Integrated Safeguards Data Sheet (Initial)

Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Integrated Safeguards Data Sheet (Initial) Section I - Basic Information Date Prepared/Updated: 06/30/2003 A. Basic Project Data (from PDS) I.A.1. Project Statistics Country: SRI LANKA Project ID: P050740 Project: HEALTH SECTOR DEVELOPMENT Task Team Leader: Michele Gragnolati Authorized to Appraise Date: November 15, 2003 IBRD Amount ($m): Bank Approval: May 30, 2004 IDA Amount ($m): 50.00 Managing Unit: SASHD Lending Instrument: Specific Investment Loan (SIL) Status: Lending Sector: Health (90%); Other social services (10%) Theme: Fighting communicable diseases (P); Other social protection and risk management (S); Other human development (S); Nutrition and food security (S); Health system performance (S) I.A.2. Project Objectives (From PDS): The Sri Lanka Health Sector Development Project will support Sri Lanka in the implementation of the recently prepared Health Sector Strategy, the aim of which is "to achieve the highest attainable health status by responding to people's needs, working in partnership, to ensure access to comprehensive, high quality, equitable, cost-effective and sustainable health services." The specific development objectives of the Sri Lanka Health Sector Development Project are: (i) to improve maternal and child health (MCH), including malnutrition, among disadvantaged groups and in underserved areas; (ii) to reduce incidence of major non-communicable diseases (NCDs) contributing to the burden of disease; and (iii) to improve efficiency, equity and quality of health care and ensuring financial and operational sustainability of the health system. I.A.3. Project Description (From PDS): The proposed project would likely consist of four components: 1. Strengthening priority health interventions. Issues to be addressed by this component include: (i) maternal and child nutrition of vulnerable groups in disadvantaged areas; (ii) maternal and child health programs; and (iii) the emergence of non-communicable chronic and degenerative diseases as the primary cause of morbidity and mortality associated to the rapidly aging population. The nutrition sub-component will support the reorientation of MOH existing clinic-based growth monitoring program to a community-based growth promotion program utilizing non-governmental organizations (NGOs) and community volunteers. Payments to NGOs will be based on their performance in terms of achieving reduction in the prevalence of malnutrition. Performance will be assessed by an independent agency. The MCH sub-component will support the rationalization of existing primary health care facilities to improve use of scarce public resources and the improvement of birth delivery services in disadvantaged areas to reduce perinatal, neonatal and maternal mortality. The NCD sub-component will focus on three areas: risk-factor surveillance, disease prevention and control, and health promotion. 2. Strengthening the stewardship function of MOH. This component will support: (i) strengthening the policy-making function of MOH, including developing a regulatory framework for private sector participation in the health care market; (ii) improving management of the health system and strengthening quality assurance mechanisms; (iii) enhancing an information-based culture within MOH; and (iv) introducing a monitoring and evaluation system for the health sector and the project. A comprehensive monitoring and evaluation system (M&E) system for the project will be developed during project

2 preparation. The system will be managed by a third party under the supervision of a M&E cell in the Department of Planning in order to ensure transparency and unbiasedness in the evaluation process. The system will be used to carry out bi-annual evaluations with the Bank and these evaluations will be an integral part of the planning process to guarantee that implementation progress is in line with the development objectives of the project. This system will include all key performance indicators, in addition to other indicators that the Bank and MOH agree to include for monitoring and evaluation purposes. Beneficiary assessment and surveys on users' satisfaction will also be key instruments to measure impact. 3. Rationalizing financing and allocation of resources. This component will support: (i) reforming the budgeting process of MOH to allocate resources through a health sector investment plan with explicit objectives and targets; (ii) improving the efficiency and responsiveness of the delivery system through the provision of greater financial and management autonomy to health care facilities; and (iii) implementing community-based health insurance schemes in uderserved areas to promote risk-pooling and pilot innovative schemes to protect the poor from catastrophic illness. The component will finance activities to make the entire budgeting process more effective, efficient and transparent. The development of a Medium-Term Expenditure Framework will contribute to ensure that the Ministry of Finance and the Ministry of Health adopt a strategic approach to resource allocation and that health strategies are consistent with broader development objectives. The component will review the case for contracting out both clinical and non-clinical services at the facility level. Community health insurance will be one of the approach that the Government will pilot to improve financing mechanisms and efficiency of the public health sector. Other alternatives include social insurance, co-payments and earmarked taxation as well as amenity beds, selling services at full costs to the private sector and raising donations through improved incentives. 4. Developing and implementing a new human resource policy. Sri Lanka lacks a comprehensive human resource strategy. This component will address the structural problems of shortages of health personnel in remote areas and the skill mismatches observed throughout the country (e.g. over-supply of general doctors and shortage of nurses and specialists). It will also support improving human resource management by strengthening capacity of the central and provincial Ministries of Health, upgrading the career development policy by introducing a performance-based, individual promotion system, and increasing performance of personnel by modernizing in-service training and continuos education. Components: 1. Strengthening priority health interventions 1.1 Nutrition 1.2 Maternal and child health 1.3 Non-communicable diseases 2. Strengthening stewardship function of MOH 2.1 Policy-making 2.2 Management and quality assurance 2.3 Information collection and management 2.4 Monitoring and evaluation 3. Rationalizing financing and allocation of resources 3.1 Budget reform 3.2 Decentralization 3.3 Community-based health insurance 4. Developing and implementing human resources policy I.A.4. Project Location: (Geographic location, information about the key environmental and social characteristics of the area and population likely to be affected, and proximity to any protected areas, or sites or critical natural habitats, or any other culturally or socially sensitive areas.) Since the proposed project is to assist the Ministry of Health, Nutrition and Welfare (MOH) in development of the

3 Health Sector in the country, project activities would cover the entire country of Sri Lanka. B. Check Environmental Classification: B (Partial Assessment) Comments: C. Safeguard Policies Triggered (from PDS) (click on for a detailed desciption or click on the policy number for a brief description) Policy Triggered Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) Yes No TBD Natural Habitats (OP 4.04, BP 4.04, GP 4.04) Yes No TBD Forestry (OP 4.36, GP 4.36) Yes No TBD Pest Management (OP 4.09) Yes No TBD Cultural Property (OPN 11.03) Yes No TBD Indigenous Peoples (OD 4.20) Yes No TBD Involuntary Resettlement (OP/BP 4.12) Yes No TBD Safety of Dams (OP 4.37, BP 4.37) Yes No TBD Projects in International Waters (OP 7.50, BP 7.50, GP 7.50) Yes No TBD Projects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60)* Yes No TBD Section II - Key Safeguard Issues and Their Management D. Summary of Key Safeguard Issues. Please fill in all relevant questions. If information is not available, describe steps to be taken to obtain necessary data. II.D.1a. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts. Health care waste management (HCWM) has been an area of critical importance that had been neglected by the authorities in Sri Lanka in the past. Health care waste (HCW) had been disposed of with municipal solid waste with little or no precautions taken to ensure minimization of adverse environmental and public health risks. In 2001, as part of the preparatory activities of the IDA financed National HIV/AIDS Prevention Project, the Ministry of Health (MOH) developed a National Policy on Health Care Waste Management, which was approved by the Cabinet of Ministers in 2002. The underlying objective of the policy is to ensure that every medical institution in Sri Lanka is responsible for taking care of all HCW generated in the respective institution in a manner that does no harm to public health and the environment. In addition, the policy identifies the institutional mechanisms for implementation of the policy at the national level as well as the provincial levels; it addresses regulatory issues and the need for specific HCWM plans at various levels of the health care system in Sri Lanka; and identifies the need for an effective monitoring system to ensure that the objectives of the national policy are met at the national and provincial levels. The national policy was complimented by the preparation of National Guidelines for HCWM which was accompanied by a Situation Analysis and the preparation of a National Action Plan. While policies, guidelines and action plans are available for a nationwide HCWM program, based on ground realities, MOH has decided to implement the program on a phased basis. Phase I, which focuses on implementation of a comprehensive HCWM program for the Colombo Municipal Council (CMC) area and a nationwide program to manage health care waste from Chest clinics, STD clinics and Blood Banks is to be commenced in 2003, with financial assistance from the National HIV/AIDS Prevention Project. The situation analysis conducted in 2001 shows that approximately 15 tons per day of hazardous health care wastes are produced in major health facilities in Sri Lanka, of which approximately 25% is from facilities in the Greater Colombo Area (GCA), which includes CMC and 22 surrounding Local Authorities. At present, there is no

4 segregation of wastes, therefore, the amount of mixed waste discharged from health care facilities contaminated with hazardous health care wastes is in the range of 45 tons per day. Virtually all of this waste is currently disposed of with municipal solid wastes in open dumps with no precautions taken to reduce public health or environmental risks and biological hazards associated with such disposal practices. The exceptions being anatomical wastes, which are generally buried within hospital premises, albeit with no precautions taken to prevent public access to such burial sites and the small amounts of radioactive wastes generated are stored in the respective hospital premises. The proposed project will assist the MOH in improving its overall management capabilities, which means that project should ensure that Sri Lanka s health care waste management problem is addressed in a manner to reduce the environmental pollution risks and biological hazards that the public is exposed to at present. The environmental objectives of the proposed project are: (i) to prevent pollution and biological hazards resulting from the ad-hoc approaches to health care waste management that is being practiced at present; (ii) treat and dispose of health care waste produced by hospitals and medical institutions in the Greater Colombo Area in an environmentally acceptable manner; (iii) undertake a pilot health care waste management program in one province (yet to be determined), with an intention to expand the program nationwide based on the experiences of the pilot program; and (iv) to ensure that a proper legislative environment exists for enforcement of an integrated health care waste management plan in Sri Lanka. There are no civil works other than waste treatment systems envisioned under the project. The present scope of the project will not involve the triggering of any safeguard policies other than the Environmental Assessment safeguard policy, hence, this will be the only safeguard policy that will be triggered. II.D.1b. Describe any potential cumulative impacts due to application of more than one safeguard policy or due to multiple project component. Since only the Environmental Assessment safeguard policy is triggered under the project, there are no cumulative impacts anticipated due to the application of more than one safeguard policy and due to multiple project components. II.D.1c Describe any potential long term impacts due to anticipated future activities in the project area. There are no civil works environed at this stage under the project, other than small scale waste management systems. Since this is a sector development project, financial and technical assistance will be provided to existing health care facilities to manage HCW, therefore, any long term environmental impacts due to future activities will be beneficial in the environmental and public health sense. Currently, the environment as well as local communities are exposed to environmental and public health risks due to ad-hoc disposal of health care wastes. The project will financed a comprehensive health care waste management system for the Greater Colombo Area, expanding the present proposal to confine HCWM to the CMC, to include the surrounding 22 Local Authorities as well as a pilot HCWM system for one province initially, in accordance with the national policy, guidelines and action plans. Therefore, this will result in an improvement in the environment and public health status of the local community exposed to ad hoc disposal of health care wastes. This situation will ensure that any new developments in the health care management system will occur within a framework where health care waste will be managed in an environmentally acceptable manner. II.D.2. In light of 1, describe the proposed treatment of alternatives (if required) The environmental issues that arise as a result of the proposed project are with regard to the need for proper management of health care waste. The health care waste management policy, guidelines and action plan prepared in 2001/2 examined alternative options for waste treatment. Based on the option analysis, the Government will select the treatment option most suitable for Sri Lanka, which will be environmentally acceptable as well as affordable and that has the greatest possibility of effective implementation. II.D.3. Describe arrangement for the borrower to address safeguard issues O.P 4.01 is the only policy triggered by the project. See Section 5.E for provisions to ensure compliance. No land is expected to be acquired and no displacement is expected to occur as a consequence of project activities. If displacement does occur, the National Policy on Involuntray Resettlement, which was agreed by the Government, the World Bank and the Asian Development Bank last year, would apply.

5 The project is not expected to affect the Veda community, whcih the only group in Sri Lanka to which the Bank policy on Indigenous People applies. If the Veda community is affected, the Bank policy would apply. II.D.4. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. There are six main groups of stakeholders: (i) politicians and policy makers at central and local levels; (ii) health officials and personnel working in the public sector; (iii) professional associations and consumer groups; (iv) private providers; (v) NGOs providing health services and involved in community mobilization; and (vi) poor and other vulnerable populations (i.e. tea estates and internally displaced). During formulation of the country s health strategy, extensive consultations (in the form of technical working groups, national and regional workshops and dissemination of the Health Sector Strategy in English, Sinhalese and Tamil) were held with officials in the public health sector at provincial and central levels, and representatives from the professional medical bodies and unions. Consultations also included representatives from private hospitals, such as Durdans, Nawaloka, and Asha Central, and from NGOs including Sarvodaya and others actively involved in health services and health promotion activities. Input from the communities, especially the poor and vulnerable populations were obtained during the preparation of a situational analysis, which relied on focus groups and in-depth interviews. A social analysis (SA) of the proposed project, which is currently being undertaken, would provide additional input into the design of this operation. The objectives of the SA are to: (i) identify the poor and other vulnerable populations in underserved areas, such as tea estates, and highlight priority health issues facing these communities (ii) identify gaps in the existing knowledge and would propose means to address these (iii) propose as a preliminary step the strategies to improve access and quality of health services for these populations (iv) propose mechanisms for continuing collaboration and involvement of stakeholder groups in monitoring and evaluation and implementation of the proposed operation. E. Safeguards Classification (select in SAP). Category is determined by the highest impact in any policy. Or on basis of cumulative impacts from multiple safeguards. Whenever an individual safeguard policy is triggered the provisions of that policy apply. [ ] S1. Significant, cumulative and/or irreversible impacts; or significant technical and institutional risks in management of one or more safeguard areas [X] S2. One or more safeguard policies are triggered, but effects are limited in their impact and are technically and institutionally manageable [ ] S3. No safeguard issues [ ] SF. Financial intermediary projects, social development funds, community driven development or similar projects which require a safeguard framework or programmatic approach to address safeguard issues. F. Disclosure Requirements Environmental Assessment/Analysis/Management Plan: Expected Actual 8/31/2003 9/15/2003 11/15/2003 Date of distributing the Exec. Summary of the EA to the Executive

6 Directors (For category A projects) Resettlement Action Plan/Framework: Expected Actual Indigenous Peoples Development Plan/Framework: Expected Actual Pest Management Plan: Expected Actual Dam Safety Management Plan: Expected Actual If in-country disclosure of any of the above documents is not expected, please explain why. Signed and submitted by Name Date Task Team Leader: Michele Gragnolati June 1, 2003 Project Safeguards Specialists 1: Sumith Pilapitiya May 15, 2003 Project Safeguards Specialists 2: Project Safeguards Specialists 3: Approved by: Name Date Regional Safeguards Coordinator: L. Panneer Selvam June 27, 2003 Sector Manager/Director Charles C. Griffin June 30, 2003