Public Disclosure Authorized. Report No.:AC634. Project ID: P Project: Health Transition Project. TTL: Enis Baris

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Integrated Safeguards Data Sheet (ISDS) Section I - Basic Information Date ISDS Prepared/Updated: April 20, 2004 A. Basic Project Data A. 1. Project Statistics Country: Turkey Project ID: P Project: Health Transition Project TTL: Enis Baris Report No.:AC634 Total project cost (base costs by component): A. Restructuring of the MOH for Effective Stewardship million B. Building Capacity of the Health Insurance and Social Security Institutions million C. Reorganizing the Delivery of Healthcare Services. C million D. Strengthening Human Resources Capacity million E. Building Infostructure for Health and Social Security. E15.13 million F. Project Management million TOTAL PROJECT COST'*): C million (*) including contingencies and front end fees Appraisal Date: March 15, 2004 Loan amount(em): IBRD: $49.40 million Board Date: May 20, 2004 Other financing amounts by source: Republic of Turkey: million Managing Unit: ECSHD Lending Instruments: Adaptable Program Loan Is this project processed under OP 8.50 (Emergency recovery? Yes? [ ] No? [X] Environmental Category: C Safeguard Classification: S3 A.2. Project Objectives The program objective is to improve the governance, efficiency, user and provider satisfaction, and longterm fiscal sustainability of the healthcare system in Turkey. Such a transition will be the first step towards achieving the longer term sectoral goal of narrowing the gap in access to, quality and utilization of health services between Turkey and other middle-income and EU countries by extending health insurance coverage to the whole Turkish population and by reducing inequalities in access to health care, especially for the poor and those living in rural and peri-urban areas. The objective of Phase I is to enable the Government to strengthen the institutional environment for the implementation of its Program of Transformation in Health that will improve system stewardship, streamline financing and service delivery, and build the institutional capacity to extend health insurance coverage to the whole population in a fiscally sustainable manner. The specific objectives, set in line with Government's PTH, are to : (i) re-structure MOH for more effective stewardship and policy making; (ii) establish a universal health insurance fund; (iii) introduce family medicine as the model for the provision of primary health care services (iv) ensure financial and managerial autonomy for all hospitals irrespective of ownership; and (v) set up a fully computerized health and social information system. Upon completion of the program, it is expected that MOH will be a smaller and leaner agency, with a resources and skills mix in line with its renewed mandate of system stewardship, namely doing "more steering and less rowing", that is mostly policy setting and regulating with no responsibilities for service provision, except for public health programs. Similarly, MOLSS is also expected to relieve itself from the function of service provision, increasingly specializing and building its institutional capacity in essential insurance functions of balancing revenues and expenditures, thus in risk assessment, actuarial analysis, definition of essential service package, premium setting, and strategic purchasing from and contracting with providers (Please see Annex 3 for key indicators). The most recent CAS, and the Policy Notes, "Turkey: Greater Prosperity with Social Justice" that was prepared in November 2002 to assist the incoming new government, Government's own UAP, released in January 2003, and its sectoral spin off, PTH, all concur almost entirely that a fundamental overhaul - as opposed to piecemeal changes - is needed and that the system would have to be "transformed". There is a general consensus that the Transition should at least entail: (i) the separation of provision and financing of

2 health care so as to achieve a more efficient resource allocation and use; (ii) introduction of universal public health insurance so as to ensure equity and access to health services; (iii) financial and administrative autonomy for public hospitals in order to improve technical efficiency and strengthen management; (iv) introduction of family medicine so as to integrate and streamnline delivery of primary health care with inpatient care and ensure comprehensiveness and continuity in health care; and (v) increased emphasis on improving maternal and child health. This program is designed to specifically assist the Government to implement its own PTH and as such its components are designed and sequenced to correspond and contribute directly to PTH's five main objectives. A.3. Project Description The proposed project has six components: Component A: Restructuring of the MOHfor Stewardship. This component supports MOH's institutional Transition from a mainly provider of services to a policy maker and regulator of service provision, while retaining key public health functions. This component has four sub-components: (i) restructuring of MOH; (ii) Establishment of a National Pharmaceutical and Medical Equipment Agency; (iii) Quality Assurance and Accreditation of Health Facilities; and (iv) Establishing Monitoring and Evaluation Capacity for the PTH. Component B: Building Institutional Capacity of the Health Insurance Fund. This component supports the establishment of a single health insurance fund by means of consolidating the four existing health insurance schemes and expanding its reach to about an additional 22 million citizens who are not fully covered. Component C: Reorganizing the delivery of healthcare services. This component has four subcomponents: (i) adoption of family medicine as an organizational model for the provision of outpatient or primary health care services; (ii) integration and harmonization of MOH and SSK hospitals towards great autonomy; and (iii) building a new patient referral mechanism to re-enforce system hierarchy. A fourth sub-component will focus mostly on population health programs, including disease surveillance, maternal and child health, prevention and control of NCDs. The reorganization will be implemented in a phased manner, with pilots in large cities. during Phase I, to be rolled out nationwide during the second phase. Component D: Strengthening Human Resources Capacity aims at developing skills and competence of health work force, in line with the changing role of the MOH and its affiliated institutions. It has two subcomponents: (i) health workforce policy and planning; and (ii) strengthening the School of Public Health, to become a center of excellence in advocacy, training and research for the MOH. Component E: Building Infostructure for Health and Social Security. This component supports the development of national standards in line with the realignment of institutional roles and responsibilities. This will be done in a phased manner; first with the development of standards and the establishment of records and information network in the social security system, and thereafter the establishment of network and information flows between the social security system and the hospitals. It has two sub-components: (i) building health information system; and (ii) building social security information system. Component F: Project Management. This component provides support for project coordination between the two ministries, overall project governance, with additional support to that of Government's PTH, and project administration. The proposed HTP will be designed and irnplemented in parallel with the proposed PPSAL, which will provide budgetary support for the overhaul and reform of the social security system. The synergies and inter-linkages between the two projects will provide both investment and budgetary support for the health reform agenda of the Government.

3 A.4. Project Location and salient physical characteristics relevant to the safeguard analysis: The project will only finance technical assistance and limited amount of office equipment and furniture. B. Check Environmental Category A [], B [], C [X], FI [] Comments: The project involves no civil works, or use of natural resources, and is not expected to have any negative imnpact on the environment. C. Safeguard Policies Triggered Environmental Assessment (OP/BP/GP 4.01) [_] _[xi Natural Habitats (OP/BP 4.04) [x] Pest Management (OP 4.09) I [x] Cultural Propertv (draft OP OPN ) [I] [x] Involuntary Resettlement (OP/BP 4.12) [ ] [x] Indigenous Peoples (OD 4.20) rx1 [x] Forests (OP/BP 4.36) [ [x] Safety of Dams (OP/BP 4.37) [xi Projects in Disputed Areas (OP/BP/GP 7.60) [] [x] Projects on International Waterways (OP/BP/GP 7.50) [ ] [xi Yes No By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas

4 Section II - Key Safeguard Issues and Their Management D. Summary of Key Safeguard Issues. D. 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts. D.2 Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area. D.3. Describe the treatment of alternatives (if relevant) D.4. Describe measures taken by the borrower to address safeguard issues. Provide an assessment of borrower capacity to plan and implement the measures described. D.5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people.

5 F. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Resettlement Action Plan/Framework/Policy Process:.. Not Applicable...Not Applicable Indigenous Peoples Development Plan/Framework:...Not Applicable Pest Management Plan:.. Not Applicable Dam Safety Management Plan:.. If in-country disclosure of any of the above documents is not expected, please explain why. The project will finance mostly technical assistance and a limited amount of office equipment and furniture. Section III - Compliance Monitoring Indicators at the Corporate Level (To be filled in when the ISDS is finalized by the project decision meeting) OPIBP Environment Assessment. Yes N Does the project require a stand-alone EA (including EMP) report? If yes, then did the Regional Environment Unit review and approve the EA report? Are the cost and the accountabilities for the EMP incorporated in the credit/loan? OP/BP Natural Habitats: Yes No Would the project result in any significant conversion or degradation of critical natural habitats? If the project would result in significant conversion or degradation of other (noncritical) natural habitats, does the project include mitigation measures acceptable to the Bank? OP Pest Management: Yes No Does the EA adequately address the pest management issues? Is a separate PMP required? If yes, are PMP requirements included in project design? Draft OP 4.11 (OPN 11.03) - Cultural Property: Yes No Does the EA include adequate measures? Does the credit/loan incorporate mechanisms to mitigate the potential adverse impacts on physical cultural resources? OD Indigenous Peoples: Yes No Has a separate indigenous people development plan been prepared in consultation with the Indigenous People? If yes, then did the Regional Social Development Unit review and approve the plan? If the whole project is designed to benefit IP, has the design been reviewed and approved by the Regional Social Development Unit?

6 OP/BP Involuntary Resettlement: Yes No Has a resettlement action plan, policy framework or policy process been prepared? If yes, then did the Regional Social Development Unit review and approve the plan policy framework / policy process? OP/IP Forests: Yes No Has the sector-wide analysis of policy and institutional issues and constraints been carried out? Does the project design include satisfactory measures to overcome these constraints? Does the project finance commercial harvesting, and if so, does it include provisions for certification system? OP/BP Safety of Dams: Yes No Have dam safety plans been prepared? Have the TORs as well as composition for the independent Panel of Experts (POE) been reviewed and approved by the Bank? Has an Emergency Preparedness Plan (EPP) been prepared and arrangements been made for public awareness and training? OP Projects on International Waterways: Yes No Have the other riparians been notified of the project? If the project falls under one of the exceptions to the notification requirement, then has this been cleared with the Legal Department, and the memo to the RVP prepared and sent? What are the reasons for the exception? Please explain: Has the RVP approved such an exception? OP Projects in Disputed Areas: Yes No Has the memo conveying all pertinent information on the international aspects of the project, including the procedures to be followed, and the recommendations for dealing with the issue, been prepared, cleared with the Legal Department and sent to the RVP? Does the PAD/MOP include the standard disclaimer referred to in the OP? BP Public Disclosure: Yes No 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: Yes No Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of the safeguard measures? Have safeguard measures costs been included in project cost? Will the safeguard measures costs be funded as part of project implementation? Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures? Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? Signed and submitted by: Name Date Task Team Leader: E,Baris April 20, 2004 Project Safeguards Specialist 1: Project Safeguards Specialist 2: Project Safeguards Specialist 3: Approved by: Na Date Regional Safeguards Coordinator: / 1g, Comments: /l{( Sector Manager: Armi Fidle April 20, 2004 Comments: