MINISTRY OF HEALTH
NORTH EAST AND RED RIVER DELTA REGIONS HEALTH SUPPORT PROJECT
ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK
Vietnam, January, 2012
TABLE OF CONTENT
I.INTRODUCTION
II.PROJECT DESCRIPTION
2.1Project design
2.2Project Area
2.3Types of potential sub-projects
2.4Project management and personnel
III.ENVIRONMENTAL POLICIES APPLICABLE TO THE PROJECT
3.1Vietnamese Environmental policies
3.2World Bank environmental safeguard policies
IV.Institutional arrangement
4.1Project hospitals
4.2Provincial Project Management Units (PPMUs)
4.3Central Project Management Unit
4.4Provincial People Committees (PPCs)
4.5The World Bank
4.6Contractor and equipment suppliers
4.7Institutional Capacity
V.POTENTIAL ENVIRONMENTAL IMPACTS AND MITIGATION MEASURES
5.1Project Environmental Category
5.2Potential Socio - Environmental Impacts
5.2.1Potential impacts during implementation phase
5.2.2Potential impacts in operation phase
5.3Typical Mitigation Measures
VI.ENVIRONMENTAL MANAGEMENT PROCEDURES
6.1Documentation requirements
6.2Project Environmental Management Procedures
6.2.1Environmental Screening for eligibility
6.2.2Impact identification
6.2.3Drafting Subproject Safeguard Document
6.2.4Public Consultation and information disclosure
6.2.5EMP review and Approval
6.2.6Licenses and Permits
6.2.7Supervision and environmental monitoring
6.2.8Documentation and record keeping
6.3Capacity building/Training plan
6.4Cost for safeguard implementation
ANNEX
Annex 1: Environmental Eligibility Screen Form
Annex 2: Environmental Impact Screening Form
Annex 3: Recommended Format of EMP for each sub-project
Annex 4: Record of Public Consultation
Annex 5: Technical specifications of facilities and equipment for HCWM
Annex 6: Vietnam Hospital Wastewater Discharge Standard
Annex 7: Vietnam Health Care Solid Waste Incinerator Emission Standard
Annex 8: Cost estimation for technical assistance and capacity building
I.INTRODUCTION
The Northern East and Red River Delta Region Health Support Project (NORRED) herein referred to as the FIRST Project or the Project is executed by the Ministry of Health (MOH) with the funding from the International Development Association (IDA) under the World Bank.
The NORRED will comply with the World Bank Safeguard Policies and Vietnamese environmental regulations to avoid or minimize impacts to humans and the environment during the implementation. Under component 1, the project will finance the activities of medical equipment purchase and minor civil work for provincial level hospitals and 50 district hospitals. These activities may cause some environmental issues relating dust, noise generation and waste management, safety issue during Project implementation and operation. These impacts are expected to be localized, mitigable and manageable through good design and appropriate mitigation measures. Therefore, the project has been categorized as Environmental Category B by the World Bank classification. As most of investment details under NORRED’s component 1 will not be known by Appraisal, during preparation an Environmental and Social Management Framework (ESMF) is prepared by MOH to ensure that the Project activities will be implemented in an environmentally and socially sustainable manner.
This EMSF lays down the principles and guidelines for addressing environmental and social impacts due to the implementation of the NORRED. It identifies the range of policies that the PPMUs should consider in project development. It will also outline the roles and responsibilities of the investors and project developers, the MOH’s PMU, PPMU, and the World Bank at each stage of the project cycle. The environmental and social safeguard policies shall be applied to all financed subprojectsunder NORRED. Adoption of ESMF shall ensure that the subprojects meet Vietnam environmental and social policies and are also consistent with the applicable safeguard policies and provisions of the World Bank.
The ESMF will be incorporated into the Project Operation Manual to ensure that environmental and social issues will be considered together with other requirements during project implementation.
II.PROJECT DESCRIPTION
2.1Project design
The Project Development Objective
The Project Development Objective (PDO) is to increase the utilization of patients to local health services in selected provinces of the North East and Red River Delta regions by strengthening the capacity of selected provincial and district hospitals to deliver more and better quality health services and reducing the financial barrier for accessing care of the economically vulnerable.
The project comprises 3 components.
- Component One: Strengthening the capacity of lower level health services to deliver quality services ($115 million): Component One aims to increase the capacity of the Provinces to provide more and better quality health services. It would consist of two subcomponents.
Subcomponent 1a - Provincial Subprojects for the Development of Medical Services and Quality Improvement about 111.5 million). This subcomponent would provide technical and financial support directly to the Provinces to increase their capacity to deliver quality health services at their general provincial hospitals or specialized pediatric or obstetrics and gynecology hospitals as well as at least three district hospitals per province. This subcomponent would be implemented as a virtual “Fund”. It would operate as a Fund because no amount of the Credit would be explicitly allocated to provinces. Provinces would apply to receive these funds to support their “sub-project” through the development of a Provincial proposal. The proposal would include the results of a needs analysis and confirm that the request is not a duplication of other activities supported by other sources of funds such as state bonds or small donor projects. It would define exactly which services the hospitals would be able to perform after the assistance provided by the Project. The proposals would cover five specialty areas (obstetrics/gynecology, pediatrics, cardiology, oncology, and trauma) at the provincial hospital level and three specialty areas at the district hospital level (obstetrics/gynecology, pediatrics, and trauma) as well as the auxiliary services at the hospitals (laboratory, intensive care). The exact services would be in accordance with the needs of the population, the inability to provide the required service currently (or provide it with sufficient quantity) and would be in accordance with the MoH guidelines (Decision 23) as updated on the services to be provided according to the hospital technical level (Level I being a tertiary facility, Level II being a secondary facility and usually denoted as a Provincial Hospital, and Level III being a basic secondary facility with a more limited scope of services and usually denoted as a District Hospital). Additionally, the proposals would define specific measurements of quality or management improvement that would be implemented in certain defined areas (at least 5% of the IDA investment in the subproject cost). Three measures of quality and management improvement would be required: (i) measuring patient satisfaction; (ii) initiating a Continuous Quality Improvement process; and (iii) development a planning and budgeting process for facility maintenance. Additionally, the Provinces shall choose among the topics to implement at least one other measure. The sub-projects would be implemented through the Provincial Departments of Health (DoH) and their Provincial Project Management Units (PPMU). The implementation plans for the subprojects would be consolidated as part of the Annual Workplan of the Project. In the event of poor implementation by Provinces (including poor management practices and delays), the sub-project scope can be reduced or cancelled in order to reallocate the funds to better performing provinces. Under Component 1b, the Ministry of Health will have technical support available to the provinces to help with the planning and implementation of the sub-projects which will, in particular, be targeted to the Provinces with less capacity.
Subcomponent 1b –Training and Technical Transfer for Reducing Hospital Overcrowding and Quality Improvement (US$3.5 million). This subcomponent would support the Ministry of Health and the other national level stakeholders to provide quality technical support to the Provinces to achieve the Components goals. This component would be implemented by the Ministry of Health and its Central Project Management Unit (CPMU). This would include two Technical Advisory Groups (TAGs) (teams of national experts, including from national institutions and hospitals). The first group would support the Provinces in the preparation and implementation of the plan for the technical transfer of the “know-how” for certain medical services and procedures; the second Technical Advisory Group would support the Provinces in the preparation and implementation of a hospital quality and management improvement plan. Particularly in the area of quality improvement and management, technical support will be provided to build the capacity of national counterparts. The component would also support the Ministry of Health in defining national level strategies and policies for implementation in the hospitals, research on the hospital overcrowding issue, such as in developing the guidelines for piloting the provision of radiation therapy treatment as primarily an outpatient treatment. The subcomponent would also include direct support to the central hospitals in development of their training capacity and the training programs in support of the technical transfer.
- Component Two: Reducing the financial barriers to access by the economically Vulnerable (US$29.0 million). Component 2 aims at reducing the financial barriers by (i) expanding access to health insurance for a specific vulnerable group largely not covered by the current insurance system; (ii) providing direct access to certain high cost services support under Component 1; and (iii) increasing the general awareness of the rights of individuals and/or households under the insurance system. It would achieve this through three subcomponents:
Subcomponent 2a - Direct subsidy to support the purchase of a health insurance card by the near poor (US$23.0 million): Building on the similar and successful examples under the Mekong and Central North Regional Health System Support Projects, this subcomponent would support an additional subsidy of 20% of health insurance premiums (on top of the 70% subsidized by the state) for the Near Poor household members, conditional upon whole family enrollment. Those who enroll individually would not receive any support from the project. The support to household enrollment will help to increase the coverage more quickly than individual enrollment, improve risk sharing and reduce adverse selection, the core principles of social health insurance. The support will provide good experience and lesson learnt for the Ministry of Health to later expand it as a national policy. The Government has a policy for expanding health insurance coverage particularly for the vulnerable groups. Based on the Government’s Universal Health Coverage Roadmap, it is expected that the Government will extend the state support to this group within the project lifetime. The Project would provide an opportunity to advance this support in a large geographical region and for the Government to learn from the policy of requiring family as opposed to individual enrollment as they are considering this policy change.
Subcomponent 2b - Supporting catastrophic health care expenditure at provincial hospitals (US$2.0 million). This subcomponent would provide seed funds to the Provinces in the re-establishment of the Health Care Funds for the poor in accordance with Government policy. The Government issued Decision 14 revising the Decree 139 re-establishing health care funds for the poor; however, the guiding circular for implementation is still under development. Among other things, Decision 14 identified the Government support to vulnerable groups, including the poor, ethnic minorities, social assistance beneficiaries, and patients with cancer, dialysis, heart operation and other high cost treatment without ability to pay. Each province has to establish the fund with Government budget and possible mobilization of funds from other sources. However, in poor provinces with a large number of beneficiaries, financial resources are limited. The available resources will spur the issuance of the Guidelines and help set up the funds in the participating project provinces.
Sub-component 2c - Information, Education and Communication support to inform the insured and uninsured about the benefits under the national health insurance system (US$4.0 million). This sub-component will promote awareness of and enrolment in health insurance by the near poor by improving IEC activities in provinces. It would also target the currently enrolled to improve the understanding and awareness of the benefits available. It would also target the providers to reduce institutional barriers of access for insured, such as how insured patients are received, medical staff attitudes, etc... Innovative IEC measures are encouraged to effectively target beneficiaries, particularly ethnic minority population.
- Component Three:Technical Support, Managerial Capacity Building and Project management, monitoring and evaluation (US$6.00 million): The aim of this component is to ensure adequate management structure, processes and human resource capacities for the project, and to setup mechanisms for effective monitoring of activities and evaluation of results. Under this component, the project would fund the operation of project management units at the central and provincial levels. To the extent possible, existing health information systems and data collection mechanisms in the MoH and in provinces will be relied upon. However, for certain information, it will be necessary to design specific data collection instruments and conduct independent data collection and auditing (e.g. small scale household surveys, patient exit interviews, hospital surveys). M&E will consist of two components: (i) monitoring of the project’s implementation progress, and (ii) monitoring of the project’s results indicators. Where the project support pilot initiatives, the project may fund specific evaluations of the pilots.
2.2Project Area
The proposed NORRED project will be implemented in 7 provinces in North East Region (Tuyen Quang, Yen Bai, Thai Nguyen, Lang Son, Bac Giang, Phu Tho, Hoa Binh) and 6 provinces in Red River Delta (Hai Duong, Hung Yen, Thai Binh, Ha Nam, Nam Dinh, Ninh Binh). Under component 1, the project will provide province level hospitals and 50 district hospitals with equipment, education, short-term training and the supervision support. Under component 2, the project will expand access to health insurance for near poor households and to improve the system’s capacity to manage health insurance. All project interventions will be taken place within existing hospitals which are located in urban areas or in densely populated rural areas. No environmental protection area or physical cultural resource will be affected.
2.3Types of potential sub-projects
During implementation, the participating Provinces will submit a proposal for a “sub-project” to be financed that would indicate explicitly: (a) the Provincial hospital which would be the ‘investment owner’; (b) services that they want to develop at that Provincial Hospital (which is on the long-list of eligible services and within their current technical level); (c) the central level hospital from which they would seek ‘sponsorship’; (c) the investment needs for those services (within the definition of eligible investments); (d) the selection of at least 3 district hospitals in rural areas to be supported and for which the Provincial hospital offers its sponsorship; (d) the identification of services to be developed in those district hospitals (which is on the long-list of eligible services and within their current technical level); and (e) the investment needs for the district hospitals (in accordance with the list of eligible investments).
The project will (i) improve the capacity of province level hospitals to provide curative health services in five priority service areas (obstetrics/gynecology, pediatrics, traumatology/orthopedics, cardiology, and oncology); and (ii) strengthen the capacity of district hospitals to provide curative health services in 3 priority service areas (obstetrics/gynecology, pediatrics, traumatology). This will be done through provision of medical equipment and telecommunications equipment, education, short-term training and the supervision support of the sponsored hospitals via an integrated satellite program. In addition, the project may provide technical support (technical assistance, training and study tours) for the establishment of an alternative service delivery model for services to be provided on an outpatient as opposed to an inpatient basis.
The Province and District hospitals would have to indicate that they have the necessary minimum conditions for receipt of the services and investments including the staff with the necessary basic qualifications and the hospital infrastructure. The project will focus on rehabilitation rather than major construction. Any need for significant additional staffing or major infrastructure investments would indicate that the hospital was not ready for investments in those services.
2.4Project management and personnel
Name of Project: Northern East and Red River Delta Region Health Support Project
Name of Donor: The World Bank (WB) / International Development Agency (IDA)
Line Agency: Ministry of Health (MOH)
a) Contact Address: 138 A Giang Vo Street, Ba Dinh, Hanoi
b) Phone: +84-4-62732273Fax: +84-4-: 38464051/84-4-62732266
Email:
Project owner: Ministry of Health
Theproject owner will establish a Central Project Management Unit (CPMU) as Implementing Agency, to act on behalf of the project owner to organize and manage the project during the implementation.
Project duration: 5 years: 2013-2018
Total Project Budget: USD $ 157.5 million, of which:
a) ODA Funds: USD $ 150.0 million
b) Counterpart Funds: USD $ 5 million
Type of ODA: ODA concessional loan - IDA Credit
III.ENVIRONMENTAL POLICIES APPLICABLE TO THE PROJECT
3.1Vietnamese Environmental policies
- Environmental Protection Law (EPL) No 52/2005/QH11 dated 29/11/2005 and in effect from 01/7/2006. EPL provides frameworks on the responsibilities of individuals and organizations in environmental assessment, environmental protection in hospitals and health facilities, and management of hazardous waste, general waste, wastewater and gas emission.
Policies relating to environmental assessment:
- Decree 29/2011/NĐ-CP dated 18/4/2011 regulating strategic environmental assessment, environmental impact assessment and environmental protection commitment;
- Circular 26/2011/TT-BTNMT dated 18/7/2011 of Ministry of Natural Resource and Environment regulating in detailed some clauses of Decree 29/2011/NĐ-CP dated 18/4/2011 regulating strategic environmental assessment, environmental impact assessment and environmental protection commitment;
- Circular 01/2012/TT-BTNMT dated 16/3/2012 regulating preparation, appraisal, approval, inspection and implementation verification of detailed environmental protection plan; preparation and registration of simple environmental protection plan;
Policies relating to hazardous waste and healthcare waste management: