Cambodia - Health Sector Support Project

ISDS THE WVORLD BANK GROUP A World Free of Poverty InfoShop Ih 1,1w >1.,m K, Integrated Safeguards Data Sheet (Initial) Date ISDS Prepared/Updated: 10/07/2002 24964 Section I - Basic Information October 7, 2002 A. Basic Project Data Country: CAMBODIA Project ID: P070542 Project: Health Sector Support Project Task Team Leader: Vincent Turbat Authorized to Appraise Date: October 2, 2002 IBRD Amount ($m): Bank Approval: December 19, 2002 IDA Amount ($m): 17.20 Managing Unit: EASHD Sector: Health (75%); Sub-national government Lending Instrument: Sector Investment & Maintenance administration (13%); Central government Loan (SIM) administration (12%) Status: Lending Theme: Fighting communicable diseases (P); Health system performance (P); Administrative and civil service reform (P) I.A.2. IProject Objectives: The objective of this project is to contribute to the improvement of the health status of the population by: (a)increasing the accessibility and the quality of health services; and (b) supporting the GOKC's health sector reform process and strengthening the sector's capacity to manage resources efficiently. The project's specific objectives are to: (i) develop affordable quality health services with emphasis on primary health care and first referral services in rural areas; (ii) increase the utilization of health services by the poor; (iii) mitigate the effects of infectious disease epidemics and of malnutrition; and (iv) improve the health sector's capacity and performance. I.A.3. Project Description: The proposed WB-HSSP design responds to: (a) Borrower's explicit demand to use the IDA credit to launch and implement the Health Sector Strategic Plan for 2003-2007 using a sector-wide management approach (SWIM) and (b) Bank's and other donors' concern with the complexity of such an approach for which the sector does not posses the entire required capacity. Consequently the WB-HSSP includes: (i) the commitment to strengthening sector capacity (to which ADB and DFID but also WHO,  2 ISDS GTZ and all other partners will also contribute through their financing and programs); and (ii) the agreement that while activities have been identified and costed for the entire duration of the project, starting with the third year of the HSSP (and using the Annual Review and Operational Planning process adopted by the Borrower to operationalize the Health Sector Strategic Plan), adjustments or new allocations will be made depending upon the needs of the sector and the level of available funding in each respective year. Further, both to examine progress in the achievement of development objectives and to help HSSP adapt, in management terms, to an annual review and planning process, the HSSP mid-term review is scheduled to take place at the end of the second HSSP year of implementation. The project aims at improving the health status of the population by providing support for: (a) reforming Cambodia's health sector; (b) strengthening the sector's capacity to manage resources efficiently; and (c) improving the performance and the quality of health services. In particular, the project will focus on equity in the utilization of health services by the poor, by improving the accessibility and affordability of health services and by increasing the demand for such services amongst underserved groups. Utilization rates of various income groups will be monitored during project implementation and changes in health outcomes evaluated. While supporting the sector-wide feature of the GOKC program for the health sector, the WB-HSSP will also focus on specific priority areas, including: (a) Longer term activities requiring a sustained, coordinated approach, e.g., infrastructure development, equipment and maintenance, pharmaceuticals (essential drugs) and human resource development; (b) Proven cost-effective interventions, relevant to the situation in Cambodia and to which the Bank and its partners are committed, specifically: (i) poverty alleviation (development of quality affordable services for the poor and of different arrangements to protect the use of services by the poor, women and children); and (ii) reduction of major public health problems (such as: infectious diseases in general, and TB, malaria, dengue, and HIV/AIDS in particular, and malnutrition); and (c) Capacity building and health sector reform, especially by addressing issues in areas such as health financing, planning and financial management, and by supporting other activities conducive to allocative efficiency and other efficiency gains, including the decentralization process, generalization of Health Management Agreements (HMAs) to ensure accountability of health providers, donor coordination, and the strengthening of provincial and Operational Districts' (OD) health administrations. Components: (1) Improved Delivery of Health Services (for the benefit of the poor and rural populatiori. Under this component the project will provide support to increase: (1.1) Accessibility and quality of health services The first objective of this sub-component is the continued development of primary health care facilities and first referral and provincial hospitals, by financing civil works (rehabilitation and new constructions), equipment, and maintenance. A health infrastructure development plan will be developed with HSSP financial support and Bank assistance will focus on rural and remote provinces. This plan will ensure that: (i) investments in infrastructure take into account Cambodia's potential to cope with the recurrent expenditures entailed by such investments; and (ii) the siting of health facilities to be constructed or rehabilitated under HSSP is  3 ISDS decided on sound criteria (such as accessibility, utilization rates, health needs, and proximity to private facilities). Other issues such as equipment needs and maintenance services will also be supported, inter alic4, by establishing maintenance workshops in districts, and by providing training and technical assistance. The project will also help reduce, through this and other components, some of the current problems with the availability of health providers (very important in rural areas and remote provinces), skill and motivation. The project will support activities to improve the quality of services by providing financial resources to carry out the training of the minimum and complementary packages of activities (MPA and CPA) and particularly, in collaboration with WHO, of the MPA Module 3 (Child Health/IMCI). Other project components will also support MPA/CPA training e.g., Nutrition, Infectious disease control. The project will also help the MOH to establish a Quality Improvement/Quality Standards unit and to finance the activities of this unit after its inception. In collaboration with GTZ, the project will support QA activities in the three districts of the Kampong Thum province. This will include training, supervision, development of quality indicators and of materials to support the health providers in the delivery of curative and preventive care. HSSP will also provide program support for the establishment of (i) performance-based reward systems and of contracts with health providers, (ii) arrangements to increase user participation in decision making and to assess user satisfaction, and (iii) equity funds to pay for the services delivered to the poor population (the equity funds will be based on the same model as the one adopted in the Sub-component 1.2 and supported financially from it). Lastly, funding will be provided to help solve current problems with drug quality, utilization and availability throughout the health services. Project supported activities related to drugs will ensure that the goal of providing affordable and good quality drugs to the entire population, and of preserving or enhancing the affordability of drugs for the poor, will be reached. These activities will include (i) upgrading the National Drug Quality control laboratory to meet international standards, (ii) carrying out of a feasibility study on cost recovery of drugs and drug revolving funds (DRF), (iii) supplying drug kits to health centers, and first & secondary referral hospitals to meet the needs of the Minimum Package (MPA) and the Complementary Package of Activities (CPA), (iv) strengthening of the capacity of the Food and Drug Department, and (v) carrying out a feasibility study on the establishment of a central drug procurement unit. Other HSSP supported activities (e.g., the expansion of health facilities, the improvement in sector financing and efficiency, the strengthening of MOH capacity and the support to programs addressing main public health problems) will also contribute to the improvement of the drug situation. (1.2) Affordability of health care servicesUnder this sub-component, the credit will finance alternative means to increase the accessibility and improve the affordability of health services for the poor and underserved populations. These include modifications of the recent, innovative donor-supported pilot programs which have been able to mitigate existing deficiencies in management capacity and funding by strengthening local management capacity and increasing sustainable local funding. In addition to activities specifically focused on helping poor individuals and households to afford health services, it should also be noted that the project will also benefit the poor through: (i) development of primary health care (preventive and curative) services; (ii) financing of health facilities in the rural areas of the country; (iii) strengthening of infectious diseases control programs; (iv) development of nutrition activities; and (v) improvement of procurement and distribution of essential drugs. Such strategies are particularly beneficial to the poor who are frequently living in  4 ISDS the remote areas of the country and more often affected by infectious diseases and malnutrition, and who cannot afford to purchase drugs from private pharmacies. Given the credit's emphasis on poor and underserved groups, it will be crucial to monitor access to and affordability of health services for these groups over the life of the project. The project design uses the information provided by initial beneficiary assessment to target the under-served population groups, while the final project evaluation will include a similar assessment as well as the data of two DHS (see also Section A.2). (2) Improved Programs Addressing Public Health Priorities. (2.1) Infectious diseases control programs.The TB, Malaria, Dengue and STI/HIV/AIDS programs will receive support from the project. These interventions are important from an epidemiological standpoint in Cambodia and are consistent with the World Bank Strategy for Health, Nutrition and Population in the East Asia and Pacific Region due to their high cost effectiveness ratios and contribution to equity. Because of their importance on the one hand and their potential to raise grants on the other hand, an agreement was reached to: (i) set aside from the IDA credit US$ 2.2 million for Malaria and US$ 2.7 million for TB, and to make yearly allocations from these amounts depending upon the respective programs' needs and financial gaps (and, if grant financing becomes sufficient, to transfer the unused part of the IDA allocation for Malaria and TB to the Component 1.1); (ii) provide US$ 0.9 million from the IDA credit to finance Dengue control activities and to entrust the execution of the respective set of activities to WHO; and (iii) provide an IDA grant of US$ 2 million to support the activities of the STI/HlIV/AIDS program. Malaria: The project will support the further development of: (a) impregnated bed-nets and hammock-nets program; (b) activities to cope with the emerging problem of parasite drug resistance; (c) case detection (laboratory equipment and training); (d) case management (with emphasis on early treatment of complicated malaria cases, malaria in children and in pregnant women); (e) supervision and improved surveillance; and (f) IEC activities with focus on minority groups and other underserved populations to increase their demand for services. The project will also support the procurement of environmentally safe insecticides to be used for the impregnated bed-nets and hammock-nets program and for indoor spraying (reducing mosquito transmission and containing malaria and dengue epidemics). Dengue: In collaboration with the National Dengue Program and WHO, the project will contribute to this program that aims at strengthening: (i) early diagnosis and appropriate clinical management; and (ii) vector control, in synergy with the malaria program where appropriate. Dengue control activities financed from HSSP will be executed by WHO. The activities that will be financed from the credit will focus on the provision of logistic support for larvicide distribution and training, and the phasing in of more sustainable control strategies (such as impregnated jar lids). Tuberculosis: The project will support the implementation of the TB program's Strategic Plan il its entirety and will focus on: (i) integrating TB activities at health center and district hospital level including the implementation of the Directly Observed Treatment (DOTS) and its further devolution to communities; (ii) increasing the TB case detection rate and reducing the defaulting rate; (iii) improving the laboratory capacity and strengthening supervision and management activities at district and province level and (iv) developing IEC and other activities promoting behavioral change to increase the detection rate and, in particular, the use of services by  5 ISDS underserved populations such as minority groups and the poor in general. HSSP will finance supervision, training, technical assistance, minor civil works, laboratory equipment. Additionally, the HSSP will finance activities in collaboration with the HIV/AIDS program aiming at controlling the spread of TB in AIDS patients and providing better care to the TB/HIV positive patients. STls/HIV/AIDS: The project will support the procurement of STI drugs and the implementation in the field of the "100% condom use" strategy that targets specifically sex workers and other high risk groups and effectively decreases STIs and HIV transmission. (2.2) Nutrition activitiesBecause of the alarmingly high rates of both undernutrition and micronutrient malnutrition in Cambodia and the consequent effect that malnutrition has on morbidity, mortality, educability and productivity, the HSS project will finance an essential package of preventive and curative nutrition activities inducive of behavior changes. The nutrition activities selected to receive financial support from the HSSP have been shown to be the most cost-effective in reducing the developmental and productive problems associated with malnutrition. This essential package includes the following: 1) exclusive breast-feeding for infants 0-6 months; 2) timely and adequate complementary foods for children from 6 months to 2 years of age with contilued breast-feeding until 2 years of age and promotion of an adequate diet for women of reproductive age, particularly pregnant women; 3) appropriate care of sick and malnourished children; 4) provision of iron-folate supplements for women and children; 5) provision of vitamin A for women and children; and 6) availability of iodized salt for all members of the household. (3) Strengthened Institutional CapacityUnder this component, the project will provide appropriate support to ongoing efforts at central, provincial, and district levels to strengthen key health sector functions, including: (a) oversight of the policy, legislative and regulatory framework for health service administration; (b) sector planning and program coordination of health care delivery; and (c) management of sector resources (human, financial, and material including infrastructure, drugs, etc.). An additional function, monitoring and evaluation of sector performance and health status, will be financed jointly by ADB and DFID. (a) Oversight of the policy. legislative and regulatorv framework The project will support: (i) local legal consulting services to help the ministry formulate a legislative program and to draft appropriate legislation; and (ii) translation services and dissemination of information through the production of materials and the organization of workshops for health personnel, local authorities, and public opinion leaders. (b) Sector planning and program coordination. In addition to sector reforms, the Project will: (i) strengthen MOH's capacity for analyzing health sector financing; (ii) develop the planning roles and capabilities at central and decentralized levels; and (iii) reinforce the coordination and monitoring of plan implementation. Specifically, the Project will use the proposed medium-term expenditure framework (MTEF) exercise as the basis for improving health sector financial analysis, introducing a medium-terpianning process, and strengthening annual planning guidelines and procedures. The Project will also support the progressive decentralization of the planning process and the integration of planning and budgeting activities. The project will contribute to the organization of annual sector reviews, which will be carried out by an independent organization, with oversight from a suitable institution within MOH (e.g., NIPH, CoCom, Directorate General for Inspection, etc.) responsible for contracting and  6 ISDS managing the reviews, disseminating the findings, and incorporating them into MOH policy-making and planning processes. (c) Management of sector resources. The Project will assist MOH to solve the present problems with human resources in regard to: (i) manpower planning and management, and (ii) improvement of skills and performance. Based on the Health Workforce Development Plan (1996-2005), the recommendations of the biennial workforce development plan reviews (of 1999 and 2001), the National Policies and Strategies for Human Resources for Health (1999-2003), and the proposed reforms of the National Program of Administrative Reform (NPAR), the Project will support measures to: (a) strengthen manpower planning and personnel management at all levels; and (b) improve the knowledge and skills of health service providers and administrators. In addition to strengthening human resource development, the project would also focus on strengthening financial resource management and procurement capabilities. With respect to financial management, the project will finance: (i) the recruitment and training of financial management staff at central, provincial, and district levels; (ii) the development and implementation of systems acceptable to both the Government and IDA along with a policy and procedures manual; and (iii) the creation of a strong internal audit function within MOH. With respect to procurement, the project will finance: (a) additional staff and training on Bank procurement policy and procedures; and (b) the recruitment of an international procurement advisor and four national procurement consultants to supplement MOH capacity. Additional training for provincial health departments will also be provided if they are to be given responsibility for procuring small contracts for civil works, drugs, other goods and services. (d) Monitoring and evaluation The project (through ADB and DFID financing) would support efforts to improve M&E analytical capabilities and expand its investigative range to include: (i) systematic comparison of the outcomes of the various on-going pilots and experiments (HMAs, contracting in and out, boosting, etc.); (ii) surveillance of health service delivery outside the public sector to provide a comprehensive view of sector-wide change; and (iii) use of the information to improve health sector governance, in particular at the local level (by increasing information to health center management committees, feedback committees, and NGOs. I.A.4. Project Location: (Geographic location, information about the key environmental and social characteristics of the area and population likely to be affected, and proximity to any protected areas, or sites or critical natural habitats, or any other culturally or socially sensitive areas.) The project provinces are: Krong Pailin, Krong Kaeb, Kampot, Banteay Mean Chey, Stueng Traeng, Preah Vihear, Bat Dambang, Otdar Mean Chey, Kampong Spueu, Pousat, Kampong Thum and Kracheh. B. Clheck Environmental Classification: B (Partial Assessment) Comments. C. Safeguard Policies Triggered Policy Applicability Environmental Assessment (OP/BP/GP 4.01) * Yes S No TBD Forestry (OP/GP 4.36) Yes *No TBD Natural Habitats (OP/BP 4.04) .Yes * No . TBD  7 ISDS Safety of Dams (OP/BP 4.37) * Yes _ No TBD Pest Management (OP 4.09) Yes * No . TBD Involuntary Resettlement (OP/BP 4.12) * Yes No . TBD Indigenous Peoples (OD 4.20) * Yes No TBD Cultural Property (OP 4.11) Yes *No TBD Projects in Disputed Territories (OP/BP/GP 7.60)* Yes 0 No TBD Projects in International Waterways (OP/BP/GP 7.50) Yes 0 No TBD *By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties 'claims on the disputed areas Section II - Key Safeguard Issues and Their Management D. Summary of Key Safeguard Issues. Please fill in all relevant questions. If infornmation is not available, describe steps to be taken to obtain necessary data. Il.D.la. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts. Environmental Assessment and Pest Management The environmental impact potentials of the project are limited in scopc and, to the extent that environmental mitigation measures are required, they are relatively simple and well known. An Environmental Review (ER) was carried out to assess the particular environmental and human health impacts with the main focus being on: construction and rehabilitation of health care facilities (HCF) focusing on civil works and drinking water supply; health care waste management (HCWM) practices; and pesticide use in malaria and dengue vector control programs. The ER complied with the provisions of OP/BP/GP 4.01 concerning Environmental Assessment, and reviewed and complied with Cambodia's environmental laws, regulations, policies, and other relevant legislation to ensure that applicable assessment requirements were fully addressed in project implementation. Extensive consultation was sought with MoH, Ministry of Environment, provincial health authorities, and national and international organizations involved in the provision of health care in Cambodia in completing the ER to ensure that potential project impacts were fully understood and appropriate conclusions and recommendations were reached. Particular attention was given to obtaining inputs from targeted provinces and technical programs expected to be involved in HSSP delivery. The recommendations of the ER will be incorporated into the proposed project, including the Project Implementation Plan, Operational Manual, Annual Operational Plans, and Health Infrastructure Development Plan. The Environmental Review Report was publicly disclosed in Phnom Penh, Cambodia on September 20, 2002. The findings summarized by activity are as follows. (a) HCF Construction and Rehabilitation - Review of this activity confirmed that it does not pose any serious environmental concerns and as such will not trigger an assessment under Cambodia's environmental impact assessment (EIA) guidelines. (b) Construction of a new National Laboratory for Drug Quality Control - This activity is expected to trigger additional assessment under Cambodian EIA requirements. Anticipated construction-related environmental impacts are expected to be minimal as the site selected is situated in an existing built urban area of Phnom Penh. No environmentally sensitive areas were identified during a site visit. Potential environmental and human health concerns that were identified relating to laboratory operations include: air emissions containing harmful pollutants; laboratory wastewater disposal; and disposal of hazardous solid laboratory wastes. These aspects of laboratory operations are well understood and readily addressed throughi adoption of industry best environmental management practices.  8 ISDS (c) Drinking Water Quality - Review of the safety of drinking water sources available to HCF identified potential risks associated with microbial water quality and naturally occurring arsenic in groundwater. Microbial water quality represents the most serious human health threat countrywide in Cambodia with infectious diseases and parasites being the most common and widespread health risk associated with drinking water. Available data indicate that overall chemical water quality in Cambodia is generally very high but that elevated arsenic levels are prevalent in some provinces targeted by the WB-HSSP. An additional study of water sources typically used by HCF in WB-HSSP provinces will be conducted prior to commencement of health infrastructure development in the respective province, to ensure that World Health Organization (WHO) guidelines for drinking water are consistently met. (d) Health Care Waste Management (HCWM) - Potential environmental and occupation risks associated with wastes generated by HCF, particularly hazardous chemical and infectious wastes, were reviewed in detail in completing the ER. It was determined that risks are well defined and are readily addressed through adoption of best HCWM management practices encompassing: waste minimization, recycling, and reuse; proper handling, storage and transportation; and treatment of waste by safe and environmentally sound methods. The need to address wastewater, a sub-category of health care waste (HCW), in construction and rehabilitation of HCF was also examined and recommendations made to provide appropriate treatment to avoid human risks associated with discharge of untreated or inadequately treated sewage to the natural environment. (e) Pesticide Use in Vector Control - Review of planned malaria and dengue vector control activities confirmed that insecticide/larvicide to be used in the WB-HSSP have successfully passed WHO's Pesticide Evaluation Scheme (WHOPES). Chemicals currently recommended by WHO pose very low risks to humans if used correctly. Of these Deltamethrine, used in insecticide treated nets (ITN), is considered the least toxic and highly unlikely to cause adverse effects in normal usage. Temperos, used in larviciding of drinking water containers, has a very low toxicity to humans. Although both chemicals are known to be highly toxic to non-target species such as aquatic organisms, environmental risks are limited under normal circumstances where only negligible quantities of these chemicals are likely to be released to the natural environment. Review of existing occupational health and environmental safeguards in place for vector control programs in Cambodia confirmed that there exists a low potential for unintentional release of these chemicals through improper handling or disposal. Indigenous Peoples -- Social Assessment The project aims at improving health outcomes with emphasis on the underserved groups including the rural and urban poor and women. The project will improve accessibility to health services for the lowest income groups by: (a) development of primary health care (i.e., preventive and curative PHC services); (b) financing, with priority, of health facilities in the rural areas of the country; (c) strengthening of infectious diseases control programs; (d) development of nutrition activities; and (e) improvement of procurement and distribution of essential drugs (such strategies offer more benefits to the low-income groups which are frequently living in the remote areas of the country, are more often affected by infectious diseases and malnutrition, and cannot afford to purchase drugs from private pharmacies). Moreover the project will: promote and assess cost recovery for services and drugs but also exemptions and equity funds for the poor; and review and finance, if warranted, the establishment of risk sharing schemes protecting the poor. Increased utilization of health services by the poor and women is one of the project's specific objectives and it will be measured by three performance indicators dealing with the utilization of outpatient services, utilization of hospital services and patient satisfaction. The access to and the  9 ISDS affordability of health services for the low-income groups will be monitored during the life of the project. The project design will use the information provided by an initial beneficiary assessment targeting the under-served population groups, while the project final evaluation will include a similar assessment as well as the data of two DHS. Preparation of the project includes a Social Assessment (SA). The specific objectives are to: (a) assist in project formulation by considering potential impact of proposed activities, how to improve the design of specific interventions and activities, and whether there are activities which should not be included because they are unlikely to work or would have undesirable social impacts; (b) ensure there is an appropriate system for monitoring the impact of the project and mechanisms for the collection of baseline data if recommended; (c) advise on the consultation and participation process required as the programme is developed and implemented, to ensure views of relevant stakeholders (including poor groups) are taken into account and proposals are agreed; and (d) review relevant parts of project documentation to ensure they are appropriate and reflect the findings from social development inputs and stakeholder consultation. SA activities involve six key stages: (a) initial assessment of gaps and planning; (b) study on access to services for ethnic minorities and for other key disadvantaged groups to identify barriers to improving their health and how to address these; (c) stakeholder analysis, to identify their interests, concerns and how they could be affected by proposed programme activities; (d) analysis to assess how well suited key institutions are to their expected roles, and how to strengthen their performance; (e) review of proposed activities and interventions and of baseline data requirements and preparation of a report providing a SA of the project proposals and recommendations for change in the project as a result; and (f) review and strengthening of project documentation required. An initial SA was carried out in November 2001, with a follow-up mission in May 2002. The appraisal mission will include a Social Development Specialist to continue SA activities. Involuntary Resettlement The WB-HSSP includes the continued development of primary health care facilities and first referral and provincial hospitals, by financing rehabilitation and new construction. A health infrastructure development plan will be developed with HSSP financial support, and Bank assistance will focus on rural and remote provinces. This plan will ensure that the siting of health facilities to be constructed or rehabilitated under WB-HSSP is decided on sound criteria (such as accessibility, utilization rates, health needs, and proximity to private facilities). Supported infrastructure projects are small in scale and are expected to cause little or no significant adverse impacts. Nonetheless, since all sites have not been identified, experience shows that such activities sometimes do cause loss of land or loss of access to other resources. Therefore, any land acquisition associated with civil works will be undertaken in accordance with an agreed Framework for Land Acquisition Policy and Procedures. The Framework defines terms and provides guidance for involuntary acquisition of land or other assets (including restrictions on asset use), and establishes principles and procedures to be followed to ensure equitable treatment for, and rehabilitation of, any persons adversely affected. Il.D. l b. Describe any potential cumulative impacts due to application of more than one safeguard policy or due to multiple project component. N/A Il.D. I c Describe any potential long term impacts due to anticipated future activities in the project area. N/A  10 ISDS II.D.2. In light of 1, describe the proposed treatment of alternatives (if required) N/A II.D.3. Describe arrangement for the borrower to address safeguard issues Environmental Assessment and Pest Management Minor environmental concerns that were identified for the WB-HSSP will be fully mitigated in project planning and implementation. The ER prepared for the project describes existing environmental regulations and guidelines relevant to individual FISSP activities to be undertaken and details corresponding environmental screening, appraisal and monitoring requirements. Each WB-HSSP activity has been examined separately for any negative impacts and recommendations made to address all potential human health and environmental concerns. The EMP and PMMP included in the ER detail appropriate safeguards in accordance with the Bank environmental assessment guidelines. Additional technical assistance and capacity building will be provided to the Borrower to complete additional assessment tasks and to ensure proper evaluation and monitoring of WB-HSSP activities to agreed environmental standards on an ongoing basis. Indigenous Peoples -- Social Assessment The Ministry of Health has developed a health development plan to safeguard the health rights of ethnic minorities. The health development plan draws upon the findings of a participatory poverty assessment of indigenous peoples (2001) and complementary project financed research to study the health seeking behaviors and constraints to accessing health services of ethnic minorities. The plan aims to increase the health status of vulnerable ethnic peoples by increasing access to appropriate, quality health services, increasing health knowledge to promote health, and ensuring the participation of ethnic groups in the planning and monitoring of service delivery. The plan rests on a two-pronged strategy. (a) Targeting health development activities at the four northeastern provinces that have large concentrations of ethnic minority peoples, as recommended by the Inter-Ministerial Committee on Ethnic Minority Development; and (b) Mainstreaming attention and responsiveness to the needs and constraints of ethnic minorities through institutional development and capacity building across the public health service. Project preparation also includes an examination of health needs, health seeking behaviors, and constraints to health access faced by different ethnic minority groups in the WB-HSSP provinces of Kracheh and Stueng Traeng. The study includes two stages. Stage 1, which has been conducted, included the collation of existing background information on the main health problems experienced by ethnic minority groups in Kracheh, and the availability of public health services. It also included the collection of health seeking behavior information from a small number of communities specifically looking at where people prefer to go for treatment, and why, and the perceptions people have of public health services and barriers to access they confront. Stage 1 will also contribute to the design of methodologies for the main part of the study to be implemented in Stage 2. Stage 2 will cover the further design of methodologies, implementation, analysis, and initial dissemination of results. This stage of the research project will be completed before project effectiveness. Overall, the study will provide critical information on which to plan health services and demand side interventions to increase access to, and use of health services by these vulnerable groups. Involuntary Resettlement  11 ISDS The WB-HSSP includes the continued development of primary health care facilities and first referral and provincial hospitals, by financing rehabilitation and new construction. A health infrastructure development plan will be developed with WB-HSSP financial support, and Bank assistance will focus on rural and remote provinces. This plan will ensure that the siting of health facilities to be constructed or rehabilitated under WB-HSSP is decided on sound criteria (such as accessibility, utilization rates, health needs, and proximity to private facilities). Supported infrastructure projects are small in scale and are expected to cause little or no significant adverse impacts. Nonetheless, since all sites have not been identified, experience shows that such activities sometimes do cause loss of land or loss of access to other resources. Therefore, any land acquisition associated with civil works will be undertaken in accordance with an agreed Framework for Land Acquisition Policy and Procedures. The Framework defines terms and provides guidance for involuntary acquisition of land or other assets (including restrictions on asset use), and establishes principles and procedures to be followed to ensure equitable treatment for, and rehabilitation of, any persons adversely affected. Il.D.4. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Environmental Assessment and Pest Management Extensive consultation has been undertaken in identifying project-related environmental concerns and in reaching consensus on appropriate mitigation and remediation measures to ensure that all human health and environmental issues are fully addressed. Additional consultation is planned with key stakeholders during project planning and implementation. Stakeholders include: local communities; provincial and operational district government health officials; Ministry of Environment officials at the national and provincial levels; and laboratory and HCF professional staff and administrators. Stakeholder inputs gathered during follow up on-site visits will guide completion of any additional assessment requirements, and refinement of recommended mitigation and remediation measures contained in the EMP and PMMP. Particular emphasis will be given to ensuring that recommendations are practical and sustainable. The Environmental Review Report, including the Environmental Management Plan and Pesticide Management and Monitoring Plan, was publicly disclosed in Phnom Penh, Cambodia on September 20, 2002. Indigenous Peoples -- Social Assessment Social assessment of the health needs, health seeking behavior, health beliefs, and constraints to accessing health services of ethnic minorities was initiated during WB-HSSP preparation and will continue into implementation. This includes participatory research to inform the development of local health plans and community participation in the planning and monitoring process. Stakeholders include the various vulnerable ethnic minorities targeted by the project, representatives of ethnic communities, NGOs, civil society organizations advocating for ethnic peoples, health workers and local health managers, Provincial Health Departments, MOH, and development partners. Stakeholders have and will continue to be consulted and involved in ongoing design and implementation processes. The project's support to the four northeastern provinces addresses the health problems identified in the recent participatory poverty assessment and supports measures for improving health identified through the consultation exercise: key issues are physical access, costs, local ethnic minority participation in health development, absence of health workers at facilities, and lack of health workers from local ethnic communities. Targeted, participatory local health development planning will be undertaken during implementation. The mainstreaming of safeguardicross the sector is necessary to support the targeted  12 ISDS interventions in the four northeastern provinces, but also to capture and respond to the interests of vulnerable ethnic minorities living in other parts of the country. Pathways for mainstreaming are: * Strengthening the social assessment capacity of the MOH. * Improving delivery of appropriate targeted information and behavior change communication. * Local ethnic minority participation in designing and monitoring health development plans. * Monitoring, evaluation and the annual sector review process. * Human resource development. Social assessment capacity This will include capacity building in social analytical skills at various levels of the health system, and the introduction of safeguard checks in key sector management processes such as planning, the allocation of resources, monitoring and evaluation, to direct attentioni to the inclusion of ethnic minorities. Access to appropriate health informationLanguage is a barrier that excludes ethnic minorities from participating in development processes. Lack of information and educational materials in the languages of ethnic minorities is a major constraint to health promotion. The WB-HSSP will, through its support for key national programs, ensure that behavior change communication strategies and materials take into account the specific needs of ethnic minorities and communication approaches and materials are developed that are appropriate for the needs of target minority groups. This will require increased understanding of the health beliefs that influence ethnic minorities in order to design appropriate materials. Where appropriate consideration will need to be given by MOH and Provincial Health Departments to sanctioning the use of local translators in health facilities and during outreach activities. Local participationof ethnic peoples will be encouraged through the development of more participatory planning and monitoring processes at local, district, provincial and the national level. To raise the profile of ethnic minorities in planning and monitoring processes throughout the country, the planning and monitoring frameworks will include specific questions on ethnic minorities, training to implement the revised methods will include attention to the health of ethnic groups and methods to promote their inclusion, and guidelines for establishing consumer participation will include representatives of ethnic minorities where they are present in the local population. Sector monitoring and evaluation The project will assist the MOH reform of sector wide monitoring and evaluation to include civil society participation in the process, and to introduce social variables such as ethnicity. Annual reviews of sector performance will disaggregate achievements in accessibility, public and client satisfaction, and health utilization by ethnicity: this will significantly increase knowledge on the health and access to health care of ethnic minorities. The participation of civil society in annual sector reviews will also allow ethnic minority interests to be heard at the national level. Human resource development Lack of trained health workers from the ethnic minority population is a major constraint to offering responsive services to ethnic groups. The MOH with support from the WB-HSSP has agreed to develop a primary nurse training course tailored to the needs of hill tribes' peoples and targeting students from the four northeastem provinces. Entry requirements will be reduced to increase access and students from the northeast offered stipends, women will be given priority. In addition, the project will support a review of human resource policy and within this,  13 ISDS consideration given to how human resource development needs to adapt to embrace the needs of ethnic minorities. The Social Assessment, including the Ethnic Minorities Development Strategy, was publicly disclosed in Phnom Penh, Cambodia on September 20, 2002. Involuntary Resettlement Consultation has been undertaken in identifying project-related involuntary resettlement concerns and in reaching consensus on appropriate mitigation and remediation measures to ensure that all issues related toinvoluntary acquisition of land or other assets (including restrictions on asset use) are fully addressed. During implementation, potentially adversely affected persons will be provided information relating to impacts and entitlements, will be consulted as to their preferences regarding implementation arrangements, and will be informed regarding methods and procedures for pursuing grievances. Stakeholders include: local communities, including Feedback Committees and Commune Councils; provincial and operational district government health officials; and government officials at the national and provincial levels for the Ministries of Economy and Finance, Health, Public Works, and Environment. The government has prepared a Framework for Land Acquisition Policy and Procedures. The Framework was publicly disclosed in Phnom Penh, Cambodia on September 30, 2002. E. Safeguards Classification. Category is determined by the highest impact in any policy. Or on basis of cumulative impacts from multiple safeguards. Whenever an individual safeguard policy is triggered the provisions of that policy apply. 1S. - Significant, cumulative and/or irreversible impacts; or significant technical and institutional risks in management of one or more safeguard areas [X] S2. - One or more safeguard policies are triggered, but effects are limited in their impact and are technically and institutionally manageable S3. - No safeguard issues SF. - Financial intermediary projects, social development funds, community driven development or similar projects which require a safeguard framework or programmatic approach to address safeguard issues.  14 ISDS F. Disclosure Requirements Environmental Assessment/Analysis/Management Plan: Expected Actial Date of receipt by the Bank 9/19/2002 9/19/2002 Date of "in-country" disclosure 9/20/2002 9/20/2002 Date of submission to InfoShop 10/1/2002 10/1/2002 Date of distributing the Exec. Summary of the EA to the ED (For category A projects) Resettlement Action Plan/Framework: Expected Actual Date of receipt by the Bank 9/26/2002 9/26/2002 Date of "in-country" disclosure 9/27/2002 10/1/2002 Date of submission to InfoShop 10/1/2002 10/1/2002 Indigenous Peoples Development Plan/Framework: Expected Actual Date of receipt by the Bank Not Applicable Not Applicable Date of "in-country" disclosure Not Applicable Not Applicable Date of submission to InfoShop Not Applicable Not Applicable Pest Management Plan: Expected Actual Date of receipt by the Bank 9/19/2002 9/19/2002 Date of "in-country" disclosure 9/20/2002 9/20/2002 Date of submission to InfoShop 10/1/2002 10/1/2002 Dam Safety Management Plan: Expected Actual Date of receipt by the Bank Not Applicable Not Applicable Date of "in-country" disclosure Not Applicable Not Applicable Date of submission to InfoShop Not Applicable Not Applicable If in-country disclosure of any of the above documents is not expected, please explain why. Signed and submitted by Name Date Task Team Leader: Vincent Turbat 09/26/02 Project Safeguards Specialists 1: Bruce M. Harris/Person/World Bank Project Safeguards Specialists 2: Robert D. Crooks/Person/World Bank Project Safeguards Specialists 3: Approved by: Name Date Regional Safeguards Coordinator: Glenn S. Morgan 10/02/02 Sector Manager/Director: Emmanuel Y. Jimenez 10/01/02 For a list of World Bank news releases on projects and reports, click here SEARCH FEEDBACK SrrE MAP SHOWCASE