Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized I. Basic Information Date prepared/updated: 12/07/2010 INTEGRATED SAFEGUARDS DATASHEET APPRAISAL STAGE Report No.: AC5155 1. Basic Project Data Country: Swaziland Project ID: P110156 Project Name: Swaziland Health, HIV/AIDS and TB Project Task Team Leader: Kanako Yamashita-Allen Estimated Appraisal Date: May 5, 2010 Estimated Board Date: March 10, 2011 Managing Unit: AFTHE Lending Instrument: Specific Investment Loan Sector: Health (65%);Other social services (16%);Central government administration (14%);Sub-national government administration (5%) Theme: Health system performance (30%);Population and reproductive health (27%);HIV/AIDS (25%);Tuberculosis (10%);Other accountability/anti-corruption (8%) IBRD Amount (US$m.): 20.00 IDA Amount (US$m.): 0.00 GEF Amount (US$m.): 0.00 PCF Amount (US$m.): 0.00 Other financing amounts by source: Borrower 2.00 EC: European Commission 19.00 21.00 Environmental Category: B - Partial Assessment Simplified Processing Simple [] Repeater [] Is this project processed under OP 8.50 (Emergency Recovery) or OP 8.00 (Rapid Response to Crises and Emergencies) [ ] No [] 2. Project Objectives The Swaziland Health, HIV/AIDS and TB Project has two main sectoral foci: a primary focus on the health sector and the services it delivers to the Swazi population, and a secondary focus on social protection to mitigate the impact of HIV/AIDS on OVC. The Project Development Objectives (PDOs) are: (i) to improve access to and quality of health services in Swaziland with a particular focus on primary health care, maternal health and TB, and (ii) to increase social safety net access for OVC. 3. Project Description The proposed project lending instrument is a Specific Investment Loan (SIL). An IBRD loan of US$ 20.0 million will be combined with financing from the EU (Euros 14.5 million or US$ 19 million equivalent) and the GOS (approximately US$ 2.0 million). The project implementation period is five years. Component 1: Strengthening the Capacity of the Health Sector (US$ 3.90 million)
This component will support interventions to strengthen the capacity of the MOH at different levels with respect to governance, management and planning. The component will support improvement of the regulatory framework for health service providers, including establishment of accreditation review criteria and systems, and of a standard care package, quality assurance, oversight and coordination. The project will support efforts to improve governance and health care regulation through the development of a regulatory and accreditation framework, and ultimately a regulatory unit. This includes: (i) further development of the essential health care package of services; (ii) review of the legal and regulatory framework, and development of regulations to incorporate international and regional health agreements; (iii) establishment of a program to develop an accreditation system for personnel, facilities and services; and (iv) support and training for the parliamentary oversight committee and professional regulatory bodies (Medical and Dental, Nursing, Allied Health Councils). Improving governance and management at district-level by: (i) supporting efforts to reenergize and better establish the credibility of the four Regional Health Management Teams (RHMTs), including management and organizational development, and team building. This includes clarification on the roles and responsibilities of RHMTs versus health facilities and improving planning and management skills in a decentralized environment; and (ii) establishing/strengthening hospital boards and improving hospital management through better planning, enhanced professional training, and increased autonomy. Planning and Coordination: (i) strengthening the Health Planning Unit, concentrating particularly on development of planning and budgeting skills and capacity; and (ii) support for enhancing the Sector-wide Approach (SWAp) processes that are still at an early stage. Fiduciary: (i) support for financial management systemic reforms and their introduction, especially around improved responsibility centers (i.e. cost) and their delegated authority (with Ministry of Finance); and (ii) additional support for the ongoing procurement reforms within the MOH. Component 2: Facility-level Support to Improve Access, Quality and Efficiency of Services (US$ 24.38 million) This component will support interventions to rehabilitate and improve targeted facilities at different levels of the health system. Management and technical skills training as well as the rehabilitation and equipping of selected clinics, health centers and hospitals will be carried out to improve the access, quality and efficiency of the services provided by these facilities. The Project will have a particular focus on Primary Health Care (PHC), the HIV and TB Co-epidemic Response and Emergency Obstetric and Neonatal Care (EmONC). The project will also support health care waste management to mitigate the environmental risks at the facilities receiving support.
Sub-component 2a: Support to Hospitals, Health Centers and Clinics This sub-component will focus on: (i) developing and disseminating guidelines and protocols; (ii) rehabilitating/renovating selected health facilities; (iii) providing essential equipment and supplies; (iv) strengthening the referral and transport system; and (v) building skills and capacity to manage health facilities (to be coordinated with support under Sub-component 1a). This sub-component will also take an integrated approach to health systems strengthening and will address the following aspects: # Improving PHC: The project will provide support for the infrastructure rehabilitation of selected clinics and health centers, including physical and utility upgrading, as well as equipment and a maintenance plan for building and equipment. This activity will be underpinned by the MOH providing appropriate human resources for the rehabilitated facilities based on the essential health care package of services at the clinic and health center levels. # Strengthening TB and HIV Co-epidemic Response: Activities include: (i) community-based interventions for early diagnosis and treatment adherence; (ii) strengthening TB infection control (IC) at the facility level; (iii) provision of digital x- rays at regional and national level; and (iv) training of health workers on managing TB/HIV. These activities are intended to better calibrate aspects of the response currently not funded by the government or other donors, and respond to priorities identified in the AAP on control and management of TB. # Improving maternal and neonatal health care, focusing on EmONC. This support will entail: (i) development and dissemination of detailed EmONC guidelines and protocols; (ii) rehabilitation of health center, clinic and hospital maternity wards through provision and upgrading of essential EmONC equipment and supplies, and training in the use of procured equipment; (iii) on-the-job training of midwives and medical doctors in EmONC, neonatal and postnatal care, post-abortion care; (iv) strengthening the referral and transport system; (v) development of maternal and perinatal death review guidelines; and (vi) training of health personnel in record-keeping and analysis to increase capacity for monitoring MNH outcomes. # HealthCare Waste Management (HCWM): The project is likely to result in increased generation of health care waste at the targeted health facilities. As such, this component will provide support for the appropriate management of health care waste. A Health Care Waste Management Plan (HCWMP) has been prepared which provides proper guidelines for comprehensive health care waste management to prevent, reduce and mitigate environmental health impacts on facility staff and the public caused by poor health care waste management. The approach of the HCWMP involves reinforcing the national legal framework for HCWM in Swaziland, improving and strengthening of the institutional arrangements, improving HCWM in health facilities, providing training for health care staff and other health care waste practitioners on acceptable waste management practices, raising awareness among the general public on risks associated
with health care waste handling, and development of a monitoring system for the implementation of the HCWMP. Sub-component 2b - Support to the nursing training institutions This sub-component will support the capacity building of the nurse training institutions (University of Swaziland Faculty of Health Sciences, Nazarene College of Nursing and Good Shepherd Nursing School). This will entail: (i) development of a national strategic plan for nursing and midwifery; (ii) rehabilitation of selected training institutions; (iii) strengthening management capacity; (iv) revision of training curriculum to ensure Basic EmONC skills for midwives; and (v) development of guidelines and manuals for mentorship and preceptorship. Component 3: OVC Cash Transfer Pilot to Mitigate the Impact of HIV/AIDS (US$ 6.17 million) This component aims to increase social safety net access for OVC households by establishing an OVC cash transfer scheme that would be appropriate in the Swaziland context. The component will strengthen the capacity of the Department of Social Welfare (DSW) and National Children#s Coordination Unit (NCCU) to ensure effective implementation of the OVC cash transfer scheme. This component will be implemented in two integrated phases that are crucial for setting up an effective and efficient cash transfer mechanism. During the first phase (Years 1-2 of project implementation), the project will provide technical assistance to establish the necessary operational systems for community sensitization, OVC identification and enrollment, payment, complaints process, M&E and a Management Information System (MIS). Once these operational systems are in place, the OVC cash transfer mechanism will be piloted during the second phase (Years 3-5 of project implementation) and the operational effectiveness as well as the welfare impact of the piloted scheme will be subject to a rigorous impact evaluation. The DHS 2006-7 defines OVC as a child (below the age of 18) who (a) has lost parents and/or (b) a child who has a very sick parent, or who lives in a household where an adult has been very sick, or has died in the past 12 months. Given the high number of OVC in Swaziland and the limited financial envelope available for this pilot, the following criteria will be used as a guide for identification of potential beneficiaries: employment status; house/land ownership; number of OVC in the household; and being beneficiaries of other OVC support programs. Validation of identified OVC will be completed in coordination with traditional Swazi structures (Council of Elders on the community level). Component 3a. Capacity Building and System Strengthening During the first phase, the project will help develop the capacity of the DSW to manage the OVC cash transfer scheme and to establish the necessary operational systems required for effective and efficient implementation of the OVC cash transfer scheme. By the end of the first phase, the following key features of the OVC cash transfer scheme will be in place:
# Outreach to potential beneficiaries o Sensitization of communities and potential beneficiaries o Explanation of eligibility/benefits/rights/obligations to potential participants # Beneficiary enrollment, registration and verification system # Management Information System (MIS) # Payment delivery mechanism # Appeals and complaints mechanisms # Sanctions on misbehavior # Program monitoring and case management system # Beneficiary graduation system based on exit criteria A consultancy firm, with extensive experience in cash transfer programs will be contracted under the project to support the DSW in the development of a program implementation manual (IM) that will detail operational procedures and processes most suitable for the Swaziland context. Many aspects of the OVC cash transfer scheme have been discussed and agreed upon with key stakeholders, but details of the key features will be refined. The consultancy firm will also support the DSW in developing a Management Information System (MIS), which will form the basis for a national registry of OVC. The MIS will not only facilitate maintaining accurate data on OVC households, but will also ensure coordination with other ongoing OVC support interventions and monitor the implementation of the OVC cash transfer pilot. Human and institutional capacity of the DSW and NCCU will be enhanced at the central and district levels to ensure effective implementation of the proposed OVC cash transfer pilot and to improve coordination with other Ministries, development partners and NGOs/CBOs for more comprehensive and efficient OVC support. In phase one, the design of an impact evaluation study will be finalized and baseline will be determined to evaluate the impact and effectiveness of the OVC cash transfer pilot. Component 3b. Cash Transfer Pilot for OVC During the second phase, the system of OVC cash transfers will be pilot tested, using the information and operational systems put in place and human resources of the DSW and NCCU that have been strengthened during the first phase. The pilot testing will take place in four constituencies (in four different regions), selected based on the data from the Swaziland Statistics Office and Quality of Impact Mitigation Survey (QIMS). The OVC cash transfer aims at strengthening the ability of vulnerable households to care for OVC and meet their basic needs (in the DHS 2006-7 children were considered to have their basic needs met if they had a pair of shoes, two sets of clothes, and at least one meal per day). The cash transfers will also contribute to promoting investments in human capital by encouraging desirable behaviors from OVC and their foster parents in areas such as health, nutrition and schooling. The beneficiaries are expected to fulfill coresponsibilities such as: (i) school enrollment; (ii) minimum level of school attendance; (iii) growth monitoring for children under 2 years; and (iv) full immunization. As part of the OVC cash transfer pilot, an impact evaluation will be conducted to determine: 1) the welfare impacts of the cash transfer scheme; 2) the human development
impacts of the cash transfer scheme; 3) the operational effectiveness of the cash transfer scheme; and 4) generate lessons for potential future expansion. At the end of phase two, the OVC cash transfer pilot is expected to provide empirical evidence on the impact of OVC cash transfer system in Swaziland and compile lessons learned. Based on this, the Government of Swaziland will be able to make an informed decision on whether to continue and expand the OVC cash transfer scheme. 4. Project Location and salient physical characteristics relevant to the safeguard analysis The project will be implemented in Swaziland and will undertake infrastructural rehabilitation works for existing health facilities and selected nurse training institutions. No major and/or irreversible negative impacts are expected from the rehabilitation works because all rehabilitation and construction will be done within existing premises where the biophysical environment is already altered. No potential large scale or irreversible impacts are envisaged as a result of rehabilitation works. It is also envisaged that there will be an increase in volumes of health care waste produced by the health facilities which if not properly managed would result in unintended infections. A Health Care Waste Management Plan has been prepared for ensuring proper management of health care waste. 5. Environmental and Social Safeguards Specialists Ms Lungiswa Thandiwe Gxaba (AFTEN) 6. Safeguard Policies Triggered No Environmental Assessment (OP/BP 4.01) Natural Habitats (OP/BP 4.04) Forests (OP/BP 4.36) Pest Management (OP 4.09) Physical Cultural Resources (OP/BP 4.11) Indigenous Peoples (OP/BP 4.10) Involuntary Resettlement (OP/BP 4.12) Safety of Dams (OP/BP 4.37) Projects on International Waterways (OP/BP 7.50) Projects in Disputed Areas (OP/BP 7.60) II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: The project is classified as category B with respect to environmental assessment. It triggers OP 4.01 on two key aspects: rehabilitation/renovation of selected health care facilities and management of health care waste. The Ministry of Health has prepared an Environmental and Social Management Framework (ESMF) that outlines potential environmental and social impacts of the
rehabilitation/renovation of health facilities, along with mitigation measures thereof. The actual facilities that will be rehabilitated/renovated have not been decided. Once specific facilities are identified, Environmental Management Plans (EMPs)will be prepared in line with the guidelines provided in the ESMF and disclosed as necessary. The project does not involve land acquisition, as the sites being rehabilitated are on government land on which there are settlers/settlements or claims. The policy for involuntary resettlement was therefore not triggerred. The Ministry of Health has also prepared a Health Care Waste Management Plan (HCWMP) that identifies training needs for health care waste management in Swaziland and provides internationally acceptable procedures and guidelines for health care waste management that will be applied during the implementation of the project. Furthermore, the HCWMP provides: a) measures for addressing shortcomings identified in the HCW management system; b) guidelines for developing a sound legal framework; c) institutional arrangements for proper HCW management in the country; d) appropriate training for health care practitioners; and e) awareness raising strategies for the general public. The expected adverse environmental impacts to be generated by the project are expected to be minimal, site specific and manageable to an acceptable level. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: No potential adverse indirect or long term impacts due to anticipated future activities in the project area are envisaged as a result of the project. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. No alternatives were applicable to the project as it deals with existing health care facilities. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. The Ministry of Health has prepared an ESMF, satisfactory to the World Bank, which provides guidelines for complying with the triggered EA policy. A Health Care Waste Management Plan was also prepared for addressing management of health care waste during the implementation of the project. The Environmental Health Unit within the Ministry of Health is responsible for ensuring implementation of and compliance with both the ESMF and the Health Care Waste Management Plan. The Unit has capacity as it is represented in all the regional offices throughout the country, but additional training would further improve the existing skills. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. During the preparation of the Health Care Waste Management Plan the Environmental Health Unit consulted with the Swaziland Environmental Authority (SEA), which is the
institution assigned the responsibility for ensuring enforcement of and compliance with national environmental management procedures and guidelines in Swaziland. 289. Extensive consultations were conducted with a wide range of stakeholders during the preparation of the ESMF which included the Swaziland Environmental Authority, local police, local churches, staff at the health care facilities, neighboring communities, local schools, Swaziland Traditional healers# Association, Ministry of Tinkundla, Traditional Rural Authorities, Ministry of Agriculture and Ministry of Public Works. The ESMF was also cleared by the Swaziland Environmental Authority (SEA). B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: Was the document disclosed prior to appraisal? Date of receipt by the Bank 03/09/2010 Date of "in-country" disclosure 02/25/2010 Date of submission to InfoShop 03/09/2010 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Resettlement Action Plan/Framework/Policy Process: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Indigenous Peoples Plan/Planning Framework: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Pest Management Plan: Was the document disclosed prior to appraisal? Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop * If the project triggers the Pest Management and/or Physical Cultural Resources, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: N/A C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting)
OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? If yes, then did the Regional Environment Unit or Sector Manager (SM) review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated in the credit/loan? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank s Infoshop? Have relevant documents been disclosed in-country in a public place in a form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included in the project cost? Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? D. Approvals Signed and submitted by: Name Date Task Team Leader: Ms Kanako Yamashita-Allen 11/24/2010 Environmental Specialist: Ms Lungiswa Thandiwe Gxaba 11/24/2010 Social Development Specialist Additional Environmental and/or Social Development Specialist(s): Approved by: Regional Safeguards Coordinator: Ms Alexandra C. Bezeredi 11/29/2010 Comments: Sector Manager: Mr John F. May 11/29/2010 Comments: