health (44%); Central government administration (24%); Sub-national government administration (24%); Other social services (4%); Compulsory health finance (4%) Theme: Health system performance (33%); Administrative and civil service reform (17%); Child health (17%); Population and reproductive health (17%); Participation and civic engagement (16%) SPF Amount (USD million): 0 GEF Amount (USD million): 0 PCF Amount (USD million): 0 Page 1 Other financing amounts by source: Borrower 0.00 Free-standing Co-financing Trust Fund (USD equivalent) 12.69 12.69 Environmental Category: B - Partial Assessment Simplified Processing Simple [X] Repeater [] Is this project processed under OP 8.50 (Emergency Recovery) or OP Yes [ ] No [X] 8.00 (Rapid Response to Crises and Emergencies) 2. Program Objectives The Second Additional Financing (AF2) for the Second Health Sector Support Program (HSSP2) is prepared to reflect the receipt into the Multi Donor Trust Fund (MDTF) for the total amount of US$12.69 million, raising the total MDTF envelop to US$112.23 million. The AF2 consists of AUD 9.5 million (equivalent to US$8.86 million) from the Australian Government and US$4.5 million from Korean International Cooperation Agency (KOICA). The above additional funds of US$12.69 million exclude US$0.66 million allocated for management and supervision costs administered by the World Bank. The HSSP2 objective is to support the implementation of Cambodia’s Health Strategic Plan 2008 -2015 that aims to ensure improved and equitable access to, and utilization of, essential quality health care and preventive services with particular emphasis on women, children and poor. The original program objective is still valid for the AF2. The AF2 will allow continued support to Health Equity Funds (HEFs) and Service Delivery Grants (SDGs) from July 1, 2014 to March 31, 2015. The original program also finances civil works and medical equipment that have not yet been completed. Therefore, the original program closing date has been extended and the remaining funds will be used in parallel with the implementation of AF2. 3. Program Description The HSSP2 has a health system strengthening focus, with four components that are aligned to the government's Second Health Strategic Plan (HSP2). It includes: Strengthening Health Service Delivery through: (a) the provision of SDGs and contracting for health services at provincial level and below; and (b) investments for the improvement, replacement, and extension of the health service delivery network. Improving Health Financing supports (a) health protection for the poor through the consolidation of HEFs under common management and oversight arrangements and expansion of HEF Page 2 coverage; and (b) the development of health financing policies and institutional reforms. Strengthening Human Resources focuses (a) strengthening pre- and in-service training; and (b) strengthening human resource management in the Ministry of Health (MOH). Strengthening Health System Stewardship Function supports (a) development of policy packages identified, strengthening the institutional capacity (in particular meeting the demands from decentralization and deconcentration); (b) private sector regulation and partnerships; (c) supporting governance and stewardship functions of the national programs and centers overseeing the three HSP2 strategic programs; and (d) empowering new structures for increasing local accountability of health care providers to citizens. The AF2 will support the following:  Component A: Strengthening Health Service Delivery. Financing of SDGs in 36 Special Operating Agencies (SOAs).  Component B: Improving Health Financing. Financing HEFs in 55 Operational Districts (ODs) and expansion into 6 additional ODs. These 61 ODs cover approximately 2.2 million people or nearly 80 percent of the poor in Cambodia. Support to further strengthen and develop an institutional framework for health financing, including making progress toward the establishment of national oversight institutions for HEFs and social health insurance is being supported by a new programmatic health analytic and advisory assistance (P145030).  Component C: Strengthening Human Resources. No additional funding.  Component D: Strengthening Health System Stewardship Functions. No additional funding. 4. Program Location and salient physical characteristics relevant to the safeguard analysis Program coverage will be national. Component A of the program finances SDGs of 36 SOAs in 14 provinces1. The 36 SOAs comprise 10 provincial referral hospitals and 26 ODs. Component B finances HEFs in 61 ODs in 23 provinces2. 1 Prey Veng, Takeo, Koh Kong, Kampong Cham, Tbong Khmum, Oddar Meanchey,Siemreap, Rattanakiri, Mondulkiri, Preah Vihear, Pursat, Battambang, Banteay Meanchey, Stung Treng. 2 Phnom Penh, Prey Veng, Takeo, Koh Kong, Kampong Cham, Tbong Khmum, Kampong Tom, Kampong Chhnang, Sihanouk Ville, Kraite, Svay Rieng, Kampot, Kep, Kampong Speu, Oddar Meanchey, Siemreap, Rattanakiri, Mondulkiri, Preah Vihea, Pursat, Battambang, Banteay Meanchey, Stung Treng. Page 3 5. Environmental and Social Safeguards Specialists Mr Satoshi Ishihara (GURDR) Ly Nareth (GHNDR) Mr. Try Thuon (GURDR) Ruxandra Maria Floroiu (EASER) 6. Safeguard Policies Triggered Yes No Environmental Assessment (OP/BP 4.01) X Natural Habitats (OP/BP 4.04) X Forests (OP/BP 4.36) X Pest Management (OP 4.09) X Physical Cultural Resources (OP/BP 4.11) X Indigenous Peoples (OP/BP 4.10) X Involuntary Resettlement (OP/BP 4.12) X Safety of Dams (OP/BP 4.37) X Projects on International Waterways (OP/BP 7.50) X Projects in Disputed Areas (OP/BP 7.60) X Page 4 II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed program. The Original Program is classified as category B given the activities related to health care facilities construction and purchase of medical items such as syringes, pharmaceuticals, etc, which could generate additional health care waste (HCW) that needs to be properly managed and disposed in line with good practices. The original program triggered the following safeguard policies: Environment Assessment (OP/BP 4.01), Pest Management (OP 4.09), Indigenous Peoples (OP/BP 4.10), and Involuntary Resettlement (OP/BP 4.12). The same safeguard policies were also triggered under the first additional financing (AF1). AF2 does not trigger the safeguard risk on involuntary resettlement (OP/BP 4.12) because no new civil works are planned. However, the Framework for Land Acquisition Policy and Procedures has been updated following lessons learned from HSSP2 and AF1. Implementation of the various safeguard policies triggered – described below – has been satisfactory throughout the program implementation. During the preparation of AF2, the Environment Management Plan (EMP) and Framework for Land Acquisition Policy and Procedures have been updated following lessons learned from the original program and AF1, and the Indigenous People Planning Framework (IPPF) has been updated taking into consideration findings from the social assessment conducted based on free, prior and informed consultations with indigenous people. All were disclosed on June 25, 2014. Environment: AF2 will not finance civil works. However, the AF2 will continue to finance activities that will pose possible environmental risks related to use of pesticides such as for control of vector-borne diseases (e.g. malaria and dengue) and improper management of HCW. HEFs purchase the benefits directly from hospitals and health centers that may use those funds to procure drugs and supplies along with financing administrative costs. SOAs may also use part of their SDGs to support the administrative costs of outreach activities which include using larvicides for dengue control.  HCW. Guidelines under the existing HCW Generation and Management Plan are deemed adequate for AF2 activities and compliance during HSSP2 has been good. The Guidelines incorporate best HCW management practices and are intended for practical Page 5 application at health care facilities. Training on the Guidelines has been provided to health facility staff all over Cambodia by Department of Hospital Services of the MOH. Compliance with the guidelines will continue to be monitored during regular program supervision, particularly maintenance of incinerators. Health facilities are expected to finance any cost associated with implementing the guidelines from the HEF payment and SDGs to the facility for health benefits.  Pest Management. Control procedures are set out in the Pest Management and Monitoring Plan. The program only supports purchase of larvicides (Abate/BTI) for dengue control. These are considered to pose very low risks to humans if used correctly and certified by WHO’s Pesticide Evaluation Scheme (WHOPES). The products are transported in safe containers provided by the vendors and used containers are disposed of according to best practice; they are not used for storage or other purposes. Social: Ill health is a leading cause and consequence of poverty in Cambodia. Health care remains for many expensive, of poor quality and difficult to access. Key social development issues pertaining to health in Cambodia, include: (i) uneven distribution of growth and significant difference between urban and rural and rich and poor households' access to health services and outcomes; (ii) different health needs and challenges among women and men; (iii) high vulnerability to poor health and poverty among the poor and ethnic minorities and in remote and difficult to access areas; and (iv) limited capacity for community participation in health service delivery. HSSP2 aims to ensure improved and equitable access to essential quality health care and preventative services. Target beneficiaries are women, children and the poor, all of whom are exposed to high health risks and are disadvantaged in accessing affordable health care. Given the program's focus on maternal and child health, children and women of reproductive age in particular are expected to benefit from the program, which will extend the health network and making it more affordable. During the implementation of HSSP2 and the first additional financing (AF1), measures were taken to address constraints of access to health care services identified by the indigenous peoples (IP). During the preparation of AF2, social assessments (including free, prior and informed consultations with IP communities) were conducted which confirmed continued support of IP communities to program activities. The Framework for Land Acquisition Policy and Procedures prepared during the preparation Page 6 of HSSP2 was updated for AF2 taking into account the lessons learned from the HSSP2 and AF1, and findings from social assessment undertaken during this AF preparation.  IP. The social assessment conducted during the preparation of AF2 found that IP communities still face particular challenges in accessing health services and tend to be particularly vulnerable to poor health. Many minority groups live in rough-terrain - highland and border areas that are hard to reach, and are generally poorer than average. The sheer physical geography of these settings poses special challenges, as well as costs, in terms of accessing, providing and maintaining health care services. The IPPF developed under HSSP2 has been updated under AF2. The nature, scale and scope of impact that may occur on IP under AF2 are expected to be the same as those under HSSP2, and IP communities will continue to benefit from the program. During the implementation of HSSP2 and AF1, steps were taken to address issues found during preparation based on the free, prior and informed consultations with affected IP communities. Such measures include: (i) building technical capacity of health facility staff at primary care level for providing quality health services to IP; (ii) providing SDGs, particularly to areas where most IP reside to improve the functioning of health facilities- 24 hours opening and improve staff attendance so that IP can access to health care services at any time as needed; (iii) financing health outreach activities so that IP in remote and difficult to access communities can receive basic preventive and curative services; (iv) establishment of HEFs to pay for health care services on behalf of poor IP; and (v) construction of new health facilities for bringing health services closer to IP. Regular exit interviews were conducted with users, including those from ethnic minorities as part of the implementation of HSSP2 and AF1, which found that they are satisfied with the services provided and that no negative impacts occurred to them under the program.  Involuntary Resettlement. This safeguard risk is not triggered under AF2 as no civil works will be financed. However the Land Acquisition Framework Policy and Procedures developed under the original program has been updated anticipating a potential third AF3 that could trigger the policy. A comprehensive review of land acquisition conducted during the original program carried out by MOH under the support of the World Bank confirmed that almost all construction sites were on state land. In a few instances, private land was acquired (either through voluntary donations or land swap, or against compensation at market prices agreeable to affected people), as per provision of the Land Acquisition Framework Policy and Procedures. According to the inventory, all plots of land acquired were less than 5 percent of the owners' properties, and no physical relocations took place. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the program area: No negative long-term impacts are foreseen. Page 7 3. Describe any program alternatives (if relevant) considered to help avoid or minimize adverse impacts. Not applicable. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. The MOH carried out social assessments including free, prior and informed consultations with IP communities during the preparation of AF2, and updated the IPPF based on the findings as well as the experience of HSSP2 and AF1. The Land Acquisition Framework Policy and Procedures was also updated in anticipation of the planned civil works under a possible third additional financing to the HSSP2 which might finance civil works. The MOH has gained some good experience implementing World Bank- financed programs with its specific requirements such as those under the World Bank’s policies triggered by this AF2. The MOH, with support from the World Bank, will continue to provide training to relevant stakeholders in implementation of the safeguard policies triggered by the program. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The primary stakeholders of the program are MOH policy makers, program planners and managers who will benefit from systems strengthening and capacity building activities, as well as from the program's endorsement of the MOH's HSP2. Ministry of Economy and Finance continues to play an important role during implementation and monitoring. Civil society and communities also play important roles in the monitoring of services to increase public accountability. Civil society members are invited to attend important bid openings and contract awards. Exit surveys at health facilities will continue to be carried out which will further improve accountability to users of services supported by the AF2. The Government updated their website on June 25, 2014 to take into account the AF2 investments and disclosed the updated safeguard instruments. Page 8 B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 6/24/2014 Date of "in-country" disclosure 6/25/2014 Date of submission to InfoShop 6/25/2014 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Resettlement Action Plan/Framework/Policy Process: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 6/24/2014 Date of "in-country" disclosure 6/25/2014 Date of submission to InfoShop 6/25/2014 Indigenous Peoples Plan/Planning Framework: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 6/24/2014 Date of "in-country" disclosure 6/25/2014 Date of submission to InfoShop 6/25/2014 Pest Management Plan: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 6/24/2014 Date of "in-country" disclosure 6/25/2014 Date of submission to InfoShop 6/25/2014 * If the project triggers the Pest Management and/or Physical Cultural Resources, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/Audit/or EMP. Page 9 If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? Yes If yes, then did the Regional Environment Unit or Sector Manager (SM) review and Yes approve the EA report? Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes OP 4.09 - Pest Management Does the EA adequately address the pest management issues? Yes Is a separate PMP required? No If yes, has the PMP been reviewed and approved by a safeguards specialist or SM? Yes Are PMP requirements included in project design? If yes, does the project team include a Pest Management Specialist? OP/BP 4.10 - Indigenous Peoples Has a separate Indigenous Peoples Plan/Planning Framework (as appropriate) been Yes prepared in consultation with affected Indigenous Peoples? If yes, then did the Regional unit responsible for safeguards or Sector Manager Yes review the plan? If the whole project is designed to benefit IP, has the design been reviewed and N/A approved by the Regional Social Development Unit or Sector Manager? OP/BP 4.12 - Involuntary Resettlement Has a resettlement plan/abbreviated plan/policy framework/process framework Yes (as appropriate) been prepared? Page 10 If yes, then did the Regional unit responsible for safeguards or Sector Manager Yes review the plan? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank's Yes Infoshop? Have relevant documents been disclosed in-country in a public place in a form and Yes language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been Yes prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included in the project cost? Yes Does the Monitoring and Evaluation system of the project includes the monitoring Yes of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed with the borrower Yes and the same been adequately reflected in the project legal documents? Page 11 D. Approvals Signed and submitted by: Name Date Task Team Leader: Laura L. Rose Environmental Specialist Try Thuon Social Development Specialist Satoshi Ishihara Ly Nareth Additional Environmental and/or Ruxandra Floroiu Social Development Specialist(s): Approved by: Practice Manager: Toomas Palu Comments: This ISDS is for the additional financing to the MDTF. The project scope is limited to financing HEFs and SDGs. There are no changes in safeguard policies and arrangements. Page 12