The World Bank Improving Healthcare Services in Project (“Damal Caafimaad”) (P172031) Public Disclosure Authorized

For Official Use Only

Public Disclosure Authorized Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage)

Date Prepared/Updated: 05/12/2021 | Report No: ESRSA01471 Public Disclosure Public Public Disclosure Authorized Public Disclosure Authorized

May 12, 2021 Page 1 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

BASIC INFORMATION

A. Basic Project Data

Country Region Project ID Parent Project ID (if any)

Somalia AFRICA EAST P172031

Project Name Improving Healthcare Services in Somalia Project (“Damal Caafimaad”)

Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date

Health, Nutrition & Investment Project 3/22/2021 6/29/2021 Population Financing For Official Use Only Borrower(s) Implementing Agency(ies)

Federal Ministry of Federal Ministry of Health Finance

Proposed Development Objective The Project Development Objective (PDO) is to improve the coverage of essential health and nutrition services in project areas and strengthen stewardship capacity of Ministries of Health.

Financing (in USD Million) Amount Public Disclosure Public Total Project Cost 100.00

B. Is the project 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 [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The proposed project, the 'Damal Caafimaad', which is the first WB health operation in Somalia, will build on ongoing ASA work and activities under RCRF, which support the establishment of the Government’s Female Health Workers (FHW) program. The 'Damal Caafimaad' project will be financed through an IDA grant of US$75 million, co-financed by the Global Financing Facility (GFF) Trust Fund with an additional US$25 million for four years. The project intends to improve access to and quality of a set of high impact basic health and nutrition services while strengthening the current weak institutional capacity in Ministries of Health at both federal and state levels and building resilience health systems.

May 12, 2021 Page 2 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

The Project has four components: (1) Expanding the coverage of high-impact health and nutrition services in select geographic areas; (2) Strengthening Government’s stewardship to enhance service delivery; (3) Project Management and Knowledge Management and Learning; and (4) a Contingency Emergency Response Component (CERC).

D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] There are gaps in essential supplies such as health workers, essential medicines, and medical equipment, particularly in public facilities. Somalia’s public health worker density is 0.43 per 1,000 people and private health worker density is 0.49 per 1,000 people. The combined health worker density figure (0.92) is significantly below the WHO’s cut-off for “critical” human resource shortages, which is 2.28 health workers per 1000 people. The availability of qualified medical staff is predictably concentrated in urban areas, with rural areas facing more pronounced recruitment and For Official Use Only retention challenges. There are also many unqualified individuals believed to be providing health services, particularly in private facilities due to lack of regulation and weak government enforcement. Supply chain management for health is challenged by the volatile security environment, poor infrastructure, human resource shortages and low capacity, limited access to supervision and monitoring, and a lack of functional, integrated sector- wide information management systems. Due to the near complete absence of government service provision, health services in Somalia are generally run by non-state actors mainly NGOs and UN agencies. The proposed Project will support the delivery of essential health and nutrition services to enhance service coverage and quality, focusing on primary healthcare services for women, children, and newborns. Learning from local and global experience and based on analysis of cost-effective interventions and burden of disease analysis, the project will support implementation of a prioritized package of services on: (i) child health and nutrition services; (ii) maternal and neonatal health services, including testing and interventions during ANC visits, basic and comprehensive emergency obstetric and newborn care, and family planning; (iii) GBV services (awareness raising, case identification, counselling, and management); (iv) disease Public Disclosure Public surveillance. These health services will be accompanied by health education and behavior change communications, as well as referral mechanisms to the appropriate level of service delivery. A single service provider for each region will be contracted, although they may sub-contract to local NGOs for up to 20% of the contract. The selection of the project target regions has been based on objective criteria jointly agreed with the Government, including poverty level, health service availability, service delivery data, and current partner support. The regions are rural with small urban centers and poor infrastructure, or is more urban often with a considerable number of IDPs, who are particularly marginalized in their access to services, which are often controlled by gate keepers, and their ability to raise complaints or concerned is severely constrained. These are likely to include: Nugaal (), (South West), Bay (South West), and Hiraan and (Hirshabelle). Government contracting of non-state actors to deliver health services is a means to successfully improve health outcomes by rapidly expanding service delivery in situations where the Government has limited capacity and there is ongoing insecurity. Afghanistan and Cambodia had notable success expanding health service coverage through a contracting out model. All the service contracts between the Government and service providers will include the reference to the Environmental Management Framework (EMF) including (IMWMP), and Social Management Framework (SocMF) including GBV action plan, Labor Management Plan and Security Management Framework. Project and area-based Security risk assessments and security management plans will be developed by an accredited security management firm contracted by the client overseen by a full time security advisor. Contractors will prepare

May 12, 2021 Page 3 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

Environmental and Social Assessment and Management Plans (ESAMPs) incorporating plans for the implementation of all instruments and E&S staffing plans. Although no land acquisition or resettlement is anticipated, minor rehabilitation of health centers, installation of incinerators or other waste management equipment, strengthening/expanding existing government health centers, and possible upgrading/installing of sanitary facilities etc. may result in an expansion of the environmental footprint of the existing Health Centers. The absence of adequate biohazard and biological waste management procedures in health institutions may allow for uncontrolled outbreaks of contagious diseases and is a threat to public health. In particular, studies show that there is no adequate incineration system in place in the majority of the health facilities in Somalia. D. 2. Borrower’s Institutional Capacity The proposed project will be the first project the Ministry of Health has designed and implemented as their own Government program, thus E&S capacity is low, although in the FGS MoH there is a Community Health Coordinator, a National GBV manager, head of environmental health and OHS manager, who is leading on OHS guidelines. However, For Official Use Only the likely NGO implementers have well developed HR and security management systems, although are likely to also suffer from clannism and elite capture, and may sub-contract to local NGOs up to 20% of the contract. Their other capacities will need to be assessed as part of the ESAMPs and due diligence as part of the contract awarding. An initial needs assessment as well as TORs, an action plan and timeline for capacity building has been included in the Environmental and Social management Frameworks. However, once the proposed staffing and implementing partners are on board, the needs assessment and plan will be updated. This will also be referenced in the ESCP. The FGS MoH will provide overall health sector stewardship including regulatory oversight and monitoring of state- level service delivery implementation and will manage the service delivery contracts. The FMS MoH will monitor and supervise contract implementation, ensuring implementation of the relevant safeguard instruments with oversight from the FGS MoH.

At the federal level, a Project Coordination and Implementation Unit (PCIU) will be established at the FGS MoH which

Public Disclosure Public will include a senior project coordinator, supported by three Contract Management/ M&E Specialists, two HMIS Specialists, a Security Advisor, a part-time Legal Advisor, a Communications Specialist, a PFM specialist, a Procurement specialist, separate social and environmental safeguard specialists, a GBV Specialist, as well as technical specialists as needed with medium- and short- term input, who will be selected according to the procurement guidelines as well as fairness and equity requirements of ESS2. A security firm will be contracted by the project to provide ongoing security assessments and alerts, due diligence, guidance and monitoring of the implementing agencies. The selected FMS will establish and maintain a PMT staffed by a project manager at every FMS, and one social/GBV (full-time) and one environmental (part-time) specialist in each of the target region FMS-MoHs only. PMTs will be gender balanced and have ethnic diversity and representation from other vulnerable and marginalized groups. The NGO contractors will outline the requisite social and environmental expertise in their ESAMPs and capacity plans, which will be reviewed and due diligence carried out as part of the contract awarding.

The country has implemented various Bank-financed projects. However, in general, the Federal Ministry of Health has limited capacity for managing social and environmental risks and impacts. Legislation and regulations and enforcement are weak in the country, although there are differences in capacity among the FMS MoH between the states. There are no functioning grievance mechanisms in place and policies are weak. There are limited waste management and disposal systems in place or policies or guidelines.

May 12, 2021 Page 4 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS

A. Environmental and Social Risk Classification (ESRC) Substantial

Environmental Risk Rating Substantial The environmental risk classification for the project is Substantial under the World Bank ESF, mainly because of the risks linked to the management of healthcare waste but also because of the risks linked to small scale renovation and of health facilities. In addition, health and safety risks also need to be taken into account given the limited capacity of the PCIU and the PMTs on these issues. Both during construction and operational phases of the project environmental risks and impacts are expected. Significant environmental risks and impacts are envisaged as a result of expansion of health facilities and ancillary activities supported under this project. These risks and impacts may occur during the rehabilitation and operational phases of the project. The refurbishment and expansion of existing For Official Use Only government health centres will entail installation of incinerators or other healthcare waste management equipment. In addition, the healthcare facilities will have placenta pits, that consider local beliefs and customs. These risks and possible impacts may result in an expansion of the environmental footprint of the existing health centres. In addition, possible heavy consumption of energy and water resources is anticipated. As a result, soil, air and water pollution will likely occur, in addition to possible greenhouse gas emissions. The disposal of toxic chemicals and other healthcare wastes and wastewater will likely be a significant challenge. The various typologies of healthcare wastes envisaged include infectious waste (waste that may contain pathogens, including used dressings, swabs and other materials or equipment that have been in contact with infected patients or excreta; may also include liquid waste such as faeces, urine, blood and other body secretions, pathological wastes (human tissues including placentas, body parts, blood and foetuses), sharps (needles, infusion sets, scalpels, blades and broken glass), pharmaceutical waste (expired or no longer needed pharmaceuticals, items contaminated by or containing pharmaceuticals), chemical wastes (waste containing chemical substances such as laboratory reagents, film

Public Disclosure Public developer, disinfectants that are expired or no longer needed, and solvents), waste with high content of heavy metals, including batteries, broken thermometers, blood-pressure gauges, etc. The project activities with environmental risks proposed under the project include minor construction activities, such as possible small-scale rehabilitation and/or refurbishment of health centres, as well as lifecycle infection control and the possible use of designated waste disposal pits or medical incinerators (especially in large urban centres) or other waste management facilities for medical waste disposal. Generally, there are no waste management and disposal systems in public health facilities in Somalia that meet international standards. As a result, improper disposal of healthcare waste by health centres, hospitals, primary health centres, community health centres and diagnostic centres pose a health hazard to the general public. The project activities will produce hazardous waste, such as mercury-containing items (thermometers) that may contaminate the environment; ash residue, which, if not properly disposed of, can contaminate groundwater at unlined waste disposal pits. On the other hand, significant amounts of pathologic waste with high moisture content requires significant energy to combust properly etc. Due diligence will be carried out to ensure that the siting, design and operation of waste management pits do not exacerbate environmental risks and impacts, however it is anticipated that they will be within existing health facilities. The use of medical waste incinerators requires trained operators, monitoring of waste segregation, appropriate waste transportation to site, and ash residue disposal. There are few trained operators in the country. Social Risk Rating Substantial

May 12, 2021 Page 5 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

The social risk is rated as Substantial taking into account the following key social risks and impacts: (i) potential exclusion of disadvantaged and vulnerable groups from project benefits and elite capture; and (ii) potential risks of increased social tension in the community (for example, on how services are delivered, or siting of services); (iii) conflict and security risks for project workers, patients and the community; (iv) labor risks including OHS risks, sexual exploitation and abuse, sexual harassment, and other forms of gender-based violence (GBV) that may occur in recruitment or retention of skilled or unskilled female workers and the delivery of services; (v) contextual risks of operating in a conflict zone and complex social context where challenges exist in conducting effective and inclusive community consultations, stakeholder engagement, and community participation and safety of staff, and developing effective and trusted grievance redress mechanisms due to difficulty in accessing rural areas, and the collective nature of traditional complaints handling. The following vulnerable and marginalized groups may be excluded from or discriminated against when seeking health services. Women culturally may not be able to attend health centres on their own if far away or staffed by male health workers. Health seeking behavior is often clan based and may disadvantage minority groups, who may not be comfortable seeking services particularly if there is lack of diversity For Official Use Only in staffing or efforts to overcome discrimination. People living with disabilities who may face social and physical barriers. Tension over the siting of services, particularly if services are concentrated in one clan area and selection criteria is not objective or widely understood. Security risks include targeting of health centres or workers by disgruntled individuals or groups in conflict affected areas if there is not strong community buy in for services or lack of transparency and understanding of selection. In previous consultations with health sector workers, sexual harassment of female health workers, discrimination in recruitment and promotion and non-observance of their labour rights including maternity leave was cited. As in similar contexts where GBV is widespread, sexual harassment, exploitation and abuse of patients is a risk. Meaningful and inclusive consultations of communities in the design and operation of services is rare due to access, security and because gatekeepers and elites dominate consultations with service providers. Grievance management is constrained by lack of trust in service providers to resolve grievances confidentially and protect whistle blowers particularly by vulnerable and marginalized groups. Risks associated with Component 2 elements of the project such as HMIS and Information Management include

Public Disclosure Public possible breaches of data security. This will be mitigated by confidentiality requirements on the part of health workers, and contractors, who will be required to comply with ESS2 provisions. Policy development will also need to be in line with the requirements of the ESF. These will be outlined in the LMP and SocMF respectively.

B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered

B.1. General Assessment

ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: Assessment and management of environmental and social risks and impacts will be required for all the project components and their activities. Under Component 1 (“Expanding the coverage of a set of high-impact health and nutrition services in selected geographic areas”), there is likelihood of environmental and social impacts that need to be mitigated. Potential environmental impacts are expected to be relatively moderate, temporary, site-specific, and mostly reversible, and mitigation measures can readily be designed. The project envisages small-scale construction works, which may entail the refurbishment of existing health facilities, installation of equipment (including incinerators) as well as the development of sanitary facilities such as placenta pits, and development and operation of

May 12, 2021 Page 6 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

medical waste management facilities, such as waste disposal pits, which may adversely affect the health of and people through air and noise pollution, generation of leachate, and contamination of groundwater. During the rehabilitation phase, there may be some minor construction waste generated, in addition to dust, noise and air pollution.

During the operational phase of the project, there will be generation of significant quantities of medical and other waste that is generally expected, for the most part, to be non-toxic and non-hazardous. The absence of adequate healthcare waste management procedures in health institutions may allow for uncontrolled outbreaks of contagious diseases and is a threat to public health. Improper handling and disposal of healthcare wastes puts the health worker, the patient and the community at large at risk through transmission of pathogens via blood or body fluids, contaminated medical equipment, or sharp instruments. Control of infections and healthcare wastes is critical. The composition of waste produced may be in the form of sharp objects (including needles, syringes, disposable scalpels and blades), waste contaminated with blood and other bodily fluids (e.g. from discarded diagnostic samples), cultures For Official Use Only and stocks of infectious agents from laboratory work or waste from patients with infections (e.g. swabs, bandages and disposable medical devices). Other waste may include chemical waste, such as solvents and reagents used for laboratory preparations, disinfectants, sterilants and heavy metals contained in medical devices (e.g. mercury in broken thermometers) and batteries, as well as pharmaceutical waste (including expired, unused and contaminated drugs and vaccines), and old medical equipment and laboratory testing equipment. As placenta pits will allow pathological waste to degrade naturally, care needs to be taken to ensure that the waste is not be treated with chemical disinfectants like chlorine before being disposed of because these chemicals destroy the microorganisms that are important for biological decomposition.

Therefore, an Environmental Management Framework (EMF), including an Infection Control and Waste Management Plan (ICWMP) and Occupational Health and Safety Guidelines (OHSG) for medical workers at the health facilities, has

Public Disclosure Public been prepared. The ICWMP has a training component for the various stakeholders involved in implementing the project on the ground. The ICWMP’s overall objective is to prevent and/or mitigate the negative EHS effects of medical waste. Medical waste must be managed in a safe manner to prevent the spread of infection and reduce the exposure of health workers, patients and the public to the risks from medical waste. In this regard, the project teams and appointed medical waste disposal firms will be trained on the use of medical waste e-manifest system for ease of traceability (“cradle-to-grave” documentation) and accountability. The ICWMP includes advocacy for good practices in medical waste management and is to be used by health, sanitary and cleaning workers who manage medical waste. While the increase of biomedical waste is an indirect impact of the project activities, it is important to ensure that this risk of health waste is properly handled, collected, transported and eliminated to avoid the spread of infectious diseases. Improper management and disposal of medical waste poses a risk to the environment and human health. Thus, it is important to develop a management plan commensurate with the amounts and risks related to the medical wastes generated by the project. An environmental screening process has been proposed under the EMF to address the aforementioned potential adverse impacts and provide recommendation on the preparation of site-specific instruments (ESIA/ESAMP). A CERC ESMF will also be prepared to guide environmental safeguards processes in case of emergency interventions, once the scope of the CERC is known. Contractors appointed under this project will be required to develop ESAMPs, which will include site-specific ICWMPs, which will be based on the overall ICWMP as detailed in the Environmental Management Framework (EMF)

May 12, 2021 Page 7 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

for the project. These ESAMPs will highlight the measures designed to ensure the safe and environmentally-sound management of healthcare wastes in order to prevent adverse health and environmental impacts from such wastes, including the unintended release of chemical or biological hazards, including drug-resistant microorganisms, into the environment. The contractors will be responsible for instituting and implementing a simple medical waste tracking system allows for the identification of current waste streams while determining how much waste is being generated from the health facility. The contractors will be responsible for keeping documentation showing details of interventions put in place for tracking, measuring and optimizing medical wastes and recycling processes as appropriate. A sample waste tracking system will be incorporated into the project’s EMF and will provide guidance notes. Contractors will be required to (a) disaggregate waste in terms of typologies (infectious waste, pathological waste, sharps, pharmaceutical waste, genotoxic waste, chemical waste, wastes with high content of heavy metals, pressurized containers, radioactive waste, general solid waste and micro-organisms), (b) report on volumes of each typology of wastes generated, (c) report on volumes of each typology of wastes collected, and (d) report on available For Official Use Only capacity for on-site handling, collection, transport and storage.

Social risks and impacts are various and will depend on locations and vary over time. These include: (i) The risk of project benefits not reaching vulnerable and marginalized groups including, nomads, internally displaced populations (IDPs), minority groups, people living with disabilities, women who have experienced GBV, both in terms of siting of services and accessibility, and how services are provided including the attitude and make up of health workers. (ii) Ensuring health services are acceptable and accessible to women particularly when delivered by men and the potential risks of sexual exploitation and abuse or sexual harassment (SEA/SH) in delivery or uptake of health services (including of midwives or female mobile health outreach workers). (iii) Potential risks of increased social tension in the community for example, around what services (e.g. family planning or survivor centric GBV services) are delivered, particularly when in competition with traditional provision or

Public Disclosure Public against the recommendations of religious leaders or others and how services are provided (by whom or how discretely due to the taboo around GBV/SEAH), or siting of services or use of community land and impacts of conflict or insecurity to staff and patients. (iv) Labor risks including OHS risks, including security risks to staff, sexual exploitation and abuse, sexual harassment, and other forms of gender-based violence (GBV) that may occur in recruitment or retention of skilled female health workers (see also ESS2 and ESS4 Sections below). Risks also exist around delayed payments and conditions (hours of work) and access or use of a GRM (due to lack of trust and confidentiality in complaints handling). (v) Exclusion and Selection Bias: Recruitment of health professionals and consultants may be influenced by nepotism and clannism where people from minority groups, IDPs, and people living with disabilities are excluded. (vi) Elite capture of project benefits, especially recruitments and contracts of private healthcare contractors and suppliers, may limit project quality and reinforce exclusion. (vii) Contextual risks of operating in a conflict zone where effective and inclusive community consultations, stakeholder engagement, and community participation and safety of staff is challenging. Challenges in developing effective grievance redress mechanisms due to difficulty in accessing rural areas, and the collective nature of traditional complaints handling and the difficulty of vulnerable and marginalised groups raising complaints. (viii) For component 2, HMIS and Information Management will include data privacy and confidentiality requirements as outlined in the SMF and LMP.

May 12, 2021 Page 8 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

(ix) Policy developments will need to be in line with the requirements of the ESF. Social risks will be mitigated as outlined in the Social Management Framework (SocMF) and the ESAMP’s for each subproject and contractor, which will include procedures on how to mitigate barriers and promote social acceptability of project interventions among vulnerable and marginalised groups. The stakeholder engagement plan outlines procedures to identify key stakeholders including vulnerable and marginalised group representatives to ensure inclusive and transparent consultation processes for input and feedback on the project throughout the project cycle, and a functional grievance redress mechanism (GRM). Labor Management Procedures (LMP) will outline fair treatment, non-discrimination and equal opportunity of project workers and contractors.

ESS10 Stakeholder Engagement and Information Disclosure A Stakeholder Engagement Plan (SEP) has been prepared, outlining how appropriate representation and participation of various stakeholders will be carried out, including women; vulnerable and marginalised groups (VMGs) e.g. IDPs, For Official Use Only minority groups, and people living with disabilities; influential groups –e.g. religious or clan elders—who may influence the perception and uptake of health services.

The SEP includes a description of a Project Grievance Mechanism which will link to mechanisms at the point of service provision and will have separate and confidential mechanisms for receiving complaints of sexual exploitation and abuse and sexual harassment, as well as other forms of GBV and established protocols to enable survivor-centered response. To the extent feasible, the project will explore strengthening of capacity of Health Centres and key medical staff to provide care for survivors should cases arise. The GM will address complaints and suggestions coming from both project-beneficiaries and other interested parties. The GM will also link to wider beneficiary feedback mechanisms that would also look at e.g. service standards, beneficiary satisfaction, and other citizen engagement tools. The stakeholder engagement plan outlines how different implementing agencies will engage with stakeholders at

Public Disclosure Public FGS, FMS, regional and community level. Virtual key informants interviews have been carried out and a stakeholder consultation meeting with NGOs and government representatives will be carried out before appraisal and issues built into the SEP, EMF and SMF. As part of the information disclosure arrangements, all environmental and social instruments including ESAMPs will be disclosed publicly on the MoH website. Due to Covid 19, initial stakeholder consultations were carried out virtually. Further consultations are planned at FMS level once contractors are on board and will observe government good practice guidance from WHO and the World Bank. Each contractor will include SEP requirements in their ESAMPs including community engagement and GRM awareness and accessible focal persons.

B.2. Specific Risks and Impacts

A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions Project workers include direct workers: ie the staff of the FGS PCIU and the FMS PMTs, as well as contracted workers of the implementing partners including those contracted to carry out minor rehabilitation, private umbrella entities and third party monitors etc. All ESS2 provisions will apply including for: fair treatment, non-discrimination and equal

May 12, 2021 Page 9 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

opportunity, as well as freedom of association and collective bargaining in a manner consistent with national laws, as well as accessible grievance mechanisms to raise workplace concerns.

Other civil servants supporting the implementation of the project will be bound by their public sector contracts, (unless their contract has been transferred to the project), although OHS, child and forced labour provisions of ESS2 will apply.

OHS provisions will also include the management of security risks (workers exposure to attacks); and GBV/SEAH risks especially for female health staff in remote areas. Primary supply workers may include those staff contacted by primary suppliers for the project (e.g. pharmaceutical suppliers) will be required to demonstrate that they are managing child labour, forced labour and serious safety measures.

For Official Use Only Community workers, where labour is provided by the community are not anticipated in this project. However, if they are found to be required ESS provisions regarding working conditions and OHS will apply.

Labor management procedures (LMP) will be developed prior to the bidding process. Key issues to be addressed in the LMP for project workers include terms and conditions of employment, non-discrimination and equal opportunity, and worker’s organizations. Due diligence is also needed to ensure that the Borrower meets requirements on child labour, forced labour and occupational health and safety for all workers including safety concerns and OHS in terms of housing / accommodation provided for the staff posted to rural/remote areas. It will also reference sections of the GBV action plan including awareness raising and codes of conduct among workers and contractors as well as civil servants. To prevent engagement of under-aged labor, all contracts will have contractual provisions to comply with the minimum age requirements of 18 years including penalties for non-compliance. The contractors will be required to maintain a labor registry of all contracted workers with age verification. While official government policy is to

Public Disclosure Public allow for female employees to take maternity leave and have access to time off for breastfeeding, women are vulnerable to losing their jobs after pregnancy since these policies are rarely adhered to in reality. Thus specific measures to address these gaps will be required. Potential risks related to labor and working conditions include (1) OHS risks; (2) child labor; (3) labor influx; (4) labor disputes over terms and conditions of employment; (5) discrimination and exclusion of disadvantaged groups; (6) security risks (workers exposure to attacks); and (7) GBV/SEAH risks.

Labour Management Procedures will be developed prior to the launch of the procurement process for the implementing partners. The LMP will detail the modalities of a GRM for project workers that will be established during project implementation. Dedicated channels to enable reporting of sexual harassment and other forms of GBV will be elaborated in the GBV Action Plan.

Medical facilities are a potential source of infectious waste in gaseous, liquid or solid forms. These could pose unsafe conditions for healthcare staff. Of particular concern are janitors handling infectious waste (including sharps) without adequate protective gear, storage of sharps in containers that are not puncture-proof. While some OHS risks will be related to new equipment or services introduced after renovation or upgrade of facilities, most other effects are existing (hence cumulative) and would only be exacerbated by increased service provision. To mitigate against this, the project will develop Occupational Health and Safety Guidelines (OHSG) for medical workers, including health

May 12, 2021 Page 10 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

workers and support staff (i.e. waste management personnel) at the health facilities. Community perceptions about medical waste, particularly waste from maternal and reproductive health services, should be understood and where necessary separate waste management plans developed.

ESS3 Resource Efficiency and Pollution Prevention and Management This Standard is relevant. There are environmental impacts of health systems supported under this project associated with the possible heavy consumption of energy and water resources in support of health centre operations due to the envisaged patient load of about 1.6 million people over the course of four years. It is also envisaged that there are possible greenhouse gas emissions, use and disposal of toxic chemicals, and production of waste and wastewater and their disposal. The generation of significant amounts of solid and liquid waste in the health centres to be supported under this project will require well-prepared disposal facilities. The waste disposal options open to the For Official Use Only project include designated waste disposal pits (especially in rural areas, where pits can be developed more easily) and the use of incinerators (which may be an option in land-stressed densely-populated large cities in Somalia, such as Hargeisa and ). In light of these considerations and the potential severe impacts of ongoing climate change in Somalia, the NGO service contract for the delivery of a prioritized health service package to targeted regions will include provisions to track and ensure optimal use of energy and water resources, and adopt low-cost, context-appropriate technologies for climate adaptation and mitigation. These may include the following climate smart approaches: (i) energy-efficient improvements to facilities, including procurement of energy efficient light bulbs to health specific equipment and low emission appliances; (ii) use of solar energy to for example power cool chain for vaccines and blood products; (iii) measures to reduce pharmaceutical waste; and (iv) climate-smart medical waste management. In addition, the project team will develop a basic toolkit for health care facility officials to assess the resiliency of their facility to climate change impacts. The toolkit will consist of a checklist for officials who will work in areas of facilities

Public Disclosure Public management and health care services, as well as a facilitator’s guide for administering the checklist, and a simple resource guidebook to inform adaptation. The toolkit and the guidebook will be prepared after project effectiveness and will take as their basis the project’s EMF and its recommendations. Air emissions: During the rehabilitation of healthcare infrastructure in the selected localities, air emissions may include fugitive dust. Those most likely to be affected are people living within the proximity of these infrastructure sites but also the workers. The implementation of mitigation measures such as dust suppression and vehicle maintenance will be applied to minimize the impact of air emissions during construction, wearing suitable masks, and residual impacts are expected to be limited in scope and duration. The project will screen activities in order to ensure efficiency of resource use and minimize pollution, and build local capacity to manage resource use efficiency during implementation. Care will be taken to ensure that the medical and other waste disposal system selected will be context-appropriate, given the low capacity levels existing in Somalia. In addition, the World Bank’s EHS Guidelines including the General, Healthcare Facilities, Healthcare Facilities will be applicable and used for screening and ES assessment of these disposal facilities. The project team will be trained in life-cycle infection control, with a focus on segregation, packaging, disinfection of infectious or dangerous healthcare waste. Waste disposal pits will be the first point for consideration in waste disposal for the project-supported health centres. However, this still presents a problem, as, typically, about two-thirds of landfill waste contains biodegradable organic waste. As this material decomposes, it releases methane gas. As a potent greenhouse gas, methane traps up to 20 times more heat in the atmosphere compared with carbon dioxide, and this presents a problem. To mitigate any

May 12, 2021 Page 11 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

probable negative outcomes resulting from the siting and operations of waste disposal pits, due diligence will be carried out by the PCIU and the PMTs in the FMSs. In addition, waste pits containing pathological or other infectious materials have the potential to contaminate soils and groundwater, which can then pose significant health risks to communities and health workers. The incineration of municipal waste may be an option for the project in the large cities that may be included in the project. However, incineration may involve the generation of climate-relevant emissions, which are mainly CO2 (carbon dioxide) as well as N2O (nitrous oxide), NOx (oxides of nitrogen), NH3 (ammonia) and organic C, measured as total carbon. CO2 constitutes the chief climate-relevant emission of waste incineration. However, according to a paper in the book “Good Practice Guidance and Uncertainty Management in National Greenhouse Gas Inventories” titled “Emissions from Waste Incineration” by Bernt Johnke, the generation of greenhouse gas emissions is limited in the context of the proposed project: the incineration of 1 Mg of waste in incinerators is associated with the production and release of about 0.7 to 1.2 Mg of carbon dioxide (CO2 output). The climate-relevant CO2 emissions from waste incineration are determined by the proportion of waste whose carbon compounds are assumed to be of For Official Use Only fossil origin: in the project context, again this is likely to be limited. On the other hand, inadequate incineration or the incineration of unsuitable materials may result in the release of pollutants into the air (including dioxins and furans) and in the generation of ash residue. Dioxin emissions from municipal solid waste incinerators are one of the major sources of environmental dioxins and are therefore an exposure source of public concern. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. To mitigate this, the project will prepare an Infection Control and Waste Management Plan (ICWMP) to address addresses aspects such as regulatory framework, planning issues, waste minimization and recycling, handling, storage and transportation, treatment and disposal options, and training. In addition, with the technical support of the Bank’s ENB team supporting Somalia portfolio, the project team will use GIS tools, in combination with dioxin soil measurements, to estimate exposure metrics, undertake classification of exposure across the population in the regions supported by the project, in order to minimize harm from carcinogenic exposure.

Public Disclosure Public The NGO service contract for the delivery of prioritized health service package will also institute and implement a simple medical waste tracking system to identify current waste streams, and determine the volume of waste generated/ collected from health facilities, as well as improve mapping of on-site capacity for waste management. This will allow the tracking, measuring and optimization of waste reduction for medical wastes and recycling processes as appropriate. In addition, the project will support the procurement of modern incinerators operating at determined standards and fitted with special gas-cleaning equipment that are able to comply with the international emission standards for dioxins and furans to minimize air pollution.

In lieu of this, the project will explore the use of alternatives to incineration such as autoclaving, microwaving, steam treatment integrated with internal mixing, which minimize the formation and release of chemicals or hazardous emissions. These should be given consideration in localities where there are sufficient resources to operate and maintain such systems and dispose of the treated waste. In addition, appropriate ESAMPs will be prepared by each implementing partners in respect of the medical waste incinerators, and will include region-specific ICMWPs. Somalia lacks appropriate medical waste management regulations. The ICWMP, therefore, will include: • Special Conditions - Management of Medical Wastes During Refurbishment Works in Annex 1 • Sample Medical Waste Management Monitoring Questionnaire in Annex 2 • Treatment and Disposal Methods for Categories of Health Care Waste in Annex 3 • KFW Health Care Waste Guidelines in annex 6 for preparation of an ICWMP.

May 12, 2021 Page 12 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

The document is aimed at managers of hospitals and other health-care facilities, policy makers, public health professionals and managers involved in waste management, and will refer to: World Health Organization (WHO)’s comprehensive guidance document, “Safe management of wastes from health-care activities”, now in its second edition.

In collaboration with other partners, WHO also developed a series of training modules on good practices in health- care waste management covering all aspects of waste management activities from identification and classification of wastes to considerations guiding their safe disposal using both non-incineration or incineration strategies.

ESS4 Community Health and Safety For Official Use Only This Standard is relevant. The disposal of untreated health care waste in waste pits can lead to the contamination of drinking, surface, and ground waters if not properly constructed, posing danger to human health and community well-being. Communities are also likely to be exposed to health problems arising from ineffective infection control and inappropriate healthcare waste management, as well as inappropriate sanitation facilities. To mitigate these risks, project teams will conduct audits to establish sources of drinking water near the facilities proposed for reconstruction (if any) and take measures to secure the sources against contamination.

There are risks related to possible reuse of needles, medicine bottles, and other used or expired medical supplies. The project teams in the regions will undertake awareness-raising campaigns aimed at sensitizing communities on the dangers of reuse. Appropriate waste management options will be provided to minimize these risks further. Where the project interventions include rehabilitation, there are community health and safety challenges that can arise. In addition, rehabilitation and/or refurbishment of health facilities may pose a danger to construction crews

Public Disclosure Public Therefore, the project team will prioritise training of the contractors and their workers on structural safety issues. In addition, communities will be trained on the risks related to construction sites and operation of the waste pits. Waste pits containing pathological or other infectious materials have the potential to contaminate soils and groundwater, which can then pose significant health risks to communities and health workers. The contractor ESAMPs will have dedicated sections on community health and safety, GBV action plan and OHS. Due care will be taken to minimise exposure of the beneficiary communities arising from poor infection control through investing in emergency preparedness and response mechanisms: this will address incidents associated with infection control as well as environmental and health incidents arising from medical waste management facilities. As armed security personnel may be required by implementing partners, contractors, third party monitors and MOH, staff, the Security Management Framework prepared by the MOH before the bidding process will outline provisions as per the World Bank directive on use of security personnel. The PCIU will have a security advisor, who will ensure due diligence of contractors on security risks provide security advice and guidance to the project’s service providers and all contractors will include a security management plan in their ESAMPs. The Borrower will be assisted by the Bank in the development of a Project Security Management Framework and Security Risk Management Guidelines. The implementation and management of the Project SMP and SRM approaches remain the Borrower’s responsibility.

May 12, 2021 Page 13 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

As w omen’s empowerment is low, and risks of and GBV incidence is high, project activities may exacerbate risks of sexual exploitation and abuse, and also sexual harassment. This is particularly important to prevent as it may further undermine women’s access to health services. To address such risks, key mitigation measures—such as the development of a GBV Action Plan, and identification of confidential and survivor-centric channels for reporting GBV/SEAH into grievance mechanisms and protocols for appropriate response—will be identified and integrated into relevant safeguard instruments which will be prepared before project effectiveness. Inclusive and appropriate engagement of communities throughout the project is essential, particularly of sensitive services (e.g. family planning and GBV survivor services); awareness raising and engagement of men, elders, religious leaders, all ages of women and traditional health providers and birth attendants will be necessary to ensure wide community support and minimize tension. The Social Management Framework outlines how implementing partners evaluating opportunities to combine the two systems by 1) valuing effective traditional practices; 2) working with traditional providers to overcome resistance and hesitancy to conventional treatment and the socio-cultural impacts For Official Use Only and risks related to these interactions should be further explored as part of stakeholder engagement and technical assistance to develop socio-culturally adapted delivery options as part of the national health care system.

Contractors will ensure that services are available to all groups in the community without discrimination by including non-discrimination clauses in code of conducts and training. Security threats to persons and their property is a key risk to persons patronising the upgraded health centres. To ensure security of persons and property, implementing contractors will be responsible for the overall security and protection of the health facilities under their management, including all staff, through increased prioritization and resourcing of security risk management. The MoH PCIU will contract an accredited security risk management firm to conduct security risk assessments and management plans for the project and implementing areas, and provide periodic updates and training, monitoring and support to the PCIU and security management advisor. The PCIU and PMTs as well as implementing partners and other contractors will update their security plans and travel security

Public Disclosure Public procedures, security training and incorporating incident reporting systems in the health facilities’ plan of work and budget. Contractors will be responsible for putting in place reporting procedures, including reporting procedures for significant security incidents, incident reporting forms, and incident logging and analysis. Significant security incidents will include (a) violent attacks at health facilities, (b) incidents involving the use of improvised explosive devices, (c) kidnapping of personnel, (d) carjacking, (e) violent attacks meted against healthcare staff at work in the project, and (f) other violent incidents that results in injuries and/or deaths at the health facilities or loss of property. The PCIU will require contractors to report to the PCIU incidents or accidents related to the Project within 48 hours of becoming aware of the incident. The PCIU shall inform the World Bank of the occurrence of a severe security incident or accident within five days after the occurrence of the incident or accident. The report shall also detail remedial action(s) taken to mitigate the effects of the incident or accident as well as measures taken to prevent or minimize the possibility of occurrence of similar incidents or accidents in the future. The contractors will assume duty of care obligations towards personnel working at the health centres and will be responsible for putting in place crisis management mechanisms for the health facilities, including a crisis management committee, crisis management plans. The spread of infectious diseases e.g. COVID-19 among patients and health workers will be carefully mitigation through the use of PPEs and care in following Government guidance as well as adapting to WHO and World Bank guidance.

May 12, 2021 Page 14 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Only small-scale repairs within existing health facilities is included in the project, with no construction activities, thus land acquisition and resettlement are not anticipated. If small waste disposal pits are required it is anticipated that these will be within existing health facility perimeters. The SMPs will outline whether there is any need for community agreement or formalisation of land use by the Government where targeted health facilities are not on public land.

ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The project will be implemented in localities that are not categorized as biodiversity hot spots – which are in the north-western mountain ranges (Golis and Cal Madow), as well as in the coastal mosaic forests of the south. On the other hand, most of the existing health centres are located in urban settings, with few in rural areas. This Standard is not, therefore, relevant for this project. However, the EMF includes screening for ecological sensitivity, as well as For Official Use Only ground- and surface water resources.

ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is not relevant to the project, as the people in the project area are not considered as Indigenous Peoples as defined under ESS7. Marginalisation of minority groups and clannism and other cultural issues are being addressed in the Inclusion plan, the SEP and the Project approach to awareness and outreach and therefore the issue of whether ESS7 should be applied to Somalia does not need to be addressed in this operation, but will be reviewed as part of a regional review.

ESS8 Cultural Heritage

Public Disclosure Public Although the project does not include construction of new facilities, in the case of expansion of health facilities or waste disposal pit screening and chance-finds procedures will be included in the EMF (project’s E&S screening) and any contractual documents with implementing partners and contractors and will be outlined in the EMF and the SocMF.

Although the SocMF outlines how the project will evaluate opportunities to combine the modern and traditional health systems by 1) valuing effective traditional practices; 2) working with traditional providers to overcome resistance and hesitancy to conventional treatment. The socio-cultural impacts and risks related to these interactions should be further explored as part of stakeholder engagement and technical assistance to develop socio-culturally adapted delivery options as part of the national health care system.

ESS9 Financial Intermediaries This Standard is not relevant for this project.

May 12, 2021 Page 15 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

C. Legal Operational Policies that Apply

OP 7.50 Projects on International Waterways No

OP 7.60 Projects in Disputed Areas No

B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts

Is this project being prepared for use of Borrower Framework? No

Areas where “Use of Borrower Framework” is being considered: For Official Use Only The Borrower's E&S Framework is not proposed to be relied on for the Project, in whole or in part.

IV. CONTACT POINTS

World Bank Contact: Naoko Ohno Title: Senior Operations Officer

Telephone No: +1-202-473-9103 Email: [email protected]

Contact: Bernard O. Olayo Title: Senior Health Specialist

Public Disclosure Public Telephone No: 5327+7611 / 254-20-293-7611 Email: [email protected]

Borrower/Client/Recipient Borrower: Federal Ministry of Finance

Implementing Agency(ies) Implementing Agency: Federal Ministry of Health

V. FOR MORE INFORMATION CONTACT

May 12, 2021 Page 16 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects

For Official Use Only Public Disclosure Public

May 12, 2021 Page 17 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

VI. APPROVAL

For Official Use Only Public Disclosure Public

May 12, 2021 Page 18 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031)

Task Team Leader(s): Naoko Ohno, Bernard O. Olayo

Practice Manager (ENR/Social) Iain G. Shuker Cleared on 12-May-2021 at 15:47:36 GMT-04:00

Safeguards Advisor ESSA Peter Leonard (SAESSA) Concurred on 12-May-2021 at 17:43:55 GMT-04:00

For Official Use Only Public Disclosure Public

May 12, 2021 Page 19 of 19