INTEGRATED SAFEGUARDS DATA SHEET APPRAISAL STAGE Report No.: ISDSA1027 Public Disclosure Copy Date ISDS Prepared/Updated: 28-Aug-2014 Date ISDS Approved/Disclosed: 02-Sep-2014 I. BASIC INFORMATION 1. Basic Project Data Country: India Project ID: P148531 Project Name: Uttarakhand Health Systems Development Project (P148531) Task Team Somil Nagpal Leader: Estimated 02-Sep-2014 Estimated 15-Jan-2015 Appraisal Date: Board Date: Managing Unit: GHNDR Lending Investment Project Financing Instrument: Sector(s): Health (75%), Non-compulsory health finance (15%), Public administration- Health (10%) Theme(s): Health system performance (50%), Child health (20%), Injuries and non- communicable diseases (20%), Other Financial Sector Developmen t (10%) Is this project processed under OP 8.50 (Emergency Recovery) or OP No 8.00 (Rapid Response to Crises and Emergencies)? Public Disclosure Copy Financing (In USD Million) Total Project Cost: 125.00 Total Bank Financing: 100.00 Financing Gap: 0.00 Financing Source Amount BORROWER/RECIPIENT 25.00 International Development Association (IDA) 100.00 Total 125.00 Environmental B - Partial Assessment Category: Is this a No Repeater project? 2. Project Development Objective(s) The PDO is to improve access to quality health services, particularly in the hilly districts of the state, and to expand health financial risk protection for the residents of Uttarakhand. 3. Project Description Page 1 of 8 The proposed project will be implemented over six years, wherein the first year will be a ‘startup year’ with a focus on commencing the revised design of Public-Private Partnership (PPP) service delivery, setting up its performance measurement system and undertaking evidence-based design of Public Disclosure Copy the integrated networked model, the health helpline system and RSBY primary care packages. This will go concurrently with strengthening the state’s capacity to implement the project. The initial rollout of the innovations in years 1 and 2 will be undertaken in a limited geographical area, with a scale-up planned by year 4. The proposed project will have two components: a) Innovations in engaging the private sector (for integrated service delivery and for health financing), and b) Stewardship and system improvement to enable innovations in engaging the private sector. A description of the activities under the two proposed project components is provided below. Component 1. Innovations in engaging the private sector (total amount: US$100 million, including IDA US$ 80 million and GoUK US$ 20 million): Innovations in engaging the private sector is the main project component that aims to create a conducive policy and institutional environment to stimulate and finance innovative engagement with the private sector in the delivery of healthcare services as well as in healthcare financing. This component will expand access to services by creating integrated, technology-enabled health system architecture with enhanced focus and availability of primary care, emergency care and necessary referral services. It will also expand financial protection by defining a benefit package of primary care services for child and adolescent care and for the management of non-communicable diseases. Component 1 comprises of two sub- components: • Innovations in integrated delivery of healthcare services (primary, referral and emergency care) (total amount: US$65 million, including IDA US$ 52 million and GoUK US$ 13 million): The objective of this sub-component is to improve access to an integrated network of primary care, referral services and emergency care in the state through engaging the private sector. The Bank’s Public Disclosure Copy support will focus on: (i) supporting the development of a conducive regulatory, policy and institutional environment to support ongoing and new PPPs as well as new investments in the state , especially in the remote areas; (ii) reviewing and restructuring ongoing PPPs for community health centers (CHCs) and mobile health vans; (iii) supporting the development of new PPPs as integrated networks of mobile health vans, outsourced CHCs as well as government-run CHCs, and specialist services and defined clinical and diagnostic services at the district hospitals. This will initially be taken up in 2-4 selected districts and backed up by the development of an information network promoting a patient centric health system, which would help patients navigate across different levels of care across public and private providers, as well as create linkages to financing entities such as RSBY/MSBY. The component will also finance a toll-free health helpline providing health information and advice, and enabling a technology-enabled integration and coordination of services offered by the health system. • Innovations in Healthcare Financing (total amount: US$35 million, including IDA US$ 28 million and GoUK US$ 7 million): This sub-component supports the expansion of primary care coverage into the state’s health insurance programs (RSBY and MSBY) by designing, implementing and evaluating benefit packages around childhood and adolescent health as well as case management of NCDs in primary care settings, purchasing care from public as well as private providers. The project will support the state with evidence and global knowledge to make key decisions on the Page 2 of 8 specifics of expanded benefit packages, provider payment mechanisms, payment rates, provider empanelment criteria (including the balance between access, quality and other provider characteristics), and interface with the existing hospital coverage. It will finance the costs of an Public Disclosure Copy implementation support agency, as well as reimburse the claims paid for primary care services and, subsequently, finance the competitively determined premium paid for the primary care coverage provided under the state’s health insurance programs. Achieving this expansion will need to begin addressing bottlenecks facing the current implementation of RSBY, addressing enrolment challenges as well as shortcomings from the supply side. The state’s expansion of RSBY into primary care will also be necessarily phased. Expanded packages will be piloted in a small number of districts. The first-phase coverage expansion is proposed to start with child health services, with a plan to expand in the next phase to non- communicable diseases. Component 2. Stewardship and system improvement (total amount: US$25 million, including IDA US$ 20 million and GoUK US$ 5 million): This component aims to strengthen the government’s ability to engage effectively with the private sector and therefore to enable the government to provide effective stewardship to the entire health system and particularly in its capacity to effectively pursue the innovations being proposed under this project. The component will focus on strengthening the institutional structures for stewardship and service delivery and augmenting the state’s human resource capacity, so that the necessary skillsets required for effective implementation of the project and the state’s health programs are available. The strengthened capacity financed by this component will serve beyond the activities of this project, as it will contribute to the government’s stewardship role for the health system as a whole. It will also promote the establishment of a governance structure and regulatory system for improving quality of care at all levels to ensure that services provided by public and private providers are of good, comparable quality. It will support research and evidence generation, use of evidence for strategic planning, and improved information systems for data generation and management, including timely feedback to providers. Finally, the component will promote a multidisciplinary approach that will Public Disclosure Copy strengthen the ability of the health system to respond to seasonal and context-specific needs. For instance, specific activities under the project would include detailed planning for the potential redeployment of mobile health vans as trauma centers in case of natural disasters, in close coordination with the disaster response mechanisms being strengthened under an existing Bank- financed project. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project will benefit the residents of the entire state of Uttarakhand, and in particular those residing in the remote, hilly and rural areas with poor availability of health services. Successful implementation of the project will have a particularly positive impact on the underserved population (women, elderly and communities living in remote areas). The strengthened availability of primary care services and improved disaster response capabilities will also support the very large floating population that visits the state for business, pilgrimage and tourism. Discussions with stakeholders on innovative approaches for hilly/remote areas will also be undertaken 5. Environmental and Social Safeguards Specialists Ruma Tavorath (GENDR) Susrutha Pradeep Goonesekera (GURDR) Page 3 of 8 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/ Yes The nature of this project provides opportunities Public Disclosure Copy BP 4.01 to enhance the sanitation, hygiene and infection control and waste management systems and processes in the state so as to further promote sound public health outcomes, while also ensuring that there are no adverse impacts to the environment. Provision of good health services requires maintenance of clean and hygienic healthcare facilities, with adequate supply of clean, potable water and proper systems for sanitation, infection control and healthcare waste management. The OP is triggered to ensure that appropriate mitigatory measures are put in place to address potential negative impacts from the above. Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources OP/ No BP 4.11 Indigenous Peoples OP/BP 4.10 Yes The indigenous people are categorized as tribal in the Indian context and the tribal population in UK Public Disclosure Copy (many of whom reside in the hilly and remote areas) constitutes a little over 3 percent of the State’s total population. The project aims to enhance access and equity of health services to all underserved populations of the state. Thus, taking into account the findings of the Social Assessment, a draft IPP is currently being developed and will be disclosed as appropriate. The core actions coming out of the IPP will also be incorporated into the project ESMP. Involuntary Resettlement OP/BP No 4.12 Safety of Dams OP/BP 4.37 No Projects on International No Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP No 7.60 Page 4 of 8 II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues Public Disclosure Copy 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: Environment: Sound hazardous solid and liquid waste management is necessary to prevent spread of infections such as HIV, Hepatitis and other viral or bacterial infections, which pose huge risk to public health. Improper occupational practices and unsafe handling of infectious waste potentially expose health care workers, waste handlers, patients and the community to infection and injuries. Open and uncontrolled slow burning of mixed waste which includes plastic waste produces emissions, such as dioxins and furans, which can be potentially carcinogenic. An integrated approach towards better sanitation, hygiene and infection management will support the project objective in providing cleaner health facilities and providing high-quality health services. The project has prepared an Environment and Social Management Plan which focuses on instituting systems to ensure that public and private sector and mobile services are in compliance with national GOI regulations related to infection control and infectious waste management. The ESMP details capacity building in good practices and emphasizes multisectoral coordination. The ESMP was consulted with key stakeholder agencies and disclosed prior to appraisal. Social: As per the design, the project will support interventions to strengthen State health systems to expand universal health coverage, ensuring affordable and high quality health care for all. Successful implementation of the project will have a positive impact, particularly on the underserved, indigenous population (including women, elderly and communities living in remote, hilly and rural areas with poor availability of health services). In terms of demographic and health status, Uttarakhand (UK) performs better than the national average of many key indicators. However, there remains room for substantial improvement in several areas. The overarching issue that determines utilization of services and health outcomes appears to be the difficult geographical Public Disclosure Copy terrain. A second important issue is the inter-district variation in disease prevalence. Low awareness of health issues amongst communities is a third issue that needs to be addressed. The declining sex ratio, particularly in certain districts of the State, is also a cause for concern. Last but not least, the difficult terrain (among other things) has had a negative impact on availability of human resources in the health sector in UK. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: NA 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. NA 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 consultations with communities, representatives from health departments, women and child development department, NGOs working in tribal areas and field visits to some of the health facilities revealed the key issues faced by the tribal communities in UK. Widespread poverty, low levels of literacy, malnutrition, lack of personal hygiene, limited access to safe drinking water, lack of sanitary living conditions and health education, poor access to maternal and child health services and ineffective coverage by national health and nutritional services were identified as the Page 5 of 8 main concerns. Due to poverty, poor accessibility of health services and various socio-cultural beliefs, when these populations fall ill, home remedies are the first resort. Only when symptoms don’t subside, help is sought from traditional healers. Illnesses are generally viewed as a curse for Public Disclosure Copy which Gods have to be appeased by making offerings. Based on discussions with various stakeholders that have a direct link to health care delivery mechanisms, an indigenous people’s plan (IPP) is being developed to address the specific issues faced by the indigenous population. The IPP will be developed keeping in mind the status of the tribal population and, as a result, will ensure positive impacts. The IPP would be tied to the project implementation plan and will be implemented by the Uttarakhand health and Family Welfare Society (UKHFWS) constituted under the Department Health and Family Welfare. The mission director for the National Health Mission (NHM) will also be the project administrator for UKHSDP and will lead the project implementation under the overall guidance of the Principal Secretary, Department of Medical Health and Family Welfare, who is also the Chairman of the society (UKHFWS), The project team consists of focal points for each of the key implementation areas supported by a core group of experts and support staff. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. The key stakeholders consulted during the Social Assessment (SA) included representatives from the Health Department, Department of Women and Child Development, NGOs working in tribal areas, health care providers and the members of the various tribal communities. The SA used Secondary data review and qualitative tools to get feedback of the primary and secondary stakeholders. The study used SA Schedules to get information from the State / District and the community. Focus Group Discussions and Key informants interviews were conducted to collect details from the stakeholders. The ESMP and the IPP were publicly disclosed on the Department of Health and Family Welfare website by 19 August, 2014 and submitted for disclosure at Infoshop by 29 August, 2014. Public Disclosure Copy B. Disclosure Requirements Environmental Assessment/Audit/Management Plan/Other Date of receipt by the Bank 18-Aug-2014 Date of submission to InfoShop 28-Aug-2014 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors "In country" Disclosure India 28-Aug-2014 Comments: The ESMP has been disclosed on the UKHSDP project website August 28, 2014. Indigenous Peoples Development Plan/Framework Date of receipt by the Bank 18-Aug-2014 Date of submission to InfoShop 28-Aug-2014 "In country" Disclosure India 19-Aug-2014 Comments: The PPP has been disclosed on the UKHSDP project website August 28, 2014. If the project triggers the Pest Management and/or Physical Cultural Resources policies, the Page 6 of 8 respective issues are to be addressed and disclosed as part of the Environmental Assessment/ Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: Public Disclosure Copy C. Compliance Monitoring Indicators at the Corporate Level OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) Yes [ ] No [ ] NA [ ] report? If yes, then did the Regional Environment Unit or Practice Yes [ ] No [ ] NA [ ] Manager (PM) review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated Yes [ ] No [ ] NA [ ] in the credit/loan? OP/BP 4.10 - Indigenous Peoples Has a separate Indigenous Peoples Plan/Planning Framework Yes [ ] No [ ] NA [ ] (as appropriate) been prepared in consultation with affected Indigenous Peoples? If yes, then did the Regional unit responsible for safeguards or Yes [ ] No [ ] NA [ ] Practice Manager review the plan? If the whole project is designed to benefit IP, has the design Yes [ ] No [ ] NA [ ] been reviewed and approved by the Regional Social Development Unit or Practice Manager? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the Yes [ ] No [ ] NA [ ] World Bank's Infoshop? Have relevant documents been disclosed in-country in a public Yes [ ] No [ ] NA [ ] Public Disclosure Copy place in a form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional Yes [ ] No [ ] NA [ ] responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included Yes [ ] No [ ] NA [ ] in the project cost? Does the Monitoring and Evaluation system of the project Yes [ ] No [ ] NA [ ] include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed Yes [ ] No [ ] NA [ ] with the borrower and the same been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader: Name: Somil Nagpal Approved By Page 7 of 8 Practice Manager/ Name: Julie McLaughlin (PMGR) Date: 02-Sep-2014 Manager: Public Disclosure Copy Public Disclosure Copy Page 8 of 8