The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031) Public Disclosure Authorized For Official Use Only Public Disclosure Authorized Appraisal Environmental and Social Review Summary Appraisal Stage (ESRS Appraisal Stage) Date Prepared/Updated: 05/12/2021 | Report No: ESRSA01471 Public Disclosure Public Disclosure Authorized Public Disclosure Authorized May 12, 2021 Page 1 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031) BASIC INFORMATION A. Basic Project Data Country Region Project ID Parent Project ID (if any) Somalia AFRICA EAST P172031 Project Name Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 3/22/2021 6/29/2021 Population Financing For Official Use Only Borrower(s) Implementing Agency(ies) Federal Ministry of Federal Ministry of Health Finance Proposed Development Objective The Project Development Objective (PDO) is to improve the coverage of essential health and nutrition services in project areas and strengthen stewardship capacity of Ministries of Health. Financing (in USD Million) Amount Public Disclosure Total Project Cost 100.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The proposed project, the 'Damal Caafimaad', which is the first WB health operation in Somalia, will build on ongoing ASA work and activities under RCRF, which support the establishment of the Government’s Female Health Workers (FHW) program. The 'Damal Caafimaad' project will be financed through an IDA grant of US$75 million, co-financed by the Global Financing Facility (GFF) Trust Fund with an additional US$25 million for four years. The project intends to improve access to and quality of a set of high impact basic health and nutrition services while strengthening the current weak institutional capacity in Ministries of Health at both federal and state levels and building resilience health systems. May 12, 2021 Page 2 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031) The Project has four components: (1) Expanding the coverage of high-impact health and nutrition services in select geographic areas; (2) Strengthening Government’s stewardship to enhance service delivery; (3) Project Management and Knowledge Management and Learning; and (4) a Contingency Emergency Response Component (CERC). D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] There are gaps in essential supplies such as health workers, essential medicines, and medical equipment, particularly in public facilities. Somalia’s public health worker density is 0.43 per 1,000 people and private health worker density is 0.49 per 1,000 people. The combined health worker density figure (0.92) is significantly below the WHO’s cut-off for “critical” human resource shortages, which is 2.28 health workers per 1000 people. The availability of qualified medical staff is predictably concentrated in urban areas, with rural areas facing more pronounced recruitment and For Official Use Only retention challenges. There are also many unqualified individuals believed to be providing health services, particularly in private facilities due to lack of regulation and weak government enforcement. Supply chain management for health is challenged by the volatile security environment, poor infrastructure, human resource shortages and low capacity, limited access to supervision and monitoring, and a lack of functional, integrated sector- wide information management systems. Due to the near complete absence of government service provision, health services in Somalia are generally run by non-state actors mainly NGOs and UN agencies. The proposed Project will support the delivery of essential health and nutrition services to enhance service coverage and quality, focusing on primary healthcare services for women, children, and newborns. Learning from local and global experience and based on analysis of cost-effective interventions and burden of disease analysis, the project will support implementation of a prioritized package of services on: (i) child health and nutrition services; (ii) maternal and neonatal health services, including testing and interventions during ANC visits, basic and comprehensive emergency obstetric and newborn care, and family planning; (iii) GBV services (awareness raising, case identification, counselling, and management); (iv) disease Public Disclosure surveillance. These health services will be accompanied by health education and behavior change communications, as well as referral mechanisms to the appropriate level of service delivery. A single service provider for each region will be contracted, although they may sub-contract to local NGOs for up to 20% of the contract. The selection of the project target regions has been based on objective criteria jointly agreed with the Government, including poverty level, health service availability, service delivery data, and current partner support. The regions are rural with small urban centers and poor infrastructure, or is more urban often with a considerable number of IDPs, who are particularly marginalized in their access to services, which are often controlled by gate keepers, and their ability to raise complaints or concerned is severely constrained. These are likely to include: Nugaal (Puntland), Bakool (South West), Bay (South West), and Hiraan and Middle Shabelle (Hirshabelle). Government contracting of non-state actors to deliver health services is a means to successfully improve health outcomes by rapidly expanding service delivery in situations where the Government has limited capacity and there is ongoing insecurity. Afghanistan and Cambodia had notable success expanding health service coverage through a contracting out model. All the service contracts between the Government and service providers will include the reference to the Environmental Management Framework (EMF) including (IMWMP), and Social Management Framework (SocMF) including GBV action plan, Labor Management Plan and Security Management Framework. Project and area-based Security risk assessments and security management plans will be developed by an accredited security management firm contracted by the client overseen by a full time security advisor. Contractors will prepare May 12, 2021 Page 3 of 19 The World Bank Improving Healthcare Services in Somalia Project (“Damal Caafimaad”) (P172031) Environmental and Social Assessment and Management Plans (ESAMPs) incorporating plans for the implementation of all instruments and E&S staffing plans. Although no land acquisition or resettlement is anticipated, minor rehabilitation of health centers, installation of incinerators or other waste management equipment, strengthening/expanding existing government health centers, and possible upgrading/installing of sanitary facilities etc. may result in an expansion of the environmental footprint of the existing Health Centers. The absence of adequate biohazard and biological waste management procedures in health institutions may allow for uncontrolled outbreaks of contagious diseases and is a threat to public health. In particular, studies show that there is no adequate incineration system in place in the majority of the health facilities in Somalia. D. 2. Borrower’s Institutional Capacity The proposed project will be the first project the Ministry of Health has designed and implemented as their own Government program, thus E&S capacity is low, although in the FGS MoH there is a Community Health Coordinator, a National GBV manager, head of environmental health and OHS manager, who is leading on OHS guidelines. However, For Official Use Only the likely NGO implementers have well developed HR and security management systems, although are likely to also suffer from clannism and elite capture, and may sub-contract to local NGOs up to 20% of the contract. Their other capacities will need to be assessed as part of the ESAMPs and due diligence as part of the contract awarding. An initial needs assessment as well as TORs, an action plan and timeline for capacity building has been included in the Environmental and Social management Frameworks. However, once the proposed staffing and implementing partners are on board, the needs assessment and plan will be updated. This will also be referenced in the ESCP. The FGS MoH will provide overall health sector stewardship including regulatory oversight and monitoring of state- level service delivery implementation and will manage the service delivery contracts. The FMS MoH will monitor and supervise contract implementation, ensuring implementation of the relevant safeguard instruments with oversight from the FGS MoH. At the federal level, a Project Coordination and Implementation Unit (PCIU) will be established at the FGS MoH which Public Disclosure will include a senior project coordinator, supported by three Contract Management/ M&E Specialists, two HMIS Specialists, a Security Advisor, a part-time Legal Advisor, a Communications Specialist, a PFM specialist, a Procurement specialist, separate social and environmental