Public Disclosure Authorized World Bank-financed Hainan Health Sector Reform Project (P171064)

Public Disclosure Authorized Stakeholder Engagement Plan (SEP)

Public Disclosure Authorized

Public Disclosure Authorized Hainan Provincial Health Commission (HPHC) December 2019

Contents

1 Project Introduction ...... …….1 1.1 PROJECT BACKGROUND ...... 1 1.2 PURPOSE, SCOPE AND IMPLEMENTATION PATH...... 1 2 Stakeholder Analysis ...... 3 2.1 STAKEHOLDER IDENTIFICATION ...... 3 2.2 OVERALL ATTITUDE OF STAKEHOLDERS TO THE PROJECT ...... 4 2.3 STAKEHOLDER DEMAND ANALYSIS ...... 4 2.4 VULNERABLE GROUPS ...... 4 2.4.1 IDENTIFICATION OF VULNERABLE GROUPS ...... 4 2.4.2 DEMAND ANALYSIS OF VULNERABLE GROUPS ...... 5 3 Stakeholders Engagement ...... 9 3.1 STARTED INFORMATION DISCLOSURE ACTIVITIES ...... 9 3.2 INFORMATION DISCLOSURE ACTIVITIES TO BE STARTED ...... 10 3.3 STARTED PUBLIC CONSULTATION ACTIVITIES ...... 11 3.4 PUBLIC CONSULTATION ACTIVITIES TO BE STARTED ...... 11 4 Grievance Mechanism ...... 17 4.1 FOR RESIDENTS ...... 17 4.2 FOR PRIMARY MEDICAL INSTITUTIONS ...... 17 5 Resources and Responsibilities ...... 18 6 Monitoring and Reporting ...... 18 Appendix 1 List of FGDs ...... 19 Appendix 2 Ethnic Minority Engagement Framework ...... 20 Appendix 3 Summary of First Round of Public Consultation ...... 29 Appendix 4 Implementation and Operation Stages ...... 34 Appendix 5 Field work Photos ...... 40

Abbreviations

EAC - Ethnic Affairs Commission FDT - Family Doctor Team FGD - Focus Group Discussion HC - Health Commission HHDRC - Hainan Health Development Research Center HHSA - Hainan Healthcare Security Administration HPHC - Hainan Provincial Health Commission HSA - Healthcare Security Administration PAO - Poverty Alleviation Office PHC - Primary Healthcare PMO - Project Management Office SEP - Stakeholder Engagement Plan WF - Women’s Federation

Units

Currency unit = Yuan (CNY) USD1.00 = CNY6 1 hectare = 15 mu

1 Project Introduction 1.1 Project Background The overall goal of the Hainan Health Sector Reform Project (HHSRP) is to strengthen the quality of primary health care (PHC) services and efficiency of the health system. Focusing on primary health care (the foundation for people-centered integrated care), the Project takes an integrated health system approach to deliver improved health outcomes for the people of Hainan. Recognizing that there is no silver bullet to achieve this goal, the project adopts a two-pronged approach: 1） The project supports the strengthening of primary care delivery system to address several key gaps that plague the health system in Hainan, including: a) poor preventive and promotive care, particularly in the context of the rising incidence of NCDs and an ageing population; b) the routine bypassing of PHC facilities in favor of hospital care; c) the declining quality of PHC, largely due to a lack of rigorously applied standards of service quality and shortage of appropriately qualified human resources; and d) inefficiencies in financing that disproportionately affect service utilization and health outcomes of the poor and most vulnerable. The central focus for PHC strengthening will be (i) to build health sector stewardship of People Centered Integrated Care (PCIC) through better integration of different levels of care and alignment of public health functions such as disease surveillance and emergency response with PHC service delivery; and (ii) to improve the performance of Family Doctor Teams (FDTs) operating in township health clinics, village clinics and community health centers through targeted strengthening of front-line service delivery , rigorous measurement of performance outputs and outcomes, supportive supervision and targeted incentives driving forward a strong/high capacity PHC system that is delivered through team-based approaches and responds efficiently to population health needs. 2）This is supported with deeper institutional, human resource, and information technology reform to create a sustainable and efficient service delivery system. At the operational level this will mean providing technical and financial support for strategic and results-oriented planning and management, evidence-based decision-making and adoption of e-governance platforms for greater coordination and efficiency. The Project will also streamline strategic purchasing of services through insurance programs in order to drive the system towards the Project goals of improving quality of primary care and efficiency of the health system. At the individual provider level, the Project will leverage incentives to change provider-level behavior and improve care for the growing burden of NCDs.

Component 1: Reforming Institutions and Strengthening Stewardship for People-Centered Integrated Care (PCIC): • Reducing institutional fragmentation in primary care services • Increasing coordination between HPHC and HPHSA • Developing a collaborative approach in which providers and patients work together to improve the self-management of health and, eventually, health outcomes Component 2: Strengthening Primary Health Service Delivery with appropriate support system: • to strengthen Family Doctor Team (FDT) performance through a mix of approaches involving a) capacity building, b) strengthened performance management and targeted incentives and c) supportive demand and supply side measures. Component 3: Strengthening Information Technology • Supporting the Provincial Health Commission IT Capacity • Supporting the Provincial Health Security Agency IT Capacity Component 4: Strategic purchasing for quality services Component 4: Technical Assistance and Project Management

1.2 Purpose, Scope and Implementation Path 1.2.1 Purpose This SEP aims to ensure that stakeholder consultation, communication and engagement is conducted continuously and effectively throughout the Project, and relevant design and measures are optimized and improved continually by collecting reasonable comments and suggestions from stakeholders, thereby benefiting all stakeholders to the greatest extent. In addition, since the Project

A4-1 involves some minority areas, this SEP includes a special Ethnic Minority Engagement Framework (EMEF) to ensure that minority residents are engaged throughout the Project to maximize the local benefits of the Project. Specifically, this includes:  Establishing and maintaining constructive relationships among all stakeholders;  Considering opinions of stakeholders in project design, and environmental and social management;  Maintaining adequate, equal and effective engagement at the implementation and operation stages to control project impacts and risks, and adjust and optimize relevant measures timely;  Ensuring timely and accessible information disclosure to stakeholders, including appropriate project information on environmental and social risks and impacts; and  Providing appropriate and inclusive ways to stakeholders, so that opinions, issues and appeals of stakeholders (especially vulnerable groups and ethnic minorities) are collective and handled effectively.

1.2.2 Scope This SEP applies to the 4 components, and the project area is the entity of Hainan Province.

1.2.3 Basic path This SEP will identify stakeholders, analyze interest correlations and engagement needs, and draft an engagement mechanism and plan across the design, implementation and operation stages.

Since the Project was at the preparation stage when this SEP was prepared, and project activities at the implementation and operation stages may be further adjusted, detailed stakeholder identification and demand analysis is not fully carried out at this stage. This SEP is an ongoing living document, it will analyze stakeholder engagement activities started and to be started at the preparation stage and plan such activities for the implementation and operation stages, focusing on mechanism set up, design and monitor, thereby to ensure that all stakeholders are engaged as in a good manner. This will be further tracked by monitoring.

A4-2 2 Stakeholder Analysis

2.1 Stakeholder Identification According to the Feasibility Study Report, the Project has 4 components, which involve different stakeholders. Therefore, stakeholders should be identified for each component, and their duties and interests learned. Stakeholders are identified and analyzed in two dimensions – impacts by the Project (positive: degree of benefiting; negative: potential environmental impacts, etc.), and influence on the Project. See Figure 2-1.

Figure 2-1 Distribution of stakeholders Note: Other departments include without limitation women’s federations (WFs), ERACs (ERACs), poverty reduction offices, ecology and environment bureaus, and county and township levelgovernments

It shows that based on the degree of impact by the Project, the primary stakeholders include: 1) Rural and urban residents, and migrant population, including 9.2576 million local rural and urban residents, and a migrant population of 1.31 million 2) Vulnerable groups, including 4.4 million women, 70,000 poor residents and 165,742 minority residents in 27 cities, counties and districts in Hainan Province 3) 9,724 (in 2017) PHC (primary healthcare) practitioners (rural and family doctors) in Hainan Province; 4) 5,177 PHC providers in Hainan Province, including 25 centers for disease control, 24 maternity and child care centers, 15 specialized disease prevention and treatment institutions, 175 community health service institutions, 299 township health centers, 51 community health centers, 1,312 village clinics, HPHC and Hainan Healthcare Security Administration (HHSA, Hainan PMO) Medical alliance, mainly including county / city 3A hospitals, such as Hainan General Hospital, Hainan Nongken General Hospital, Affiliated Hospital of Hainan Medical University, and central hospitals

The secondary stakeholders include: 1) Hainan Provincial Development and Reform Commission (responsible for project approval), and Hainan Provincial Finance Department (responsible for financial management); 2) County (district) health commissions (HCs) and healthcare security administrations (HSAs) 3) Design agency, competent authorities, and information system operation and maintenance contractors; 4) Local WFs, ethnic affairs commissions (EACs), and poverty alleviation offices (PAOs) in 218 townships (21 Xiangs, 175 towns and 22 sub-district offices) in 5 county-level cities, 4 counties, 6 autonomous counties and 8 districts in 4 prefecture-level cities

A3-3 2.2 Overall Attitude of Stakeholders to the Project Different stakeholders have different attitudes to the Project. Most government agencies support the Project, including HPHC, PHC providers and their staff, as well as residents, who think that the Project will improve their livelihoods greatly to improve the PHC quality and reduce the financial burden. Table 2-1 analyzes their general roles in and attitudes to the Project.

Table 2-1 Stakeholder Analysis Attitude to Direct stakeholder Rights and duties remarks the Project HPHC (including information center) Project coordination, regulation and Positive and HHSA implementation management Hainan Provincial Development and Research Project assessment and approval Supporting Reform Commission tasks Hainan Provincial Finance Department Financial management Supporting Information Protecting and managing the systems WFs Supporting interests of women Institutional Protecting and managing the capacity EACs Supporting interests of minority residents building Protecting and managing the PAOs Supporting interests of poor people Design agency Project design and research Positive Research PHC providers (township health centers Project implementation Positive tasks / community health centers and clinics) Information Providing advanced medical systems Medical alliances technologies and staff for two-way Positive Institutional diagnosis and treatment capacity Improving their own medical level, PHC practitioners Positive building and increasing training opportunities Enjoying better medical services at Rural residents Positive the village level Community Enjoying better medical services at Local residents Positive residents the community level Enjoying better medical services in Migrant population Positive their locations Research Enjoying better medical assistance tasks Women for gynecological diseases at the Positive Information primary level systems Vulnerable Enjoying such medical services as groups Poor people healthy diagnosis and treatment, Positive and a green channel Enjoying medical treatment that is Minority residents Positive identical to or better than Han people

2.3 Stakeholder Demand Analysis Different project activities often involve different stakeholder, and the same stakeholder may have different attitudes to different project activities. For example, residents in a village may highly support the Project in general, because they don’t have to go to remote hospitals, and spend more money and time for ordinary chronic diseases, thereby reducing their medical costs and improving their medical efficiency; however, on the other hand, the improper disposal of medical waste may have negative impacts on them, so they may hold a prudent attitude. Therefore, engagement needs of stakeholders should be analyzed based on project activities, as shown in Table 2-2.

2.4 Vulnerable Groups 2.4.1 Identification of Vulnerable Groups Vulnerable groups / individuals have relatively weak affordability, and are more likely to suffer disproportionate losses and be excluded from the engagement process. Therefore, appropriate A3-4 measures should be taken to ensure that they are fully engaged in the Project. Vulnerable groups include women, poor people and minority residents. In Hainan Province, Han, Li, Miao and Hui are local resident ethnic groups, while other ethnic groups moved Hainan island after 1949 and are lived in Hainan. The Li, Miao and Hui people mostly live in central and southern Hainan, while the Han people mostly in northeast and north Hainan, and coastal areas. The Project will affect minority residents greatly. See Appendix 2 “Ethnic Minority Engagement Framework”.

2.4.2 Demand Analysis of Vulnerable Groups The survey shows that vulnerable groups affected by the Project have generally the same interests as ordinary local residents, and have the following 3 features: 1) Local poor people enjoy good primary healthcare benefits, have access to priority channel offered by all PHC providers, and receive medical care almost free of charge under the provincial health poverty alleviation project. 2) Local women receive a subsidy for childbirth, and receive free cervical and breast cancer screening. They think that the Project will provide them with more benefits, such as breastfeeding rooms at PHC providers. 3) Some minority residents have difficulty in communicating in Mandarin and expect a language assistance platform. It can be seen that preferential measures for vulnerable groups are in place under the primary healthcare system. Table 2-3 summarizes key features and potential needs of vulnerable groups.

Table 2-3: Engagement Demand Analysis of Vulnerable Groups / Individuals Stakehold Type Key feature Interest Need for engagement er About 70,000, having not 1) The same as local 1) Paying special received higher education, residents (see Table 2-2); attention to the Poor people entitled to healthcare poverty 2) Ensuring that vulnerable interests of poor alleviation and a green groups and minority people, women and channel residents are engaged minority residents, and Vulnerable 47.51% of gross population, equally, and that primary communicating in the groups having not received higher doctors speak both Hainan dialect and Women education, mostly Mandarin and dialects minority languages; housewives (Hainan dialect, Li and Miao 2) Needing non- Having not received higher languages, etc.) holiday, non-weekend Minority education, no difference from and child care residents Han people consultation

A3-5 Table 2-4 Stakeholder Engagement Demand Analysis Component Output / activity Stakeholder Interests Engagement demand analysis Improving 1. Reducing institutional HCs (including Preparing a scientific and rational project design to HCs and HSAs conduct an in-depth survey and Primary fragmentation in primary care information center), reach the expected objectives consultation with all stakeholders at the Health Care services HSAs preparation stage to receive useful information. Performance 2. Addressing the human Local residents,  Chronic disease prevention and treatment 1. Rural and family doctors maintain close ； Strategic resource gaps especially chronic  Treatment of ordinary diseases and drug routine communications on disease prevention purchasing 3. The project will target a set disease patients purchase and treatment with local residents at the for quality of results areas that will aim to  Learning the situation of primary doctors, and implementation and operation stages. services further the outcomes achieved selecting suitable / satisfactory ones 2. Township hospitals communicate with rural for key Non-Communicable  Higher percentage of reimbursement and family doctors and ordinary residents on Diseases  Public health needs, e.g., preventive injection relevant issues within their jurisdiction regularly 4. Upgrading PHC  Environmental pollution impact management at the implementation and operation stages, infrastructure  Health publicity and education such as medical quality, reimbursement, drug 5. Progressively improve the Primary doctors: rural  Learning the health status of local residents supply, public health management and medical generosity of benefit package and family doctors  Health publicity and education environment management. for outpatient services  Leaving a good impression to local residents 3. County hospitals or medical alliances and receiving good performance evaluation communicate with township hospitals and results to increase income village clinics on relevant issues regularly at the  Receiving support from superior authorities, implementation and operation stages, including especially technical support from general equipment, technical support, talent training and practitioners and specialists performance evaluation. PHC providers:  Learning the health status of local residents township hospitals /  Health publicity and education village clinics  Obtaining better equipment and talents  Receiving support from superior authorities, especially technical support from general practitioners and specialists County hospitals or  Allocating resources to meet needs of primary medical alliances hospitals Vulnerable groups See the “Vulnerable groups” section of Chapter 2 and Appendix 2:“Ethnic Minority Engagement and minority residents Framework“. Other administrative  Implementing work in relevant fields The monitoring agency consults with competent units practically, e.g., women health protection and authorities regularly to track relevant issues at medical support for poor people the implementation and operation stages. Migrant population  Some common problems can be solved at primary hospitals.  Major hospitals should not be too crowded.  Non-local security settlement

A3-6 Building leadership for quality Local residents,  Scope, role, charges, etc. of healthcare Rural and family doctors communicate routinely in primary care services especially old people services with local residents on healthcare issues at the implementation and operation stages. PHC/QAC integrated  Learning primary healthcare in depth, and PHC management teams communicate with management teams discovering and solving issues quickly primary institutions and doctors regularly at the implementation and operation stages. 1.County/Prefecture HCs and HSAs  Establishing an effective primary healthcare 1) HCs and HSAs conduct an in-depth survey management teams will lead quality regulation system and design at the preparation stage. the service delivery Quality monitoring  Collecting primary healthcare quality 2) Quality monitoring teams collect medical strengthening effort, and build teams information accurately and timely quality information of local residents and doctors quality monitoring teams Local residents  Convenient access to medical quality through the proposed information system at the 2. Support PHSA to become a information; convenient reporting of medical implementation and operation stages. strategic purchaser by problems 3) Quality monitoring teams provide transparent introducing performance- Primary doctors  Transparent medical quality monitoring medical quality information with primary doctors based payment to FDTs system that allows doctors to file appeals to the public at the implementation and 3. A key responsibility for the operation stages. County/Prefecture will be to 4) Quality monitoring teams establish an appeal implement a “Performance and feedback mechanism for primary doctors at Enhancement Program” (PEP) the implementation and operation stages. for the FDT

Technical Public service subsystem HCs and HSAs  Designing projects suited to primary needs 1) HCs and HSAs conduct a survey on PHC Assistance providing IT services PHC providers:  Mastering technical requirements for relevant providers, doctors and community residents at ； Improving township hospitals / services the preparation stage. Primary village clinics  Learning relevant service policies, such as 2) HCs and HSAs organize training for PHC Health Care Primary doctors: rural reimbursement providers and their staff at the implementation Performance and family doctors and operation stages. Local residents  Learning relevant service policies, such as 3) PHC providers and doctors explain relevant reimbursement service policies to local residents at the implementation and operation stages. Addressing the human HCs and HSAs  Designing and organizing rational skills 1) HCs and HSAs conduct a survey on PHC resource gaps training courses to improve the skill level of providers, doctors and community residents at primary doctors the preparation stage. PHC providers:  Learning skills training types, policies, etc. 2) HCs and HSAs organize training for PHC township hospitals / providers and their staff at the implementation village clinics and operation stages. Primary doctors: rural 3) PHC providers and doctors explain relevant and family doctors service policies to local residents at the implementation and operation stages.

A3-7 1. Building an Interconnected HCs and HSAs  Designing a scientific and reliable integrated 1) HCs and HSAs conduct a survey on PHC Provincial Health Information information system; providers, doctors and community residents at System  Adjusting the system to practical needs the preparation stage. 2. Strengthening IT efficiently and continually 2) HCs and HSAs organize training for PHC Governance and Stewardship  Improving treatment effects using big data providers and their staff at the implementation and other high techs and operation stages, so that PHC providers  Building a provincial health database on PHC and their staff master relevant skills. providers and doctors using the information 3) Primary healthcare staff explains how to use system for scientific investment and the relevant app to local residents at the management implementation and operation stages.  Establishing a result-oriented primary 4) Information system authorities set up a hotline healthcare incentive mechanism based on or forum to collect information on system data system operation from primary healthcare staff and PHC providers:  Improving treatment effects using big data residents through PHC providers at the township hospitals / and other high techs implementation and operation stages. village clinics Primary doctors: rural  Improving treatment effects using big data and family doctors and other high techs; transparent medical quality monitoring system that allows doctors to file appeals Local residents  Convenient access to medical quality information; convenient reporting of medical problems Information system  Collecting issues on system operation timely authorities for upgrading and improvement Technical 1.Financing key TA activities HCs  Purchasing demand for relevant techs Government agencies communicate regularly at Assistance 2.Support for the HPHC and HSAs  Financial support for relevant diseases the implementation and operation stages. PHSA to play a strong Finance bureaus  Making unified funding arrangements stewardship role in the health sector 3.Support for project management through specific activities

A3-8 3 Stakeholders Engagement This SEP is based on the stakeholder in the previous chapter, especially stakeholder engagement demand analysis. Different stakeholders’ needs are described for the preparation, implementation and operation stages, while those at the implementation and operation stages are largely identical.

At the preparation stage (or feasibility study stage), many stakeholder engagement activities were conducted under the leadership and coordination of HPHC to collect their opinions on the project design. Since the Project was at the preparation stage when this SEP was prepared, and project activities at the implementation and operation stages may be further adjusted, detailed stakeholder identification and demand analysis is not fully carried out at this stage.. This SEP will plan stakeholder engagement activities for the implementation and operation stages, focusing on mechanism set up, design and monitor, thereby to ensure that all stakeholders are engaged as planned. This will be tracked by monitoring.

3.1 Started Information Disclosure Activities In December 2018 at preparation stage, the National Development and Reform Commission, and Word Bank Team conducted a healthcare survey in Hainan Province. During December 10-13, the Department of Foreign Capital and Overseas Investment of the National Development and Reform Commission organized Bank experts to conduct a healthcare survey in Hainan Province, and organized Bank experts, China Medical Board, National Health Commission, Hainan Provincial Development and Reform Commission, Finance Department, HPHC, etc. to hold seminars and FGDs. During this period, project information was disclosed. See Table 3-1.

A3-9 Table 3-1 Summary of First Round of Information Disclosure Time Venue Stakeholders / participants Key points Method National Development and Learning the current Reform Commission, Bank Field District / county situation of the 2018.12 mission, Hainan Provincial investigation, PHC providers healthcare industry of Development and Reform online disclosure Hainan Province Commission, HCs Bank representative, Duke Kunshan University, Chronic Disease and Aging Office of Discussing the project HPHC meeting Chinese Center for Disease lifecycle and the current 2019.7 Seminar room Control and Prevention, situation of primary Project Regulation Center of healthcare the National Health Commission Current situation and Field District / county issues of PHC 2019.8 HPHC, EIA agency, SA agency investigation, PHC providers providers in Hainan FGD, interview Province School of Medicine of Current situation of District / county 2019.8 Tsinghua University, professor primary healthcare in Field investigation PHC providers of Sichuan University Hainan for reference District / county Environmental issues 2019.8 HPHC, EIA agency Field investigation PHC providers of PHC providers HPHC meeting 2019.8 Bank experts Project discussion Seminar room

3.2 Information Disclosure Activities to be Started In order to make stakeholders further aware of the Project’s risks, impacts and potential opportunities, HPHC should disclose project information at different stages, especially the Project’s potential local risks and impacts, suggestions to alleviate such risks and impacts, potential risks that may further disadvantage vulnerable groups, measures to avoid and alleviate such risks and impacts, in order to make adequate preparations for incorporating public opinions. At the implementation stage, HPHC will ensure that information on environmental and social issues (whether positive or negative) is disclosed to the APs and other stakeholders (including the public and NGOs) at appropriate places, and in understandable forms and languages timely. See Table 3-2.

Information disclosed and disclosure modes at different stages should be based on local conditions, as shown in Table 3-3.

Table 3-2 Times and channels of information disclosure Stage Time Time and channel First round: Sep. First round: Sep. 2019; 2019 Second round: Sep. – Dec. 2019; Feasibility study Second round: Information disclosure and feedback channels: HPHC website; PHC Sep. – Dec. 2019 provider bulletin board; village bulletin board; health day publicity Each December during the implementation stage; Information disclosure and feedback channels: HPHC website; PHC Implementation Each December provider bulletin board; county / district public account; village bulletin board; village committee notice; health day publicity Each December; Information disclosure and feedback channels: HPHC website; PHC Operation Each December provider bulletin board; county / district public account; village bulletin board; village committee notice; health day publicity

A3-10 3.4 Started Public Consultation Activities To date, HPHC and HHSA have conducted a series of public consultation activities with the Hainan Provincial Finance Department, Development and Reform Commission, and other departments of the provincial government to discuss the Project’s current portfolio, overall environmental and social risks, alleviation measures and suggestions, etc.

In August and September 2019, HPHC, and the EIA and SA agencies conducted the first round of stakeholder consultation by means of organizational interview, FGD, key informant interview and field investigation. The findings are as follows:  All agencies in Hainan Province support the Project, and are willing to support its preparation and implementation.  Township health centers are short of talents and techniques, and do not have an effective incentive mechanism to attract and retain talents.  In addition, township health centers also have an urgent need for advanced IT systems, and technical and talent exchanges with 3A hospitals. Since rural doctors have very few patients in a daily basis (2-3 persons per day), they expect to improve their medical skills through training to meet public healthcare needs.  Community health centers have operating difficulties due to fund shortage and the small population served. They should have the drug dispensing function for the convenience of old people.  With the implementation of the targeted poverty alleviation program, the difficulty of poor people in medical care has been largely solved; the utilization rate of PHC providers is still low, and both men and women would go to 3A hospitals; there are Li and Miao doctors in minority areas.  In addition, ordinary residents spend much money and time on healthcare, even more than the middle class, because they would see a doctor when diseases develop to a certain extent and prefer doctors who prescribe drastic drugs. See Table 3-4 and Appendix 3.

3.5 Public Consultation Activities to be Started Stakeholder consultation is a two-way process that should run through the whole project lifecycle. First, initial opinions on the Project should be collected from the early stage of project planning; second, stakeholders should be encouraged to give feedback as a means of project design, stakeholder engagement, and the alleviation of environmental and social risks; relevant, transparent, objective, meaningful and accessible information should be disclosed and communicated in advance in order to conduct meaningful consultation with stakeholders in a culturally compatible manner, the local language and an understandable form to support active and extensive engagement. Stakeholder consultation covers the preparation, implementation and operation stages. See Table 3-5.

Stakeholder engagement during project implementation and operation is detailed in Appendix 4.

A3-11 Table 3-3 Proposed Information Disclosure Measures Stage Information to be disclosed Proposed mode Venue / date Target stakeholders Persons responsible HPHC contact First round of information Internet; HPHC website, bulletin Local residents, PHC Township officials (HCs, disclosure: project information Bulletin board; boards of PHC providers practitioners, government WFs, PAOs, ERACs, etc.) (mainly including purpose, nature, Village official notice; and village committees / agencies, vulnerable Village / community officials scale, duration, etc.), SEP Public account notice Sep. 2019 groups, etc. Component agencies Preparation HPHC contact Internet; HPHC website, bulletin Local residents, PHC Second round of information Township officials (HCs, Bulletin board; boards of PHC providers practitioners, government disclosure: ESMF, SEP (including WFs, PAOs, ERACs, etc.) Village official notice; and village committees / agencies, vulnerable EMEF) Village / community officials Public account notice Oct. – Dec. 2019 groups, etc. Component agencies Internet; HPHC contact HPHC website, bulletin Local residents, PHC Bulletin board; Township officials (HCs, Time and scope of boards of PHC providers practitioners, government Implementation Village official notice; WFs, PAOs, ERACs, etc.) implementation, etc. and village committees, agencies, vulnerable Village congress; Village / community officials project area / 2020-2025 groups, etc. Public account notice Component agencies Internet; HPHC contact HPHC website, bulletin Local residents, PHC Bulletin board; Township officials (HCs, boards of PHC providers practitioners, government Operation Project operation Village official notice; WFs, PAOs, ERACs, etc.) and village committees, agencies, vulnerable Village congress; Village / community officials project area / 2025 groups, etc. Public account notice Component agencies

A3-12 Table 3-4 Opinions of First Round of Public Consultation Time Venue Stakeholder Key points Method used Findings 1) Current situation and 1) All agencies support the Project actively. issues of PHC providers in 2) All local ethnic minorities are highly assimilated to Han Provincial Hainan, and solutions people, and there is no preferential medical policy for authorities 2) Roles and responsibilities ethnic minorities; there is no special healthcare need, Organizational 2019.8-9 HC offices (HPHC, HHSA, of all agencies e.g., doctor gender. Their healthcare awareness may be interview, FGD WF, PAO, EAC, 3) Current situation of women, improved in conjunction with minority festivals. etc.) minority residents and poor 3) EACs and WFs will participate in project publicity. people in all cities, counties and districts 1) Project introduction 1) Township health centers are short of talents and Xiangshui Town 2) Basic information of techniques, and do not have an effective incentive Health Center, township health centers mechanism to attract and retain talents. Township FGD, key informant Hainan No.2 3) Opinions and suggestions 2) Doctors think they have no development opportunity 2019.8-9 health interview, field People’s Hospital, on the Project at the township level and are poorly paid. centers investigation Maoyang Town 3) An advanced information system should be Health Center established. 4) Talents should be introduced. 1) Project introduction 1) Rural doctors have very few patients in a daily basis 2) Basic information of village (2-3 persons per day), and can only treat minor diseases, clinics so they expect more training opportunities. Hekou and FGD, key informant Village 3) Opinions and suggestions 2) Patients are mostly old people and children. 2019.8-9 Maojian Village interview, field clinics on the Project 3) Villagers usually receive medical advice and treatment Clinics investigation at village clinics for free. 4) Many rural doctors are contracted and regularly trained. 1) Project introduction 1) Outpatients include many local residents and 2) Basic information of migrants. community health centers 2) The center is not running at full capacity. Fenghuang, 3) Opinions and suggestions 3) Residents think that doctors make detailed inquiries, Community Sanyawan, on the Project FGD, key informant but are not skilled enough. 2019.8-9 health Haiken and Binya interview, field 4) Family doctors contract with local residents, with a centers Community investigation contracting rate of 30%. Health Centers 5) A medical alliance has been established with 3 hospitals for medical care at different levels. 6) It operates with difficulties, because it serves a small population and is short of funds.

A3-13 7) Community health centers should have the drug dispensing function for the convenience of old people. Villagers of Hekou 1) Project introduction 1) Many poor old people would go to village clinics for and Maogui 2) Village conditions and minor diseases. Villages, medical situation FGD, key informant 2) Villagers prefer more expensive but more efficacious residents of 3) Opinions and suggestions interview urban hospitals. Fenghuang on the Project Community 1) Project introduction 1) Poor families contract with family doctors, and usually 2) Situation of poor people go to township hospitals. and medical care FGD, key informant 2) Poor families are entitled to a green channel. Poor people 3) Opinions and suggestions interview 3) Poor families can reimburse most medical expenses Village / on the Project under health poverty alleviation and new-type rural 2019.8-9 community medical insurance. committees 1) Project introduction 1) Women usually go to major hospitals for childbirth. 2) Situation of women and 2) There is a fixed subsidy for childbirth. FGD, key informant Women medical care 3) Women receive free cervical and breast cancer interview 3) Opinions and suggestions screening on the Project 1) Project introduction 1) Rural minority residents are superstitious in medical 2) Situation of minority care. FGD, key informant Minority residents residents and medical care 2) There are Li and Miao doctors in minority areas. interview 3) Opinions and suggestions 3) There are language barriers for minority residents, and on the Project language help desks are expected.

A3-14 Table 3-5 Proposed Modes of Public Consultation Stage Key topic Method Venue / date Target stakeholder Organizer FGD, key informant Local residents (including Different groups’ suggestions Township governments, HCs interview, questionnaire, villagers, community on and expectations for the village committees Township heads “12345” and “12306” residents, migrant Project Sep. – Dec. 2019 Village / community heads hotlines population) Medical safety, PHC providers FGD, key informant HCs PHC practitioners; and staff, vulnerable groups’ interview, questionnaire, PHC providers Customer service staff of PHC vulnerable groups; local suggestions on and health day consultation, Sep. – Dec. 2019 providers residents expectations for the Project public satisfaction survey Doctors FGD, key informant PAOs, poor people’s needs interview, questionnaire, HCs PAOs for, suggestions on and “12345” and “12306” Poor people; PAOs PAO heads Sep. – Dec. 2019 Preparation attitudes to the Project hotlines, annual inspection Village / community heads of PAOs FGD, key informant ERACs, minority residents’ Village committees, HCs interview, needs for, suggestions on and meeting rooms of ERACs Minority residents; ERACs ERAC heads “12345” and “12306” attitudes to the Project Sep. – Dec. 2019 Village / community heads hotlines WFs, women’s needs for, FGD, key informant Meeting rooms of WFs HCs suggestions on and attitudes interview, “12345” and Women; WFs Sep. – Dec. 2019 WF heads to the Project “12306” hotlines Identification of emission Meeting rooms of HCs Provincial authorities; standards for production FGD HCs, government agencies Sep. – Dec. 2019 PHC providers wastewater and medical waste HCs Local media / medical Every month during 2020- Project publicity Local residents Village / community heads extension 2024 PHC providers Meeting rooms of PHC Local residents HCs Environmental pollution FGD providers PHC providers Heads of PHC providers 2020-2024Each December Implementati Offices of HCs and HSAs Consultation on medical Local residents HCs and HSAs on Key informant interview Every month during 2020- quality, reimbursement, etc. PHC providers Heads of PHC providers 2024 “12345” and “12306” Every month during 2020- Local residents Grievances and appeals HCs hotlines 2024 PHC providers and staff HCs Talent training, remuneration, FGD Meeting rooms of PHC PHC practitioners Customer service staff of PHC doctor performance rating, etc. Questionnaire survey providers providers

A3-15 Every month during 2020- 2024 PHC providers HCs Operation and issues of the Every month during 2020- Medical alliances FGD Information system O&M medical information system 2024 Information system O&M contractor contractor HC offices HCs Implementation of work on Vulnerable groups FGD Every month during 2020- Other administrative units vulnerable groups Other administrative units 2024 (WFs, EACs, etc.) HCs Local media / medical Every month during 2025- Project publicity Local residents Village / community heads extension 2044 PHC providers Meeting rooms of PHC Local residents HCs Environmental pollution FGD providers PHC providers Heads of PHC providers 2025-2044Each December Offices of HCs and HSAs Consultation on medical Local residents HCs and HSAs Key informant interview Every month during 2025- quality, reimbursement, etc. PHC providers Heads of PHC providers 2044 “12345” and “12306” Every month during 2025- Local residents Grievances and appeals HCs hotlines 2044 PHC providers and staff Meeting rooms of PHC Operation HCs Talent training, remuneration, FGD providers PHC practitioners Customer service staff of PHC doctor performance rating, etc. Questionnaire survey Every month during 2025- providers 2044 PHC providers HCs Operation and issues of the Every month during 2020- Medical alliances FGD Information system O&M medical information system 2024 Information system O&M contractor contractor Public satisfaction survey after Every month during 2025- Local residents, PHC Customer service staff of PHC Public scoring PHC provider reform 2044 providers providers HC offices HCs Implementation of work on Vulnerable groups FGD Every month during 2020- Other administrative units vulnerable groups Other administrative units 2024 (WFs, EACs, etc.)

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4 Grievance Mechanism In order to respond to concerns and grievances about environmental and social performance, a special grievance redress mechanism (GRM) has been established for the Project:

For subjects of primary healthcare services, namely residents, a collection, handling and feedback mechanism for relevant concerns and appeals that may be received at the implementation stage will be established;

For primary healthcare staff, a collection, handling and feedback mechanism for relevant issues at the implementation stage will be established.

4.1 For Residents At HPHC and HHSA, any appeal or issue related directly to the Project will be handled through the following procedure. This GRM will also be disclosed on the websites of HPHC and HHSA. All appeal records and related dispositions will be saved through the annual environmental and social monitoring mechanism and reported to the Bank.

Stage 1: An AP or stakeholder may ask questions to the opinion handling department (customer service department of the hospital) under the township/community medical institutions. The opinion handling department will record on site and deal with it within 10-15 working days, and give a reply or resolution to the AP. Stage 2: If AP have any objection to the treatment results of the township/community medical institutions, they can put forward relevant opinions to the county and city medical institutions/county and city health and health commission departments. The relevant departments will make records and consult with them, and provide the AP with replies or solutions within 10 working days. Stage 3: If the AP have objections to the results of the county mentioned in Stage 2, they can respond directly to the provincial health and fitness commission, or file a lawsuit directly to the court.

HPHC and HHSA may be reached in the following manner. See Table 4-1.

Table 4-1 Contact Information Method Time of response e-mail / 48 hours “12345” and “12306” hotlines Real time; or 48 hours Telephone Hotlines of HCs, health supervision offices, etc. for messages Letter / 15 days Appeal handling agencies / One week Online compliant / 15 days Customer service staff of PHC / One week providers Public satisfaction survey Public scoring Monthly

4.2 For Primary Medical Institutions In addition, HPHC and HHSA have established a sound internal appeal channel for PHC provider staff, and such channel is embedded into the existing labor management system. Staff may file appeals through the staff organization, customer service department, general administration department, etc., or resort to the arbitration procedure or judicial system.

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6 Resources and Responsibilities The Hainan PMO (composed of HPHC and HHSA) promises to appoint a coordinator to implement this SEP, and provide a sufficient budget for stakeholder engagement. This coordinator should be familiar with the requirements of this SEP, and work closely with the relevant implementing agencies to ensure that this SEP is implemented practically.

7 Monitoring and Reporting The Hainan PMO (composed of HPHC and HHSA) will keep records of all stakeholder engagement and information disclosure activities, and appeals and dispositions to be included in annual environmental and social monitoring reports.

8 Budget According to the actual situation of the project and the upcoming activities, the budget is estimated, as shown in Table 8-1. Table 8-1 Budget of SEP County Activities Budget (RMB) Source of financing Haikou, Sanya, FGD 5000 (per county) Bank loan Wuzhishan, Health day publicity tour 5000 (per county) Bank loan Wenchang, Public satisfaction 5000 (per county) Bank loan Qionghai, Wanning, survey Ding’an, Tunchang, Medical education 10000 (per county) Bank loan Chengmai, Lingao, animation video Danzhou, Dongfang promotion 12 counties Total 25000 (per county) Bank loan Ledong, FGD 5000 (per county) Bank loan Qiongzhong, Health day publicity tour 5000 (per county) Bank loan Baoting, Lingshui, Public satisfaction 5000 (per county) Bank loan Baisha, Changjiang survey Medical education 10000 (per county) Bank loan animation video promotion The healthy entry of 5000 (per county) Bank loan ethnic minorities into the countryside 6 Counties Total 30000 (per county) Bank loan Total / 480000 Bank loan

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Appendix 1 List of FGDs

City / Participants Venue Key points county 1 HC office 1) Project introduction (current situation Xiangshui Town of primary healthcare, women, minority 2 Health Center residents and poor people in Baoting Baoting County HC, County) 3 PAO, ERAC and WF; Hekou Village Clinic 2) Public consultation: public opinions head of the Xiangshui Baoting and suggestions on primary healthcare; Town Health Center; County opinions of heads and staff of PHC rural doctors in Hekou A villager’s home in providers (rural doctors, etc.); opinions 4 Village; villagers of Hekou Village of minority poor people and women Hekou Village 3) Organizational consultation: opinions of WFs, PAOs, EACs, etc. on primary healthcare and the Project Wuzhishan Municipal 1) Project introduction (current situation 5 Wuzhishan Municipal HC of primary healthcare, women, minority HC, PAO and ERAC; Hainan No.2 People’s residents and poor people in Wuzhishan 6 contact of Hainan No.2 Hospital City) People’s Hospital; Maogui Village 2) Public consultation: public opinions 7 Wuzhishan villagers of Maogui Committee and suggestions on primary healthcare; City Village; head of the Maoyang Town Health opinions of heads and staff of PHC 8 Maoyang Town Health Center providers (rural doctors, etc.); opinions Center; Maojian of minority residents and women Village Clinic rural 3) Organizational consultation: opinions 9 Maojian Village Clinic doctors of WFs, PAOs, EACs, etc. on primary healthcare and the Project 10 Sanya Municipal HC 1) Project introduction (current situation Fenghuang of primary healthcare, women, minority 11 Sanya Municipal HC, Community Health residents and poor people in Sanya PAO, ERAC and WF; Center City) head of the 2) Public consultation: public opinions Fenghuang and suggestions on primary healthcare; Sanya City Community Health opinions of heads and staff of PHC Center; staff of the Sanyawan Community providers (rural doctors, etc.); opinions 12 Sanyawan Community Health Center of minority residents and women Health Center 3) Organizational consultation: opinions of WFs, PAOs, EACs, etc. on primary healthcare and the Project Haiken Community 1) Project introduction (current situation 13 Health Center of primary healthcare, women, minority Binya Community residents and poor people in Haikou 14 Longhua District HC; Health Center City) head of the Haiken 2) Public consultation: public opinions Community Health and suggestions on primary healthcare; Haikou City Center; head and staff opinions of heads and staff of PHC of the Binya providers (rural doctors, etc.); opinions 15 Community Health HPHC office of minority women Center 3) Organizational consultation: opinions of WFs, PAOs, EACs, etc. on primary healthcare and the Project

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Appendix 2 Ethnic Minority Engagement Framework

A2.1. Basic information of minority population in Hainan Province According to the 2018 Statistical Yearbook of Hainan Province, at the end of 2017, Hainan had a minority population of 1,657,423, accounting for 18.2% of gross population, including 1,502,415 Li people, accounting for 90.65%; 79,515 Miao people, accounting for 4.8%; 40,218 Zhuang people, accounting for 2.43%; 13,225 Hui people, accounting for 0.8%; and 22,050 people of other ethnic minorities, accounting for 1.33%, distributed mainly in Sanya and Wuzhishan Cities, and Baoting, Qiongzhong, Lingshui, Baisha and Changjiang Counties.

There are over 30 ethnic minorities in Hainan, in which Han, Li, Miao and Hui are resident ethnic groups, while other ethnic groups have moved in after 1949 and are scattered. The Li, Miao and Hui people mostly live in central and southern Hainan, while the Han people mostly in northeast and north Hainan, and coastal areas.

According to the Constitution of the People’s Republic of China, and the Law on Regional Ethnic Autonomy, a township in which minority population accounts for over 30% of gross population may become a minority township. See Table 1:

Table A2-1 Distribution of Minority Population in Hainan Province Percentage of minority Division Han Li Miao Zhuang Hui Other population (%) Hainan Province 7446704 1502415 79515 40218 13225 22050 18.2 Sanya City 339626 233934 4074 2280 9710 2582 42.7 Wuzhishan City 28217 70718 5975 351 109 428 73.3 Ledong County 328792 203067 3096 1903 36 507 38.8 Lingshui County 162633 216529 866 727 30 474 69.5 Qiongzhong County 79472 112969 15460 6680 79 1499 63.2 Baoting County 51104 104461 7457 3856 61 877 69.5 Baisha County 66106 122610 2078 3058 14 1180 66.1 Changjiang County 148926 103123 299 888 723 566 41.5

The dialects spoken in Hainan include: 1) Hainan dialect, which is the dialect most spoken in Hainan by over 5 million residents; 2) Li language, which is spoken by all Li people; 3) Lingao dialect, which is close to the Zhuang language and is spoken by about 500,000 residents; and 4) Miao language, which is spoken by about 50,000 Miao people. In the 4 sample cities / counties, almost all minority residents can speak the Hainan dialect or Mandarin, except some old people aged above 75 years or those leading a secluded life in mountains.

In Hainan, minority and Han residents are highly integrated in living habits, and Mandarin is very popular among minority residents.

Minority residents have no taboo in doctor gender and are similar to Han residents in health status and diseases. In Wuzhishan City, Li and Miao residents have a higher incidence of thalassemia for genetic reasons, and patients are mostly from poor families with a weak sense of antepartum examination. In addition, some minority residents like drinking, and have a higher incidence of liver cirrhosis than Han residents. There are Li and Miao doctors in minority areas, and some rural minority residents are superstitious in medical care. In addition, although some minority residents cannot speak the Hainan dialect or Mandarin, there are many doctors and nurses speaking the Li language in rural primary healthcare teams, so their medical care is not affected. See Table 2.

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Table A2-2 Distribution of Minority PHC Providers Ethnic Village Community health Township health City / county minority clinics centers centers Sanya City Li, Hui 85 23 4 Wuzhishan City Li, Miao 4 0 9 Ledong County Li 176 2 13 Lingshui County Li 0 0 1 Qiongzhong County Li, Miao 6 1 15 Baoting County Li, Miao 47 0 9 Baisha County Li 60 1 11 Changjiang County Li 67 2 11

A2.2. Impacts on minority residents 1) Positive impacts The Project will improve the overall primary healthcare level of Hainan, so local minority residents will benefit from more medical resources, and higher primary healthcare quality and efficiency, especially poor minority residents. On the whole, Hainan's ethnic minorities are no different from the han in terms of health status, medical treatment tendency, medical treatment procedures and health poverty alleviation policies. Baoting county, Wuzhishan city and other cities and counties where the population of ethnic minorities accounts for more than 40% have consistent medical treatment policies. Therefore, after the implementation of the project, the minorities will share the benefits of the expansion of medical resource capacity at the same level, the improvement of the quality and efficiency of primary medical treatment, and the minority poor residents will benefit more. In addition, the Project will solve the difficulty of minority residents in receiving medical care, and overcome the language barrier by setting up language help desks.

2) Negative impacts The investment in the Project will be focused on technical design, service transformation, and primary healthcare improvement. The Project will involve no construction, no land acquisition, and no materially adverse impact on local communities and minorities. Based on a rapid social assessment, the Project has no crowding out effect and no negatively affected population.

A2.3. Application of EMEF or EMDP Ethnic minority engagement framework (EMEF) will be implemented when the subproject is not located in any ethnic minority autonomous counties but located in areas/communities involving ethnic minority people.

Ethnic minority development plan (EMDP) should be prepared when the subproject is in any ethnic minority autonomous counties.

A2.4 Minority engagement A2.4.1 Information disclosure to minority residents 1) Started information disclosure activities Since local minority and Han residents are highly integrated, information disclosure activities for minority residents are similar to those for Han residents. See Table 3.

Table A2-3 Started Information Disclosure Activities for Minority Residents Stakeholders / Time Venue Key points Method participants Learning the current Field District / National Development and situation of the healthcare investigation, 2018.12 county PHC Reform Commission, Bank industry of Hainan online providers mission, Hainan Provincial Province disclosure

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Development and Reform Commission, HCs, EACs Current situation and issues of PHC providers Field District / HPHC, EIA agency, SA in Hainan; project investigation, 2019.8 county PHC agency, municipal / county awareness, and FGD, providers EACs frequency and willingness interview to use PHC providers of minority residents School of Medicine of District / Tsinghua University, Current situation of PHC Field 2019.8 county PHC professor of Sichuan providers in Hainan investigation providers University, municipal / (including minority areas) county EACs District / Environmental issues of HPHC, EIA agency, Field 2019.8 county PHC PHC providers in minority municipal / county EACs investigation providers areas

2) Information disclosure activities about to be started Since local minority residents have their own spoken languages, and some old people cannot speak Mandarin, local dialects and minority languages should be used as appropriate in future information disclosure activities. See Table 4.

A2.4.2 Public consultation for minority residents 1) Started public consultation activities The SA agency has conducted consultation with the provincial and local EACs, agencies concerned in minority areas, and minority residents to collect suggestions and needs. Based on the first round of consultation, local minority residents show no significant difference from Han residents in medical care, and have no special need for doctor gender and ethnic group. However, some rural minority residents are superstitious in medical care. In addition, language is also a main concern, especially for some old minority residents. See Table 5. 2) Public consultation activities about to be started In order to ensure that minority residents are engaged at different stages to express their needs and suggestions, an ethnic minority engagement plan has been developed. See Table 6.

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Table A2-4 Information Disclosure Activities about to be Started for Minority Residents Stage Information to be disclosed Proposed mode Venue / date Persons responsible Remarks First round of information HPHC website, HPHC contact Use minority languages Internet; disclosure: project information bulletin boards of PHC Township officials (HCs, in oral communication, Bulletin board; (mainly including purpose, providers and village WFs, PAOs, ERACs, etc.) and provide dialect Village official notice; nature, scale, duration, etc.), committees / Village / community officials interpretation when Public account notice SEP Sep. 2019 Component agencies necessary. Preparation HPHC website, HPHC contact Internet; Second round of information bulletin boards of PHC Township officials (HCs, Bulletin board; disclosure: ESMF, SEP providers and village WFs, PAOs, ERACs, etc.) Village official notice; (including EMEF) committees / Oct. – Village / community officials Public account notice Dec. 2019 Component agencies Internet; HPHC website, HPHC contact Ensure that a certain Bulletin board; bulletin boards of PHC Township officials (HCs, percentage of village Time and scope of Implementation Village official notice; providers and village WFs, PAOs, ERACs, etc.) congress attendees are implementation, etc. Village congress; committees, project Village / community officials minority residents; use Public account notice area / 2020-2025 Component agencies minority languages in Internet; HPHC website, HPHC contact oral communication, Bulletin board; bulletin boards of PHC Township officials (HCs, and provide dialect Operation Project operation Village official notice; providers and village WFs, PAOs, ERACs, etc.) interpretation when Village congress; committees, project Village / community officials necessary. Public account notice area / 2025 Component agencies

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Table A2-5 Started Public Consultation Activities for Minority Residents Time Venue Stakeholder Key points Method used Findings 1) Current situation and 1) All local ethnic minorities are highly assimilated to Han people, issues of PHC providers in and there is no preferential medical policy for ethnic minorities; there Provincial Hainan, and solutions is no special healthcare need, e.g., doctor gender. Their healthcare authorities 2) Roles and awareness may be improved in conjunction with minority festivals. 2019.8- Organizational HC offices (HPHC, HHSA, responsibilities of all 2) EACs and WFs will participate in project publicity. 9 interview, FGD WF, PAO, EAC, agencies etc.) 3) Current situation of minority residents in all cities, counties and districts 1) Project introduction Findings: 2) current situation of 1) The main ethnic minority of Baoting County is Li. There is no primary healthcare and preferential medical policy for ethnic minorities; there is no special Baoting County 2019.8- Baoting minority residents in Organizational healthcare need, e.g., doctor gender. HC, PAO and 9 County Baoting County; interview Suggestions: ERAC 3) Opinions and 1) Local minority residents’ healthcare awareness may be improved suggestions of agencies on in conjunction with minority festivals. primary healthcare 2) EACs will participate in project publicity. 1) Project introduction Findings: Villagers of 2) Basic information of 1) Rural minority residents are superstitious in medical care. A villager’s Hekou Village personal healthcare 2) Many poor old people would go to village clinics for minor 2019.8- home in (incl. women, 3) Opinions and Key informant diseases. 9 Hekou poor people and suggestions on the Project interview Suggestions: Village minority 1) Rural doctors should be able to treat more diseases. residents) 2) There should be breastfeeding and kid playing spaces at hospitals. 1) Project introduction Findings: 2) Basic information of 1) There are Li and Miao doctors in minority areas. Villagers and Maogui Village 2) Villagers prefer more expensive but more efficacious urban Maogui 2019.8- women’s 3) Opinions and hospitals. Village FGD 9 director of suggestions on the Project Suggestions: Committee Maogui Village 1) Provide more investment in township hospitals 2) More capable doctors should be introduced. 3) Technical gaps of township health centers should be made up. Sanya 1) Project introduction Findings: Meeting 2019.8- Municipal HC, 2) current situation of Organizational 1) Minority residents have the same medical care habits as ordinary room of 9 EAC, PAO and primary healthcare and interview residents, but sometimes need language support. Sanya WF Suggestions:

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Municipal minority residents in Sanya 1) Relevant jobs should be first made available to minority and local HC City; residents. 3) Opinions and 2) Language help desks should be set up as appropriate. suggestions on the Project

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Table A2-6 Ethnic Minority Engagement Framework Form Other (filing, disclosure, Component Stakeholder Interests Activity Organizer (channel/time) monitoring) Improving Minority  Thalassemia prevention 1) Rural and family rural and  Village clinics  Recorded by organizer, Primary Health residents and treatment doctors maintain close family doctors  Follow-up and always available for Care (especially  Treatment of ordinary routine communications public access Performance； thalassemia) diseases and drug on disease prevention and  Open to third party Strategic purchase treatment with minority access (e.g., monitoring purchasing for  Learning the situation of residents at the agency) quality services primary doctors, and implementation and  Number of participants: 5 selecting suitable / operation stages.  Dialect interpretation satisfactory ones 2) Township hospitals Township  Village clinics  Recorded by organizer,  Building a language communicate with rural hospitals  Township and available online or service platform and family doctors and hospitals physically for public  Public health needs, e.g., ordinary residents on  Specified time access preventive injection relevant issues within their  Open to third party  Environmental pollution jurisdiction regularly at the access (e.g., monitoring impact management implementation and agency) operation stages, such as  Frequency and number medical quality, of participants: monthly, reimbursement, drug 10 at a time supply, public health  Dialect interpretation management and medical environment management. 3) County hospitals or County  Fixed place  Recorded by organizer, medical alliances hospitals or and time and available online or communicate with medical  Or online physically for public township hospitals and alliances follow-up access village clinics on relevant  Open to third party issues regularly at the access (e.g., monitoring implementation and agency) operation stages,  Frequency: monthly, 15 including equipment, at a time technical support, talent  Dialect interpretation training and performance evaluation.

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Minority primary  Learning the health PHC providers maintain PHC  Village clinics  Recorded by organizer, doctors: rural status of minority close routine providers  Township and always available for and family residents communication on skills, hospitals public access doctors  Leaving a good training and salary needs  Specified time  Open to third party impression to minority of minority rural and family access (e.g., monitoring residents, and gaining doctors at the agency) performance and implementation and  Dialect interpretation popularity to increase operation stages. income  Receiving support from superior authorities, especially technical support from general practitioners and specialists PHC providers:  Learning the health HCs learn needs of PHC HCs  PHC providers  Recorded by organizer, township status of minority providers for technical  Fixed place and always available for hospitals / residents equipment and talents and time public access village clinics  Obtaining better through regular  Online follow-  Open to third party equipment and talents communication via certain up access (e.g., monitoring  Receiving support from channels at the agency) superior authorities, implementation and especially technical operation stages. support from general practitioners and specialists EACs Implementing work in The monitoring agency Monitoring  Through  Recorded by organizer, relevant fields practically consults with competent agency external and available online or authorities regularly to monitoring physically for public track relevant issues at the mechanism access implementation and  Consistent  Open to third party operation stages. with external access (e.g., monitoring monitoring in agency) time Technical Minority  Learning relevant service Primary healthcare staff PHC  Village clinics  Recorded by organizer, Assistance residents policies, such as explains how to use the providers  Follow-up and always available for reimbursement relevant app to local public access residents at the

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 Convenient access to implementation and  Open to third party medical quality operation stages. access (e.g., monitoring information agency)  Reflecting medical issues conveniently Technical EACs  Implementing work in Government agencies HCs  Fixed place  Recorded by organizer, Assistance relevant fields practically communicate regularly at and time and always available for the implementation and  Working public access operation stages. meeting

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Appendix 3 Summary of First Round of Public Consultation

Time Venue Stakeholder Key points Method used Findings 2019.8-9 HPHC office Provincial 1) Current situation and Organizational All agencies support the Project actively. authorities (HPHC, issues of PHC providers in interview HHSA, etc.) Hainan, and solutions 2) Roles and responsibilities of all agencies 2019.8-9 Days Inn Hot Baoting County HC, 1) Project introduction Organizational Findings: Spring Baoting PAO, ERAC and 2) Current situation of interview 1) The main ethnic minority of Baoting County is Li. There WF primary healthcare, women, is no preferential medical policy for ethnic minorities; there minority residents and poor is no special healthcare need, e.g., doctor gender. people in Baoting County 3) Baoting County has a high incidence of thalassemia, 3) Opinions and suggestions and special measures are in place. of agencies on primary 4) In Baoting County, health poverty alleviation is for rural healthcare areas only. 5) In Baoting County, women receive a fixed childbirth subsidy of 800 yuan. Suggestions: 1) Local minority residents’ healthcare awareness may be improved in conjunction with minority festivals. 2) EACs and WFs will participate in project publicity.

2019.8-9 Xiangshui Town Head of the 1) Project introduction Key informant Findings: Health Center Xiangshui Town 2) Basic information of interview 1) The health center has only two doctors. Health Center Xiangshui Town Health 2) The health center’s capacity is not fully utilized (50%). Center 3) The outpatient utilization rate of the health center is low. 3) Opinions and suggestions 4) The self-paid consultation rate of migrants is only 3.6%. on the Project Suggestions: 1) The doctors should receive more training to improve their skills. 2) An advanced information system should be established.

2019.8-9 Hekou Village Doctors and health 1) Project introduction Key informant Findings: Clinic workers of Hekou 2) Basic information of interview 1) Rural doctors have few patients in a daily basis, and can Village Clinic, Hekou Village Clinic only treat minor diseases. women’s director of 3) Opinions and suggestions 2) Patients are mostly old people and children. Hekou Village on the Project 3) The income of rural doctors is average.

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4) Villagers usually receive medical care at village clinics for free. Suggestions: 5) Poor families contract with family doctors. Suggestions: 1) Training opportunities are expected.

2019.8-9 A villager’s Villagers of Hekou 1) Project introduction Key informant Findings: home in Hekou Village (incl. 2) Basic information of interview 1) Poor families contract with family doctors, and usually Village women, poor personal healthcare go to township hospitals. people and minority 3) Opinions and suggestions 2) Rural minority residents are superstitious in medical residents) on the Project care. 3) Many poor old people would go to village clinics for minor diseases. Suggestions: 1) Rural doctors should be able to treat more diseases. 2) There should be breastfeeding and kid playing spaces at hospitals.

2019.8-9 Meeting room Wuzhishan 1) Project introduction Organizational Findings: of the Municipal HC, PAO 2) Current situation of interview 1) Patients of village clinics are mostly old people and Wuzhishan and ERAC primary healthcare, women, children; most residents go to Hainan No.2 People’s Municipal HC minority residents and poor Hospital. people in Wuzhishan City 2) The utilization rate of township health centers is only 3) Opinions and suggestions 30%-50%. of agencies on primary Suggestions: healthcare 1) Strengthen manpower and equipment. 2) Increase the number of doctors and improve medical quality. 3) Increase the turnover rate of hospitals. 4) Design capacity based on resident population and in consideration of migrant population. 5) Set up language help desks for old minority people.

2019.8-9 Hainan No.2 Contact of Hainan 1) Project introduction Key informant Findings: People’s No.2 People’s 2) Basic information of interview 1) Poor families are entitled to a green channel. Hospital Hospital, pediatrics Hainan No.2 People’s 2) The hospital is not running at full capacity. outpatient doctors, Hospital 3) The hospital is short of manpower.

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service head, 3) Opinions and suggestions 4) The hospital is about to establish a medical alliance for patients on the Project hierarchical and two-way diagnosis and treatment. 5) Some patients need to communicate in the Hainan dialect. 6) The hospital handles patient appeals through its customer service department and the 12345 platform. Suggestions: 1) Talents should be introduced. 2) Introducing advanced equipment

2019.8-9 Maogui Village Villagers and 1) Project introduction FGD Findings: Committee women’s director of 2) Basic information of 1) Rural doctors are not resident, and are contacted by Maogui Village Maogui Village telephone when necessary. 3) Opinions and suggestions 2) This village is close to the town, and most villagers go on the Project to the town for medical care. 3) There are Li and Miao doctors in minority areas. 4) Villagers prefer more expensive but more efficacious urban hospitals. Suggestions: 1) Investing heavily in township hospitals 2) More capable doctors should be introduced. 3) Technical gaps of township health centers should be made up.

2019.8-9 Maoyang Town Head of the 1) Project introduction Key informant Findings: Health Center Maoyang Town 2) Basic information of interview 1) Patients are mostly old people and children. Health Center Maoyang Town Health 2) There is only one competent middle-rank doctor, and Center there is no incentive mechanism. 3) Opinions and suggestions Suggestions: on the Project 1) Talents should be introduced under a sound incentive mechanism. 2) Doctors should be trained externally.

2019.8-9 Maojian Village Maojian Village 1) Project introduction Key informant Findings: Clinic Clinic rural doctors 2) Basic information of interview 1) The rural doctors’ salary is higher than average. Maojian Village Clinic 2) Many rural doctors are contracted. 3) Opinions and suggestions 3) Rural doctors are trained regularly. on the Project

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2019.8-9 Meeting room Sanya Municipal 1) Project introduction Organizational Findings: of the Sanya HC, EAC, PAO and 2) Current situation of interview 1) Sanya City has many migrant people, who mostly go to Municipal HC WF primary healthcare, women, 3A hospitals. minority residents and poor 2) There are already medical alliances in Sanya City. people in Sanya City 3) Community health centers are understaffed, especially 3) Opinions and suggestions in winter. on the Project 4) Village clinics cannot attract and retain talents. 5) Minority residents have the same medical care habits as ordinary residents, but sometimes need language support. 6) Healthcare for poor people is still available after the completion of the poverty alleviation program. Suggestions: 1) Talents should be introduced. 2) A remuneration reform and primary standardization should be conducted. 3) Major hospitals should be established in rural areas. 4) Relevant jobs should be first made available to minority and local residents. 5) Language help desks should be set up as appropriate.

2019.8-9 Fenghuang Residents 1) Project introduction Key informant Findings: Community (including migrants 2) Basic information of interview 1) Outpatients include many local residents and migrants. Health Center and poor people); Fenghuang Community 2) The center is not running at full capacity. head of the Health Center 3) Residents go to the health center for minor diseases. Fenghuang 3) Opinions and suggestions 4) Residents think that doctors make detailed inquiries, but Community Health on the Project are not skilled enough. Center 2019.8-9 Sanyawan Head 1) Project introduction Key informant Findings: Community 2) Basic information of interview 1) The migrant population visiting the service center Health Center Sanyawan Community decreases year by year. Health Center 2) Equality for migrant population should be realized. 3) Opinions and suggestions on the Project 2019.8-9 Crowne Plaza Sanya Municipal 1) Project introduction FGD Suggestions: Sanya Bay HC; EIA agency; SA 2) Opinions and suggestions 1) A sound organizational structure with clear duties should agency on the Project be established. 2) The scope of the Project should be defined.

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2019.8-9 Haiken Longhua District 1) Project introduction Key informant Findings: Community HC; head of the 2) Basic information of interview 1) The health center has many female staff members, and Health Center community health Haiken Community Health about half of its staff members are minority residents, center; HPHC Center especially Li residents. 3) Opinions and suggestions 2) The outpatient utilization rate of the health center is only on the Project 50%. 3) Patients are mostly low residents. 4) Family doctors contract with local residents, with a contracting rate of 30%. 5) A medical alliance has been established with the Second Affiliated Hospital of Hainan Medical University for medical care at different levels. 6) It operates with difficulties, because it serves a small population and is short of funds.

2019.8-9 Binya Longhua District 1) Project introduction Key informant Findings: Community HC; head and staff 2) Basic information of Binya interview 1) The outpatient utilization rate of the health center is only Health Center of the service Community Health Center 40%. center; HPHC 3) Opinions and suggestions 2) Medical expenses here cannot be reimbursed. on the Project 3) The health center conducts volunteer medical consultation every week, mainly for special diseases, such as diabetes and hypertension. 4) The contracting rate of family doctors is about 45%. 5) A medical alliance has been established with the provincial hospital. Suggestions: 1) Community health centers should have the drug dispensing function for the convenience of old people.

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Appendix 4 Implementation and Operation Stages

At the implementation and operation stages, a certain stakeholder engagement mechanism should be established based on project activities and engagement needs to ensure that stakeholders are engaged effectively. Such mechanism may be adjusted flexibly to local conditions, but should include the following basic factors: 1) Subjects: Who organizes each engagement activity? Who are subjects of communication? 2) Form: modes and times of communication, such as face-to-face, telephone and online communication 3) Scope: What is the scope of communication? 4) Filing and disclosure: How to keep and save records, and how is information disclosed? 5) Monitoring: How to conduct monitoring?

The stakeholder engagement mechanism of the implementation and operations under the above framework is shown in Table A4-0-1.

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Table A4-0-1 Stakeholder Engagement Plan of the Implementation and Operation Stages Form Other (filing, disclosure, Component Stakeholder Interests Activity Organizer (channel/time) monitoring) Improving Local residents, • Chronic disease prevention 1) Rural and family doctors Rural and • Village clinics • Recorded by organizer, and Primary especially and treatment maintain close routine family doctors • Follow-up always available for public Health Care chronic disease • Treatment of ordinary communications on disease access Performanc patients diseases and drug purchase prevention and treatment with • Open to third party access e；Strategic • Learning the situation of local residents at the (e.g., monitoring agency) purchasing primary doctors, and implementation and operation • Number of participants: 5 for quality selecting suitable / stages. (incl. women and minority services satisfactory ones residents) • Higher percentage of • Dialect interpretation reimbursement 2) Township hospitals Township • Village clinics • Recorded by organizer, and • Public health needs, e.g., communicate with rural and hospitals • Township available online or preventive injection family doctors and ordinary hospitals physically for public access • Environmental pollution residents on relevant issues • Specified • Open to third party access impact management within their jurisdiction regularly time (e.g., monitoring agency) at the implementation and • Frequency and number of operation stages, such as participants: monthly, 10 at medical quality, reimbursement, a time (incl. women and drug supply, public health minority residents) management and medical • Dialect interpretation environment management. 3) County hospitals or medical County • Fixed place • Recorded by organizer, and alliances communicate with hospitals or and time available online or township hospitals and village medical • Or online physically for public access clinics on relevant issues alliances follow-up • Open to third party access regularly at the implementation (e.g., monitoring agency) and operation stages, including • Frequency: monthly, 15 at a equipment, technical support, time (incl. women and talent training and performance minority residents) evaluation. Primary doctors: • Learning the health status of PHC providers maintain close PHC • Village clinics • Recorded by organizer, and rural and family local residents routine communication on skills, providers • Township always available for public doctors • Leaving a good impression training and salary needs of hospitals access to local residents and minority rural and family doctors • Specified • Open to third party access receiving good performance at the implementation and time (e.g., monitoring agency) evaluation results to operation stages. increase income

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• Receiving support from superior authorities, especially technical support from general practitioners and specialists PHC providers: • Learning the health status of HCs learn needs of PHC HCs • PHC • Recorded by organizer, and township local residents providers for technical equipment providers always available for public hospitals / village • Obtaining better equipment and talents through regular • Fixed place access clinics and talents communication via certain and time • Open to third party access • Receiving support from channels at the implementation • Online follow- (e.g., monitoring agency) superior authorities, and operation stages. up especially technical support from general practitioners and specialists County hospitals • Allocating resources to meet County hospitals or medical County • Fixed place • Recorded by organizer, and or medical needs of primary hospitals alliances conduct regular hospitals or and time available online or alliances communication and resource medical • physically for public access allocation for primary schools at alliances the implementation and operation stages. Other • Implementing work in The monitoring agency consults Monitoring • Through • Recorded by organizer, and administrative relevant fields practically, with competent authorities agency external available online or units e.g., women health regularly to track relevant issues monitoring physically for public access protection and medical at the implementation and mechanism support for poor people operation stages. • Consistent with external monitoring in time Migrant • Some common problems Rural and family doctors maintain Rural and • Village clinics • Recorded by organizer, and population can be solved at primary close routine communications on family doctors • Follow-up always available for public hospitals. disease prevention and treatment access • Major hospitals should not with migrant population at the • Open to third party access be too crowded. implementation and operation (e.g., monitoring agency) stages. • Number of participants: 5 Local residents, • Scope, role, charges, etc. of Rural and family doctors Rural and • Village clinics • Recorded by organizer, and especially old healthcare services communicate routinely with local family doctors • Follow-up always available for public people residents on healthcare issues at access the implementation and operation • Open to third party access stages. (e.g., monitoring agency)

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• Number of participants: 5 (incl. women and minority residents) • Dialect interpretation PHC integrated • Learning primary healthcare PHC management teams PHC • Fixed place • Recorded by organizer, and management in depth, and discovering communicate with primary management and time available online or teams and solving issues quickly institutions and doctors regularly teams • Or online physically for public access at the implementation and follow-up • Open to third party access operation stages. (e.g., monitoring agency) • Frequency: monthly Quality • Establishing an effective 1) Quality monitoring teams Quality • Village clinics • Recorded by organizer, and monitoring teams primary healthcare quality collect medical quality monitoring • Follow-up always available for public regulation system information of local residents and teams access doctors through the proposed • Open to third party access information system at the (e.g., monitoring agency) implementation and operation • Dialect interpretation stages. • Collecting primary 2) Quality monitoring teams Quality • Fixed place • Recorded by organizer, and healthcare quality provide transparent medical monitoring and time available online or information accurately and quality information with primary teams • Or online physically for public access timely doctors to the public at the follow-up • Open to third party access implementation and operation (e.g., monitoring agency) stages. • Frequency: monthly Local residents • Convenient access to 3) Quality monitoring teams Quality • Fixed place • Recorded by organizer, and medical quality information; establish an appeal and monitoring and time available online or convenient reporting of feedback mechanism for primary teams • Or online physically for public access medical problems doctors at the implementation follow-up • Open to third party access and operation stages. (e.g., monitoring agency) Primary doctors • Transparent medical quality Primary doctors file appeals Quality • Fixed place • Recorded by organizer, and monitoring system that through the appeal and feedback monitoring and time available online or allows doctors to file mechanism at the teams • Or online physically for public access appeals implementation and operation follow-up • Open to third party access stages. (e.g., monitoring agency) Technical PHC providers: • Mastering technical HCs and HSAs organize training HCs and • Fixed place • Recorded by organizer, and Assistance township requirements for relevant for PHC providers and their staff HSAs and time available online or ；Improving hospitals / village services at the implementation and • Or online physically for public access Primary clinics • Learning relevant service operation stages. follow-up • Open to third party access Health Care policies, such as (e.g., monitoring agency) reimbursement • Frequency: monthly

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Performanc 2) PHC providers and doctors PHC • Village clinics • Recorded by organizer, and e explain relevant service policies providers and • Follow-up always available for public Primary doctors: to local residents at the doctors access rural and family implementation and operation • Open to third party access doctors stages. (e.g., monitoring agency) Local residents • Learning relevant service • Dialect interpretation policies, such as reimbursement PHC providers: • Learning skills training 1) HCs and HSAs organize HCs and • Fixed place • Recorded by organizer, and township types, policies, etc. training for PHC providers and HSAs and time available online or hospitals / village their staff at the implementation • Or online physically for public access clinics and operation stages. • Open to third party access (e.g., monitoring agency) • Frequency: monthly 2) PHC providers and doctors PHC • Village clinics • Recorded by organizer, and explain relevant service policies providers and • Follow-up always available for public Primary doctors: to local residents at the doctors access rural and family implementation and operation • Open to third party access doctors stages. (e.g., monitoring agency) • Dialect interpretation HCs and HSAs • Designing a scientific and 1) HCs and HSAs organize HCs and • Fixed place • Recorded by organizer, and reliable integrated training for PHC providers and HSAs and time available online or information system; their staff at the implementation • Or online physically for public access • Adjusting the system to and operation stages, so that • Open to third party access practical needs efficiently PHC providers and their staff (e.g., monitoring agency) and continually master relevant skills. • Frequency: monthly • Improving treatment effects 2) Primary healthcare staff Primary • Village clinics • Recorded by organizer, and using big data and other explains how to use the relevant healthcare • Follow-up always available for public high techs app to local residents at the staff access • Building a provincial health implementation and operation • Open to third party access database on PHC providers stages. (e.g., monitoring agency) and doctors using the • Dialect interpretation information system for 3) Information system authorities Information • Hotline or • Recorded by organizer, and scientific investment and set up a hotline or forum to system forum always available for public management collect information on system authorities • Anytime access • Establishing a result- operation from primary • Open to third party access oriented primary healthcare healthcare staff and residents (e.g., monitoring agency) incentive mechanism based through PHC providers at the on data system

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PHC providers: • Improving treatment effects implementation and operation township using big data and other stages. hospitals / village high techs clinics Primary doctors: • Improving treatment effects • Hotline or rural and family using big data and other forum doctors high techs; transparent • Anytime medical quality monitoring system that allows doctors to file appeals Local residents • Convenient access to medical quality information; convenient reporting of medical problems Information • Collecting issues on system • Anytime system operation timely for authorities upgrading and improvement Technical HCs (incl. • Purchasing demand for Government agencies HCs • Fixed place • Recorded by organizer, and Assistance information relevant techs communicate regularly at the and time always available for public center) implementation and operation • Working access HSAs • Financial support for stages. HSAs meeting relevant diseases Finance bureaus • Making unified funding Finance arrangements bureaus

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Appendix 5 Field work Photos

September 18, 2019: interview at the Health bulletin board of the Xiangshui Town Xiangshui Town Health Center Health Center

September 18, 2019: interview at the Hekou September 18, 2019: interview with villagers Village Clinic of Hekou Village (women and minority residents)

September 18, 2019: interview with villagers September 18, 2019: organizational FGD in of Hekou Village (poor and old people) Baoting County

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September 19, 2019: interview with medical September 19, 2019: interview at the staff of Hainan No.2 People’s Hospital customer service department of Hainan No.2 People’s Hospital

September 19, 2019: FGD with villagers of September 19, 2019: interview with head of Maogui Village the Maoyang Town Health Center

September 19, 2019: interview with a rural September 19, 2019: organizational doctor interview in Wuzhishan City

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September 20, 2019: FGD with residents of September 20, 2019: organizational FGD in Fenghuang Community Health Center in Sanya City Sanya City

September 22, 2019: interview with head of September 22, 2019: interview with medical the Haiken Community Health Center staff of the Binya Community Health Center

Health bulletin board of the Haiken Health bulletin board of the Sanyawan Community Health Center Community Health Center

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