Government of the Republic of Trinidad and Tobago Ministry of Health COVID-19 EMERGENCY RESPONSE PROJECT (P173989) ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK (ESMF) July 2023 ABBREVIATIONS AND ACRONYMS APR Air Pollution Rules BFP Bank Facilitated Procurement BPfA Beijing Platform for Action CARPHA Caribbean Public Health Agency CDC United States Centers for Disease Control and Prevention CEDAW Convention on the Elimination of all Forms of Discrimination against Women CHMTF Couva Hospital and Multi Training Facility CHSP Community Health and Safety Plan CMO Chief Medical Officer CMOH County Medical Officer of Health COVAX Vaccine Pillar of the Access to COVID-19 Tools (ACT) Accelerator COVID-19 Novel Coronavirus SARS-CoV-2 Disease CSO Central Statistical Office CTB Central Tenders Board CTF COVID Task Force DA Designated Account DIQE Division of Infrastructure, Quarries and the Environment DOE Department of the Environment ECOP Environmental Codes of Practice EIA Environmental Impact Assessment EMA Environmental Management Authority 1|Page EPI Expanded Programme on Immunization EPR Extended Producer Responsibility ERHA Eastern Regional Health Authority ERP Emergency Response Plan E&S Environmental and Social ESCP Environmental and Social Commitment Plan ESAVI Events Supposedly Attributable to Vaccination or Immunization ESF Environmental and Social Framework ESMF Environmental and Social Management Framework ESMPs Environmental and Social Management Plans ESS Environmental and Social Standard FM Financial Management GAVI Gavi, the Vaccine Alliance GBV Gender Based Violence GDP Gross Domestic Product GHG Greenhouse Gas GIIP Good International Industry Practice GNI Gross National Income GORTT Government of the Republic of Trinidad and Tobago GM Grievance Mechanism GRS Grievance Redress Service HCAI Health Care Associated Infection HCF Health Care Facility HCI Human Capital Index 2|Page HCW Health Care Waste HDU High Dependency Unit ICT Information and Communication Technology ICU Intensive Care Unit IDB Inter-American Development Bank IDSR Integrated Disease Surveillance and Response IFRs Interim Financial Reports IHR International Health Regulations ILO International Labour Organization IMF International Monetary Fund IPV Intimate Partner Violence IRA Industrial Relations Act IT Information Technology LAC Latin America and the Caribbean LMP Labour Management Procedures M&E Monitoring and Evaluation MEAU Multilateral Environmental Agreements Unit MoH Ministry of Health MOLSED Ministry of Labour and Small Enterprise Development MPD Ministry of Planning and Development MORDLG Ministry of Rural Development and Local Government MOTI Ministry of Trade and Industry MPA Multiphase Programmatic Approach MPD Ministry of Planning and Development 3|Page MPU Ministry of Public Utilities MSW Municipal Solid Waste NCRHA North Central Regional Health Authority NDS National Development Strategy NEU National Epidemiology Unit NGO Non-governmental Organization NTF National Task Force NWRHA North West Regional Health Authority NVDP National Vaccine Deployment Plan ODS Ozone Depleting Substances OIE World Organisation for Animal Health OSH Occupational Safety and Health PAD Project Appraisal Document PAHO Pan American Health Organization PDCA Plan Do Check Act PLWHA Persons Living with HIV/AIDS PDO Project Development Objective PPE Personal Protective Equipment PIU Project Implementation Unit PS Permanent Secretary QC Quality Control RC Regional Corporation RHA Regional Health Authority SAPA Southern Academy for the Performing Arts 4|Page SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus 2 SDGs Sustainable Development Goals SEA Sexual Exploitation and Abuse SEP Stakeholder Engagement Plan SOP Standard Operating Procedure SFARP So Far As is Reasonably Practicable SPRP Strategic Preparedness and Response Program SRAs Stringent Regulatory Authorities STEP Systematic Tracking of Exchanges in Procurement SWM Solid Waste Management SWMCOL Trinidad and Tobago Solid Waste Management Company Limited SWRHA South West Regional Health Authority TPHL Trinidad Public Health Laboratory TRHA Tobago Regional Health Authority UNDP United Nations Development Programme UHC Universal Health Coverage USA United States of America UTT University of Trinidad and Tobago VAC Vaccine Approval Criteria VIRAT/VRAF Vaccine Introduction Readiness Assessment Tool/Vaccine Readiness Assessment Framework TTO The Republic of Trinidad and Tobago WASA Water and Sewerage Authority WB World Bank 5|Page WBG World Bank Group WHO World Health Organization 6|Page TABLE OF CONTENTS Executive Summary ............................................................................................................................................ 11 1.0 Introduction and Background .................................................................................................................... 18 1.1 Purpose of this Document.................................................................................................................. 18 1.2 COVID-19 World Bank Program ....................................................................................................... 18 1.3 World Bank Programming in the Country Health Sector ............................................................... 19 2.0 Project Description ...................................................................................................................................... 22 2.1 Development Objectives and Indicators .......................................................................................... 22 2.2 COVID-19 Project Components and Activities ............................................................................... 22 2.2.1 Component 1: Emergency Response to COVID-19 (US$19.75 million) ............................ 23 2.2.3 Component 2: Project Management and Monitoring (US$0.25 million) ............................. 24 2.3 Key Risks.............................................................................................................................................. 24 2.3.1 Political and Governance Risk .................................................................................................. 25 2.3.2 Fiduciary Risk ................................................................................. Error! Bookmark not defined. 2.3.3 Institutional Capacity Risk ............................................................. Error! Bookmark not defined. 2.3.4 The Environmental and Social Risks (E&S)............................................................................ 25 2.4 Project Area ......................................................................................................................................... 25 3 Policy, Regulatory and Institutional Framework ...................................................................................... 29 3.1 Policies.................................................................................................................................................. 29 3.1.1 National Environmental Policy (NEP), 2018 ........................................................................... 29 3.1.2 Integrated Solid Waste/Resource Management Policy for Trinidad and Tobago, 2013 .. 30 3.1.3 Occupational Safety and Health (OSH) Management Policy of the Ministry of Health, 2012 .............................................................................................................................................. 31 3.1.4 Climate Change Policy, 2011 .................................................................................................... 33 3.1.5 National Policy Guidelines on Preparing Workplaces in Trinidad and Tobago for COVID- 19, 2020 ........................................................................................................................................ 34 3.2 Relevant National Laws and Regulations and International Treaties .......................................... 34 3.2.1 Environmental Management Act, No. 3 of 2000 .................................................................... 34 3.2.2 Occupational Safety and Health Act, 2004 as amended .............................................................. 36 3.2.3 Industrial Relations Act (IRA), 1972, Chapter 88:01...................................................................... 38 3.2.4 Healthcare Specific Regulatory Framework............................................................................ 40 3.2.5 Pandemic COVID-19 Plan ......................................................................................................... 42 3.3 World Bank Environmental and Social Standards ......................................................................... 43 7|Page 3.3.1 The World Bank Environmental and Social Framework (ESF) ............................................. 43 3.3.2 The World Bank Group Environmental Health and Safety (EHS) Guidelines ................... 45 3.3.3 World Bank Technical Note on Public Consultations and Stakeholder Engagement ...... 46 3.4 World Health Organization (WHO) Guidance ................................................................................. 46 3.5 International Treaties and Protocols ................................................................................................ 50 3.6 Roles and Responsibilities of Governmental and Regional Entities ........................................... 52 3.7 Gap Analysis ........................................................................................................................................ 55 4 Environmental and Social Baseline .......................................................................................................... 62 4.1 Socio-Economic Baseline ................................................................................................................. 62 4.1.1 Health and Health Care Service ............................................................................................... 63 4.1.2 Gender Equality ........................................................................................................................... 64 4.1.3 Gender Based Violence ............................................................................................................. 64 4.1.4 Disadvantaged and Vulnerable Groups................................................................................... 65 4.2 Environmental Baseline .................................................................................................................... 66 4.2.1 Solid Waste Management in Trinidad and Tobago ................................................................ 67 4.2.2 Health Care Waste Management and Infection Control ....................................................... 68 4.2.3 Air Quality and Healthcare Waste Incineration ....................................................................... 69 4.3 National COVID-19 Response .......................................................................................................... 72 4.3.1 Testing for COVID-19 ................................................................................................................. 73 4.4 National Vaccine Deployment Plan .................................................................................................. 73 4.4.1 Shipment and Storage ................................................................................................................ 74 5 Potential Environmental and Social Impacts and Mitigation Measures .............................................. 79 5.1 Methodology for Assessing Risk and Impacts ................................................................................ 79 5.2 Risks Summary ................................................................................................................................... 79 5.2.1 Environmental Risks ................................................................................................................... 80 5.2.2 Social Risks .................................................................................................................................. 81 6 Procedures to Address Environmental and Social Issues .................................................................... 97 6.1 Screening Process .............................................................................................................................. 97 6.2 Environmental and Social Management Plans ............................................................................. 100 6.3 Health-Care Waste Management ........................................................................................... 100 7.0 Stakeholder Engagement, Consultation and Disclosure ..................................................................... 101 7.1 Project Stakeholders......................................................................................................................... 102 7.1.1 Affected parties.......................................................................................................................... 102 8|Page 7.1.2 Other interested parties ............................................................................................................ 102 7.1.3 Disadvantaged/vulnerable individuals or groups.................................................................. 103 7.2 Proposed Strategy for Information Disclosure .............................................................................. 104 7.4 Consultation and Disclosure during Project Implementation...................................................... 105 7.5 Reporting Back to Stakeholders ..................................................................................................... 107 7.6 Grievance Procedures...................................................................................................................... 107 7.6.1 Grievance Mechanism .............................................................................................................. 107 7.7 Monitoring and Reporting...................................................................... Error! Bookmark not defined. 8.1 Implementing Agency ....................................................................................................................... 110 8.1.1 Technical Oversight Committee:............................................................................................. 110 8.1.2 Project Implementation Unit (PIU) .......................................................................................... 110 8.1.3 COVID-19 Vaccine Task Force............................................................................................... 112 8.2 Capacity Building............................................................................................................................... 112 8.3 E&S Risk Management Budget ...................................................................................................... 113 9.0 Annexes ...................................................................................................................................................... 115 9.1 Annex I - Screening Form for Potential Environmental and Social Risks ................................. 115 9.2 Annex II – Environmental and Social Management Plan (ESMP)............................................. 117 9.3 Annex III - Infection Control and Waste Management Plan (ICWMP) ...................................... 150 9.4: Annex IV - Community Health and Safety Plan (CHSP) ............................................................. 183 9.6 Annex VI – Environmental and Social Commitment Plan (ESCP) ............................................ 194 9.7 Annex VII – Labour Management Procedures (LMP) ................................................................. 207 List of Figures Figure 1: Location of Health Centres and Hospitals in Trinidad 27 Figure 2: Location of Hospitals and Health Centres in Tobago 28 Figure 3: Plan Do Check Act 32 Figure 4: Schedule 2 of APR – Stack Release Limits 71 List of Tables Table 1: The actions involved in delivering effective arrangements........................................................................... 31 Table 2: Summary of Applicable Environmental Rules ................................................................................................ 35 Table 3: Summary of Labour related Acts ...................................................................................................................... 39 Table 4: Policies, Regulations and Guidelines issued by the Ministry of Health ...................................................... 41 9|Page Table 5: Summary of Applicable Standards ................................................................................................................... 44 Table 6: WHO Guidelines related to COVID-19 ............................................................................................................ 47 Table 7: Summary of Roles and Responsibilities of Institutions ................................................................................. 52 Table 8: Gap Analysis between ESF Requirements and National Legislation ......................................................... 56 Table 9: Ineligible Activity List .......................................................................................................................................... 99 Table 10: Stakeholder Consultations Held ................................................................................................................... 104 Table 11: Disclosure Plan ............................................................................................................................................... 106 Table 12: ESMF Annual Implementation Costs .......................................................................................................... 113 10 | P a g e Executive Summary The Project Development Objective of the COVID-19 Emergency Response Project is to strengthen the Republic of Trinidad and Tobago’s capacity to prevent, detect, and respond to the threat posed by COVID-19 and to strengthen national systems for public health preparedness for future health crisis. The Environmental and Social Management Framework (ESMF). The Project consists of a number of different activities and/or investments (subprojects) for which the risks and impacts cannot be determined until implementation. The ESMF describes the principles, processes, and technical guidance for the Project implementing agencies and their consultants to assess the environmental and social risks and impacts of the Project activities. This ESMF assists the Ministry of Health (MoH) in identifying the type of environmental and social assessment that should be carried out for the project activities that involve either the construction, expansion, rehabilitation and/or operation of healthcare facilities, and the deployment of and effective vaccine in response to COVID-19, and in developing the environmental and social (E&S) management plans in accordance with the World Bank’s Environmental and Social Framework (ESF). The ESMF is applicable to all investments under the Project. It aims to (a) assess the potential environmental and social (E&S) risks and impacts of the Project and propose mitigation measures which will effectively address these risks/impacts; (b) establish clear procedures for the E&S screening, review, approval, and implementation of activities; (c) specify appropriate roles and responsibilities, and outline the necessary reporting procedures, for managing and monitoring E&S issues related to eligible activities; (d) identifythe training and capacity building needed to successfully implement the provisions of the ESMF; (e) address mechanisms for public consultation and disclosure of project documents as well as redress of possible grievances; and (f) establish the budget requirement for implementation of the ESMF. E&S Audit/Rapid Assessment. Where activities are retroactively financed, an E&S Audit/Rapid Assessment is required to demonstrate how the project requirements have been met. Retroactive financing will be applied for this project and therefore an E&S Audit/Rapid Assessment has been completed that demonstrates how the E&S 11 | P a g e requirements of the project have been met during implementation to date. Eligible Project Activities. The Project is national in coverage and scope, and retroactively finances a number of activities that could include the following: (i) essential equipment for disinfection and sterilization procedures, including medical supplies, and supplies to ensure safe hospital waste management practices; (ii) key health care delivery inputs, including personal protective equipment and other medical supplies for frontline health workers involved in patient case management; (iii) medicines and equipment for the treatment of COVID-19 patients; (iv) training of health staff on appropriate clinical care for COVID-19 patients and the safe disposal of medical waste; (v) procurement and administration of COVID-19 vaccines. Potential Environmental Impacts and Risks. Overall, the environmental risk is expected to be substantial due to the emergency nature of the project. The direct and indirect environmental impacts that may arise due to the project activities are: (i) Occupational safety and health risks (OSH). The profiling and screening of patients prior to vaccination, the administration of the vaccine, and the operation of medical facilities and laboratories involved in COVID-19 response might expose the health care workers to a higher risk of contracting the virus if infection prevention and control measures are not implemented, can cause an unsafe environment. There are also OSH risks to the workers/labourers due to the possible exposure during the construction activities in the health facilities and laboratories. Occupational safety and health risks for cleaners and waste handlers in health facilities and the waste service providers are present due to the possible exposure to infectious healthcare wastes during the collection, storage, treatment, and disposal stages. Risks to work-related stress will be assessed as a concern to healthcare workers’ mental health. Risks to muscular-skeletal disorders arising out of and in connection with manual handling activities will also be assessed. (ii) Risks from infectious healthcare wastes. The wastes generated from the COVID- 19 testing, other diagnostic procedures, clinical management of patients, and vaccination activities, including waste collection from the healthcare facility by the 12 | P a g e facility’s waste handlers and cleaners and by the contracted waste service providers, as well as community health and safety issues related to the handling, transport, treatment, and disposal of the healthcare wastes are present. (iii) Logistics and distribution risks of the vaccine. The COVID-19 vaccines require specific temperatures during storage and distribution to maintain efficacy and safety. Hence, the contraindications and storage and transport condition requirements of the vaccine may pose risks. The availability of cold storage and refrigerated transportation suitable to the temperature needs of the vaccine and in the location of vaccine administration is a potential risk to the Project’s implementation. Relatedly, the cold storage to be procured or rented may contain refrigerants which do not conform to the requirements of the Montreal Protocol, Kigali Agreement, and the chemical control order on ozone-depleting substances (ODS) and contribute to the generation of greenhouse gases (GHG). Other refrigerants are also toxic and flammable and can pose risk to people’s health and safety. Cold storage systems also require huge amount of energy to operate that may have an impact on climate change. The compliance with biosafety protocols during the transport of the vaccines is also a risk, as breakage of the vials and spillage of the vaccine might occur. Similarly, natural disasters such as earthquake, landslide, flooding, storm surge and other climate change-related risks as well as unstable power supply resulting to power outages exist in some areas in the country which may affect the security of the delivery and distribution of the vaccines. The possible hot weather in the country may also have an effect on the efficacy of low temperature- requiring vaccines. (iv) The small construction activities which could potentially be included as part of the project components, such as the expansion or rehabilitation of existing buildings and facilities, pose occupational health and safety risks to the workers. The project could possibly include limited civil works such as small retrofitting activities on existing premises, but in such cases, it would be ensured through the screening process that there would be no land acquisition and involuntary resettlement involved. Potential Social Impacts and Risks. There are substantial risks related to the direct and indirect social impacts of the eligible activities. These risks can be mainly classified as (i) biosafety issues, (ii) case management of population for vaccination, (iii) regulatory 13 | P a g e measures, (iv) community health and safety, (v) affordability, social inequity, and risk of exclusion, (vi) stigma, discrimination, and vaccine acceptance; and (vii) misinformation, lack of information, and disinformation: i. Biosafety Issues of the vaccine. Due to the novelty and relatively shorter time frame of the development and clinical trials of the COVID-19 vaccine, the communities may have fear and apprehension on its scientific integrity, efficacy, and safety. The contraindications and storage and transport condition requirements of the vaccine may pose risk. Transparency on the vaccine information and manufacturer credibility are important considerations for the public. Misinformation on the adverse health effects of vaccine is also a risk which should be addressed through an effective risk communication strategy. ii. Case management of population for vaccination. There are risks of contraindications and adverse health effects as result of improper or inadequate profiling and screening of individuals prior to vaccination. There is also a risk of not completing the vaccine dose/shots due to the individual’s apprehension and/or schedule mismanagement. The data management of the vaccination program, including the establishment of good surveillance system and schedule monitoring, are also risks. With the use of more than one vaccine during the immunization period, close monitoring of adverse events in vaccinated individuals using information technology, i.e., digital tracking system should be conducted. As the possibility of adverse effects of the vaccine is a risk, tracking of health effects in vaccinated individuals and follow-up assessments should be conducted. iii. Regulatory measures. Due to the global demand for the vaccine and the limited vaccine production, access to the COVID-19 vaccines is a risk. The conduct of strict regulatory measures should be ensured in view of the of the vaccine. Regulation and access concerns should be equally taken into consideration. Moreover, the work of relevant bodies should be continually aligned and synchronized to ensure the expeditious national approval of the vaccines. iv. Community health and safety. The vaccine administration may also lead to crowding and violation of physical distancing measures, increasing the risk of exposure of the health workers, the vaccines, and the community, especially the residents within the vicinity of the immunization site. Thus, compliance to minimum public health standards is strongly advised. Infectious health care 14 | P a g e wastes generated from the vaccination and other COVID-19 related response pose risk to community health and safety if not handled, transported, treated, and disposed of according to the proper healthcare waste management practices. Hospital visitors and other non COVID-19 patients may also be exposed to the virus as well as the workers when establishing or upgrading health facilities. There is also a risk of not completing the vaccine dose/shots due to the individual’s apprehension and/or schedule mismanagement. v. Affordability, social inequity, and risk of exclusion. The accessibility of COVID-19 vaccines due to its price is a risk. Due to the novelty and urgent need of the vaccine, there is a risk in price regulation and compliance with fair trade guidelines. Although the national government has already identified its eligible population to be immunized from 2021 – 2023, strict adherence to this list to ensure that the most-at-risk are the ones vaccinated first is a risk. There is an indirect risk of social exclusion, in particular, the most vulnerable and marginalized groups, the sexual and gender minorities or refugees. The elderly, those with underlying medical conditions, and people living with disability, though included in the priority populations to be vaccinated as identified in the WHO1 may have limited access to the vaccines due to reduced mobility. The vulnerable groups may also be excluded from coverage of the national program and local responses to COVID- 19. The vaccine distribution and deployment may also exclude populations based on geographical distribution, i.e., those in far-flung areas, and on socioeconomic status, such as less access for the marginalized. vi. Stigma, discrimination, and vaccine acceptance. The fear and apprehension of individuals and communities on the scientific integrity, efficacy, and safety of the COVID-19 vaccines may lead to people refusing vaccination. The possibility of having COVID-19 may also cause individuals to hide symptoms, avoid getting tested, and reject hygiene measures, which could lead to further spread of the virus. The health workers involved in the vaccine administration activities may 1 World WHO SAGE roadmap for prioritizing uses of COVID-19 vaccines in the context of limited supply: an approach to inform planning and subsequent recommendations based on epidemiological setting and vaccine supply scenarios, first issued 20 October 2020, latest update 16 July 2021. https://apps.who.int/iris/handle/10665/342917 15 | P a g e face discrimination and harassment when going back to their communities due to people’s fear in contracting the virus, frustrations over medical care, or misinformation vii. Misinformation, lack of information, and disinformation. Misinformation and disinformation on COVID-19 and the adverse health effects of vaccines and hearsays on the conspiracy theories and underlying political agenda on the vaccines are widespread. The information materials on COVID-19 and the vaccine to be developed could exclude the most vulnerable or be developed in a way that is not sensitive to the needs and access of these different groups. Messages on COVID-19 and the vaccine may also not be in the language appropriate and may not be readily accessible for communities as mentioned above. Procedures to Address Environmental and Social Issues. The ESMF provides a screening tool for potential project activities to allow determination of potential environmental and social issues. The screening process identifies possible instruments, e.g., Environmental and Social Management Plan (ESMP), Environmental Codes of Practice (ECOP), to be applied during Project implementation, based on subproject typology. These issues will also be addressed through relevant capacity building activities, observance of the labour management procedures and environmental and social management plans for project sites, conduct of community consultations, and active observance of the Grievance Redress Mechanism. The Stakeholder Engagement Plan (SEP) which was finalized and disclosed October 20212 includes provisions for engaging affected and interested stakeholders throughout the project implementation. Measures to address concerns of vulnerable groups, including persons with disabilities and refuges, are included in the ESMF and SEP. Management of healthcare waste will take into consideration workers and waste management service providers and the community health and safety issues related to the handling, transport, and disposal of healthcare wastes, which are addressed throughout the ESMF. To ensure the safety of the vaccines to be procured, the vaccine regulatory approval of the Stringent Regulatory Authorities (SRAs) identified by the World Health Organization will be required2. Appropriate messages have been 2 Final SEP can be found here: https://health.gov.tt/sites/default/files/2021- 10/Ministry%20of%20Health%E2%80%99s%20Action%20Plan%20for%20the%20Novel%20Coronavirus.pdf 16 | P a g e developed under the risk communication plan to address the vaccine safety and identification of priority population concerns of communities. The MoH has developed key messages on COVID-19 information, prevention, and treatment. A Communications Campaign Plan was developed by the MoH for the COVID-19 immunization program. It has a whole-of-government, whole-of-system, and whole-of-society approach which encompassed general information on (i) COVID-19 and the need for sanitation and hygiene practices, (ii) COVID-19 vaccine basic information, (iii) trials results and procurement, and (iv) vaccine program roll-out. Serial obtaining of informed consent from the identified vaccines and counselling was conducted prior to the administration of the COVID-19 vaccine. The profiling and screening of candidate individuals to be vaccinated was performed so as to avoid the risk of vaccine contraindications. A comprehensive data management system is also needed to support the profiling, screening, and scheduling to address the risk of individuals not completing the required shots/doses of the vaccine. Coordination with the local government units as well as the uniformed personnel was done to assist in crowd management and for the successful conduct of the program. Institutional Arrangement for ESMF implementation. The Ministry of Health (MoH) is responsible for the coordination, management, and implementation of the project at the national and sub-national levels including financial management, procurement, and environmental and social management. The Project’s implementation shall be mainstreamed in the MoH processes and shall involve a Project Implementation Unit. This has been strengthened by the recruitment of additional staff responsible for environmental and social management. 17 | P a g e 1.0 Introduction and Background 1.1 Purpose of this Document The purpose of the Environmental and Social Management Framework (ESMF) is to guide the Ministry of Health (MoH), Pan American Health Organization (PAHO), and other proponents on the environmental and social screening, assessment, and management of specific project activities during implementation. The document also provides guidance on the preparation of location specific Environmental and Social Management Plans (ESMPs), when needed, in accordance with the ESMF. The ESMF covers all applicable provisions of the relevant World Bank Environmental and Social Standards (ESSs). Five Environmental and Social Standards (ESSs) of the World Bank Environmental and Social Framework (ESF) are relevant for the Project. These are ESS1: Assessment and Management of Environmental and Social Risks and Impacts; ESS2: Labour and Working Conditions; ESS3: Resource Efficiency and Pollution Prevention and Management; ESS4: Community Health and Safety; and ESS10: Stakeholder Engagement and Information Disclosure. Additionally, other environmental and social instruments as required by the ESF, such as the Stakeholder Engagement Plan (SEP), are appropriately summarized or referenced in the ESMF and ESMP checklist. The type of environmental and social instruments and their timings of development and implementation are defined in the project Environmental and Social Commitment Plan (ESCP) (Annex VI). 1.2 COVID-19 World Bank Program An outbreak of the coronavirus disease (COVID-19) caused by the 2019 novel coronavirus (SARS- CoV-2) has been spreading rapidly across the world since December 2019, following the diagnosis of the initial cases in Wuhan, Hubei Province, China. Since the beginning of March 2020, the number of cases outside China has increased thirteen-fold and the number of affected countries has tripled. On March 11, 2020, the World Health Organization (WHO) declared a global pandemic as the coronavirus rapidly spreads across the world. As of 6:21pm CEST, 20 October 2022, there have been 623,470,447 confirmed cases of COVID-19, including 6,551,678 deaths, 18 | P a g e reported to WHO. As of 19 October 2022, a total of 12,814,704,622 vaccine doses have been administered3. The project, under the MPA (Multiphase Programmatic Approach) Program4, will support adaptive learning throughout project implementation, as well as from such organizations as the WHO, Pan American Health Organization (PAHO), Inter-American Development Bank (IDB), International Monetary Fund (IMF), United States Centre for Disease Control and Prevention (CDC), and others. Given the recent emergence of the pandemic, the exchange of information across countries, facilitated by international partners such as the World Bank, will be instrumental for the Government of the Republic of Trinidad and Tobago (GROTT) in terms of managing its response to COVID-19. Learning needs to include methods on supply chain approaches during times of emergencies and disrupted global supply chains, including assessments for timely distribution of medicines and other medical supplies. Another area of learning is how to implement appropriate policies for testing, triage and isolation of patients. The World Bank (WB) and other partners will provide continuous support to facilitate learning on good practices learned through their experience with other countries. The TTO Project under the MPA Program will also benefit from the early lessons of COVID-19 project implementation in other countries. The Project has been designed to allow for flexibility to adapt to emerging evidence throughout its implementation. 1.3 World Bank Programming in the Country Health Sector The project is aligned with the World Bank Group (WBG) strategic priorities and the mission to end extreme poverty and boost shared prosperity. The Program is focused on preparedness which is also critical to achieving Universal Health Coverage (UHC). It is aligned with the World Bank’s support to national plans and global commitments to strengthen pandemic preparedness through three key actions under Preparedness: (i) improving national preparedness plans including organizational structure of the government; (ii) promoting adherence to the International Health Regulations (IHR); and 3 https://covid19.who.int/ 4 The MPA allows countries to structure a long, large, or complex engagement as a series of smaller linked operations (or phases) under one program; for example, numerous COVID-19 emergency response actions across several countries in a geographic region 19 | P a g e (iii) utilizing international framework for monitoring and evaluation of IHR. The economic rationale for investing in the MPA interventions is strong, given that success can reduce the economic burden suffered both by individuals and countries. The project complements both WBG and development partner investments in health systems strengthening, disease control and surveillance, attention to changing individual and institutional behaviour, and citizen engagement. One of the major development partners in Trinidad and Tobago is the Inter-American Development Bank (IDB). The IDB has been supporting the health sector broadly and also provides the MoH with support for its COVID- 19 response plan. The existing IDB-financed investment project (Health Services Support Program, TT-L1039) focuses on strengthening the organizational and institutional capacity of the health system to address the challenges of the sector. The project contributes to the implementation of IHR (2005), Integrated Disease Surveillance and Response (IDSR), the World Organisation for Animal Health (OIE) international standards, the Global Health Security Agenda, the Paris Climate Agreement, the attainment of Universal Health Coverage and of the Sustainable Development Goals (SDG), and the promotion of a One Health approach. The Project is aligned with the World Bank’s Human Capital Project5, which calls for countries to make more and better investments in health and education to increase the productive capacities of their populations. The COVID-19 health emergency has elevated the priority of protection of health and human capital of vulnerable and poor population. The Project is also closely aligned with the SDGs, which emphasize the importance of achieving UHC and financial protection. Additionally, the Project is consistent with the Priority Directions of the Health, Nutrition, and Population Global Practice 2016-2020. Finally, the Project is in line with the World Bank climate change commitments, particularly by incorporating climate change considerations throughout the Project design that reduce observed vulnerabilities of TTO’s population and enable the health system to adapt to climate induced changes while effectively responding to COVID-19 related risks. This project supports the National Development Strategy (NDS) 2016-2030, Vision 2030 of Trinidad and Tobago, which is the foundation and pathway for attaining developed 5 https://www.worldbank.org/en/publication/human-capital 20 | P a g e country status by the year 2030, Vision 20306. More specifically, it supports Theme I, Putting People First: Nurturing Our Greatest Asset, Goal 4 The Healthcare System of Trinidad and Tobago will be sustainable and modern and deliver higher standards of healthcare. 6 https://www.planning.gov.tt/content/vision-2030 21 | P a g e 2.0 Project Description 2.1 Development Objectives and Indicators The Project Development Objective (PDO) is to detect and respond to the threat posed by COVID-19 and to strengthen the national health system for the emergency response to the COVID-19 pandemic. Three DO level outcomes indicators for the project are: • Percentage of COVID-19 patients hospitalized in critical care units that are treated as per national clinical practice guidelines. • Percentage of the persons, included in the Government’s COVID-19 testing strategy, who receive a virology test for COVID-19 • Population vaccinated, based on the targets defined by Trinidad and Tobago's National COVID-19 Vaccination Plan (total and disaggregated by gender). 2.2 COVID-19 Project Components and Activities The Project would finance retroactively critical medical and laboratory equipment, personal protective equipment (PPE), medical and laboratory supplies, medicines, vaccines for COVID-19 or medicines for its treatment and the training of medical staff on the appropriate use of equipment and supplies, where needed. The Project was originally anticipated to finish by December 2022, but an extension was granted so the new project end date is June 30, 2024. The Project will aim to strengthen disease detection capacity through the provision of laboratory equipment and supplies to ensure prompt testing and diagnosis. By procuring equipment and medical supplies needed for the provision of intermediate and intensive care services in response to COVID-19, the Project will support critical aspects of health service provision in order to mobilize surge response capacity. The Project will support a flexible procurement approach to maximize chances of success in procuring items that are hard to procure in strained global supply chains. The Project will use PAHO as the primary procurement agent to act on behalf of the GROTT and BFP as a complementary approach, whenever it adds value for the Government. The proposed Project has two components to support the Government’s capacity to detect 22 | P a g e and respond to the threat posed by COVID-19. Specifically, it will support the identification and treatment of patients with COVID-19 to minimize disease spread, morbidity, and mortality. The Project would include climate change adaptation and mitigation measures when possible and address gender issues by ensuring non-discrimination and wide access to COVID-19-related health care services. An exclusion list is provided in Table 9, and any activities on this list will be ineligible for project financing. 2.2.1 Component 1: Emergency Response to COVID-19 (US$11.70 million) This component provides immediate support to respond to the COVID-19 pandemic through the procurement and importation of key medical equipment and supplies for the treatment of COVID-19. The component will finance critical inputs for infection control in health facilities. The Component will finance safe working conditions for health staff treating COVID-19 patients through the provision of PPE, training on their safe use and disposal, training on the safe operation of equipment for the treatment of COVID-19 patients, pharmaceutical products for the response to COVID-19. The activities under this component will prioritize energy- efficient goods and services and ensure the use of climate-smart technologies in medical supplies and medical devices to treat COVID-19 cases, where relevant. This component will support efforts to strengthen the health care system’s capacity to provide a comprehensive range of services for the treatment and care of COVID-19 patients, in accordance with WHO clinical practice guidelines. The component will finance as needed the following: i. essential equipment for disinfection and sterilization procedures including medical supplies, and supplies to ensure safe hospital waste management practices; ii. key health care delivery inputs, including personal protective equipment (PPE) and other medical supplies for frontline health workers involved in patient case management; iii. training of health staff on appropriate clinical care for COVID-19 patients and the safe disposal of medical waste; iv. equipment for the treatment of COVID-19 patients. Procurement under this subcomponent will prioritize, when possible, the use of climate-smart technologies. The COVID-19 vaccination, treatment and care will be provided in existing health 23 | P a g e care facilities, and the infrastructure is in place to enable the services to be delivered in accordance with relevant guidance for infection control and medical waste management. Therefore the building of new infrastructure or amendments to facilities involving construction activity has not been required. By incorporating relevant observed and anticipated climate change risks into the design of the component, the Project will also improve the resilience of the health care system and the ability to respond to future health threats, including climate-related ones, as appropriate. This will be achieved by providing climate-smart technology and training health facility staff and front-line workers undertaking relevant activities. 2.2.2 Component 2: Support to COVID-19 Vaccination Campaign (US$8.05 million) This component supports the retroactive financing of vaccine procurement and technical assistance for demand generation, tailored communications and reporting on compliance with the NVDP to support the implementation of the NVDP. 2.2.3 Component 3: Project Management and Monitoring (US$0.25 million) This Component will finance the recurrent operational costs of strengthening the Project Implementation Unit (PIU) established under an existing IDB-financed health project at the MoH that will be in charge of overall implementation and supervision of the Bank-financed Project. The main activities of PIU staff are to ensure successful implementation of the Bank-financed Project include: (i) project management including monitoring and evaluation; (ii) procurement through PAHO or BFP; (iii) financial management; and (iv) compliance with environmental and social framework requirements. 2.3 Key Risks The overall risk of the Project is Substantial. The large-scale acquisition and deployment of COVID-19 vaccines entails certain significant risks. First, the initial 24 | P a g e vaccines that meet Bank’s Vaccine Approval Criteria (VAC) may not be the most effective for the specific context of Trinidad and Tobago, or they may not be purchased in a timely manner. Second, a mass vaccination effort stretches capacity, entailing risks. The proposed Bank support for TTO to develop vaccination acquisition strategies specifically aims to mitigate these risks. The remaining risk must be considered against the risk of the country having less timely and effective deployment of vaccines, potentially exacerbating development gaps and eroding past development gains. The respective mitigating measures are described below: 2.3.1 The Environmental and Social Risks (E&S) The Environmental and Social risks will be identified and managed through the Project’s ESMF and SEP, development of an Infection Control and Waste Management Plan, a Community Health and Safety Plan, and capacity strengthening through hiring E&S staff. Section 5 of this ESMF has more detailed information on the E & S risks. 2.3.2 Project Area The Project Activities will be undertaken throughout Trinidad and Tobago. The MoH has 109 health centres, and nine hospitals. The health centres were assessed for their capacities to become vaccination sites. Based on this assessment the following health care locations were initially identified for vaccine distribution: Eastern Regional Health Authority (ERHA • Cumana Outreach Centre • Mayaro District Health Facility • Rio Claro Health Centre • Sangre Grande Enhanced Health Centre North Central Regional Health Authority (NCRHA) 25 | P a g e • Arima District Health Facility • Chaguanas District Health Facility • La Horquetta Health Centre • St Joseph Enhanced Health Centre North West Regional Health Authority (NWRHA) • Barataria Health Centre • Diego Martin Health Centre • Carenage Health Centre • Morvant Health Centre South West Regional Health Authority (SWRHA) • Couva District Health Facility • Freeport Health Centre • La Romaine Health Centre • Marabella Health Centre • Point Fortin Health Centre • Princes Town District Health Facility • Siparia District Health Facility • St Madeleine Health Centre 26 | P a g e Mass vaccination sites used so far are located at the Queen’s Park Savannah in Port of Spain, the National Racquet Centre of Trinidad and Tobago in Tacarigua, the Southern Academy for the Performing Arts (SAPA) in San Fernando and the University of Trinidad and Tobago (UTT) Campus, Chaguanas. The sites are identified in the figures below. Figure 1: Location of Health Centres and Hospitals in Trinidad 27 | P a g e Figure 2: Location of Hospitals and Health Centres in Tobago 28 | P a g e 3 Policy, Regulatory and Institutional Framework The Republic of Trinidad and Tobago has a written Constitution which was enacted in 1976 (Chapter 1:01 of the Laws of Trinidad and Tobago). The Constitution is the supreme law of the land, in that no law may amend, abridge or infringe the Constitution without the requisite majority of Parliament. The system of government in Trinidad and Tobago is a Parliamentary democracy based on the Westminster system. There are three arms of State: The Executive, the Legislature and the Judiciary. The establishment, function and powers of each of these arms are provided for in the Constitution. The Constitution of Trinidad and Tobago recognizes and guarantees citizens certain basic human rights and freedoms, such as the right to life, liberty and security, the right to equality before the law and the right to freedom of expression. The right to freedom of association and assembly is also a fundamental right protected by the Constitution. 3.1 Policies 3.1.1 National Environmental Policy (NEP), 2018 The NEP is intended to endorse the preservation and insightful utilization of the environment of Trinidad and Tobago and to serve as the proposal of goals, objectives, and principles which would guide the administration of natural resource so that the requirement of present and future generation and improvement of the equality of life is met. The Environmental Policy espouses two (2) key principles: • Polluter Pays Principle: the cost of preventing pollution or of minimising environmental damage due to pollution will be borne by those responsible for pollution. 29 | P a g e • Precautionary Principle: if there are threats of serious irreversible environmental damage, lack of full scientific certainty will not be used as a reason for postponing measures to prevent environmental degradation. 3.1.2 Integrated Solid Waste/Resource Management Policy for Trinidad and Tobago, 2013 The four specific objectives, which represent elements of the sustainability vision are: Objective 1: To manage waste in a manner that will protect public health, and the environment and that will conserve natural resources. Objective 2: To manage waste as an integrated management system in accordance with the preferred hierarchy where the focus is placed on prevention rather than disposal. The hierarchy seeks to minimize landfilling, with an increased emphasis on maximizing the reduction of waste volumes, through the initiatives of reuse, recycling and source segregation. Objective 3: To manage waste in a cost-effective manner that maximizes environmental benefits and minimizes long-term financial liability for the population. Objective 4: To ensure that generators take responsibility for the environmentally sound management of their wastes and to identify, allocate and communicate solid waste management system costs equitably among those who use or benefit from the system. While the overall policy will address the integrated solid waste management system, particular attention should be paid to specific categories of waste regarding the handling of these waste types. The recovery of these waste categories will be governed by incentives such as deposit/refund, disposal fees, pay-as-you-throw, buy-back mechanisms and disposal bans. Collection, delivery and disposal alternatives will be developed under a regulated framework. These waste types are: • Household Waste; • Hazardous Waste (include bio-medical wastes) • Industrial Waste; 30 | P a g e • Electronic Waste; • Special Bulk Wastes. 3.1.3 Occupational Safety and Health (OSH) Management Policy of the Ministry of Health, 2012 The health and safety policy sets out our general approach to health and safety. It explains how the MoH, as an employer, will manage health and safety throughout the organization and the RHAs. It clearly says who does what, when and how. And because MOH has more than twenty-five employees, our safety, health and environmental policy is written down. This policy is shared, and any changes to it, with our employees. The Safety and Health Policy provides the framework for the development of an effective Occupational Safety and Health Management System, this is archived by delivering effective arrangements: The Plan, Do, Check, and Act approach (See the table and figure below 3)7. Plan, Do, Check, Act helps the MoH/RHAs seek to achieve a balance between the systems and behavioural aspects of management. PDCA also treats health and safety management as an integral part of good management generally i.e. E&S, QC, and Labour Management, rather than as a stand-alone system. Table 1: The actions involved in delivering effective arrangements Plan, Do, Conventional health and safety Process safety Check,Act management PLAN Determine your policy/Plan for Define and communicate implementation acceptable performanceand resources needed DO Profile risks/Organise for health and Identify and assess safety/Implement your plan risks/Identify controls/Record and maintainprocess safety knowledge Implement and manage control measures CHECK Measure performance (monitor before Measure and review events, investigate after events) performance/Learn from 7 https://www.hse.gov.uk/pubns/priced/hsg65.pdf 31 | P a g e Plan, Do, Conventional health and safety Process safety Check,Act management ACT Review performance/Act on lessonslearned measurements and findings of investigations Figure 3: Plan Do Check Act It also aims to manage workers’, and members of the public, risk of exposure to occupational health and safety hazards: improve the working environment and safe systems of work; promote a positive safety culture in support of health and safety at work by improving every persons’ knowledge, practice and attitude towards occupational health and safety. When reference is made to the term ‘safety culture’ the acceptable definition used here is: “The safety culture of an organization is the product of 32 | P a g e individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Organisation with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures.�8 Therefore, the of the objective of this ESMF is to ensure that MoH/RHA’s develop robust systems i.e., safety and health management systems, and improve the human capital to meet the needs of a changing world where the safety and health of workers, and stakeholders is given due consideration by creating a positive safety culture. This OSH policy is applicable to all assets under the purview of the Ministry of Health and Regional Health Authorities as well as to all employees during the course of their employment, visitors, clients and service providers. 3.1.4 Climate Change Policy, 2011 The Climate Change Policy seeks to address, inter alia, the impacts of climate change including sectoral vulnerability and mitigation potential in major emitting sectors; current and proposed legislation related to mitigation and the identification of gaps in the legislation; and finally a Strategy and Action Plan. The objectives of the National Climate Change Policy include: • Reducing or avoiding greenhouse gas emissions from all emitting sectors • Enhancing carbon sinks • Protection of the natural environment and human health • Conserving and building resilience of human and natural systems to adapt to the adverse impacts of climate change including through capacity building, the application of cleaner and energy efficient technologies and relevant research and development • Enhanced agricultural production and food security 8 https://www.hse.gov.uk/humanfactors/topics/common4.pdf 33 | P a g e • Educating the wider public on the potential impacts of climate change and the recommended adaptation strategies • Conserving and guaranteeing a sustainable supply of potable water 3.1.5 National Policy Guidelines on Preparing Workplaces in Trinidad and Tobago for COVID-19, 2020 The objective of this Policy is to minimize the spread of coronavirus by keeping Employees safe and well at work. Policy Goals The goals of this policy are as follows: • Preparedness, prevention, mitigation, response and recovery from the spread of COVID-19; • To ensure that health and safety at workplaces in Trinidad and Tobago is maintained; • To ensure business continuity; • To define the workplace roles and responsibilities of Employees, Employers, Trade Unions and state agencies; and • Manage the effects of COVID-19 on workplaces and/or businesses in Trinidad and Tobago. 3.2 Relevant National Laws and Regulations and International Treaties This section presents an overview of laws and regulations that have relevance for environmental and social issues for the Trinidad and Tobago Emergency COVID- 19 Project: 3.2.1 Environmental Management Act, No. 3 of 2000 This Act recites that sustainable development should be encouraged through the use of economic and non-economic incentives and that polluters should be held responsible for the costs of their polluting activities. Amongst the objects of the Act, set out in section 4, are the encouragement of the integration of environmental concerns into private and public decisions and the development and effective implementation of written laws, policies and 34 | P a g e growth in accordance with sound environmental practices. This Act formed the Environmental Management Authority (EMA) which is responsible for the administering of same. The EMA also manages all supporting rules and regulations developed. Under this Act, a number of rules were developed. These are summarised in the Table below: Table 2: Summary of Applicable Environmental Rules RULE DESCRIPTION Certificate of The Rules guide the assessment of small and large-scale Environmental developmental projects which may have both positive and Clearance (CEC) negative environmental effects. Rules, 2001 The Certificate of Environmental Clearance (Designated Activities) Order, 2001, as amended defines the forty-four (44) activities which require a CEC. At the preliminary phase of the assessment of the proposed project, if potential significant environmental and human health impacts have been identified, the applicant may be asked to conduct an Environmental Impact Assessment (EIA). Air Pollution Rules, A Source Emitter refers to any facility from which currently an air 2014 (refer to the pollutant or pollutants releases into the atmosphere. It also updated version) includes proposed facilities, which in the near future will release pollutants into the atmosphere. In defining an air pollutant, it can be described as certain substances released into the atmosphere above a specific quantity, concentration or level, or which has an impact on the atmosphere. In Schedules 1 & 2 of the Air Pollution Rules, 2014, the maximum allowed levels of emissions of air pollutants are listed. Dioxins and Furans are included in both Schedules. Waste These rules define hazardous wastes as those wastes that Management display hazardous characteristics and includes radioactive and Rules: Hazardous infectious waste. These characteristics are set out in Part C of 35 | P a g e RULE DESCRIPTION Waste (Draft) 2014 the first Schedule. It provides for generators of hazardous wastes to register with the EMA and discusses their obligations. It discusses hazardous waste storage requirements, packaging, labeling that is required prior to transport. Any persons who store, treats or disposes of hazardous wastes must have a waste-handling permit. These Rules also describes a Hazardous Waste Manifest System which allows the waste to be tracked from the point of origin to the point of disposal. The Rules require the EMA to establish a Waste Management Register. It also describes storage requirements, waste incineration transit and export of wastes. Draft Waste The draft legislation proposes a regulatory regime which will Management consist of registration and permitting processes. Persons who Rules 2018. generate wastes above specific quantities will be required to obtain a registration certificate and waste handlers (persons who receive waste for transport, treatment, recovery, recycling and disposal) will be required to obtain a permit. 3.2.2 Occupational Safety and Health Act, 2004 as amended The Occupational Safety and Health Act, 2004 as amended (OSH Act 2004) is the Country’s legislation governing all aspects of health and safety in the workplace. The scope and applicability of the OSH Act is to ensure that industrial establishments manage in a safety and health “so far as is reasonably practicable�, and workers, as well as persons likely to be affected by work activities, are not exposed to unnecessary risks to their safety and health. Welfare facilities are to be provided and maintained to an acceptable standard in the workplace. This Act forms the basis of the legal compliance requirements of the Country’s legal framework. Sections 6(1) of the OSH Act 2004 as amended states; 36 | P a g e “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the safety, health and welfare at work of all his employees�. This duty of care for employees is also extended towards persons who are likely to be affected by the employer’s activities. The law qualifies the care to be provided by the phrase “so far as is reasonably practicable� (SFARP), which means: “[That…]Reasonably practicable is a narrower term than ‘Physically possible’ and implies that a computation must be made […] in which the quantum of risk is placed in one scale and the sacrifice involved in the measures necessary for averting the risk (whether in time, trouble or money) is placed in the other and that, if it be shown that there is a great disproportion between them – the risk being insignificant in relation to the sacrifice – the person upon whom the obligation is imposed discharges the onus which is upon him.� Asquith L.J. In essence, making sure a risk has been reduced SFARP is about weighing the risk against the sacrifice needed to further reduce it. The decision is weighted in favour of health and safety because the presumption is that the duty-holder should implement the risk reduction measure. To avoid having to make this sacrifice, the duty-holder must be able to show that it would be grossly disproportionate to the benefits of risk reduction that would be achieved. Thus, the process is not one of balancing the costs and benefits of measures but, rather, of adopting measures except where they are ruled out because they involve grossly disproportionate sacrifices. (Edwards v National Coal Board [1949] 1 All ER 743 CA) This important principle is conjoined with Sections 13A (1) of the OSH Act 2004 as amended, which states: Every employer shall make a suitable and sufficient annual assessment of— (a) the risks to the safety and health of his employees to which they are exposed whilst they are at work; and 37 | P a g e (b) the risks to the safety and health of persons not in his employment arising out of or in connection with the environmental impact of his undertaking, for the purpose of identifying what measures are necessary for compliance with this Act or any other statutory provision. This assessment (risk assessment) is qualified by the phrase; “suitable and sufficient� which means, that a risk assessment is 'suitable and sufficient', i.e. it should show that: • a proper check was made • you asked who might be affected • you dealt with all the obvious significant risks, taking into account the number of people who could be involved • the precautions are reasonable, and the remaining risk is low • you involved your workers or their representatives in the process The level of detail in a risk assessment should be proportionate to the risk and appropriate to the nature of the work. Insignificant risks can usually be ignored, as can risks arising from routine activities associated with life in general, unless the work activity compounds or significantly alters those risks. Risk assessments should only include what you could reasonably be expected to know - you are not expected to anticipate unforeseeable risks. It is to be noted, this Section of the OSH Act links directly with the Environmental Management Act 2000. By stating, “…arising out of or in connection with the environmental impact of his undertaking…�, it is clear that risk assessments are essential tools needed to manage not only safety and health risks in the workplace but also risks to the environment. Both sections of the OSH Act, illustrates a participative approach when managing risks to worker’s safety and health, persons affective by work activities and the environment. Therefore, it is essential that the MoH/RHAs make careful examinations of what in their work could cause harm (to people and the environment), and weigh up whether they are doing enough to prevent such harm, avoid it altogether or do more in the interest of those likely to be affected. Workers must be consulted on all risk assessments as well as having a say in the formulation of OSH Policy. OSH Act 2004 as amended Sections 6(7,7A). 3.2.3 Industrial Relations Act (IRA), 1972, Chapter 88:01 38 | P a g e The IRA provides for the following: • free collective bargaining between employer and workers through their representative associations, • the development of a peaceful and expeditious procedure for the settlement of disputes, • the establishment of the Industrial Court, • the recognition and registration of trade unions, • the freedom to be represented by a trade union and the right not to associate, and • industrial action which may be taken by both employer and employee. The industrial relations policy in Trinidad and Tobago is based on collective bargaining between employers and workers, via their recognised majority trade unions, for agreement on terms and conditions of employment. The employment relationship in Trinidad and Tobago is governed by either or a combination of both the principles and practices of good industrial relations, and legislation. Other labour legislation is summarized in Table 3 below: Table 3: Summary of Labour related Acts Act Description Maternity Protection Act, provides maternity leave and related benefits to No. 4 of 1998 female employees. Retrenchment and guarantees the payment of severance pay to Severance Benefits Act retrenched employees No. 32 of 1985 The Equal Opportunity prohibits discrimination of persons on grounds of Act, No. 69 of 2000 sex, race, ethnicity, origin, marital status, religion or disability. Part III of the Act deals specifically with employment discrimination 39 | P a g e Act Description Minimum Wages Concerns minimum wages and terms and (Amendment) Act, No.11 conditions of employment. The Act relies on orders of 2000 issued by the Minister to set actual minimum wages Workmen’s Compensation Provides for the payment of compensation to Act, 1960 workers for injuries suffered in the course of their employment Criminal Injuries Sets up a Criminal Injuries Compensation Unit Compensation Act, 1999 which pays compensation to people injured as a result of criminal activities Trade Disputes and Makes provisions in respect of trade disputes and for Protection of Property Act, the protection of property and public utility services 1943 OCCUPATIONAL See: “3.2.2 Occupational Safety and Health Act, SAFETY AND HEALTH 2004 as amended� ACT CHAPTER 88:01 Act 1 of 2004 Amended by 3 of 2006 The Labour Management Procedure (LMP) for the project is included in Annex VII. 3.2.4 Healthcare Specific Regulatory Framework The Public Health Ordinance, Chapter 12 No.4 This Ordinance outlines the restrictions and penalties in place as it relates to Public Health practices. These are detailed in Section 4. Further a number of Public Health regulations have been developed and circulated as part of the country’s COVID-19 Response Tool Kit. Some of these are summarized in the table below: 40 | P a g e Table 4: Policies, Regulations and Guidelines issued by the Ministry of Health TITLE OF DOCUMENT DESCRIPTION Public Health [2019 Novel The primary measures and restrictions Coronavirus (2019-nCoV)] currently in force in TTO as of March 17th Regulations, 2021. 2021, are consolidated here, and are being updated as the pandemic situation evolves. Guidelines for Health Care Personnel These guidelines outline the risk exposure (HCP) Exposure to COVID-19 Patients categories for health care workers and identifies in Trinidad and Tobago (2020) measures to prevent the spread of infection. The guidelines also incorporate considerations for resource limited countries especially staff resource limitations. COVID-19 Discharge Criteria for These establish the criteria for discharge form Persons in Home Isolation and Home these two areas, which are different. It further Quarantine (2020) defines cases that are symptomatic vs asymptomatic Guidelines for the Repatriation of These provide protocols on the quarantine and Nationals during the Community Spread care of returning nationals via ports of entry from Phase of COVID-19 in Trinidad and the various countries (based on risk) to minimise the risk and interrupt the transmission of COVID- Tobago from 1. Low Risk Countries and 19 2. High Risk Countries Bio-medical Waste (Infectious Waste) Bio-medical waste management is governed by a National Code of Practice for Bio- Medical Waste Management (drafted in 2008 and revised in 2012). This Code of Practice outlines the minimum requirements deemed necessary for the safe collection, storage, transportation, treatment and disposal of bio-medical wastes. In 2011, the Ministry of Health published a Manual of Infection Prevention and Control Policies and Guidelines for Health Care Services. This Manual outlines the polices and guidelines which must be implemented by all health care personnel in primary, secondary and tertiary health care environments in both public and private health care facilities. Key 41 | P a g e areas of infection prevention and control such as epidemiology, isolation, standard precautions, disinfection and sterilization, waste management and risk management are addressed. It also includes components of Surveillance Methodology for Health Care Associated Infections (HCAI’s) including Microbiological support and Guidelines for Invasive Procedures in the prevention of HCAI’s. Since the outbreak of COVID-19 in March 2020, the various RHAs and major hospitals have developed COVID-19 risk mitigation plans. These are: • North West Regional Health Authority (NWRHA): COVID-19 Policy and Guidelines: • Management of Healthcare Workers Exposed to Coronavirus Disease 2019 (COVID- 19), (2020) • North West Regional Health Authority (NWRHA): COVID-19 Staff Guidelines; (2020) • Guidelines for COVID-19 management at Port of Spain General Hospital, (2020) • South West Regional Health Authority (SWRHA): Occupational Risk Assessment of Health Care Workers Exposed to Confirmed or Suspected COVID-19 Cases; (2020) 3.2.5 Pandemic COVID-19 Plan The MoH prepared a Pandemic COVID-19 Plan in February 2020 (updated June, 2020). The Plan targets a wide range of people who will be involved in planning and responding to a COVID-19 pandemic; emergency responders, health planners, health care workers, public health laboratories, as well as those involved in the manufacture, registration and supply and distribution of pharmaceuticals. However, the primary audience for this plan is both the regional and local health authorities, as the provision of health care and essential services is within the jurisdiction of these bodies. The objectives of the Plan are: • To develop a National Plan that comprehensively addresses the issues with respect to a COVID-19 pandemic and is acceptable and applicable to all stakeholders. • To indicate the inter-sectoral relationships and to identify their respective roles and responsibilities. 42 | P a g e • To provide clear and comprehensive guidelines to ensure optimal operational viability; and a Plan that is flexible enough to incorporate new developments, as well as to ensure consistencies with best practices. • To provide planning considerations for the appropriate prevention, care and treatment before and during a pandemic. • To provide suggestions for planning considerations for appropriate communications, resource management and preventive measures to minimize societal disruption. The Ministry of Health has developed a COVID-19 Communications Plan that outlines the strategies to be implemented to manage the communications needs during the response. The plan identifies its stakeholders and the mechanisms of engagement for each. 3.3 World Bank Environmental and Social Standards 3.3.1 The World Bank Environmental and Social Framework (ESF) As discussed above, the project is required to comply with the ESF. The ESF sets out the World Bank’s commitment to sustainable development, through a Bank Policy and a set of Environmental and Social Standards (ESS) that are designed to support Borrowers’ projects, with the aim of ending extreme poverty and promoting shared prosperity. The ESSs9set out the requirements relating to the identification and assessment of environmental and social risks and impacts associated with projects supported by the Bank through Investment Project Financing. The World Bank believes that the application of these standards, by focusing on the identification and management of environmental and social risks, will support Borrowers in their goal to reduce poverty and increase prosperity in a sustainable manner for the benefit of the environment and citizenry by: a. Supporting Borrowers/Clients/Implementing Agencies in achieving good international best practice regarding environmental and social sustainability; b. Assisting Borrowers/Clients/Implementing Agencies in fulfilling national and international environmental and social obligations; 7 www.worldbank.org/en/projects-operations/environmental-and-social-framework/brief/environmental-and-social- standards and http://projects- beta.vsemirnyjbank.org/ru/projects-operations/environmental-and-social- framework/brief/environmental-and-socialstandards 43 | P a g e c. Enhancing nondiscrimination, transparency, participation, accountability and governance; and d. Enhancing the sustainable development outcomes of projects through ongoing stakeholder engagement. Of the ten ESSs10 five are relevant to the Trinidad and Tobago COVID-19 Emergency Project. They establish standards that the Implementing Agency and the Project will meet through the project life cycle, as follows (see Table 5 below): Table 5: Summary of Applicable Standards ENVIRONMENTAL DESCRIPTION STANDARD ESS 1 - Assessment ESS 1 sets out the Client’s responsibilities for assessing, and Management of managing and monitoring environmental and social risks Environmental and and impacts associated with each stage of a project Social Risks and supported by the Bank through Investment Project Impacts Financing, in order to achieve environmental and social outcomes consistent with the ESSs. ESS 2 – Labour and ESS 2 recognizes the importance of employment Working Conditions creation and income generation in the pursuit of poverty reduction and inclusive economic growth. Borrowers can promote sound worker-management relationships and enhance the development benefits of a project by treating workers in the project fairly and providing safe and healthy working conditions. ESS2 applies to project workers including full-time, part-time, temporary, seasonal and migrant workers. ESS 3 – Resource ESS 3 recognizes that economic activity and and Efficiency, urbanization often generate pollution to air, water, and Pollution Prevention land, and consume finite resources that may threaten and Management people, ecosystem services and the environment at the 8 https://www.worldbank.org/en/projects-operations/environmental-and-social-framework 44 | P a g e ENVIRONMENTAL DESCRIPTION STANDARD local, regional, and global levels. ESS 4 – Community ESS 4 recognizes that project activities, equipment, and Health and Safety. infrastructure can increase community exposure to risks and impacts. In addition, communities that are already subjected to impacts from climate change may also experience an acceleration or intensification of impacts due to project activities. ESS 10 – ESS 10 recognizes the importance of open and Stakeholder transparent engagement between the Borrower and Engagement and project stakeholders as an essential element of Information good international practice. Effective stakeholder Disclosure engagement can improve the environmental and social sustainability of projects, enhance project acceptance, and make a significant contribution to successful project design and implementation. 3.3.2 The World Bank Group Environmental Health and Safety (EHS) Guidelines11 The EHS Guidelines are technical reference documents with general and industry-specific examples of Good International Industry Practice (GIIP) and are referred to in the ESF. The EHS Guidelines contain the performance levels and measures that are normally acceptable to the World Bank Group, and that are generally considered to be achievable in new facilities at reasonable costs by existing technology. The World Bank Group requires borrowers to apply the relevant levels or measures of the EHS Guidelines. When host country regulations differ from the levels and measures presented in the EHS Guidelines, projects will be required to achieve whichever is more stringent. In the case of the Trinidad and Tobago Emergency COVID-19 Project, the General EHS Guidelines apply. The implementing agency will pay particular attention to the following 11 http://documents.worldbank.org/curated/en/157871484635724258/Environmental-health-and-safety-general-guidelines 45 | P a g e General EHS Guidelines: a. EHS Section1.5 – Hazardous Materials Management; b. EHS Section 2.5 – Biological Hazards; c. EHS Section 2.7 – Personal Protective Equipment (PPE); d. EHS Section 2.8 – Special Hazard Environments; e. EHS Section 3.5 – Transportation of Hazardous Materials; and f. EHS Section 3.6 – Disease Prevention. Additionally, the EHS for Health Care Facilities (HCF)12 also apply to the project. The EHS Guidelines for Health Care Facilities include information relevant to the management of EHS issues associated with HCFs which includes a diverse range of facilities and activities involving general hospitals and small inpatient primary care hospitals, as well as outpatient, assisted living, and hospice facilities. Ancillary facilities may include medical laboratories and research facilities, mortuary centers, and blood banks and collection. 3.3.3 World Bank Technical Note on Public Consultations and Stakeholder Engagement Due to possible issues of COVID-19 transmission arising from face-to-face consultations associated with the pandemic, the Bank has prepared a “Technical Note on Public Consultations and Stakeholder Engagement in World Bank supported operations when there are constraints on conducting public meetings, March 20, 2020�. This technical note will be taken into consideration when implementing the SEP. 3.4 World Health Organization (WHO) Guidance The WHO has a website specific to the COVID-19 pandemic13 with up-to-date country and technical guidance. As the situation remains fluid it is critical that those managing both the 12 https://www.ifc.org/wps/wcm/connect/960ef524-1fa5-4696-8db3-82c60edf5367/Final%2B- %2BHealth%2BCare%2BFacilities.pdf?MOD=AJPERES&CVID=jqeCW2Q&id=1323161961169 13 https://www.who.int/emergencies/diseases/novel-coronavirus-2019 46 | P a g e national response as well as specific health care facilities and programs keep abreast of guidance provided by the WHO and other international best practice. Current technical guidance provided by the WHO is updated regularly. These are summarized in the table below, and Annex V has a more detailed Resource List for COVID-19 Guidance. Table 6: WHO Guidelines related to COVID-19 WHO Guideline Content COVID-19 guidance Guidance on the cleaning and disinfection of rooms environmental on cleaning and wards or areas in healthcare facilities occupied for healthcare facilities 17 with suspected and confirmed COVID-19 patients. April 2020 COVID19-stigma-guide Methods to address risk of social stigma and discriminatory behaviours against people of certain ethnic backgrounds as well as anyone perceived to have been in contact with the virus. Critical preparedness Update to the interim guidance document. This readiness and response version provides updated links to WHO guidance actions COVID-10 2020-03- materials and provides the full list of WHO technical 22_FINAL-eng guidance available for COVID-19 and provides updated recommendations in the table. WHO-2019-nCoV- Countries will need to make difficult decisions to essential_health_services- balance the demands of responding directly to 2020.1-eng COVID-19, while simultaneously engaging in strategic planning and coordinated action to maintain essential health service delivery, mitigating the risk of system collapse. Establishing effective patient flow (including screening, triage, and targeted referral of COVID-19 and non-COVID-19 cases) is essential at all levels. WHO-2019-nCov- Hand hygiene is the most effective single measure Hand_Hygiene_Stations- to reduce the spread of infections through 2020.1-eng multimodal strategies. 47 | P a g e WHO Guideline Content WHO-2019-nCoV- To guide the care of COVID-19 patients as the HCF_operations-2020.1 – response capacity of health systems is challenged; eng to ensure that COVID-19 patients can access life- saving treatment, without compromising public health objectives and safety of health workers. WHO-2019-nCov- This data collection form and risk assessment tool HCW_risk_assessment- can be used to identify infection prevention and 2020.2-eng control breaches and define policies that will mitigate health care worker’s exposure and nosocomial infection (infection originating in a hospital). WHO-2019-nCov- This document highlights the rights and HCWadvice-2020.2-eng responsibilities of health workers, including the specific measures needed to protect occupational safety and health. WHO-2019-nCov- It is possible that people infected with COVID-19 IPC_Masks-2020.3-eng could transmit the virus before symptoms develop. It is important to recognize that pre-symptomatic transmission still requires the virus to be spread via infectious droplets or through touching contaminated surfaces. WHO-2019-nCoV- Frequent and proper hand hygiene is one of the IPC_WASH-2020.2- most important measures that can be used to eng prevent infection with the COVID- 19 virus. WASH practitioners should work to enable more frequent and regular hand hygiene by improving facilities and using proven behaviour-change techniques. WHO-2019-nCoV-IPC- Guidance on infection prevention and control (IPC) 2020.3-eng strategies for use when COVID-19 is suspected. WHO-2019-nCoV- Summarizes WHO’s recommendations for the rational use of personal protective equipment (PPE) 48 | P a g e WHO Guideline Content IPCPPE_use-2020.2-eng in health care and community settings, as well as during the handling of cargo. WHO-2019-nCoV- Several countries have demonstrated that COVID- Leveraging_GISRS- 19 transmission from one person to another can be 2020.1–eng slowed or stopped. The key actions to stop transmission include active case finding, care and isolation, contact tracing, and quarantine. WHO-COVID-19- Laboratory testing guidance for COVID-19 in lab_testing-2020.1-eng suspected human cases. WHO-COVID-19- Interim guidance for all those, including managers IPC_DBMgmt-2020.1-eng of health care facilities and mortuaries, religious and public health authorities, and families, who tend to the bodies of persons who have died of suspected or confirmed COVID-19. WHO-WPE-GIH-2020.2- The purpose of this document is to provide interim eng guidance on laboratory biosafety related to the testing of clinical specimens of patients that meet the case definition of the novel pathogen identified in Wuhan, China, that is, coronavirus disease 2019 COVID-19. WHO 2019 Overview of The purpose of this document is to provide 1) criteria the Technologies for the for selecting technologies to facilitate decision Treatment of Infectious making for improved health care waste and Sharp Waste from management in health care facilities and 2) an Health Care Facilities? overview of specific health care waste technologies for the treatment of solid infectious and sharp waste for health care facility administrators and planners, WASH and infection prevention control staff, national planners, donors and partners. 49 | P a g e WHO Guideline Content Monitoring Vaccine The purpose of the document is to review the factors wastage at Country Level: affecting vaccine wastage and to discuss the tools Guidelines for Programme available for reducing wastage and their relationships Managers to each other, with the aim of providing assistance to programme managers to establish a system for monitoring vaccine wastage as a programme quality indicator. Management of Wastes The purpose of the document is to provide guidelines from Immunization for planners, managers of health-care facilities or Campaign Activities: mobile vaccine team leaders to improve planning and Practical Guidelines for coordination at central level as well as waste Planners and Managers management practices at the local level where immunization activities are conducted. Prior to the adoption of this ESMF, MoH adopted an ‘Interim Environmental and Social Guidance, June 2020’ document which provided references for the international standards that need to be followed in project implementation to deal with COVID-19 risks and challenges. The interim guidance included basic protocols on Infection and Prevention Control Protocol (IPCP) and Health Care Waste Management Guidelines. These guidelines are now replaced by the more detailed procedures contained in this ESMF. Additionally, the MoH has published Guidelines and Regulations for specific economic sectors such as Funeral Agencies, Restaurants and Fitness Centres14. 3.5 International Treaties and Protocols In addition to national legislation and regulations on environmental and social issues, Trinidad and Tobago is also party to several international treaties focused on environmental, labour and social issues. These are listed below: • Paris Agreement 14 50 | P a g e • Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal (2016) • The Rotterdam Convention on Prior Informed Consent (PIC) Procedure for Certain Hazardous Chemicals and Pesticides in International Trade (1998) • The Stockholm Convention on Persistent Organic Pollutants (2002) • The Vienna Convention for the protection of the Ozone Layer and its Montreal Protocol on substances that deplete the Ozone Layer (1998) • Protocol Concerning Pollution from Land-Based Sources and Activities (LBS Protocol) • The United Nations Convention to Combat Desertification (1997) • The Ramsar Convention (2000) • The United Nations Framework Convention on Climate Change (1998) and its Kyoto Protocol • Convention on Biological Diversity (1997) and to its Cartagena Protocol on Biosafety (2004) 51 | P a g e 3.6 Roles and Responsibilities of Governmental and Regional Entities The Following table summarises the roles of the various entities Table 7: Summary of Roles and Responsibilities of Institutions INSTITUTIONS ROLES AND RESPONSIBILITIES Ministry of The Ministry of Health is the national authority charged with Health (MOH) oversight of the entire health system in Trinidad and Tobago. The Ministry develops and implements governments policy. The Ministry plays a central role in the protection of the population’s health and in ensuring that all organizations and institutions that produce health goods and services conform to applicable standards. Regional Health The RHAs work at the regional level, managing hospitals and Authorities health service providers by region. There are four RHAs in Trinidad (RHAs) and one in Tobago. Together, they oversee 13 hospitals, 90 health centres and 7 DHFs health centres. Ministry of The Ministry of Planning and Development has been designated Planning and as the: Development • National Focal Point and the Official Contact Point under (MPD) the Stockholm Convention. • Focal Point under the Basel Convention. • Designated National Authority under the Rotterdam Convention. Technical support for the Focal Point is provided by the Multilateral Environmental Agreements Unit (MEAU) of the Environmental Policy and Planning Division (EPPD). The MEAU also undertakes the dissemination of information concerning the Conventions, including seminars and workshops. EMA Responsible for developing and establishing national 52 | P a g e INSTITUTIONS ROLES AND RESPONSIBILITIES environmental standards and criteria, and monitoring compliance with those standards and criteria. Ministry of Focuses on the provision of decent work, the facilitation of Labour and industrial peace and, the provision of employment opportunities Small Enterprise through on-the-job training and job placements Development (MOLSED) Occupational Ensures compliance with the OSH Act. The enforcement policy Safety and places specific duties on, employers of industrial establishment, Health (OSH) workers and occupiers (Duty holders). Public awareness raising, Authority/Agency the involvement and sensitisation of tripartite partners and other stakeholders are considered critical in promoting a preventative safety and health culture in Trinidad and Tobago. Trinidad and Responsible for the design and implementation of solid and Tobago Solid hazardous waste management systems and structures, and Waste landfill management of three landfills - Beetham, Forres Park and Management Guanapo. SWMCOL also collects, handles, treats and disposes Authority of solid waste in Trinidad and Tobago. (SWMCOL) Municipal Entitled to inspect and approve all design drawings for buildings, Corporations water reticulation systems, wastewater treatment systems and on- site solid waste disposal facilities, and are also involved in municipal waste collection and disposal. DOE, DIQE, Represented on the Multilateral Environmental Agreements Tobago House of Committee of the Ministry of Planning and Development and also Assembly undertakes specific roles and functions of the EMA under a Memorandum of Understanding. The DOE also involves a large number of agencies of the Tobago House of Assembly (THA) and other stakeholders in the Certificate of Environmental Clearance (CEC)/Environmental Impact Assessment (EIA) 53 | P a g e INSTITUTIONS ROLES AND RESPONSIBILITIES Process. Caribbean Public The Caribbean Public Health Agency (CARPHA) is the regional Health Agency public health agency for the Caribbean and may address the (CARPHA) following sorts of issues: 1. Emergency responses to disasters (hurricanes, earthquakes, flooding). 2. The surveillance and management of non-communicable diseases that have reached epidemic proportions 3. The surveillance and management of communicable diseases. 4. The surveillance and prevention of injuries, violence and job related illnesses. 5. Contribution to global health agreements and compliance with international health regulations Pan American Provides technical cooperation in a range of specialized health Health fields. The Organization’s essential mission is to strengthen Organisation national and local health systems and improving the health of the (PAHO) peoples of the Americas, in collaboration with Ministries of Health, other Government agencies and international agencies, non-governmental organizations, and civil society. 54 | P a g e 3.7 Gap Analysis This section presents a gap analysis between the ESF requirements and the national requirements (see table below). The main environmental gap is the lack of national waste management regulations specific to COVID-19 vaccination derived wastes. There are other relevant waste management regulations, for example the Public Health Ordinance, the Litter Act Chap 30:52, and the Yellow Fever Regulations; and, there are guidelines which are also relevant such as the Code of Practice for Biomedical Waste Management as well as MoH-promulgated Quality Manuals that provide guidelines for the health sector. Also relevant though not yet finalized are the EMA established ‘Draft Waste Rules 2018’ and the ‘Waste Management (Registration and Permitting) Rules 2018’. There is also a National Waste Recycling Policy and relevant other instruments. This will be addressed by ensuring that the Code of Practice for Bio-Medical Waste Management is followed for those wastes derived from project activities, specifically vaccination related waste. There are mechanisms in place for periodic audits of the waste management system by the MoH Engineering Department and OSH Department personnel who perform and oversee waste management functions for the RHAs. The Environmental and Social Specialist for the project will review the periodic audits and thereby verify that any project-derived wastes are being adequately managed. Further, an Environmental and Social Audit that includes biomedical waste management was prepared in May 2022 and updated in September 2022. (See Environmental and Social Commitment Plan (ESCP)) 15 The main social risks are the exclusion of vulnerable groups in the vaccination plan and the risk of COVID-19 spread in the community. Information about vulnerable groups is contained in the SEP as well as additional measures to reduce these risks. (http://documents.worldbank.org/curated/en/735421635435848392/Revised- Stakeholder-Engagement-Plan-SEP-Republic-of-Trinidad-and-Tobago-COVID-19- EMERGENCY-RESPONSE-PROJECT-P173989) 15 Environmental and Social Commitment Plan (ESCP) 55 | P a g e Table 8: Gap Analysis between ESF Requirements and National Legislation Environmental Objective Country Laws and Regulatory System Gap Analysis and Project and Social Actions Standard ESS1: Assessment • To identify, evaluate and manage • The Environmental Management (2000) • This ESMF has been the environment and social risks and created the Environmental Management developed to guide the management and Management impacts of the project in a manner Authority (EA) and describes the Environmental or E&S risks as project activities of Environmental consistent with the ESSs. Impact Assessment (EIA) process that become defined. • To adopt a mitigation hierarchy categorizes impacts and requires them to be and Social Risks • The MOH has undertake a approach to: (a) Anticipate and avoid avoided, minimized, and mitigated. and Impacts risks and impacts; (b) Where rapid assessment/audit of compliance avoidance is not possible, minimize • Subsidiary environmental regulations of the activities that have been or reduce risks and impacts to address air quality, water quality, and noise, undertaken with the ESMF and other acceptable levels; (c) Once risks and among other aspects. requirements. This is in addition to impacts have been minimized or audits of biomedical waste reduced, mitigate; and (d) Where management to ensure compliance significant residual impacts remain, with the Code of Practice for compensate for or offset them, where Biomedical Waste Management. technically and financially feasible. • To adopt differentiated measures so that adverse impacts do not fall disproportionately on the disadvantaged or vulnerable, and they are not disadvantaged in sharing development benefits and opportunities resulting from the project. • To utilize national environmental and social institutions, systems, laws, regulations and procedures in the assessment, development, and implementation of projects, whenever appropriate. • To promote improved 56 | P a g e environmental and social performance, in ways which recognize and enhance Borrower capacity. ESS2: Labour and • To promote safety and health at • The Occupational Safety and Health Act, • Labour law will be applied work. 2004 as amended is a comprehensive law throughout the project. Working Conditions • To promote the fair treatment, non- governing all aspects of health and safety in the discrimination, and equal opportunity workplace. The scope and applicability of the • In addition, Labour of project workers. OSH Act require that industrial establishments Management Procedures (LMP) • To protect project workers, manage safety, health and welfare in the following the ESF requirements were including vulnerable workers such as workplace, using the legal compliance developed for this project. women, persons with disabilities, requirements as a minimum standard. children (of working age, in • The LMP mentions that for accordance with this ESS) and • The Industrial Relations Act provides for this project, the minimum age will be migrant workers, contracted workers, the free collective bargaining between employer 18 years. This rule will apply for both and workers through their representative national and international workers. community workers and primary associations. Workers will be required to provide supply workers, as appropriate. proof of their identify and age before • To prevent the use of all forms of forced labour and child labour. • Maternity Leave in Trinidad and Tobago commencing any works on site. • To support the principles of is governed by the Maternity Protection Act, No. • The LMP code of conduct freedom of association and collective 4 of 1998 which binds both private employers includes provisions to prevent sexual and the State. The purpose of the Act is to harassment and sexual exploitation bargaining of project workers in a establish a minimum level of rights and benefits and abuse. manner consistent with national law. • To provide project workers with for women workers. • The project ESMF includes accessible means to raise workplace • Retrenchment and Severance Benefits an Infection Control and Waste concerns. Act No. 32 of 1985 guarantees the payment of Management Plan (ICWMP) severance pay to retrenched employees developed to address COVID-19 • The Equal Opportunity Act, No. 69 of mitigation strategies. 2000 prohibits discrimination of persons on • The principles and practices grounds of sex, race, ethnicity, origin, marital of good industrial relations as it status, religion or disability. Part III of the Act relates to grievance handling in the deals specifically with employment workplace in the Republic of Trinidad discrimination and Tobago has established that all • Minimum Wages (Amendment) Act, “workers� (including Contractor’s No.11 of 2000 concerns minimum wages and workers) as defined in the IRA have a terms and conditions of employment. The Act right to be heard. relies on orders issued by the Minister to set • All aspect of the provisions of actual minimum wages the OSH Act 2004 will be complied • Workmen’s Compensation Act, 1960 with during this project, including 57 | P a g e provides for the payment of compensation to relevant Guidance provided by the workers for injuries suffered in the course of Health and Safety Executive (UK) their employment which afford needed context to the OSH Act 2004 as amended. ESS3: Resource • To promote the sustainable use of • Environmental regulations address air • Code of Practice for resources, including energy, water, quality and water quality to limit emissions and Biomedical Waste Management and Efficiency and and raw materials. pollution. other guidelines are largely adequate Pollution • To avoid or minimize adverse for project activities. impacts on human health and the • PAHO has issued a code of practice for Prevention and biomedical waste management (2012) and this • The PIU will strengthen the environment by avoiding or Management minimizing pollution from project has been adopted by all the RHAs. monitoring mechanism for waste activities. manifesting by examining periodic • To avoid or minimize project-related • Licensing of health care facilities is audits and through the E&S Audit emissions of short and long-lived required under the Private Hospitals Act (1960) conducted for retroactive financing. climate pollutants. (amended 1980) and subsidiary regulations • To avoid or minimize generation of (2008). • The procurement process will require energy conservation hazardous and non-hazardous • The Certificate of Environmental measures as part of an overall waste. Clearance (CEC) Rules, 2001 apply for the • To minimize and manage the risks recognition of climate change issues. establishment, decommissioning or and impacts associated with pesticide abandonment (inclusive of associated works) of use a hospital, a health centre and a nursing home with a capacity for 500 or more persons including staff • The CEC Rules also apply to the establishment, modification, expansion, decommissioning or abandonment (inclusive of associated works) of chemical or medical or other scientific research laboratories. • Laboratories are regulated by ISO certification standards. • The Pesticides and Toxic Chemicals Act (1979) regulates pesticides and provides a registry for toxic chemical import, should it be 58 | P a g e required. • The draft Waste Rules 2018 and the Waste Management (Registration and Permitting) Rules 2018 would establish a licensing and permit system for waste management facilities. ESS4: Community • To anticipate and avoid adverse • Public Health Ordinance, Chapter 12 No. • The project ESMF includes impacts on the health and safety of 4 grants powers to local authorities for waste an Infection Control and Waste Health and Safety project-affected communities during removal, street sweeping, creation of disposal Management Plan (ICWMP) the project life cycle from both routine sites, etc. developed to address COVID-19 and non-routine circumstances. mitigation strategies. • To promote quality and safety, and • The Regional Health Authorities Act No. considerations relating to climate 5 of 1994 authorizes RHAs in specific • A Community Health and change, in the design and geographical areas to conduct health services. Safety Plan (CHSP) was developed construction of infrastructure, and included in the ESMF to address including dams. • Biomedical waste management code of any gaps in the national regulatory • To avoid or minimize community practice (2012) was developed by PAHO system. exposure to project-related traffic and • The regulation of drugs (antibiotics and road safety risks, diseases, and • The CHSP includes narcotics) is carried out by the Drug Inspectorate Emergency Response Procedures. hazardous materials. of the Ministry of Health. The functions of the • To have in place effective Drug Inspectorate are authorized by legislation, measures to address emergency including the Antibiotics Act and Regulations, events. Chapter 30:02; the Food and Drugs Act and • To ensure that the safeguarding of Regulations, Chapter 30:01; Pharmacy Board personnel and property is carried out Act and Regulations, Chapter 29:52; and other in a manner that avoids or minimizes legislation. risks to the project-affected communities. • Air and road transport services are registered and licensed for safety. This includes The Motor Vehicles and Road Traffic Act (Ch. 48:50) • Military personnel are bound by international standards of conduct in the execution of their duties. ESS5: Land The standard is not relevant to the project; therefore, no gaps are addressed by project instruments Acquisition, 59 | P a g e Restrictions on Land Use and Involuntary Resettlement ESS6: Biodiversity The standard is not relevant to the project; therefore, no gaps are addressed by project instruments. Conservation and Sustainable Management of Living Natural Resources ESS7: Indigenous The standard is not relevant to the project; therefore, no gaps are addressed by project instruments. Peoples/Sub- Saharan African Historically Underserved Traditional Local Communities ESS8: Cultural The standard is not relevant to the project; therefore, no gaps are addressed by project instruments. Heritage ESS9: Financial The standard is not relevant to the project; therefore, no gaps are addressed by project instruments. Intermediaries ESS10: • To establish a systematic See the Stakeholder Engagement Plan (SEP) • All project ESF instruments approach to stakeholder engagement for a discussion of relevant laws, norms, have been disclosed publicly, Stakeholder that will help Borrowers identify standards, and regulations. including the draft ESMF http://documents.worldbank.org/curated/en/735421635435848392/Revised- Engagement and stakeholders and build and maintain Stakeholder-Engagement-Plan-SEP-Republic-of-Trinidad-and-Tobago-COVID- a constructive relationship with them, • The project finalized and 60 | P a g e 19-EMERGENCY-RESPONSE-PROJECT-P173989 Information project-affected parties. disclosed a Stakeholder Engagement • To assess the level of Plan (SEP) to continue Disclosure stakeholder interest and support for communication and outreach during the project and to enable implementation. stakeholders’ views to be considered in project design and environmental • The SEP includes a project and social performance. GM • To promote and provide means for effective and inclusive engagement with project-affected parties throughout the project life cycle on issues that could potentially affect them. • To ensure that appropriate project information on environmental and social risks and impacts is disclosed to stakeholders in a timely, understandable, accessible, and appropriate manner and format 61 | P a g e 4 Environmental and Social Baseline 4.1 Socio-Economic Baseline Trinidad and Tobago (TTO) is a high-income economy with a population of 1.4 million. TTO’s gross national income (GNI) per capita rose from less than US$4,000 in the early 1990s to about US$16,550 in 2018.16 As a small island state economy, TTO is vulnerable to exogenous shocks and disproportionally affected by the COVID-19 pandemic. The economic growth of the twin-island Republic has been mostly tied to exogenous factors, especially global oil and gas prices since the oil and gas production alone accounts for almost 40 percent of the Gross Domestic Product (GDP)17. While Trinidad’s economy is mainly based on the energy sector, the much smaller island Tobago (with a population of just about 60,000 according to the last census in 2011)18strongly relies on tourism, fishing and the government sector. After expanding at an annual average rate of 7.8 percent between 1995 and 2007, the country’s economy has been on the decline due to developments in the global energy sector. Notably, real GDP contracted on average by 2.2 percent between 2016 and 201919. The Central Statistical Office (CSO) estimates that the annual GDP in Trinidad and Tobago contracted by 1.2 percent in 2019. A 4.5 percent contraction in real GDP in the Energy sector, primarily on account of developments within the crude oil and refining sub-sectors, outweighed the 1.7 percent growth recorded in the Non-Energy sector. The Energy sector’s contribution to GDP also fell marginally to 34.0 percent in 2019 from 35.1 in 201820. With a Human Capital Index (HCI) Score of 0.61, TTO ranks in the second quartile of countries regarding its ability to mobilize the human capital potential of the country’s citizens, but has worse health outcomes than comparably ranked countries. In comparison to countries with a similar HCI Score, TTO performs well with respect to the number of learning-adjusted years of school that children complete (9.1 years) and harmonized test scores that students achieve (a score of 458)21. Household survey data from 2012 shows 16 https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=TT 17 http://www.energy.gov.tt/our-business/oil-and-gas-industry/ 18 https://www.undp.org/content/dam/trinidad_tobago/docs/DemocraticGovernance/Publications/TandT_Demographic_Report _2011.pdf 19 IMF World Economic Outlook, April 2020. 20 GORTT, Review of the Economy, 2020 21 Countries with a HCI Score of 0.60-0.62: Albania, Bosnia and Herzegovina, Costa Rica, Malaysia, Montenegro, Oman, Argentina, Georgia, Mexico, Qatar, Trinidad and Tobago, Azerbaijan, Ecuador, Romania, Thailand, Uruguay 62 | P a g e that the head-count ratio of poverty stood at 3.5 percent and extreme poverty at 1.3 percent22. 4.1.1 Health and Health Care Service The Ministry of Health (MoH) is responsible for financing, regulation, and governance; monitoring of population health; setting policies; and enacting legislation. However, the delivery of services in the public sector has been decentralized to five Regional Health Authorities (four in Trinidad and one in Tobago). About 70% of the population primarily use public health services, while the other 30% primarily frequent private providers23. Access to public healthcare services in TTO is free of charge, but out-of-pocket expenditures for healthcare make up about 40% of total health expenditure (for the use of private healthcare services and medicines), indicating limitations in the benefit package. Public health care services are delivered through a network of health centres. Accounting for the recent completion of three major hospital projects, there is a ratio of 3.1 beds per 1,000 population, significantly higher than the 2.2 beds per 1,000 population in LAC. However, human resource density is at 1.8 physicians and 3.5 nurses and midwives per 1,000 people, versus the LAC average of 2.1 physicians and 4.7 nurses and midwives per 1,000 people. While TTO has an adequate normative framework for health emergencies with the highest possible International Health Regulation (IHR) compliance and a Global Health Security (GHS) Index Score of 100 there are significant gaps in terms of medical countermeasures and personnel deployment (0 score since basic measures are not in place/information is not available), access to healthcare (score of 27), and the general capacity to prevent (score of 28), detect (score of 14) and respond (score of 43) to health emergencies.24 There is a significant vulnerability of the system in regard to management of zoonotic diseases (score of 8.6, ranked 138 of 195 countries) and laboratory systems (score of 16.7, ranked 161 of 195 countries), two areas that the Project will support. 22 Central Statistics Office of Trinidad and Tobago. 23 The World Bank, 2018 Public Expenditure Review 24 Global Health Security Index. Retrieved on May 14, 2020. The Global Health Security Index is expressed a percentage, where 100% is the highest score possible for a given category and 0% is the lowest. 63 | P a g e Healthcare is addressed in the NDS 2030. Theme 1, Goal 4 states that “the Healthcare System of Trinidad and Tobago will be sustainable and modern and deliver higher standards of healthcare�. There are three main areas of focus for the health system in the short term. These are: the sustainable funding of the system; maintenance of health infrastructure; and ensuring that policies and standards are adhered to towards better service delivery. With respect to health infrastructure, the E&S Audit/Rapid Assessment reviewed fire and life systems at the existing factilities and confirmed that Emergency Response Plans and life and fire systems in hospitals were either in place or in the process of being developed. 4.1.2 Gender Equality The National Policy on Gender and Development (Draft) is a framework which encourages the consideration of the different needs, constraints, opportunities, and priorities of men and women thereby allowing them to participate fully in the development process. It provides the outline for the collaborative approach among State, Civil Society and Private Sector to address cross-cutting issues of gender equity and equality. 4.1.3 Gender Based Violence A 2018 study stated that one-third of women in Trinidad and Tobago experience intimate- partner violence (IPV) in their lifetime25. The study highlights that the IPV that Trinidadian and Tobagonian women face varies in severity and includes moderate and severe acts, emotional abuse, controlling behaviours, threats, stalking and sexual and physical violence. TTO is party to several international conventions that address gender based violence (GBV). These are: • The UN General Assembly’s Declaration on the Elimination of Violence against Women, adopted in 1993, 25 Global Health Security Index. Retrieved on May 14, 2020. 64 | P a g e • The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) • The Beijing Platform for Action (BPfA), • The Inter-American Convention on the Prevention, Punishment and Eradication of Violence against Women • The 1994 Cairo Programme of Action, its subsequent Montevideo Consensus on Population and Development, • The Convention on the Rights of the Child 4.1.4 Disadvantaged and Vulnerable Groups Vulnerability- is the threat of deprivation in multiple dimensions that reduce core human capabilities below the threshold. Vulnerability is a human condition or process resulting from physical, social, economic and environmental factors, which determine the likelihood and scale of damage from the impact of a given hazard. The Ministry of Social Development and Family Services (MSDFS) of the GORTT defines vulnerable groups as those persons who face special difficulties in supporting themselves because of some particular aspect of related to their live. The MSDFS assists those who are socially challenged with issues such as poverty, social inequality and social exclusion. Particular emphasis is placed on vulnerable and marginalized groups in society such as women, children, persons with disabilities, the elderly, the poor/indigent, the socially displaced, ex-prisoners, deportees and persons living with HIV/AIDS26. Vulnerable groups in Trinidad and Tobago include over 25,000 beneficiaries of the National Food Support Program (60% of whom are women); 20,500 households with school-age children who received the School Nutrition Program prior to the closure of schools due to the COVID-19 emergency; 2,000 low-income persons aged 65 and over; 500 adults 18-65 years of age who are permanently disabled from earning a livelihood and 39,233 households with persons who have suffered involuntary termination, suspension or loss of 26 MSDFS, Strategic Plan 2018 - 2023 65 | P a g e income in the informal sector27. There are other groups in the country who may face barriers accessing health care and vaccinations due to health or other vulenrabilities. The approach to consult with them so that the project can respond to their unique needs has begun and is described in the project’s SEP. 4.2 Environmental Baseline Trinidad and Tobago is an archipelagic State which consists of the two main islands, Trinidad and Tobago, and 21 smaller islands and islets. Trinidad is the larger of the two islands, with an area of approximately 4,827 km2 while Tobago has an area of 303 km2. Trinidad and Tobago boasts a rich biota relative to its size. The country’s rich biodiversity is attributable to its geological history and location to the South American continent. Rapid and sustained development in both Trinidad and Tobago has led to changes in the extent and integrity of natural ecosystems. These changes have been most apparent in forests and coastal systems (such as mangroves, coral reef and sea grasses), and have generally been more intensive in the western section of both islands. Land use and land cover changes are the main driving forces contributing to biodiversity loss in all biomes in Trinidad and Tobago. Deforestation and conversion of land principally for agriculture and housing have been the main drivers, and these have resulted in the reduction in forest cover and coastal ecosystems, as well as greater fragmentation of remaining natural systems. Industrial development in Trinidad, largely driven by the growing petrochemical sector over the last several years, has resulted in the conversion of significant tracts of coastal ecosystems, principally mangroves along the western coast of Trinidad, to industrial estates. There is also coastal conversion occurring in the south-western region of the island28. 27 https://www.iadb.org/en/news/trinidad-and-tobago-increase-social-support-vulnerable-groups-idb-help 28 https://www.cbd.int/countries/profile/?country=tt 66 | P a g e 4.2.1 Solid Waste Management in Trinidad and Tobago The current institutional framework for waste management in Trinidad and Tobago consists of a myriad of agencies involved in varying aspects of the Solid Waste Management (SWM) system, each with their own priorities and agendas. Among the key agencies involved are Ministry of Rural Development and Local Government and Ministry of Public Utilities (MOPU) (through SWMCOL) for SWM in Trinidad; Tobago House of Assembly (THA) responsible for waste management in Tobago; Regional Health Authorities for medical waste management in Trinidad; the Ministry of Planning and Development (MOPD) for the establishment of the Waste Recycling Management Authority; the Environmental Management Authority (EMA) responsible for drafting rules on hazardous and non- hazardous waste management; the Ministry of Trade and Industry (MOTI) for scrap metal management; and Regional Corporations (RCs), responsible for monitoring solid waste contractors for MSW collection and transportation in Trinidad. As discussed above, waste management in Trinidad and Tobago is multijurisdictional, and therefore, the legislation governing SWM has originated from different institutions. Some of the key existing regulations include the Environmental Management Act, No. 3 of 2000 which formed the EMA, giving it the responsibility to develop and implement laws, policies in accordance with sound environmental practices. Other legislation include the Waste Management Rules: Solid Waste (Collection and Disposal) (Draft) which apply to the collection and disposal of wastes not covered by the Hazardous Wastes Rules; the Waste Management Rules: Hazardous Waste (Draft) which are intended to regulate all aspects of hazardous waste handling; the Municipal Corporation Act which confers functions such as the disposal of garbage from public and private property, the development and the maintenance of sanitary landfills on corporations established under that Act ;the Public Health Ordinance, Chapter 12 which grants powers to local authorities for waste removal, street sweeping, creation of disposal sites, etc.; the Litter Act which seeks to control the littering of public places and premises; and the previously debated Beverage Container Bill (2012) (updated in 2019) which sought to provide for the establishment of the Beverage Containers Advisory Board, a deposit and refund system for prescribed sizes of beverage containers, a regime for the collection of beverage containers to reduce their disposal into the environment, thereby alleviating the pollution. In 2016 a National Waste Recycling Policy was introduced and this covered more aspects than just Beverage Containers. This Policy called for the establishment of a Waste Recycling Management Authority and a 67 | P a g e Resource Recovery Fund to facilitate the efficient coordination of the implementation of a waste recycling system that would protect human health and the environment. SWMCOL manages waste disposal at three (Beetham, Guanapo and Forres Park) of the four disposal sites in Trinidad; the fourth site, the Guapo disposal site, is managed by Point Fortin Borough Corporation. The private sector operators (at the three SWMCOL-managed disposal sites) and local government (Point Fortin Borough Corporation for the Guapo site) have made limited investments in basic equipment and machinery (such as landfill compactors, bulldozers, etc.). The Public Health Services Department (under the aegis of the THA) is responsible for the collection and disposal of waste in Tobago. This is done through sub-contracted waste collection services. Waste is collected in Tobago on a daily basis and the collection system is currently working well. The wastes collected are disposed of at Studley Park disposal site which is also managed by this department. 4.2.2 Health Care Waste Management and Infection Control Whilst there are no waste regulations currently in place that specifically address health care waste management, through the CEC Rules, the EMA requires any facility that manages hazardous wastes or incinerates waste must have a Certificate of Environmental Clearance (CEC). To address the risks associated with bio-medical waste management, a Code of Practice for Bio-medical Waste Management (BMW) was developed by the Pan American Health Organisation (PAHO) in 2012. It was designed to elicit the voluntary commitment of all practitioners involved in bio-medical waste management and to enable them to adopt environmentally best practices in the collection, storage, transportation, treatment and disposal of these wastes in a safe and cost effective manner. Each of the five RHAs have adapted the Code of Practice and developed procedures for bio-medical waste management within their respective regions. Each RHA manages the bio-medical waste from their respective health centres and hospitals. They organise collection of the bio-medical waste from these facilities whereby they are transported to a centralised location on each region. Thereafter, the wastes are either incinerated at the on- 68 | P a g e site incinerator or transported off-site for incineration at a private facility. The E&S Audit/Rapid Assessment indicated that hospitals are operating in accordance with the Code of Practice, and that there has not been a need to transport waste to the private facility at this time. Waste Management for Vaccines Deployment Specific provisions were made for disposal of COVID-19 vaccines. Collection and documentation of any unused COVID-19 vaccines is to be done at the vaccination sites, and opened/used/expired vials will be collected by the Expanded Programme on Immunization (EPI) makes arrangements with each facility to have timely removal of waste. The labels of all opened/expired/used vials labels have to be blackened out before disposal in the designated biohazard containers. Once all vaccine vials are accounted for, then they are to be transferred for proper disposal (incineration) to ensure there is no mismanagement of vials according to waste management protocols. Other, routine biomedical wastes (for example Sharps – used needles and syringes) will be disposed of as part of the Regional Health Authority schedules for removal of biohazard waste. In case that a contingency plan is required, it will be considered an acceptable alternative to dispose of used/opened/expired vials following verification and documentation at three (3) sites. These sites are: 1. Eric Williams Medical Sciences Complex incinerator (Mount Hope) 2. San Fernando General Hospital Incinerator 3. Tobago Old Hospital incinerator 4.2.3 Air Quality and Healthcare Waste Incineration The Environmental Management Act, Chapter 35:05, states that ‘no person shall release or cause to be released any air pollutant into the environment, which is in violation of any 69 | P a g e applicable standards, conditions or permit requirements under this Act’. The Air Pollution Rules, 2014 (APR) is legislation developed under the Environmental Management Act Chapter 35:05. Through the APR, the EMA seeks to manage the levels of specific air pollutants known to cause harm to human health and the environment, thereby improving overall air quality. The APR are applicable to both ambient air and stack releases (from equipment such as incinerators). Schedule 2 (see Figure below) lists the maximum permissible limits for specific parameters. 70 | P a g e Figure 4: Schedule 2 of APR – Stack Release Limits Under the CEC Rules, all waste incinerators need a Certificate of Environmental 71 | P a g e Clearance (CEC) before they can be installed and operated. This CEC will stipulate, amongst other requirements, the requirements for air quality systems that must be installed to ensure that the emissions are acceptable. 4.3 National COVID-19 Response TTO reported its first case of COVID-19 on March 12, 2020. On March 22, the country closed its borders to everyone including TTO nationals and health workers. TTO has drafted a comprehensive COVID-19 Preparedness and Response Plan, which is aligned with the WHO’s Strategic Preparedness and Response Program (SPRP). The Plan is aimed at reducing serious illness and overall deaths and at minimizing societal disruption among citizens of TTO as a result of the pandemic. The plan has guided the multi-sectoral response to address the public health and socioeconomic challenges resulting from the pandemic and recognizes the following vulnerable populations’ needs including: the elderly, the impoverished, the health workforce, migrants, differently abled and socially displaced, children and youth. A National Task Force (NTF) was formed to guide and oversee the response to COVID- 19. This NTF includes a representative of the Tobago House of Assembly (THA) to ensure that the COVID-19 response takes into account the smaller island’s needs. The NTF is a multi-sectoral committee that is chaired by the Chief Medical Officer from the MoH. It has the mandate to lead the development and implementation of integrated and multi-sectoral activities and to monitor and evaluate those activities for the COVID-19 response. It reports to the Ministers of Health and of National Security. As in the case of all national health projects and initiatives, all RHAs including the Tobago RHA are included in the operational planning to ensure that each RHA’s needs get considered. The MOH has been implementing a two-pronged strategy for the prevention of and response to COVID-19: (i) contain imported cases of the disease and (ii) isolate the treatment of COVID-19 patients and the support for those patients that tested positive but do not require inpatient care from the rest of healthcare provision. Identification, isolation and quarantining of positive cases have been supplemented by an increase in the Government’s contact tracing capacity. The Government of TTO is also faced with the need to expand testing. Providing facilities 72 | P a g e for the isolation of recovering patients is an important aspect of the strategy for treatment and care. The strategy is being complemented by extensive public communications to increase social awareness about the COVID-19 epidemic and planned behaviour change communications. In addition, the response to COVID-19 includes an emphasis on the mental health of patients, the health care workforce and the general population, including attention to gender-based violence. 4.3.1 Testing for COVID-19 Testing for COVID-19 is being facilitated at both public and private healthcare facilities. Currently this test requires a nasopharyngeal. This swab is then transported to the lab at CARPHA via the national Trinidad Public Health Laboratory (TPHL). The samples are being tested at the Caribbean Public Health Agency (CARPHA). Other laboratories approved for COVID-19 testing are: • St Augustine Medical Laboratory • Caribbean Forensic Services Limited • Victoria Laboratories Limited • Maitri Diagnostics • Medical Research Foundation 4.4 National Vaccine Deployment Plan The Ministry of Health developed this plan to provide explicit guidance for the introduction of the COVID-19 vaccine throughout Trinidad and Tobago. The strategies, goals and objectives were built on the foundations created by the long-established national immunization programme that has been in use by the Ministry of Health for the last four decades. These processes were updated and improved to inform the approaches taken by the COVID-19 Vaccine Task Force and will be focused on the management of the distribution in a prescribed and equitable manner, of vaccine supplies to the population of Trinidad and Tobago. The objectives of this Vaccination Plan are to reduce morbidity and mortality amongst the 73 | P a g e population of Trinidad and Tobago. Vaccines are critical public health interventions used to mitigate disease across all population levels by offering protection to individuals and, depending on the modality of action of the vaccine options, they restrict community transmission. Vaccination will be free at all points of delivery. As at July , 2023, Trinidad and Tobago has recorded 191,496 cases, 4,390 deaths, and the percentage of the population vaccinated with a complete primary series is 51.4%29. In May 2023 the rolling 14 day average for new 10 per day, more recent inofmation in not available30. Part of the country’s response has been to collaborate with the Pan American Health Organisation (PAHO) and the World Health Organisation (WHO) to ensure synergies in the strategies and plans, with the rest of the world, for the delivery of vaccine services.This Plan includes the measures contained in the Vaccine Introduction Readiness Tool (VIRAT-VIRAF) and be also guided by the processes included in the PAHO/WHO Guide for planning for the introduction of COVID-19 Vaccines. Trinidad and Tobago has signed on to the COVAX Facility as one of the 190 countries desirous of mitigating the effects of the COVID-19 pandemic, through the provision, to its population, of adequate quantities of safe and efficacious vaccines, at the most economical cost. As part of the preparation for the receipt of the vaccines, the MoH assessed the capacity of the country to determine readiness and preparation for the importation of the vaccine, establishment and preservation of cold chain with storage and transportation across both islands. The MoH also specified standard operating procedures (SOPs) ensure integrity, security and proper transportation and storage systems are utilized at all points in the cold chain network. 4.4.1 Shipment and Storage The E&S Audit/Rapid Assessment confirmed that appropriate processes were being followed for the transport and storage of vaccines. 29 https://covid19.who.int/table 30 https://health.gov.tt/covid-19-fortnightly-update-tuesday-may-02-2023 74 | P a g e Supply Chain The vaccination programme will require a supply chain process which will involve the receipt of vaccines in Trinidad and Tobago from a number of manufacturers and the storage of these vaccines in a temperature controlled central storage facility constructed at the Couva Hospital and Multi Training Facility. Storage facilities are also available at the National Insurance Property Development Company Limited (NIPDEC) C40 Central Stores, and the Office of the County Medical Officer of Health (CMOH), Tobago. Preparation of vaccines for distribution to vaccination sites and the delivery logistics to vaccination locations will include as necessary procedures for both - o o 20 C and -70 C vaccine types, in addition to those already used for +2°C to +8°C vaccines. Trinidad and Tobago will leverage and build on existing vaccination delivery services and structures for the deployment of COVID-19 vaccines. The process will be managed using the collaborative expertise of Principal Pharmacist and the EPI Unit. Additional supply chain and logistics expertise across the wider public sector and the private sector may be included if necessary. The arrangements for further supply of WHO approved vaccines from pharmaceutical companies and the timing of delivery to Trinidad and Tobago are currently being negotiated. The initial supplies were received in March, 2021 and supply is anticipated to continue. Storage Given Trinidad and Tobago’s size and population, storage of the vaccines will be centralised and managed by a central logistics lead, having substantial relevant experience. As the different types of vaccines require varying temperature storage requirements, Ultra-low Freezers (-70°C to -80°C), (-15°C to -25°C) and Refrigerated Room (+2°C to +8°C), the MoH has constructed a new facility with suitable storage capacity for each vaccine temperature range at Couva. The construction was completed, and the site was commissioned. The other storage sites are at NIPDEC in Chaguaramas and the office of the County Medical Officer in Tobago. Vaccine Distribution Capacity 75 | P a g e Human resource and specific training needs have been completed for each distribution point. Mapping of available and eligible personnel determined will be based on the selection criteria, and the capacity of the EPI system to efficiently deliver the vaccine to the selected location. Currently, the vaccines are being transported in a cooler, with an ice pack and thermometer and distributed to the health centres. Vaccine Allocation, Ordering, Distribution and Inventory Management These requirements developed and approved by the COVID-19 Vaccine Task Force will guide the delivery or coordination of delivery of vaccines to the targeted populations. The Task Force will also identify populations of focus, how to address limited supply scenarios and how to make sure that immunization practices are adhered to by the various stakeholders along the procurement and delivery of vaccines chain, as determined in this Plan. Cold-chain capacity can only be assessed based on the requirements of the vaccines’ types that are to be received. The Couva Hospital and Multi Training Facility (CHMTF) is to operate as the central hub for distribution. Other arrangements will be explored to ensure that if required adequate stores of dry ice are available, in country, to support the transport of vaccines from the Couva hub to the delivery points. Vaccine Storage and Handling All vaccines will be managed by EPI as per the norm and training materials and short videos or instructions will be available on the COVID-19 vaccine segment of the MoH’s website. Personnel will be given new training or be retrained prior to being the recipients and use of vaccines and related supplies. Phase 1 In phase, the EPI will strictly monitor audits from all vaccination sites, to ensure allocation based on numbers of targeted population to be vaccinated against planned usage rates. Phase 2 In phase two, EPI will also monitor and manage the distribution process to make sure that all requests are equitably addressed. 76 | P a g e Vaccine wastage will be monitored using a vaccine management system (part of the information and communications technology (ICT) Solution) which will be linked to the electronic immunization register and will assist in facilitating the distribution and deployment of vaccines based on amounts needed and ordered. Alerts would also be identified if the storage of the vaccines in the hub is beyond a specified period of time. This period will be unique to each distribution point based on their ability to maintain cold storage and consistent power supply in the location where the vaccines are being stored. Protocols for adherence to cold-chain storage have been defined. All deliveries will be chilled at (+2 to +8 ºC) distribution using the Cold Chain transport provider. Two of the potential vaccines must be stored centrally at -20oC and -70ºC but are thawed to +2ºC to +8ºC for onward distribution and localized storage. In order to support the data and information management and service delivery components of the program, vaccine personnel must commit to: • Handling COVID-19 vaccines under proper conditions including maintaining cold chain conditions and chain of custody at all times in accordance with the vaccine manufacturer’s package insert as well as EPI processes for vaccine storage and handling guidelines; • Monitoring the vaccine storage unit temperatures using equipment and practices that comply with guidance from the EPI unit; • Complying with immunization programs instructions and guidelines that manage temperature excursions; • Monitoring and adhering to instructions with respect to the expiration dates for the vaccines; • Preserving and secure all records related to the vaccine for a minimum of five years; and, • Ensuring that all data input into the electronic vaccine register system as well as the vaccine inventory management system will be preserved. Cold-chain capacities at all vaccination sites will be assessed continuously to ensure that cold chain storage can be maintained at all times, and this may require visits from the EPI team. Vaccine redistribution will be determined by the defined protocols. All Vaccination 77 | P a g e locations will require appropriate resourcing, consumables and equipment. The handling and storage of vaccines at vaccination sites requires Standard Operating Procedures (SOPs) and specialist training for on-site staff. For certain vaccine types, there are also additional steps in preparing the vaccine for use that will need to be done by trained individuals or vaccine personnel on-site before administering the vaccines. Vaccine Administering Documentation and Reporting The Ministry of Health has developed a Vaccination Deployment Plan31 that outlines the processes to administer, document and report on the vaccination process of the population. The E&S Audit/Rapid Assessment identified areas where communication and outreach regarding the vaccination campaign could be strengthened. 31 MoH, National Vaccination Deployment Plan, June 2021 78 | P a g e 5 Potential Environmental and Social Impacts and Mitigation Measures The environmental and social risks (E&S) are rated as Substantial, given the occupational health and safety risk to health care and other workers deploying the goods and services procured under the Project, and the biomedical waste that is generated. These risks will be identified and managed through the Project’s ESMF and SEP, development of an Infection Control and Waste Management Plan (ICWMP) (See Annex III) a Community Health and Safety Plan, and capacity strengthening through hiring E&S staff. 5.1 Methodology for Assessing Risk and Impacts The ESMF is prepared based on an assessment of direct and indirect risks and impacts of the specific project activities. A direct impact is defined under the ESF as “…an impact which is caused by the project, and occurs contemporaneously in the location of the project.� An indirect impact is one “…which is caused by the project and is later in time or farther removed in distance than a direct impact, but is still reasonably foreseeable, and will not include induced impacts�. Induced impacts are those that are unknown, speculative, uncertain, or remote. Induced impacts are not considered further in this document as they cannot be reasonably assessed or mitigated at this time. Induced impacts emerging during project implementation will be managed responsively and the ESMF amended accordingly. Overall, the Project will have positive social and environmental impacts as it should improve COVID-19 immunization, surveillance, monitoring, and containment. However, the project may also result in environment and social risks. 5.2 Risks Summary Planning for risks and developing risk management strategies start at the procurement stage. Failures in procurement process e.g. equipment that is inappropriate or incorrect PPE and could lead to: 79 | P a g e • Health & safety risks to workers; • Adverse environmental impacts such as environmental contamination due to improper waste disposal; • Spread of infection to health-care workers; • Unsustainable procurement and use of goods; and, • Spread of COVID-19 to health-care workers, • Vaccine readiness and prioritization, • surveillance of adverse events following immunization, • estimated healthcare waste streams, • approach to procurement of goods, • life and fire safety, • oxygen risks management (although neither oxygen nor oxygen delivery systems have been purchased under the project), • emergency preparedness risks, • risks related to waste management, and • risks of exclusion for different groups. 5.2.1 Environmental Risks The project’s Environmental Risk rating is substantial but should be temporary and manageable once mitigation measures are implemented. The project will finance laboratory equipment, supplies, test kits and reagents for the diagnosis of COVID-19 during the outbreak. Personal Protective Equipment (PPE), epidemiological surveillance kits, software and hardware will also be procured to support case detection, confirmation, contract tracing, recording, and reporting. In addition, it will finance as needed for the following: i. essential equipment for disinfection and sterilization procedures including medical supplies, and supplies to ensure safe hospital waste management practices; ii. key health care delivery inputs, including personal protective equipment and other medical supplies for frontline health workers involved in patient case management; iii. training of health staff on appropriate clinical care for COVID-19 patients and the safe disposal of medical waste; 80 | P a g e iv. medicines (v) vaccines and v. equipment for the treatment of COVID-19 patients. Procurement under this subcomponent will prioritize, when possible, the use of climate-smart technologies. The potential environmental and human health risks associated with the project activities are: 1. Occupational health and safety (OHS) risks during the operation of medical facilities and laboratories involved in COVID-19 response which inherently expose staff to infection risk; 2. OSH risks to the health care workers as they may be exposed to infection from patients; 3. OSH risks for cleaners and waste handlers in health facilities and the waste service providers are present due to the possible exposure to infectious health care wastes during the collection, storage, treatment, and disposal stages. There are risks from infectious healthcare wastes as they are generated from the testing and vaccination activities, including waste collection from the health care facility by the facility’s waste handlers and cleaners and by the contracted waste service providers; 4. Community health and safety issues related to the uncontrolled transmission of the COVID-19 virus due to the lack of adequate testing, laboratory and quarantine facilities and contamination due to the improper handling, transportation and disposal of healthcare wastes (e.g. liquid waste such as blood or body fluids, and infected materials (e.g. wash water, laboratory solutions and reagents, syringes, bed sheets, and other biomedical waste that requires special handling and disposal; 5. The cold storage facilities contain refrigerants which do not conform to the requirements of the Montreal Protocol. Other refrigerants are also toxic and flammable and can pose risk to people’s health and safety; 6. Cold storage systems also require huge amount of energy to operate that may have an impact on climate change. 5.2.2 Social Risks 81 | P a g e The project’s Social Risk rating is substantial but should be temporary and manageable once mitigation measures are implemented. The risks include: • Communities may have fear and apprehension on the scientific integrity, efficacy, and safety of the vaccines. This may lead to many persons refusing to take the vaccines; • Misinformation and disinformation on the adverse health effects of vaccine is also a risk which should be addressed; • The vaccine administration may also lead to crowding and violation of physical distancing measures, increasing the risk of exposure of the candidates and the residents within the vicinity of the site; • The health workers involved in the vaccine administration activities may face discrimination and harassment when going back to their communities due to people’s fear in contracting the virus, frustrations over medical care, or misinformation; • There are risks of adverse health effects as result of improper or inadequate profiling and screening of individuals prior to vaccination. There is also a risk of not completing the vaccine dose/shots due to the individual’s apprehension and/or schedule mismanagement; and, • The data management of the vaccination program, including the establishment of good surveillance system and schedule monitoring, are also risks. With the use of more than one vaccine during the immunization period, close monitoring of adverse events in vaccinated individuals using information technology, i.e., digital tracking system should be conducted. As the possibility of adverse effects of the vaccine is a risk, tracking of health effects in vaccinated individuals and follow-up assessments should be conducted. The project’s Stakeholder Engagement Plan (SEP) is a separate document that includes the necessary measures to guarantee that all affected parties are properly consulted and engaged with throughout the project cycle. All forms of communication as outlined in the Communications Plan will be used to mitigate the risk of exclusion of select groups. The potential risks and impacts will be addressed through the implementation of a Stakeholder Engagement Plan (SEP), including a Grievance Mechanism, and this Environmental and Social Management Framework (ESMF), including Labour 82 | P a g e Management Procedures (LMP) including a workers level Grievance Mechanism, prepared based on an assessment of environmental and social risks and impacts in line with the applicable WB ESSs of the WB’s ESF, the WHO COVID-19 guidance on risk communication and community engagement, and national laws and regulations. 83 | P a g e 6 Procedures to Address Environmental and Social Issues This section sets out in detail the procedures to be followed in identifying, preparing and implementing the subprojects. It will be used by the Project Implementation Unit (PIU) to screen for the potential environmental and social risks and impacts for different types of subproject activities. 6.1 Screening Process The purpose of the screening is to: (i) determine whether activities are likely to have potential negative environmental and social risks and impacts; and (ii) identify appropriate mitigation measures for activities with adverse risks or impacts. The mitigation measures will then be incorporated into implementation of each activity, by identifying and following the relevant environmental and social risk management tools. The MoH E&S Specialist will supervise these aspects during project implementation. Annex I is the Screening Form for Potential Environmental and Social Issues. This form is available for use by the MoH to screen for the potential environmental and social risks and impacts of specific activities. This screening will allow the MoH to identify the applicable Environmental and Social Standards (ESS), establish an appropriate environmental and social risk rating, and specify the type of environmental and social risk management measures required, including specific instruments, if needed. Results from application of the VIRAT/VRAF can inform the procedures to address environmental and social issues that will guide the development of the Vaccine Delivery and Distribution Manual and National Deployment and Vaccination Plan (NDVP). The VIRAT/VRAF has key indicators related to environmental and social risk management for the deployment of the COVID-19 vaccine including planning and coordination; budgeting, regulatory planning, and coordination; budgeting; regulatory framework; prioritization, targeting and COVID-19 surveillance; service delivery; training and supervision; monitoring and evaluation; cold chain, logistics and infrastructure; safety surveillance; and demand generation and communication. Various activities in the VIRAT/VRAF are in progress, albeit mostly in early stages related to Vaccine service delivery, cold chain, logistics and infrastructure. For many project activities, the screening process has already been done. However, the following steps are required to complete the screening for each particular activity, once details of particular activities become well defined. 97 | P a g e • Step 1 – Determine Type of Activity. The first step of screening is to determine what type of activity is being proposed. If it is one of the project component activites described in section 2.2 above, then the types of E&S risk management tools are already defined in this ESMF and the screening process proceeds to the next step described below. Otherwise, if it is a different type of activity, then refer to Annex I and complete the screening checklist. • Step 2- Screening of Eligibility. The next step is to compare the activity to the exclusion list in the Table 9 below. The table lists Ineligible Activities that cannot be performed with project funding. • Step 3 – Determine E&S Risk Management Tool(s). The third step is to determine what specific E&S risk management tool(s) are required or apply, if any. The screening form in Annex I will assist in determining the E&S risk management tool(s) that need to be prepared or followed. • Step 4: Consultation with Project Team. If required, the screening outcomes will be discussed with the PIU to identify ways to reduce or avoid any adverse impacts. Any adjustments to the design, categorization or E&S risk management tools can be refined following this process. • Step 5: Preparation and Disclosure of E&S Risk Management Tools. If required, the next step is to prepare the relevant E&S risk management tool(s). This process may include site visits and data gathering, consultation, and public disclosure of the documents in accordance with the Chapter 7 – Consultation and Stakeholder Engagement. • Step 6 – Procurement Due Diligence. Determine if procurement is required for the activity. If yes, then incorporate the appropriate E&S provisions into bidding documents or procurement process. • Step 7: Implementation of Mitigation Measures. The implementation of the E&S risk management tools and conditions of any environmental approvals will need to be implemented, monitored and enforced. Training of implementing staff may be needed to ensure that conditions of the E&S risk management tools are met. For contractors or suppliers (if applicable), monitoring and supervision will be needed to ensure that conditions of the E&S risk management tools are met. Ensure there are adequate human and financial resources to implement mitigation measures. • Step 8: Monitoring and Reporting. Monitoring is required to gather information to determine the effectiveness of implemented mitigation and management measures and to ensure compliance with the approved E&S risk management tools. Monitoring methods must provide assurance that E&S risk management tool(s) measures are undertaken effectively. Specific requirements can be found in the ESCP in Annex IV. Quarterly reports will need to be prepared and provided to the WB. The Quarterly E&S monitoring reports to the Bank will include: 98 | P a g e (i) the status of the implementation of mitigation measures; and (ii) the findings of monitoring programs; (iii) stakeholder engagement activities; (iv) grievances log, and (v) any incidents/accidents with adverse impacts and the actions taken to address it and prevent reoccurrence. Table 9: Ineligible Activity List The following type of activities shall not be eligible for financing under the project: • Activities of any type classifiable as “High� risk pursuant to the World Bank’s Environment and Social Standard 1 (ESS1) of the Environment and Social Framework (ESF). The following activities are illustrative examples of “High� risk activities: o Activities that may cause long term, permanent and/or irreversible (e.g. loss of major natural habitat) adverse impacts; o Activities that have high probability of causing serious adverse effects to human health and/or the environment not related treatment of COVID-19 cases; and, o Activities that may have significant adverse social impacts and may give rise to significant social conflict. • Activities that may affect lands or rights of indigenous people or other vulnerable minorities. • Activities that will have impacts on practices, representations, expressions, knowledge, skills related to their traditional health practice. • Activities that may involve permanent resettlement or land acquisition or any involuntary taking of land (even temporary) or adverse impacts on cultural heritage. • Activities that are considered by the World Bank (a) to have potential to cause significant loss or degradation of critical natural habitats whether directly or indirectly or those that could adversely affect forest and forest health; (b) that could affect sites with archaeological, paleontological, historical, religious, or unique natural values; and (c) that will result in adverse impacts on relocation of households, loss of assets or access to assets that leads to loss of income sources or other means of livelihoods, and interference with households’ use of land and livelihoods; and, • Use of goods and equipment as considered by the World Bank to meet the following conditions: (a) lands abandoned due to social tension/conflict, or the ownership of the land is disputed or cannot be ascertained; (b) to demolish or remove assets, unless the ownership of the assets can be ascertained, and the owners are consulted; (c) involving forced/conscripted labour, child labour (under the age of 18), or other harmful or exploitative forms of labour; (d) activities that would affect indigenous peoples, unless due consultation and broad support has been documented and confirmed prior to the commencement of the activities; and/or other paramilitary purposes. 99 | P a g e 6.2 Environmental and Social Management Plans Specific activities in the project would require an Environmental and Social Management Plan (ESMP). A template is attached in Annex II. The ESMP shall be site-specific, and proportionate and relevant to the hazards and risks associated with the particular activity and will be implemented by the health facility and contractors. When designing mitigation measures the ESMP should address site-specific environmental and OHS issues and shall draw on the Environmental Codes of Practice (ECOP) and relevant, up-to-date guidance from WHO, MoH, NTF and other relevant government agencies on COVID-19 specific advice (Annex V). The site specific ESMP or ECOP will include as attachments, as needed, the LMP, GM, and ICWMP. For each identified environmental and social risk, the format shows (1) proposed risk mitigation measures, (2) responsibility for each risk mitigation measure, (3) Timelines; and (4) Budget. The implementation of E&S risk mitigation measures will be reported and will be a condition for approval of payments. 6.3 Health-Care Waste Management Health-Care waste management in Trinidad and Tobago is guided by the Code of Practice for Bio-Medical Waste Management that was developed by PAHO in 2012. Each of the five RHAs have adapted this code and developed procedures for bio-medical waste management within their respective regions. Each RHA manages the bio-medical waste from their respective health centres and hospitals. They organise collection of the bio-medical waste from these facilities whereby they are transported to a centralised location on each region. Thereafter, the wastes are either incinerated at the on-site incinerator or transported off-site for incineration at a private facility. More details of this were discussed in section 4.4.2. Management of health care wastes for this project is described in the ICWMP (Annex III). 100 | P a g e 7.0 Stakeholder Engagement, Consultation and Disclosure The Stakeholder Engagement Plan (SEP) has been developed to ensure that stakeholders are informed about project risks and mitigation measures and that information is disclosed properly. The SEP outlines the ways in which the project team will communicate with stakeholders and provides a mechanism through which people can raise concerns, provide feedback, or make complaints about the project or any activities related to the project. The participation of the local population is essential to ensure collaboration between project staff and local communities and to minimize and mitigate environmental and social risks related to the proposed project activities. Broad-ranging, culturally appropriate and adapted awareness raising activities are particularly important to sensitize the communities to the risks related to infectious diseases. http://documents.worldbank.org/curated/en/735421635435848392/Revised-Stakeholder-Engagement-Plan-SEP-Republic-of- Trinidad-and-Tobago-COVID-19-EMERGENCY-RESPONSE-PROJECT-P173989 The ESMF is prepared together with the Project’s SEP and Environmental and Social Commitment Plan (ESCP). The first drafts of the SEP and the ESCP were developed on May 2020 and June 2020 respectively, the final SEP was disclosed on the MoH and World Bank website on October 17, 2021. The SEP will be updated and re-disclosed if the need arises. The finalized version of the ESMF will be made available on the websites of both the MoH and World Bank once it has been approved by the World Bank. Stakeholder engagement will continue throughout the life of the project and will include formal scheduled consultations and meetings as well other means of communication. The stakeholder engagement process has two components: • Early and ongoing engagements with key stakeholders at national, sub national and community to provide information on the project and obtain feedback on experiences and outcomes of the Project and its activities. • A Grievance Mechanism (GM) to address any public complaints during the implementation of the project. The SEP is a living document. The objectives of the SEP are: • To identify all project stakeholders including their priorities and concerns, and ensure the project has ways to incorporate these; • Identify strategies for information sharing and communication to stakeholders in ways that are meaningful and accessible; 101 | P a g e • To specify procedures and methodologies for stakeholder consultations, documentation of the proceedings and strategies for feedback; • To establish an accessible, culturally appropriate and responsive GM; and, • To develop a strategy for stakeholder participation in the monitoring of project impacts 7.1 Project Stakeholders To ensure effective and targeted engagement, the project identifies three core stakeholder categories: affected parties, other interested parties and disadvantages/vulnerable individuals or groups. 7.1.1 Affected parties Affected Parties include local communities, community members and other parties that may be subject to direct impacts from the Project. Specifically, the following individuals and groups fall within this category: • Health facility staff, laboratory workers and emergency workers • COVID-19 patients and infected people • Households with COVID-19 infected people • People under COVID-19 quarantine • People detained in prisons and detention centers • Communities with COVID-19 infected people or people under COVID-19 quarantine • Local government units where isolation/quarantine/screening facilities will be located • Communities around proposed isolation/quarantine/screening facilities • Workers involved in waste collection and management • Migrants, temporary workers, and asylum seekers from neighbouring countries • Workers/professionals coming back to the Trinidad and Tobago from abroad; and • Business entities and individual entrepreneurs supporting and/or supplying key goods and services for prevention of and response to COVID-19. 7.1.2 Other interested parties The projects’ stakeholders also include parties other than the directly affected communities, including: • General public who are interested in understanding the Governments prevention and response to COVID-19; 102 | P a g e • Government officials, permitting and regulatory agencies at the national, regional, and community levels, including environmental, technical, social protection and labour authorities; • Civil society organizations at the global, regional, and local levels that may become partners of the project; • Business owners and providers of services, goods and materials that will be involved in the project’s wider supply chain or may be considered for the role of project suppliers in the future; • Mass media and associated interest groups, including local, regional and national printed and broadcasting media, digital/web-based entities, and their associations. 7.1.3 Disadvantaged/vulnerable individuals or groups It is particularly important to understand how the project impacts will disproportionately fall on disadvantaged or vulnerable individuals or groups, and how they might be excluded from the projects benefits and then to consider ways to mitigate this. Vulnerability may stem from a person’s origin, gender, age, health condition, economic deficiency and financial insecurity, disadvantaged status in the community (e.g. migrants) dependence on other individuals or natural resources, and regional or geographic location. etc. Engagement with vulnerable groups and individuals requires the special consideration to their situation and tailored outreach so they are not harmed and so they benefit from the project. Within the COVID-19 context, the vulnerable or disadvantaged groups will include: o elderly people; o those with underlying health conditions e.g. diabetes, cancer, hypertension, coronary heart diseases, and respiratory diseases; o persons with disabilities including physical and mental health disabilities (and their caretakers): o poor, economically marginalized, groups particularly asylum seekers and others without clear legal status; o Women headed households or single mothers with underage children; o Homeless people; o Older adults in high risk living situations (examples: long term care facility, those unable to physically distance); o Social groups unable to physically distance (examples: geographically remote clustered populations, detention facilities, dormitories, military personnel living in tight quarters, refugee camps); o Groups living in dense urban neighbourhoods; 103 | P a g e • Groups living in multigenerational households (extended families). Other vulnerable/minority groups that are identified during project implementation and not explicitly mentioned here who may need additional measures to ensure they are included32 7.2 Proposed Strategy for Information Disclosure In order to meet best practice approaches, the project will apply the following principles for stakeholder engagement: • Openness and life-cycle approach: public consultations for the project(s) will be arranged during the whole lifecycle, Consultations would be carried out in an open and transparent manner; • Informed participation and feedback: information will be provided to and widely distributed among all stakeholders in an appropriate format; opportunities are provided for communicating stakeholders’ feedback, for analysing and addressing comments and concerns; and, • Inclusiveness and sensitivity: stakeholder identification will be undertaken to support better communications and build effective relationships. Sensitivity to stakeholders’ needs will be the key principle underlying the selection of engagement methods. Special attention will be given to vulnerable groups, in particular women, youth, elderly and the cultural sensitivities of diverse ethnic groups. Stakeholder engagements were conducted after project approval to inform a revision of the SEP within 30 days after effectiveness. The summary in the table below outlines stakeholder engagements to date. Table 10: Stakeholder Consultations Held Stakeholder Consultations Held GROUP STATUS ACTIONS Media Ongoing Media to promote and encourage approved COVID-19 response messaging. Media continues to be utilized as the official sources to facilitate credible publications. Media is being used to support public engagement strategies through adopting ads etc. Vulnerable Virtual Meeting Based on the feedback from this Groups held on July consultation, the MoH organized transport 32 More detailed description can be found in the SEP. 104 | P a g e GROUP STATUS ACTIONS 23rd, 2021 for the Special Needs persons and their families and caretakers through the national bus system. They also ensured that there was enough time allocated for vaccination, group numbers were small and that persons were allowed to recover in a quiet space. Medical and Ongoing Development of use of PPE guidelines clinical staff Vaccine acceptance and promotion. Public Ongoing Through public health education campaigns and ongoing advertisements. Information about the consultation process, along with information about the project was posted in advance in the MoH website, and MoH social media. The objective of the consultations waw obtain feedback from stakeholders on the project's risks, impacts, and possible mitigation measures proposed by them and PIU. The PIU consulted with the stakeholders on the risks, and impacts identified in the ESMF, SEP and LMP. Considering that risks, and impacts can impact and affect differently each stakeholder groups, special attention was given to identify risk and impacts per stakeholder group. For example consultations were held separately with special needs groups, the summary of the consultations with special needs groups are provided in annex II of the SEP. For future consultations during the project cycle, the stakeholders will be notified about how their feedback was taken into consideration. This will be done through disclosing the report of the consultations. The report of the consultations will be available in the MoH website.. Stakeholders will be notified about how their feedback was included in the project during consultations as well. 7.4 Consultation and Disclosure during Project Implementation Two-way mechanisms for ongoing consultation will operate throughout the life of the project, to disclose information and seek feedback (see table below). Dedicated channels for information dissemination will be established to ensure consistent communication at national and local levels throughout the project. Project stakeholder engagement will be carried out on two fronts: • Awareness-raising activities to sensitize communities on risks of COVID-19; and, 105 | P a g e • Consultations with stakeholders throughout the entire project cycle to inform them of the project and to solicit their concerns, feedback and complaints about any activities related to the project and consultations to improve Project design and implementation. This will be done every 6 months. Stakeholders will be kept informed as the project develops, including reporting on Project environmental and social performance and implementation of the SEP and the grievance mechanism. This will be important for the wider public, but more particularly for suspected and/or identified COVID-19 cases and their families. Table 11: Disclosure Plan Project stage Target stakeholders List of Methods and timing proposed information to be disclosed Preparation, Different government Project objectives and Disclosure on World prior to ministries and activities. Bank and MoH effectiveness agencies including websites. Ministry of Health, Ministry of Stakeholder Communications, Engagement Plan (SEP) Ministry of Education, 5 and Grievance Regional Health Mechanism (GM). Authorities Social Media. Hospitals and Medical Facilities Environmental and Social Commitment Plan General public (ESCP). Civil society organizations Interim Environmental IP organizations and Social Guidelines. Development partners Mass media Vaccination Plan. Project Different government Updated ESF Updated ESF Implementation ministries and instruments. documents to be agencies including uploaded on MOH and Ministry of Health, World Bank websites Ministry of Feedback of project within 30 days of project Communications, consultations. effectiveness. Ministry of Education, 5 Regional Health Authorities. Information about Traditional channels Hospitals and Medical project activities in of communications Facilities. line with the World (TV, newspaper and Health Organization radio). Local government units. (WHO) COVID-19 guidance on risk Local communities communication and Social Media. particularly those community around proposed isolation/quarantine engagement. centers. 106 | P a g e Project stage Target stakeholders List of Methods and timing proposed information to be disclosed Medical waste Ministry of Health’s collection and Facebook Page. management workers. Updated Vaccination Plan. General public. Information leaflets Civil society and brochures to be organizations. distributed with Development partners. sufficient physical distancing measures. Mass media. Public consultation meetings if situation improves. 7.5 Reporting Back to Stakeholders Stakeholders will be kept informed about the project progress, including reporting on project environmental and social performance and implementation of the SEP and GM. This will be done by disclosing relevant consultations reports in the MoH website. Also, information relevant to E&S matters will be announced in social media and communication channels such as TV and radio. Information leaflets and brochures will be distributed as well with sufficient physical distancing measures. Public consultations meetings will be also taken into consideration if the situation improves and in accordance with the national guidelines. 7.6 Grievance Procedures 7.6.1 Grievance Mechanism The main objective of a Grievance Mechanism (GM) is to assist to resolve complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Specifically, it provides a transparent and credible process for fair, effective and lasting outcomes. It also builds trust and cooperation as an integral component of broader community consultation that facilitates corrective actions. Specifically, the GM: ▪ Provides affected people with avenues for making a complaint or resolving any dispute that may arise during the course of the implementation of project; ▪ Ensures that appropriate and mutually acceptable redress actions are identified and implemented to the satisfaction of complainants; and ▪ Avoids the need to resort to judicial proceedings. The GM has been adopted and is described in the SEP, to date there have been no complaints 107 | P a g e received. The Ministry of Health already operates a complaint handling system across its health facilities to respond to issues pertaining to the quality of care received. The system does not make it clear if anonymous complaints can be submitted and investigated, but the final GM for the project will allow anonymous complaints to be submitted. The Environmental and Social Safeguard Specialist will ensure, based on the requirements as outline in ESMF and as established by the principles and practices of natural justice, anonymous complaints (grievances) will be accepted (see general public grievance form ATTACTMENT 3) There are several ways to lodge a complaint. These are: • By telephone: 627-0010 • In person at Ministry of Health Trinidad and Tobago, #63 Park Street, Port of Spain • In writing to the Customer Relations Officer / Representative at the following address: hospital complaints@health.gov.tt Walk-ins may register a complaint on a grievance logbook at healthcare facility, vaccination site or suggestion box at clinic/hospitals For non-quality of care related complaints the project will promote the IDB Health Sector Program’s GM • Toll-free telephone hotline: 800-WELL (9355); 877-WELL (9355) • E-mail qualitymanagement@health.gov.tt Once a complaint has been received, it will be recorded in the complaints logbook or grievance excel-sheet/grievance database. Grievances will be handled at the regional level by the respective Regional Health Authorities and at the national level by the Ministry of Health which will also be in charge of keeping a database of grievances and monitoring their resolution. The GM will include the following steps: Step 1: Submission of grievances either orally or in writing to the Regional Health Authorities. This can be done either orally, via telephone, email or written (through suggestion boxes). Suggestion boxes at the health centres shall be opened weekly. Step 2: Recording of grievance and providing acknowledgement, immediately for oral complaints and within two working days for written complaints. The complaints shall be recorded on a complaint register at each facility and then submitted to the MoH. These are 108 | P a g e then logged in a central database. Step 3: The complaints will be sorted and then forwarded to the respective departments for investigation. The resolution and communication to the complainant (if they identified themselves) shall take place within 7 days. Step 4: Complainant Response: either grievance closure or taking further steps if the grievance remains open. If grievance remains open, complainant will be given opportunity to appeal to Regional Health Authorities first and if needed at the national level (Judicial system of the Republic of Trinidad and Tobago, i.e. High Court, Industrial Court (IRA chapter 88.01 PART V Sec.51), Equal Opportunity Commission etc. Once all possible redress has been proposed and if the complainant is still not satisfied then they should be advised of their right to legal recourse. At no time should the complainant be given the impression that legal recourse is not available because they are using the GM. Up until step 3 there will be no financial cost associated with the filing of grievances. However, if the complaint remains unresolved or the complainant is dissatisfied with the outcome proposed by the MoH/RHAs, the Aggrieved Person may refer the matter to the appropriate legal or judicial authority, or Ministry of Labour/Industrial Court, at the complainant’s own expense. A decision of the Court will be final. 109 | P a g e 8.0 Implementation Arrangements, Responsibilities and Capacity Building This section describes the institutional arrangements to implement the ESMF including the screening of subprojects for environmental and social risks and impacts, preparation and consultation in relation to the assessment and identification of mitigation measures for subprojects, review, clearance and disclosure of documentation and instruments, and monitoring the implementation of the ESMP. 8.1 Implementing Agency 8.1.1 Technical Oversight Committee: There will be a Technical Oversight Committee, chaired by the Chief Medical Officer (CMO) and consisting of the Principal Medical Officers for Epidemiology and Institutions as well as other technical leads to ensure adequate procurement and overall Project implementation are in line with the MoH’s technical policies as related to the components under the loan. This Committee will also guide the relevant departments within the MoH and the Regional Health Authorities (RHAs). The Permanent Secretary, Ministry of Health will be overall responsible for the project and the project governance with an execution mechanism and governance arrangements for the World Bank Loan. 8.1.2 Project Implementation Unit (PIU) The Ministry of Health (MoH) has the overall implementation responsibility for the Project, including fiduciary, monitoring and evaluation (M&E), and environmental and social safeguards and rely on the existing Project Implementation Unit for execution and monitoring and evaluation of the loan components. Notably, the PIU established for the IDB’s Health Services Support Program33 to implement the Project activities and reports directly to the Permanent Secretary (PS) of the MoH. The MoH has designated the Project Implementation Unit established for the Inter-American Development Bank’s (IDB’s) Health Services Support Program (HSSP) as the Project Implementation Unit (PIU) for the World Bank COVID-19 project. The PIU reports directly to the Permanent Secretary (PS) of the MoH. The existing PIU will be strengthened through the hiring of four experts (one of them as part- time hire) within 30 days of Project effectiveness. The staff newly hired for the WBG Project will constitute a Sub-unit of the PIU. The sub-unit will share office spaces with the existing PIU (whenever in-presence working at 33 The Project (with Number: TT-L1039) was approved on December 17, 2014 and provides US$48.4 million for the objective of preventing and controlling risk factors and non-communicable diseases. 110 | P a g e the MoH is feasible) and rely on the same administrative support as the existing PIU. The PIU already includes a Financial Management Specialist, a Procurement Specialist, a Monitoring and Evaluation Specialist and an Administrative Assistant. The staffing arrangement for the World Bank loan consists of the following: • A Project Coordinator in charge of overseeing the implementation of the proposed Project (including the management of the contract with PAHO, monitoring, evaluation and reporting); • Financial Specialist; • Procurement Specialist; • Environmental and Social Specialist; and • Administrative Assistant. The WBG Project will finance the salaries of the PIU personnel to be hired for the implementation of the WBG Project, information technology (IT) equipment (i.e. one computer per staff hired) and the cost of extending the license of the SAGE50 accounting software to be used for the WBG Project as well. All other operational costs (e.g. office spaces etc.) will be covered by counterpart funds. A Technical Director (TD) of the PIU will be responsible to provide general oversight for the management of the staff and operations of the World Bank Loan and report directly to the Permanent Secretary or designate at the MoH. The TD has overall accountability for the project and will be responsible for the overall project management functions, including but not limited to planning, implementation, financial management, procurement, monitoring, and evaluation and reporting. In addition to the TD, the team responsible for project/project execution will include a Project Coordinator, Financial Specialist, Procurement Specialist, and an administrative assistant who will assist the TD in project execution. The Project Operations Manual, includes guidance on standard project fiduciary, environmental and social risk management (a summary of the ESMF and SEP provisions and arrangements, including for GM), implementation, and M&E requirements, as well as relevant official documents to be developed. However, the SEP and ESMF, along with the ESCP, are the documents that describe the ESF provisions and implementation arrangements. The ESCP also details reporting requirements for this project. The implementation of ESF instruments will be supported and monitored by World Bank staff throughout project implementation to assist the implementing agencies to undertake the planned environmental and social risk management measures, including stakeholder engagement and preparation of required management plans to be applied under the Project and provide training to the assigned staff. 111 | P a g e 8.1.3 COVID-19 Vaccine Task Force A COVID-19 Vaccine Task Force wasestablished to oversee the introduction of the COVID-19 Vaccine programme with Terms of Reference outlining roles and responsibilities. The Task Force assessed the Programme Plan, Monitored Progress and provided oversight for the following sections which comprise the Plan, namely: 1. Funding and Procurement; 2. Legal, Regulatory and Legislative Requirements; 3. Prioritization, Targeting and COVID-19 Surveillance Elements - Identification of the Target Populations, prioritization, demand generation & demographics; 4. Service Delivery - Human Resources, Training needs and Supervision; 5. Monitoring and Evaluation: determination and proof of eligibility, proof of vaccination, monitoring of coverage among at-risk groups, and monitoring of vaccine impact; 6. Vaccine, Cold Chain & Logistics; 7. Safety Surveillance; 8. Communications Planning; and, 9. Budget and Cost Breakdown Structures. 8.2 Capacity Building Trinidad and Tobago has been greatly challenged in responding to the unprecedented COVID- 19 pandemic. The project includes the provision of capacity development to reduce the risk of further spread of COVID-19 from use of medical facilities. Under Component 1 of the project, health care professionals will receive training on personal protective equipment (PPE) use and training related to the COVID-19 pandemic. The medical equipment and supplies financed under Component 1 will also require that staff and any contractors be trained in their use and receive any certification required. The ESCP has described the training required for the Project Implementation Unit and other relevant implementing support staff responsible for the Project on the Project’s Environmental, Social, and Health and Safety plans and instruments, fair, equitable and inclusive access and allocation of Project benefits, including with regards to vaccines, and the roles and responsibilities of key agencies in the ESF implementation. Project workers will receive training on the contents and requirements detailed in the ESMF, the Infection Control and Waste Management Plan and Emergency Preparedness and 112 | P a g e Response Plan to ensure compliance with environmental and social requirements. As of July 2023 some training on ESF related topics have been conducted by the Environmental specialist in four of the 5 Regional health authories, these are provided in Annex 9.8 The Envinronmental and Social Specialist that the Regional Health Authorities are aware of the Project GM and its functioning and contact points for referrals. Armed forces, if they are deployed in support of the project, shall be trained on the applicable standards and code of conduct in line with the guidance provided in the WB’s Technical Note “Use of Military Forces to Assist in Covid-19 Operations�. 8.3 E&S Risk Management Budget ESMF implementation costs are allocated according to the budget line items in the table below. Such costs include the E&S Specialists, training, and other costs to be determined during project implementation. Costs for undertaking travel to conduct monitoring and trainings as well as participation with World Bank supervision missions are also identified. The anticipated cost for all these initiatives is estimated at US$41,000 per year. Table 12: ESMF Annual Implementation Costs (Further interpretation and clarification is needed on this table’s content, is this still relevant to the project and if not should it be removed altogether. E&S risk management resource USD ESS Specialist $20,000 • Screening of activities • Preparation and disclosure of activity level instruments • Supervision, monitoring, and reporting • Information and communication • Monitoring including preparation of six-monthly monitoring reports on the environmental, social, health and safety (ESHS) performance of the project. • Training and workshops • Coordinating the project’s Grievance Mechanism • Implementing the Labour Management Procedure Training and Communications $3,000 • E&S specialist/s to travel to provide ESHS training at regional level. • Consultation activities in accordance with the SEP Supervision, monitoring, and reporting $15,000 • E&S specialist/s to travel to the various regions semi-annually for conducting project supervision, monitoring and reporting Other items like materials and supplies for consultations $3,000 TOTAL $41,000 113 | P a g e 114 | P a g e 9.0 Annexes 9.1 Annex I - Screening Form for Potential Environmental and Social Risks This form is to be used by the Project Implementation Unit (PIU) to screen for the potential environmental and social risks and impacts for different types of project activities. It will help the PIU in identifying the relevant Environmental and Social Standards (ESS), establishing an appropriate E&S risk rating for these subprojects and specifying the type of environmental and social assessment required, including specific instruments/plans. Use of this form will allow the PIU to form an initial view of the potential risks and impacts of a subproject. It is not a substitute for project-specific E&S assessments or specific mitigation plans, if needed for different kinds of activities. The screening form will be used for participating health facilities benefiting from the project (e.g. receiving equipment, vaccines and PPE). Subproject Name Subproject Location Subproject Proponent Estimated Investment Start/Completion Date Questions Answer ESS relevance Due diligence / Yes no Actions Does the subproject involve civil works ESS1 ESIA/ESMP, including new construction, expansion, SEP upgrading or rehabilitation of healthcare facilities, vaccine cold storage units and/or waste management facilities? Is the subproject associated with any ESS3 ESIA/ESMP, external waste management facilities such SEP as a sanitary landfill, incinerator, or wastewater treatment plant for healthcare waste disposal? Is there a sound regulatory framework and ESS1 ESIA/ESMP, institutional capacity in place for SEP healthcare facility infection control and healthcare waste management? Does the subproject have an adequate ESS3 IWCMP system in place (capacity, processes and management) to address waste? Does the subproject involve recruitment of ESS2 LMP, SEP workers including direct, contracted, primary supply, and/or community workers? Does the subproject have appropriate ESS3 ESIA/ESMP, OHS procedures in place, and an LMP adequate supply of PPE (where necessary)? 115 | P a g e Questions Answer ESS relevance Due diligence / Yes no Actions ESS10 SEP, GM Does the subproject have a GM in place, to which all workers have access, designed to respond quickly and effectively? ESS3 ESIA/ESMP, Does the subproject involve SEP transboundary transportation (including Potentially infected specimens may be transported from healthcare facilities to testing laboratories, and transboundary) of specimen, samples, infectious and hazardous materials? Does the project area present ESS1 ESIA/ESMP, considerable Gender-Based Violence SEP (GBV) and Sexual Exploitation and Abuse (SEA) risk? Does the subproject carry risk that ESS1 ESIA/ESMP, disadvantaged and vulnerable groups may SEP have unequitable access to project benefits? Conclusions: 1. Proposed Environmental and Social Risk Ratings (High, Substantial, Moderate or Low). Provide Justifications. 2. Proposed E&S Management Plans/ Instruments. 116 | P a g e 9.2 Annex II – Environmental and Social Management Plan (ESMP) This Environmental and Social Management Plan (ESMP) is an instrument that details (i) the measures to be taken during the implementation and operation of project activities to eliminate or offset adverse environmental and social impacts, or to reduce them to acceptable levels; (ii) the actions needed to implement these measures and (iii) the responsibilities, timelines and budget required. This ESMP for Project activities has been prepared consistently with regards to the following project documents: ▪ Environmental and Social Management Framework (ESMF) ▪ Infection Control and Waste Management Plan (ICWMP) ▪ Labour Management Procedure (LMP) ▪ Stakeholder Engagement Plan (SEP) ▪ Environmental and Social Commitment Plan (ESCP) This ESMP template was adapted from the World Bank ESMF template for COVID-19 response, and includes several matrices identifying key risks and setting out the required E&S mitigation measures. The matrices illustrate the importance of considering lifecycle management of E&S risks, including during the different phases of the project identified in the ESMF: planning and design, construction, operations and decommissioning. The WBG EHS Guidelines, WHO technical guidance documents and other GIIPs provide additional detail on the various mitigation measures and good practices, and can be used by the E&S specialists to provide additional information during implementation of the ESMP. Proper stakeholder engagement should be conducted in determining the mitigation measures, including close involvement of medical and healthcare waste management professionals. This ESMP should be incorporated into project activities during implementation, including any bidding document and/or contract document. The tables below describes the various stages of the project, the risks, major mitigation measures recommended, responsibilities, timelines and allocated budget. 117 | P a g e ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN (ESMP) CHECKLIST ENVIRONMENTAL /SOCIAL SCREENING Will the site activity Activity Status Additional references include/involve any of A. General conditions See Section A the following potential B. General construction/installation of the mobile issues/risks: COVID 19 hospital activities or repurposing of Health Care Facilities (reconstruction) • Site specific vehicular traffic [] Yes [ ] No If “Yes� , See Section A, B below • Increase in dust and noise from construction activities • Generation of waste • Transport of materials and waste C. Are the construction/installation of the mobile COVID 19 hospital activities taking place near water bodies such as rivers, lakes, etc.? • Increase in sediments loads in water bodies [] Yes [ ] No If “Yes�, See Section A, B below • Changes of water flow • Pollution of water due to temporary waste disposal or spill leakages • Need for cutting the trees in the hospital D. Vicinity of any historical building/s or areas • Risk of damage to known/unknown [ ] Yes [] No If “Yes�, See Section A, B, C below historical buildings/areas • Risk of damage of nearby hospital buildings E. Traffic and Pedestrian Safety • Site specific vehicular traffic in the hospital [] Yes [ ] No If “Yes�, See Section A, B, C below • Site is in a populated area F. Usage of hazardous or toxic materials and generation of hazardous waste1 • Removal and disposal of toxic and/or hazardous waste (infective waste) during the [] Yes [ ] No If “Yes�, See Section A, B, D below installation activities during construction/reconstruction works • Removal and disposal of infection waste during the operation of mobile hospital/vaccination point • Storage of machine oils and lubricants 1 Toxic/hazardous materials include but not limited to fuels, motor/hydraulic oils, lubricants, toxic paints, etc. 118 | P a g e ENVIRONMENTAL /SOCIAL SCREENING G. Does the subproject involve recruitment of workers including direct, contracted, primary [ ] Yes [] No If “Yes�, See Section A, B, C, D below supply, and/or community workers? H. Are there any restrictions and health measures in [ ] Yes [] No If “Yes�, See Section A, B, C, D, E below force due to COVID 19 pandemic? I. Does the project have a GM in place, to which all workers have access, designed to respond [ ] Yes [] No If “Yes�, See Section A, B, C, D, F below quickly and effectively? 119 | P a g e ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST Community OH&S measures: (a) The public in the Area should be notified of the works through appropriate notification in the media and/or at publicly accessible sites (including the site of the works, Regional Corporation information table and Regional Corporation website, local community and Healthcare Facility (HCF) notice board); (b) The Regional Corporation should be notified for the project activities construction of the mobile hospital (If required); (c) All legally required permits have been acquired for the project activities; (d) Preparation of the Traffic Management Plan (explanations if it is needed) (e) Preparation and implementation of the Site Management Plan; • Appropriate installation of signposting of the project site will inform workers of key rules and regulations to follow; • Ensure appropriate marking out and out of the reconstruction site; • Placed warning tapes signalizing forbidden entrance of unemployed persons. (f) All work will be carried out in a safe and disciplined manner designed to minimize impacts on workers, patients, health workers, citizens at the project location and environment; OH&S measures for workers: (g) Community and Worker’s OH&S measures should be applied (first aid, protective clothes for the workers, appropriate machines and tools); Community safety and (h) Workers who will be engaged, will comply with international good practice (will always wear hats, masks and A. General Conditions safety glasses, harnesses and safety boots); OH&S for workers (i) Equipment should be handled only by experienced and trained personnel, thus reducing the risk of accidents; Implementation of the proposed measures for protection from COVID 19 adopted by the Government of the Republic Trinidad and Tobago at the proposal of the Ministry of Health; (j) Stay up to date with the newest instructions/recommendations provided by the official authorities (k) Nomination of one person from the Contractor that will be responsible for following the measures adopted by the Government and will apply them in the operation of the construction site at the project location. (l) To ensure implementation of all necessary requirements by providing the necessary protection personal equipment for all workers on site according the proposed measures: keeping records on COVID 19 cases, support workers who are in quarantine and regular informing the official institutions if any case occur. (m) Implementation of measures for COVID - 19 for different aspects are given in ANNEX IV that are related with OH&S during COVID – 19 pandemic. . Firefighting measures: (n) There is an appointed person on the site responsible for the fire protection; (o) Procedures in the case of fire are well known to all employees; (p) Constant presence of firefighting devices should be ensured in case of fire or other damage. Their position is communicated to workers and marked. The level of fire-fighting equipment must be assessed and evaluated through a typical risk assessment (fire risk assessment); (q) The part of the project location that is not under construction should be kept clean. 120 | P a g e ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST (a) Construction machinery and equipment should be in proper working condition; (b) At the project location there should be Spill prevention kit which will prevent further extension of the spillage; Accidents prevention (c) Firefighting distinguishers should be in proper condition; (d) Work site should be protected by a warning type. (a) Identify numbers and types of workers; (b) Consider ways to minimize/control movement in and out of construction area/site; (c) If workers are accommodated on site require them to minimize contact with people outside the construction area/site or prohibit them from leaving the area/site for the duration of their contract; (d) Implement procedures to confirm workers are fit for work before they start work, paying special to workers with underlying health issues or who may be otherwise at risk; (e) Check and record temperatures of workers and other people entering the construction area/site or require self- reporting prior to or on entering; Labour issues (f) Provide daily briefings to workers prior to commencing work, focusing on COVID-19 specific considerations including cough etiquette, hand hygiene and distancing measures; (g) Require workers to self-monitor for possible symptoms (fever, cough) and to report to their supervisor if they have symptoms or are feeling unwell; (h) Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days; (i) Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days. B. General (a) Ensure all vehicles and machinery use fuel from official sources (licensed gas stations) and on fuel Air Emission and Air determined by the machinery and vehicles producer; construction of the Quality (b) Ensure all transportation vehicles and machinery is regularly maintained and attested; mobile COVID 19 hospital or (c) All machinery needs to be equipped with appropriate emission control equipment; (d) When transporting waste/materials the vehicles must be covered in order to decrease the dust emission; repurposing of Health (e) To minimize dust the construction materials should be stored in appropriate places and be covered; Care Facilities – (f) Washing of road transport vehicles and wheels will be conducted regularly, in previously identified sites reconstruction equipped with, minimally, oil and grease collector; activities (g) Clearing activities must be done during agreed working times and permitting weather conditions to avoid drifting of dust into neighboring area. Noise disturbance (a) The level of noise should not exceed more than the national limit level (according to national legislation for areas of degree of noise protection – due to hospital areas and EMA requirement); (b) The construction of the mobile COVID19 hospital or repurposing of Health Care Facilities (reconstruction) work should 121 | P a g e be not permitted during the nights, the operations on site shall be restricted to the hours 7.00 -19.00; 122 | P a g e ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST (c) Noise suppression measures must be applied to all construction equipment. During operations the engine covers of generators, air compressors and other powered mechanical equipment should be closed. Should the vehicles or equipment not be in good working order, the constructer may be instructed to remove the offending vehicle or machinery from the site; (d) Mechanical equipment is effectively maintained. 123 | P a g e (a) Containers for each identified waste category are provided in sufficient quantities and positioned for separate collection; (b) Communal service enterprise for waste collection (……….) is the responsible for communal and inert waste collection and transportation within the (………) Regional Corporation. The waste disposal will be performed in the (……...) landfill. For the expected waste types from cleaning and construction of the mobile hospital or repurposing of Health Care Facilities (reconstruction) activities the waste collection and disposal pathways and sites will be identified; (c) The different waste types that could be generated at the construction site need to be identified and classified according to the List of Waste (d) The main waste would be classified under Construction and demolition wastes (including excavated soil from contaminated sites, excavated soil, mixed waste from construction site, Waste from concrete, infection waste, chemicals consisting of or containing dangerous substances, medicines other than cytotoxic and cytostatic, asphalt; (e) Small amount of solid municipal waste can be found (beverages, food), as well as packaging waste (bottles, paper, glass, etc.); (f) The construction waste will be separated from the general waste, liquid and chemical waste on site, by sorting in Waste management appropriate containers; (g) The medicines other than cytotoxic and cytostatic from the mobile COVID 19 hospital will be separated from the general waste on site, by sorting in appropriate containers; (h) The records of waste disposal will be regularly updated and archived; (i) Only licensed collectors of waste (with whom the hospital in (………) RHA will sign the Contract) will collect and dispose of the medicines other than cytotoxic and cytostatic; (j) Only licensed collectors of waste will collect and dispose of the construction waste (k) All of the records of the disposed waste will be kept as proof for proper management; (l) Construction waste from site needs to be instantly removed and reused if possible; (m) For the possible hazardous waste (motor oils, vehicle fuels) an authorized collector needs to be appointed to collect and dispose of it properly; (n) The materials should be covered during the transportation to avoid waste dispersion; (o) Burning of medical waste should be prohibited; (p) Burning of construction waste should be prohibited; (q) Estimate potential waste streams; (r) Consider the capacity of existing facilities, and plan to increase capacity, if necessary, through construction, expansion etc.; (s) Specify that the design of the facility considers the collection, segregation, transport and treatment of the anticipated volumes and types of healthcare wastes; 124 | P a g e ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST (t) Require that receptacles for waste should be sized appropriately for the waste volumes generated, and color coded and labeled according to the types of waste to be deposited; (u) Develop appropriate protocols for the collection of waste and transportation to storage/disposal areas in accordance with WHO guidance; (v) Design training for staff in the segregation of wastes at the time of use; (w) Where possible avoid the use of incinerators; (x) If small-scale incineration is the only option, this should be done using best practices, and plans should be in place to transition to alternative treatment as soon as practicable (such as steam treatment prior to disposal with sterile/non-infectious shredded waste and disposed of in suitable waste facilities); (y) Do not use single-chamber, drum and brick incinerators; (z) If small-scale incinerators are used, adopt best practices to minimize operational impacts. (a) In the event when hazardous spillage occurs, it needs to be stopped and removed, then the site needs to be cleaned and the procedures and measures for hazardous waste management need to be followed; (b) In the case of any run-off coming from the works, in order to avoid contamination of the area it needs to be collected on site and placed in a temporary retention basin; Water and soil (c) The temporary or final disposal of any waste stream near the water courses is forbidden; (d) Servicing of vehicles and machinery is forbidden to be conducted on the construction-site; (e) Prevent as much as possible, oil and other pollutants leakages to water and soil. (a) Collection of the generated waste on daily basis, selection of waste, transportation and final disposal on Nature protection appropriate places; (b) After finishing with construction/installation activities, the location should be return to the pre work condition and if not possible than it will be adequately managed. 125 | P a g e (a) The routes for the machines are clearly defined; (b) Access of the construction and material delivery vehicles are strictly controlled, especially during the wet weather; (c) Ensure all transportation vehicles and machinery have been equipped with appropriate emission control equipment, regularly maintained and attested (d) Distribution of materials for the construction of the mobile COVID 19 hospital need to be announced and coordinated with the (……...) Regional Corporation. The Contractor will take safety measures to prevent Transport and Materials accidents; Management (e) All materials prone to dusting are transported in closed or covered trucks; (f) All materials prone to dusting and susceptible to weather conditions are protected from atmospheric impacts either by windshields, covers, watered or other appropriate means; (g) Project area is regularly swept and cleaned. Spilled materials are immediately removed from a project area and cleaned. Access roads are well maintained and safety for and safe for the movement of healthcare workers and patients. (h) Technical specifications for procuring equipment should require good hygiene practices in line with WHO technical guidance to be observed when preparing the procured goods. (i) Good hygiene and cleaning protocols should be applied. During the transport, truck drivers should be required to wash hands frequently and /or be provided with hand sanitizer, and taught how to use it. 126 | P a g e ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST C. Traffic and Direct or indirect hazards The construction site including the regulation of the traffic will be accordingly secured by the Contractor. This Pedestrian Safety to public traffic and includes but is not limited to: children and parents and (a) The citizens from the neighboring buildings (……….) need to be timely informed of the upcoming works; construction of the (b) In the operational phase the citizens will need to obey the established traffic regime; (c) In an event where the traffic around the project area will be interrupted the Contractor in cooperation with the mobile hospital (………) Regional Corporation need to organize alternative routes; activities (d) Placing of sign posts, warning signs, barriers (vertical signalization and signs at the construction site): the citizens will be warned about the potential hazards; (e) Adequate warning tapes and signage need to be provided and placed; (f) Forbidden of entrance of unemployed persons within the fence; (g) Set up a special traffic regime for the vehicles of the contractor during the period of construction of the mobile hospital (together with the municipal staff and police department) and installation of signs to ensure safety, traffic flow and access to land and facilities; (h) During the operational phase a special traffic regime for the vehicles entering the hospital needs to be prepared; (i) Ensure pedestrian safety. Special focus for safety of citizens if the project activities take place during the citizens works (fence off the site, install safe corridors, etc.). (a) Temporarily storage on site of all hazardous or toxic substances (including wastes) will be in safe containers labeled with details of composition, properties and handling information. Chemicals and medical waste are managed, used and disposed, and precautionary measures taken as required in the Safety Data Sheets (SDS); (b) The containers with hazardous substances including medical waste must be kept closed, except when adding or removing materials/waste. They must not be handled, opened, or stored in a manner that may cause them to leak; D. Usage of hazardous (c) The medical waste and the waste containing disinfectants during the operational phase needs to be stored in Toxic / hazardous labeled containers that will not leak; or toxic materials and materials management (d) The containers holding ignitable or reactive wastes must be located at least 15 meters from the facility’s property generation of and Hazardous line. Large amounts of fuel will not be kept at the site; hazardous (e) The containers of hazardous substances shall be placed in a leak-proof container to prevent spillage and waste waste and infectious leaking. This container will possess secondary containment system such as bunds (e.g. banded-container), management waste during double walls, or similar. Secondary containment system must be free of cracks, able to contain the spill, and be operation emptied quickly; (f) Hazardous waste (medical waste) should not be mixed and will be transported and disposed/incinerated only by licensed companies in line with the national regulation; (g) Possible hazardous waste (motor oils, vehicle fuels, lubricants) should be collected separately and authorized company should be sub-contracted to transport and finally dispose the hazardous waste; (h) Hazardous waste will be disposed only to licensed landfills or processed in licensed processing Plants; 127 | P a g e (i) Paints with toxic ingredients or solvents or lead-based paints will not be used; (j) Provide cleaning staff with adequate cleaning equipment, materials and disinfectant ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST (k) The safe health-care waste management should have applied for the Infectious waste (hazardous health-care waste) according the national legislation, guidance from the Ministry of Health and WHO recommendations (l) Review general cleaning systems, training cleaning staff on appropriate cleaning procedures and appropriate frequency in high use or high-risk areas; (m) Where cleaners will be required to clean areas that have been or are suspected to have been contaminated with COVID-19, provide appropriate PPE: gowns or aprons, gloves, eye protection (masks, goggles or face screens) and boots or closed work shoes. If appropriate PPE is not available, provide best available alternatives; (n) Train cleaners in proper hygiene (including handwashing) prior to, during and after conducting cleaning activities; how to safely use PPE (where required); in waste control (including for used PPE and cleaning materials). (o) Develop Infection Control and Waste Management Plan for vaccination program to consider the use of non- HCF for deployment (p) Estimate potential waste streams, including sharps and vaccine program wastes (a) Implement good infection control practices (see WHO Infection Prevention and Control for the safe Arrangements are E. Mortuary management of a dead body in the context of COVID-19); insufficient/ arrangements (b) Use mortuaries and body bags, together with appropriate safeguards during funerals (see WHO Practical Processes are insufficient considerations and recommendations for religious leaders and faith-based communities in the context of COVID-19). (a) PIU is responsible for implementation of the project activities will establish two types of Grievances: Health Care Workers Grievance Form and General Public Grievance Form. Grievance forms will be available at the location where the activities will take place, as well as on the MoH website (b) Any comments/concerns/grievance can be submitted to the MoH on-line, verbally (personally or by telephone) or in writing by filling in the Project Grievance Form (by personal delivery, post, fax or e-mail to the MoH F. Grievance Types of Grievance contact person). Individuals who submit comments or grievances have the right to request that their name be Mechanism kept confidential. Grievances may be submitted anonymously, although in such cases, the person will not receive any response. All comments and grievances will be responded to either verbally or in writing, in accordance with the preferred method of communication specified by the complainant, if contact details of the complainant are provided. (c) The complainant will be informed about the proposed corrective action and follow-up of corrective action within 15 calendar days upon the acknowledgement of grievance. The acknowledgment will be done within 48 hours. 128 | P a g e MONITORING PLAN How much When What Where How is the parameter By Whom is the cost parameter is to is the parameter to is the parameter to be monitored (what to be monitored is the parameter to be associated with be monitored? be monitored? should be measured and how)? (timing and monitored– implementation frequency)? (responsibility)? of monitoring Preparatory phase By checking if there is a Board with information about the Contractor and Supervisor, fencing and marking the location, to prevent health Supervisor Community safety Before works Included in the On the site and safety risks – mechanical injures and to Representative from and OH&S for commencemen project budget provide safe access and mobility of all which will the Regional workers t be affected near the project location in (……...) Corporation/RHA of Regional Corporation (………) Obtained all Supervisor (……..) Regional Inspection of all Included in the required permits Before works start Representative from Corporation required project budget … the ( …… …) Regional . documents Corporation By checking if there are spill kits, Supervisor firefighting appliances, the vehicles and Before works Included in the Accidents prevention On the site Representative from equipment is in working condition at the commencemen project budget … the ( ………) RHA project location in t RHA/Regional Corporation of (…………) Construction of the mobile COVID 19 hospital phase or repurposing of Health Care Facilities Upon complaint or Air emission and Air At and around Accredited Contractor Measurement of concentration of dust in the air negative quality (dust) the site inspection finding laboratory/ Supervisor budget Contractor; Accredited company for Measuring levels of noise should be carried out Part of the measuring the Noise disturbance On site in the case of complaints and negative findings Regularly regular level of provided by of the inspection. Contractor cost the contractor; Authorized environmental inspector, Construction inspector, RHA/PIU 129 | P a g e Contractor – Bidder At the beginning of Review the documentation – identification of Supervisor (………) Included in the Waste management On the site works, than the waste type according the List of waste, Regional project budget periodically Corporation HCF 130 | P a g e MONITORING PLAN How much When What Where How is the parameter By Whom is the cost parameter is to is the parameter to is the parameter to be monitored (what to be monitored is the parameter to be associated with be monitored? be monitored? should be measured and how)? (timing and monitored– implementation frequency)? (responsibility)? of monitoring - Visual inspection that the waste is collected separately in adequately labeled containers, leakages. - review of the waste Contracts and licenses of companies contracted for the collection and disposal of waste Contractor; Supervisor of the At the site of the construction works; construction and where the During the works, Included in the Water and soil Visual checks Authorized machines and vehicles daily project budget environmental are operating inspector, EMA Contractor On the site and around Included in the Nature protection Visual checks Periodically Supervisor (………) the construction site project budget Regional Corporation/RHA Part of the Transport and Visual checks on how the materials are On site Regularly Supervisor regular Materials Management disposed of and whether they are properly Contractor cost transported Check the documentation: Direct or indirect hazards - Whether all competent authorities have to public traffic on been notified, Included in the construction of the On the site - Whether all the necessary permits and Continuously Contractor project budget mobile COVID 19 approvals have been obtained, hospital activities Visual check of the transport of materials, corridors and crossings, traffic regulation, etc. 131 | P a g e -Proper handling and storage is checked Toxic / hazardous Part of the according to Safety Data Sheets (SDS) Supervising materials management On site visual assessment Continuously, regular -Visual inspection and review of documents engineer, Inspection and (hazardous waste when the Contractor cost in terms of: Contractor Hazardous containers and remains are Included in the - Adequate collection and storage of hazardous Supervisor waste documentation) removed project budget and toxic substances (including fuel) and waste management 132 | P a g e MONITORING PLAN How much When What Where How is the parameter By Whom is the cost parameter is to is the parameter to is the parameter to be monitored (what to be monitored is the parameter to be associated with be monitored? be monitored? should be measured and how)? (timing and monitored– implementation frequency)? (responsibility)? of monitoring - Transportation, disposal and incineration of hazardous waste only by authorized companies, - Review of declarations of purchased paint and solvents (avoidance of hazardous paint and solvents) Operation Phase of the installed mobile COVID 19 hospital or repurposing of Health Care Facilities (reconstruction) Representatives from Plan for regular WASA and Facilities Before the start of maintenance of the Manager the Hospital On site visual assessment Overview of the Plan for regular and the operation of Hospital installations (water supply, RHA and checks of the preventive maintenance the hospital budget sewage network, Responsible persons electricity, heating) within documentation employed in the the hospital hospital Facilities Manager RHA and To ensure that all fire Review of the Plan and proposed fire At the beginning of MSE Manager Hospital Fire Protection Plan protection measures protection measures and risk assessment hospital operation. employed in the budget are implemented hospital Facilities Manager/HCF - Adequate collection and storage of Representatives from hazardous and toxic substances (including medical infectious waste), including sharps Continuously after the Regional Waste management On site visual assessment the start of the Corporation Health and vaccine program wastes and other waste Hospital plan (special attention care inspector and checks of the streams operation of the budget to infectious waste) HSE Manager documentation - Signing contract for transportation, disposal hospital/HCF and incineration of hazardous waste employed in the (including medical infectious waste) only by hospital authorized companies, - Review of declarations of purchased disinfectants 133 | P a g e Visual evaluation and check if all health Every day Labour management Human Resource On site visual assessment care measures for medical workers and before the Hospital procedures applied for Manager and checks of the applied starting the budget all medical staff Ministry of Labour Small documentation The medical PPE provided in appropriate medical care Enterprise Development quantity activities, cleaning to each medical person 134 | P a g e MONITORING PLAN How much When What Where How is the parameter By Whom is the cost parameter is to is the parameter to is the parameter to be monitored (what to be monitored is the parameter to be associated with be monitored? be monitored? should be measured and how)? (timing and monitored– implementation frequency)? (responsibility)? of monitoring activities, etc. in the mobile hospital On line, on the web page of MoH Reporting of adverse reactions from the application of the vaccine is done electronically on a Form that Vaccine adverse is published on the website effects from physicians collection of complaints related to vaccine During the Included in of the Agency adverse effects from physicians and reporting vaccination MoH budget. https://health,gov.tt or in upon them. process written Form through the registry office 135 | P a g e Procurement Stage Activity Significant Potential Risks / Impacts Key Mitigation Methods Responsibilities Timeline Budget 1. Equipment Procurement of Failures in procurement process e.g. Due diligence and assessments will be laboratory and equipment that is inappropriate and undertaken by MoH regarding purchase of medical equipment could lead to: equipment to ensure correct fit for purpose equipment is procured to local standards. • spread of infection to health- care workers and/or cleaners. Energy efficient equipment will be favoured. • health & safety risks to workers. • adverse environmental impacts. 2. Goods and Services Procurement of Failures in the procurement process Due diligence and assessments will be N/A goods e.g. PPE e.g. incorrect standard or quality of undertaken by MOH to ensure fit for purpose PPE leads to spread of infection to equipment is procured. health-care workers. The MOH purchases will follow the WHO interim Procurement and use of goods will not guidance on rational use of PPE for coronavirus be sustainable. disease 2019 which describes the types of PPE 136 | P a g e Activity Significant Potential Risks / Impacts Key Mitigation Methods Responsibilities Timeline Budget that are required for different functions. Sustainable use of goods and materials will be encouraged through capacity building and training of health service personnel. Procurement of The global demand for the vaccine and Explore all options for vaccine procurement vaccines the limited vaccine production makes (including donations) access to the COVID- 19 vaccines a risk Implementation Stage Activity Significant Potential Risks / Impacts Key Mitigation Methods Responsibilities Timeline Budget 1. Equipment Use of medical and Occupational health and safety risks Labour Management Procedures (LMP) have LMP laboratory related to exposure to infections / been developed and will be implemented to equipment diseases e.g. from testing, laboratory protect project direct workers and contracted and health care waste, treatment of staff who may be at risk of exposure to infected ICWMP COVID-19 patients etc. patients, hazardous waste etc. Occupational health and safety risks An Infection Control and Waste Management Worker H&S plans related to the delivery and storage of Plan (ICWMP) has been developed and will be goods, including samples, implemented. pharmaceuticals, reagents and other Worker H&S Management plans will be SEP 137 | P a g e hazardous materials. developed by MOH and submitted to the E&S Specialist for approval prior to activities Surfaces of imported materials may be commencing. Development of H&S plans will contaminated during handling and refer to IFC EHS Guidelines – 2.0 Occupational transportation which may result in the Health and Safety. spread of infection. If concerned about contaminated imported General occupational health and materials (for example when dealing with goods safety risks from working in a medical that have come from countries with high facility /laboratory e.g. manual handling numbers of infected people) equipment may be injuries, such as sprains and strains decontaminated using disinfectant. After from lifting and carrying patients; falls, disinfecting, workers should wash hands with trips, and slips; injuries caused by soap and water or use alcohol -based hand rub. moving objects; and mental stress fatigue, psychological distress, stigma. Clear communication of risks and prevention measures will be included in training and stakeholder engagement activities. Training and awareness raising should incorporate the WHO guidance tools for COVID-19 preparedness and response including the COVID-19 Risk Communication Package for Healthcare Facilities which provides healthcare workers and healthcare facility management with the information, procedures, and tools required to safely and effectively work. 2. Goods and Services 138 | P a g e Use of goods Incorrect use of PPE leads to spread Infection Control and Waste Management Plan ICWMP including PPE of infection to health-care workers and (ICWMP) was developed and will be SEP cleaners. implemented. Inequitable distribution of goods. Clear communication of risks and prevention Negative reaction to perceived measures will be included in training and unfairness of resource distribution. stakeholder engagement activities. MOH has committed to the provision of services and supplies to all people in the project ESCP. COVID-19 testing Improper collection of samples and Collection of samples, transport of samples and LMP and diagnosis testing for COVID-19 and appropriate testing of the clinical specimens from patients laboratory biosafety could result in meeting the suspect case definition will be spread of disease to medical workers performed in accordance with WHO interim ICWMP or laboratory workers, or population guidance “Laboratory testing for coronavirus during the transport of potentially disease 2019 (COVID-19) in suspected human affected samples. cases.� Tests will be performed in appropriately equipped laboratories (specimen handling for molecular testing requires BSL-2 or equivalent facilities) by staff trained in the relevant technical and safety procedures. National guidelines on laboratory biosafety will be followed. There is still limited information on the risk posed by COVID-19, but all procedures will be undertaken based on a risk assessment. For more information related to COVID-19 risk 139 | P a g e assessment, see specific interim guidance document: WHO interim guidance for laboratory biosafety related to 2019-nCoV. Samples that are potentially infectious materials (PIM) will be handled and stored as described in WHO guidance to minimize risks for facilities collecting, handling or storing materials potentially infectious for polioviruses (PIM Guidance). For general laboratory biosafety guidelines, see the WHO Laboratory Biosafety Manual, 3rd edition. Generation of Medical waste management and Project ICWMP developed and implemented to ICWMP (see health care wastes community health and safety issues ensure the correct separation, storage, Appendix III) related to the exposure, handling, transport and disposal of health care wastes transportation and disposal of (both infectious, hazardous and non-infectious hazardous and infectious health-care wastes). wastes with respect to physical harm Training of medical, laboratory and waste (eg cuts and bruises), disease management personnel to ensure compliance transmission and contamination of the with the ICWMP, National Infection Prevention receiving environment such as soil or and Control Policy 2018, WHO guidance and water. GIIP. Waste handlers and offsite disposal The following preventive measures can also facilities (if used) are exposed to hcw is be implemented during an emergency 140 | P a g e not properly segregated and as such response phase to reduce public and enter the municipal waste system occupational health risks: • Provide hepatitis B vaccination to all health care personnel and waste handlers. • Encourage hand hygiene • Use gloves and masks for handling HCW. • Contain and promptly clean up spillages of infectious materials and disinfect quickly to avoid pathogen transmission. • Disinfect body fluids before their discharge. • Conduct on-site awareness-raising activities to remind health care personnel about occupational exposures and the safe practices for managing HCW. Wastes from The vaccination activities will The management of wastes from the ICWMP COVID-19 produce wastes such as sharps vaccination program will be in accordance Vaccination and infectious non-sharp wastes with the ICWMP. Measures to be that can cause direct negative implemented include the following: health impacts on the community • Segregate sharps from non-sharps and healthcare workers. There are also indirect health effects to the • Discard entire syringe with needle into 141 | P a g e community and environment a biohazard container immediately resulting from inadequate after use treatment and disposal of these • All opened/expired/used vials labels wastes. have to be blackened out before disposal in the designated biohazard containers Waste treatment and final disposal: • The biohazard container with the vaccine vials will be collected by the EPI drivers and taken to Central Level where they will be accounted for. They will then be transported to the allocated incinerator. • Properly incinerate the infectious medical wastes within the facility’s premises. If the facility does not have the incineration facilities, ensure appropriate measures for safe handling and transportation to a nearby incinerator. • If waste is moved off-site, an assessment will be carried out to understand where and how it will be treated and disposed. Monitoring will be ensured for appropriate waste management including incineration at controlled temperatures. 142 | P a g e • All healthcare facilities should manage the medical waste through incineration facilities. Incineration should only be used for waste that may already require incineration (pathological/trace chemical/non-hazardous medical waste). Follow the WHO guidance, Safe management of wastes from health-care activities (https://apps.who.int/iris/bitstream/handle/1066 5/259491/WHO-FWC-WSH-17.05- eng.pdf;jsessionid=D5B2E6A28927FB7CA2C3 4177481A6827?sequence=1) Return to Supplier. The vaccine procurement program will apply the Extended Producer Responsibility (EPR) concept or return back condition as a green procurement approach in managing vaccine wastes. The return-back condition in the contract agreement with n vaccine suppliers will be specifically applied i areas with limited capacities for safe onsite disposal or in areas with no available third-party hazardous waste treatment facilities or whose municipal landfills do not have dedicated cells for hazardous wastes. 143 | P a g e Poor sanitation and Poor sanitation and improper Health facilities will ensure the provision of safe ICWMP improper management of wastewater related to water, sanitation, and hygienic conditions, management of COVID-19 diagnosis and treatment which is essential to protecting human health wastewater services transmitting diseases to during all infectious disease outbreaks, communities and polluting including the COVID-19 outbreak. environment. Health facilities will establish and apply good practices in line with WHO guidance on water, sanitation and waste management for COVID- 19, the National Infection Prevention and Control Policy 2018, and the ICWMP. Operation of the Air quality negatively impacted by The E&S Specialist will follow the EMA’s air Follow air pollution incinerators incinerators e.g. Persistent Organic pollution permit process (if applicable) to permit process Pollutants (POP) emissions when not identify the status of permits and approvals, and operated at the correct temperatures. then apply the identified conditions for the Incinerators can generate particulates, incinerators and autoclaves. ICWMP heavy metals, dioxins and furans, which may be present in the waste gases, water or ash. Project ICWMP developed and implemented to EHS Plan ensure the correct separation, storage, Incorrect disposal of ash or transport and disposal of health care wastes inadequately sanitized waste causing (both infectious, hazardous and non-infectious adverse environmental and social wastes). impacts e.g. soil contamination and/or spreading the virus. Training for operators on operation of the Operator Training incinerators including the method to achieve the Other minor environmental impacts Plan desired combustion conditions and emissions 144 | P a g e associated with the operation of the will be provided for example, appropriate start- incinerator such as minor fuel spills. up and cool-down procedures, achievement Maintenance Plan and maintenance of a minimum temperature Community health and safety impacts before waste is burned, use of appropriate from reduced air quality due to the loading/charging rates (both fuel and waste) to incorrect positioning or operation of the maintain appropriate temperatures, proper incinerators. disposal of ash and equipment to safeguard OHS impacts to staff operating the workers. incinerator (contact with contaminated Project will further develop and implement medical waste, reduced air quality and existing maintenance plans that specify the use of combustible fuel etc.) responsibilities for regular maintenance Temperature of incinerators is not schedules to replace or repair defective sufficient to kill viruses. components. Maintenance plans will be prepared by the MOH and submitted to the E&S Lack of ongoing maintenance causing Specialist for approval and use in training. incinerators to no longer operate or operate inefficiently. Cold Chain The use of refrigerants in the cold chain Use of alternative refrigerants with low climate Vaccination Plan Operation system can cause depletion of the impact in the refrigeration system (including ozone layer and can contribute to Use of more energy-efficient technology for the transportation) greenhouse gas emissions that cause Procurement Plan refrigeration system global warming. Include relevant technical specifications as part High energy use of the cold chain of procuring cold storage/chain equipment and storage transport providers Energy use in transportation of the 145 | P a g e vaccines Ensure that the refrigeration system including its maintenance and servicing, complies with the requirements of the established protocols on ozone depleting substances (ODS) Transport vaccines during non-peak traffic hours Labour Rights and Workers, in particular health personnel All workers must be paid for overtime in SEP Gender may be asked to work overtime to accordance with Government labour laws; LMP respond to the COVID-19 pandemic. It All workers must be provided with security of is important that these personnel are medical care, in particular ensuring they can able to access overtime pay as needed access free medical care if they contract and required by law; COVID-19. Health care and other staff, including Ensure that all health care workers also have cleaners, or workers in access to the required Personnel Protection upgrade/rehabilitation may need Equipment (PPE) – including gloves, gowns, medical care if they contract COVID- masks and eye protection if exposed to patients 19; with COVID-19 Health workers, a big proportion who Vulnerable workers should be identified, such are female, may face mental issues or as female single heads of household, who may burnout as result of an outbreak; and need additional support in order for them to do Health workers, cleaners or workers their job (for instance, female nurses who are involved in upgrades experiencing single heads of household may need additional respiratory symptoms may fear not 146 | P a g e getting paid and continue to show up support if they have to work overtime). at work. Health care workers must be actively supported There is a risk that health care by their employers and offered psychological, workers are exposed to COVID-19 emotional or mental support if possible; during the initial screening and All workers must be reassured that they will vaccine administration in the health continue to get paid if they need to self- isolate if facility or community setting. they are showing with COVID-19/respiratory There is also a risk that the cleaners symptoms. These provisions must be made and waste collectors of the health care including for contracted staff facilities and waste service providers are exposed. Community Health Risk of transmission in the community The ICWMP contains procedures based on ICWMP and Safety Impacts from project activities e.g. transport of WHO guidance, for the safe operation of health waste, operation of the incinerators, facilities and protection of the public from etc. if they are not properly managed exposure to the virus as a result of these SEP/GM and controlled. operations. The proper storage conditions and Collection and transport of all COVID-19 wastes transport of the vaccines are also major and laboratory tests, blood samples, would be risks as they are needed to ensure the collected safely in designated containers and Community Health efficacy and safety of the vaccine. bags, treated and then safely disposed; and Safety Plan (CHSP) (Annex IV) Crowding or influx of people in the The operation of medical centres will be vaccination sites as well as the implemented in a way that both the wider public, violation of physical distancing are also as well as the patients are treated in line with international best practice as outlined in WHO 147 | P a g e risks. guidelines. Wider public and patients are not The project’s Stakeholder Engagement Plan treated with respect for their dignity, (SEP) will ensure widespread engagement with human rights and fundamental communities – including its more vulnerable freedoms. This is especially important groups – to disseminate information related to for migrants and other vulnerable community health and safety, particularly about people social distancing, high-risk demographics, self- quarantine, and mandatory quarantine. There is a risk of adverse health effects if the profiling and Project grievance mechanism (GM) enables screening of candidate individuals communities to raise project related concerns to be vaccinated and proper data and grievances management were not observed The profiling and screening of candidate to monitor adverse vaccine individuals to be vaccinated should be effects performed so as to avoid the risk of vaccine contraindications. A comprehensive data management system is also needed to support the profiling, screening, and scheduling to address the risk of individuals not completing the required shots/doses of the vaccine Access for Marginalized, high-risk and vulnerable MOH is committed to the provision of services SEP Vulnerable Groups social groups (poor, disabled, elderly, and supplies to all people and ensure that migrants, LBGTQI, PLWHA) are unable individuals or groups who, because of their or unwilling to access facilities and particular circumstances, may be 148 | P a g e services disadvantaged or vulnerable, have access to the development benefits. The MOH will implement WHO guidance tools for COVID-19 risk communication and engagement, including with respect to social stigma Social Stigma Risk of fear and/or stigma towards the When developing communication messages SEP virus, which may make people hide about COVID-19, it is important to have social symptoms, avoid getting tested and stigma issues in mind and choose language that even reject hygiene measures or does not exacerbate stigma. wearing masks Ensure accurate information about the virus is The fear and apprehension of widely disseminated, and that there is also a individuals and communities on the focus on people who have recovered. scientific integrity, efficacy, and safety Engage influencers, such as religious leaders, of the COVID-19 vaccines may lead to who can help communicate accurate messages people refusing vaccination on the vaccines, help to reduce social stigma and support those who may be stigmatized 149 | P a g e 9.3 Annex III - Infection Control and Waste Management Plan (ICWMP) 1. Introduction Activities under this project will be undertaken at hospitals, health centres and associated laboratories throughout the country which have been assigned for COVID-19 patient management. Trinidad and Tobago does not have specific regulatory mechanisms for guiding and enforcing biomedical waste management. However, TTO has adopted the Code of Practice for Bio-Medical Waste Management, 2012 that was developed by PAHO. This document describes methods of generation, minimization, pollution prevention, source segregation, identification and labelling, handling and storage, transportation, treatment, disposal, occupational health and safety, public and environmental health, and stakeholder awareness and education. The Ministry of Health of Trinidad and Tobago is the national authority responsible for the oversight of the country’s entire health system. In 1994, the Regional Health Authorities (RHA) Act No. 5 was passed and the responsibility for the provision of health care in Trinidad and Tobago was no longer the sole responsibility of the Ministry of Health. There are currently five (5) Regional Health Authorities (RHAs) in Trinidad and Tobago that provide primary and secondary health care services to the population. They are: the North West Regional Health Authority (NWRHA), the South West Regional Health Authority (SWRHA), the Eastern Regional Health Authority (ERHA), the North Central Regional Health Authority (NCRHA) and the Tobago Regional Health Authority (TRHA). Based on the Code, each RHA has developed procedures for bio-medical (infectious) waste management. These procedures are generally similar in nature. With the exception of the EHRA and the NWRHA, the other RHAs have an incinerator located at the major hospital in the respective regions. This incinerator is used to dispose of the bio-medical waste from that hospital as well as the other respective hospitals and health centers in that region. In events where the incinerator is not working, an external facility is used. In the cases of both the NWRHA and ERHA, a private transport and disposal company, is used. 2. Definition Biomedical waste may be defined as any solid or liquid waste which may present a threat of infection to humans, including non-liquid tissue, body parts, blood, blood products, and body fluids from humans and other primates; laboratory and veterinary wastes which contain human disease-causing agents; and discarded sharps. 150 | P a g e 3. Bio-medical waste generation The various categories of bio-medical waste shall be sorted at the source of generation and placed into colour-coded plastic bags and containers. Contained bio-medical waste shall be visibly identifiable with the international biological hazardous symbol and one of the following labels: “BIO-MEDICAL WASTE�, “BIOHAZARDOUS WASTE�, “BIOHAZARD�, “INFECTIOUS WASTE� or “INFECTIOUS SUBSTANCE�. The table below outlines the recommended colour-coding for bio-medical waste. Type Identification Colour and Container Type Labelling Infectious Waste, pathological LABELLED INFECTIOUS WASTE Leak-proof plastic bag or and anatomical waste, animal container waste and tissues; microbiology and biotechnology wastes; solid waste contaminated with blood and body fluids Genotoxic/Cytotoxic Waste; solid LABELLED BIOHAZARDOUS Leak-proof plastic bag or waste other than sharps (i.e. WASTE disinfected container catheters, tubing, intravenous CYTOTOXIC WASTE sets etc.) Sharps (needles, syringes, LABELLED BIOHAZARDOUS Puncture-proof container scalpels blades, (used and WASTE – SHARPS unused) glass Chemical and Pharmaceutical LABELLED BIO-MEDICAL Plastic bag or container Waste WASTE Radioactive Waste RADIOACTIVE SYMBOL Lead container General waste BLACK Plastic The bio-medical waste generated at each vaccination site would be sharps, vaccine vials, cotton pads, gauze etc. This waste would be treated as part of the existing bio-medical waste management system at each facility. Once the sharps are used, they will be placed in the allocated sharps disposal box. Other associated wastes would be disposed of in the red-bags that are allocated for bio-medical waste. 4. Waste Segregation Waste segregation guided by appropriate occupational health and safety procedures ensures that bio-medical waste is not mixed with general domestic waste that may pose a threat to the generators, waste handlers and the general community. a. All waste shall be segregated at the point of generation into the various waste types, containerized using appropriate colour codes and labelled to facilitate appropriate waste recovery, treatment and disposal. Separate bins would be required for each waste stream. b. Bio-medical waste is not placed with general domestic waste. 151 | P a g e c. Waste generators and any contracted waste management company is required to practice waste segregation. d. Waste contaminated with cytotoxics shall be separated and treated as cytotoxic waste. 5. Storage and Transportation The red bags and sharps containers are collected from the wards and taken to a centralised storage area at the facility. For the health centres, there is also a centralised area (usually located at the back of the building) known as the sluice room. The minimum requirements for this room are: • Sealed off of area • Controlled access to storage area by authorized personnel only • Labelling of containers and signage for central storage areas • Construction of compartmentalized structure for hazardous and non-hazardous waste • Covered structure with floor made of an impervious surface, surrounded with an impervious wall to contain spills • There should be adequate water supply for routine cleaning. • Easy access to staff and vehicles yet secure from unauthorized persons, animals, insects, and birds • Equipped with signage using the biohazard symbol and other labelling appropriate to types of waste stored in the area • A spill kit must be in close proximity to storage area. The spill kit contents should include absorbents, disinfectants, shovels, buckets, gloves, disposable overalls, facemasks, and tongs for sharps, sharp containers, and plastic bags with appropriate labelling • Emergency plan to address accidental spillage of hazardous waste • NOTE: Human and anatomical waste shall not be stored in this structure From there they are either transported to the on-site incinerator for disposal or picked up by the assigned bio-hazard vehicle for transport to the assigned incinerator in the region or to a private contractor for final disposal. When transporting bio-medical waste measures should be taken to minimize risk to employees, the community and the environment regarding exposure to hazardous material during loading and offloading, or as a result of an accident that might result in spillage from the vehicle. All bagged waste must be placed in a secondary container for 152 | P a g e transport. All RHAs have an enclosed panel van with bio-hazard labels. The drivers and handlers of the waste are required to wear full PPE such as gloves and coveralls. Bio-medical waste from the health centres is picked up either daily or at least every 2-3 days by the respective RHAs and taken to their respective incinerators for disposal. For the Eastern region the transport from the Sangre Grande Hospital to the private incinerator in Las Lomas is done by a private contractor. Similarly, waste is picked up from the Port of Spain General Hospital for disposal by a private contractor to the Las Lomas facility. The contractor issues a delivery note upon pick up and also weighs the waste. The waste is also weighed and segregated at the private facility. When the waste is disposed of, a disposal certificate is issued to the generator. 6. Vaccines Collection and documentation of all remaining COVID-19 vaccines will be done at the vaccination sites and opened/used/expired vials will be collected by the EPI Programme drivers where it will be taken up to Central Level. All opened/expired/used vials labels have to be blackened out before disposal in the designated biohazard containers. Once all vaccine vials are accounted for then it will be transferred for proper disposal (incineration) to ensure there is no mismanagement of vials according to waste management protocols. These wastes will be picked up at the end of every month. 7. Disposal The disposal facilities currently available for bio-medical waste disposal are located at the San Fernando General Hospital, Eric Williams General Hospital (Mt. Hope), Old Scarborough General Hospital and Las Lomas. These are all incinerators. The new facility for Tobago at Roxborough also utilizes microwave technology to render bio-medical waste inactive. Once this system has been commissioned, it is anticipated that this can be a viable option for the bio-medical waste from Tobago. The current disposal options for the regions are as follows: • Bio-medical waste from the North-West is transported and disposed of by a private contractor. • Bio-medical waste from the East is transported to the Sangre Grande General Hospital before being picked up and disposed of by a private contractor. • Bio-medical waste from Central is transported to and disposed of at the incinerator at the Eric Williams General Hospital 153 | P a g e • Bio-medical waste from South is transported to and disposed of at the incinerator at the San Fernando General Hospital • Bio-medical waste from Tobago is transported to and disposed of at the Old Scarborough General Hospital. 7.1 Incineration Incineration is the process of reducing combustible waste to inert residues by high temperature combustion. The process entails burning of waste at temperatures ranging from 1,800ºF to 2,000ºF (982ºC to 1093ºC). The waste is exposed to these temperatures in the first chamber and subsequently to the second chamber where it continues to burn resulting in the generation of carbon dioxide and water. This process changes the chemical composition and toxicity of the substances burnt. Two of the major advantages of this technology are high levels of volume reduction achieved as well as the ability to dispose of recognisable waste and sharps. The major environmental concern with this technology is air pollution. Incineration is an activity that requires a Certificate of Environmental Clearance (CEC) from the EMA. San Fernando There are two incinerators at the San Fernando General Hospital. The older incinerator is currently being used. The CEC Reference Number is 3631/2012 which is for the newer incinerator. Eric Williams Hospital (Mt Hope) This incinerator is about 5 years old and has a CEC for its operation. Las Lomas This incinerator is operated by a private contractor. It is a dual chamber incinerator with a functional scrubber in place to manage emissions. The contractor is in the process of decommissioning this facility and setting up a new facility in Rio Claro. CEC’s are being prepared for both sets of activities. Tobago The incinerator at Scarborough is a CP30. The CEC Reference Number is 6089/2020. There is a new one located at Roxborough but this is not yet operational. Its model number CP50 (larger capacity than CP30). There is also a Microwave Based Technology 154 | P a g e Equipment system for the treatment of medical waste at Roxborough. The CEC Reference Number is 5683/2019. The CP series is a small dual-chamber incinerator ranging from 5 to 100 kg/hr. The incinerator has its own software system to monitor, control and view operating parameters. These incinerators can handle infectious waste, pathological waste, sharps, pharmaceutical waste, genotoxic waste, chemical waste, and low level radioactive waste. 8 Occupational Risk and Management There are two occupational safety and health issues associated with the management of bio-medical waste, the risk of injury and the risk of disease. Mechanisms and procedures must be put in place to minimize risk, contact with, or exposure to: • Infectious agents • Toxic or hazardous chemicals • Sharps; and • Cytotoxics To avoid accidents and prevent injury to personnel, including generators, the following procedures shall apply: a. Develop clear channels of communication to ensure that safe and consistent practices are maintained b. Provision of appropriate amenities for hand washing/showers and lunchrooms. c. Ensure the availability and correct use of personal protective equipment. d. Ensure adequate storage location and space, and the use of appropriate signage and bins. e. Eliminate any handling involving the direct physical contact of the contents of bio-medical waste containers, in particular sharps waste. 9 Monitoring and Reporting As part of its focus to strengthen healthcare system in the country, the project will stimulate the need to establish and institutionalize in country infectious waste management monitoring system. Many facilities face the challenge of inadequate monitoring and records of healthcare waste streams. The facilities should establish an information 155 | P a g e management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. The facilities are encouraged to develop an IT based information management system should their technical and financial capacity allow. Monitoring will verify if predicted impacts have occurred and check that mitigation actions are implemented and their effectiveness. Monitoring by EMA and the Standards Department can be considered “third party monitoring�. Monitoring will be done through site inspection, review of grievances logged by stakeholders and ad hoc discussions with potentially affected persons (residents near the project beneficiary health facilities, patients and healthcare staff). On the other hand, due diligence of the contracted services of waste treatment and disposal will be carried out by the respective health facilities public health officers with support from the PIU Environmental and Social Specialist. Externally, reporting should be conducted per government and World Bank requirements. See: ICWMP 156 | P a g e ICWMP Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y 1.0 Waste Generation in HCF at patient care station 1.1 In emergency situations, all waste Waste at the patient care station- i.e. Isolation Patients, On generation HCF RHA’s/MoH from patients arriving at a healthcare room, wardroom, ICU station should be Health Care Operational facility should be classified as segregated on generation and placed in the Waste Workers budget potentially. appropriate bin as per the segregation rules in (HCWWs), Infectious to minimize the HCF Visitors transmission of secondary infection. 1.2 Direct exposure of HCF workers and All HCWs working directly with COVID-19 infected HCF At all times HCF RHA’s/MoH HCWWs to infectious and biohazard persons. are required to ensure that they are attired Management, within HCF Operational waste from the generate source in full PPE as per the guidance provided by WHO for and MoH when in budget leading to risks of exposure to COVID- COVID- 19 response contact with 19 and other patients conditions. 1.3 Management and final disposal of All HCW generated should be categorized as HCWWs, During waste HCF RHA’s/MoH HCW and the risk of comingling with hazardous waste as per the WHO guidelines, Regional Waste management Operational general waste streams can have segregated and disposed as per the guidance Collection practices Budget impacts on the environment such as provided in this Infection Control and Health Care Company and toxic emissions of leachate and air Waste Management Plan.stew Trinidad and emission and lead to exposure of Tobago Landfill communities to spread of infectious Management diseases via adhering to WHO Company guidance and following international (SWMCOL) best practice on management of HCW 1.4 Looking at waste minimization, reuse, Facilities should consider practices and HCF/MoH Long Term HCF RHA’s/MoH and recycling where possible and in procedures to minimize waste generation, without Planning of Operational the long term within the HCF. This will sacrificing patient hygiene and safety facility budget facilitate in the reduction of waste that considerations, including: specific needs to be handled, especially in - Source reduction measures: HCWPs smaller HCFs, more in the longer ▪ Consider options for product / material substitution term. to avoid products containing hazardous materials that require the product to be disposed as hazardous or special waste (e.g. mercury or aerosol cans). ▪ Selecting preferring products with less packaging or products that weigh less than comparable products that perform the same function. ▪ Use of physical rather than chemical cleaning practices (e.g. using microfiber mops and cloths), where such practices do not affect disinfection and meet relevant standards for hygiene and patient safety as per national and international guidelines. - Waste toxicity reduction measures such as; ▪ Consider options for product/material 157 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y substitution for equipment containing mercury or other hazardous chemicals; products that may become hazardous waste when disposed; products made of polyvinyl chloride (PVC); halogenated compounds; products that off-gas volatile organic compounds (VOCs), or products that contain persistent, bio accumulative and toxic (PBT) compounds products that contain substances which are carcinogenic, mutagenic or reproductive toxins (CMR). - Use of efficient stock management practices and monitoring (e.g. for chemical and pharmaceutical stocks), including: ▪ Small / frequent orders for products that spoil quickly and strict monitoring of expiry dates ▪ Complete use of old product before new stock is used - Maximization of safe equipment reuse practices, including: ▪ Reuse of equipment following sterilization and disinfection (e.g. sharps containers) 2. Segregation and Storage Prior to Collection 2.1 Infectious Waste/ Biohazardous All waste indicated here should be placed in red HCWs, On generation HCF HCF Waste: All waste generated from care biohazard bags, labeled, “Biohazardous Waste� or HCWWs, Operational Management, of COVID-19 patients will be placed with the international biohazard symbol and the word, budget PIU, MoH under this category. This kind of waste “Biohazard�. is typically consisting of human • Full red bags must be tied so that leakage or tissues, body fluids, laboratory expulsion of contents does not occur and should be cultures, waste from isolation wards, contained in a rigid container. tissues (swabs), materials or • Strong, leak-proof plastic bag, or container equipment that have been in contact capable of being autoclaved should be used. with infected patients and containers • The container can be of any (preferred to be red) or equipment containing fluid blood or color with a tight-fitting lid and labeled “Biohazard,� fluids generated in patient care areas. readable from any lateral direction. Can spread infection to HCWs and • As COVID-19 associated waste has not been lead to contamination unless properly classified highly infectious. For any waste classified segregated and stored. Such waste as highly infectious the following procedures must can Infectious and direct or indirect be adopted. contact through a carrier can lead to • Yellow bags marked “HIGHLY INFECTIOUS�, with infection as well as exposure to the biohazard symbol must be used. Or Red Bag pathogens can result in contraction of autoclavable bags market Universal Biohazard HIV/ AIDS, Hepatitis B, Hepatitis C Symbol on the outside. and other blood-borne diseases • Strong, leak-proof plastic bag, or container capable of being autoclaved should be used. 2.2 Sharps Waste: Patient care and • Used sharps should be placed into the HCWs, On generation HCF HCF clinical support areas generate sharps appropriate sharp’s container immediately after HCWWs, Operational Management, that are infectious and can spread use- contains must be puncture proof. budget PIU, MoH 158 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y disease and cause minor injuries to • All sharps are disposed of in either a labeled HCWs unless properly handled. sharps container or a pharmaceutical/chemo Sharps include hypodermic needles, sharps container. hypodermic needles with attached • Containers should be labeled “SHARPS WASTE� syringes, needles with attached tubing, or “BIOHAZARD,� with the international biohazard blades, broken glass, acupuncture symbol. needles, and pipettes, whether or not • Full sharps containers must be collected contaminated with regularly and replaced with empty containers. biohazardous or pharmaceutical • All re-usable sharp containers must be disinfected material. Direct contact this waste can prior to reuse and thoroughly cleaned. cause HIV, HBV and physical injury. 2.3 Pharmaceutical Waste: • Pharmaceutical waste should be places in brown HCWs, On generation HCF HCF Pharmaceutical waste and hazardous plastic bags or a rigid container, labelled with the HCWWs, Operational Management, pharmaceutical waste are produced appropriate hazards’ symbols budget PIU, MoH from most patient care and clinical • As per WHO guidance, they should be marked support areas are not suitable to be INCINERATION ONLY� so that it can be visible disposed to the environment and can from any lateral direction. be toxic to living organisms. This • Pharmaceutical waste, including empty vials and category of waste includes, but is not syringes, is placed into a sharp’s container or limited to unused, partially used or chemo container at the point of generation, stored in expired prescription or over the- a utility room, and then transported to a central counter medications (e.g. vials, holding area at the loading dock. tablets, capsules, powders, liquids, • Bulk unused and expired pharmaceutical waste, creams/ lotions, eye drops, independent of where generated, should be returned suppositories), IV bags and tubing, to the supplier as per contractual requirements on full syringes, glass vials and ampules, cradle to grave provisions-the supplier will be narcotics and controlled substances responsible for disposal in according to procedures in syringes, narcotic patches (cut in specific to the medication type half), carpujets, and tubexes. Hazardous Pharmaceutical Waste: includes, but is not limited to, syringes, inhalers, tubexes or IV bags/piggybacks with residual (>5ml) of medication (i.e.: all cytotoxic drugs, cyclosporine, mycophenolate, oxytocin, coumadin, warfarin, epinephrine, and nitroglycerin tablets). This waste stream also includes items that may contain mercury, including vaccines, eye, ear and nose drops. 159 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y 2.4 Waste Mixed with Hazardous The minimal norms of segregation should be employed. HCWs, On generation HCF HCF Chemicals: Medical waste mixed with • waste should be places in brown plastic bags or a HCWWs, Operational Management, hazardous chemicals is generated rigid container, labelled with the appropriate budget PIU, MoH primarily in Pathology and Laboratory hazard’s symbols Medicine areas from activities associated with tissue fixing and preservation. The chemicals are usually solvents such as alcohol and xylenes, or formalin. This waste is maintained within and under the control of Pathology and Laboratory Medicine. Disinfectants, laboratory chemicals and reagents, film developer and solvents. Mercury: found in thermometers, blood pressure gauges and dilators and contained hazardous chemical waste and contact through proximity to such waste can lead to burns and severe skin reactions, poisoning, allergies and asthma. Substances such as mercury causes damage to nervous system and to kidney and urinary system, especially in fetuses and newborns. Contact through release into water bodies and atmosphere can cause serious harm. 2.5 General Waste generated • General health-care waste such as food waste HCF On generation HCF HCF will be also considered operational staff, Operational Management, • General waste will be collected via a separate HCWWs, budget PIU, MoH stream from all health care waste and will not be comingled under any circumstances. 3. Transport of HCW Within HCFs for Storage or Direct Final Treatment 3.1 Onsite transport of waste from point of • General requirements HCWs, On generation HCF HCF generation to storage needs to be • Onsite transport should take place during less busy HCWWs, Operational Management, managed in a planned manner in times whenever possible. Set routes should be used budget PIU, MoH order to avoid environmental risks to associated with cross contamination prevent o exposure to staff and patients and to with general waste, accidental spillage minimize the passage of loaded carts through patient and exposure of HCWs and patients. care and other clean areas. • Depending on the design of the HCF, the internal transport of waste should use separate floors, stairways or elevators as far as possible. Regular 160 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y transport routes and collection times should be fixed and reliable. • Associated staff should wear adequate personal protective equipment, gloves, strong and closed shoes, overalls and masks. • Hazardous and non-hazardous waste should always be transported separately. • The following three different transport systems should be adopted in line with best practice: • Waste transportation trolleys for general waste should be painted black, only be used for non- hazardous waste types and labelled clearly “General waste� or “Non- hazardous waste�. • Infectious waste can be transported together with used sharps waste. Infectious waste should not be transported together with other hazardous waste, to prevent the possible spread of infectious agents. Trolleys should be colored in the appropriate color code for infectious waste (yellow) and should be labelled with an “Infectious waste� sign. • Pharmaceutical wastes should be transported separately in boxes to central storage sites. • The use of waste chutes in health-care facilities is not recommended, because they can increase the risk of transmitting airborne infections. • Transport trolleys • Health-care waste can be bulky and heavy and should be transported using wheeled trolleys or carts that are not used for any other purpose. • To avoid injuries and infection transmission, trolleys and carts should: • be easy to load and unload • have no sharp edges that could damage waste bags or containers during loading and unloading • Other hazardous waste, such as chemical and be easy to clean and, if enclosed, fitted with a drainage hole and plug • be labelled and dedicated to a particular waste type • be easy to push and pull • not be too high (to avoid restricting the view of staff transporting waste) • be secured with a lock (for hazardous waste) • be appropriately sized according to the volumes of 161 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y waste generated at a health-care facility. • Waste, especially hazardous waste, should never be transported by hand due to the risk of accident or injury from infectious material or incorrectly disposed sharps that may protrude from a container. • Spare trolleys should be available in case of breakdowns and maintenance. The vehicles should be cleaned and disinfected daily. • All waste bag seals should be in place and intact at the end of transportation. 3.2 Routing of the infected waste in Routing HCWs, On generation HCF HCF HCFs should be maintained to • Separate hazardous and non-hazardous routes HCWWs, Operational Management, minimize risks of exposure and should be planned and used. budget PIU, MoH accidents during operating hours. • A specific routing plan should be developed based on the lay out of the HCF. • A waste route should follow the general requirements below. • the route should start from the most hygienically sensitive medical areas (e.g. intensive care, dialysis, theatres). • A fixed route around other medical areas and interim storage locations should be followed. • The frequency of collection should be refined through experience to ensure that there are no overflowing waste containers at any time. • Biologically active waste (e.g. infectious waste) must be collected at least daily. • A facility specific routing plan would be influenced by: • waste volume and number of waste bags or containers • waste types • capacity of the waste storage within medical areas and at interim storage areas • capacity of the transportation trolleys • transport distances and journey times between the collection points. • The route should be prepared with the facility specific layout. 4. Storage of Waste within the HCF Premises or Storage of Treated Residuals 162 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y 4.1 Establishment of central storage areas • The following general requirements relevant to HCWs, On generation HCF HCF within a health-care facility for safe most types of HCF’s where sufficient waste is HCWWs, Operational Management, retention of waste until it is treated produced and needs to be stored centrally. budget PIU, MoH onsite or collected for transport and • Note: Waste storage for specific particular items treatment offsite. (e.g. blood, radioactive substances, and chemicals) are only likely to be required at and specialized medical centers. • Storage facilities should be built appropriate to the volumes of waste generated from the respective HCF. All areas designated for health care waste should: • have an impermeable, hard-standing floor with good drainage (away from watercourses); the floor should be easy to clean and disinfect; • include the facility to keep general waste separated from infectious and other hazardous waste; • have a water supply for cleaning purposes; • have easy access for staff in charge of handling the waste; • be lockable to prevent access by unauthorized persons; • have easy access for waste-collection vehicles; • have protection from the sun; • be inaccessible to rodents, other animals, insects and birds; • have good lighting and at least passive ventilation; • not be situated in the proximity of fresh food stores and food preparation areas; • have a supply of cleaning equipment, protective clothing and waste bags or containers located conveniently close to the storage area; • have a washing basin with running tap water and soap that is readily available for the staff; • be cleaned regularly (at least once per week); • have spillage containment equipment; • Storage facilities should be labelled in accordance with the hazard level of the stored waste. • show typical signs advising the hazard posed by waste. In general, there are four different kinds of waste-storage 163 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y areas: • non-hazardous or general waste • hazardous waste (infectious and pathological waste, sharps waste) • chemical and hazardous pharmaceutical waste • radioactive waste 4.2 Specific measures for storage of • The following specifications should be considered HCWs, On generation HCF HCF Infectious waste such as those for the storage of all waste generated from the care HCWWs, Operational Management, generate in association to care of of positive COVID-19 patients, in addition to the budget PIU, MoH COVID-19 Patients. general requirements stipulated in point 2.5. • The storage place designated of waste storage must be identified as an infectious waste area by using the biohazard sign. • Floors and walls should be sealed or tiled to allow easy disinfection. • If present, the storage room should be connected to a special sewage system for infectious hospital wastewater. • The compacting of untreated infectious waste or waste with a high content of blood or other body fluids destined for offsite disposal (for which there is a risk of spilling) should not be permitted. • Sharps must be stored contained at all times. • All other infectious waste, including discarded PPE of HCW’s, should be kept cool or refrigerated at a temperature preferably no higher than 3 °C to 8 °C if stored for a period more than a week. • Unless a refrigerated storage Infectious waste storage room is available, storage times for infectious waste (e.g. the time gap between generation and treatment) should not exceed the following periods for warm climates as per WHO guidelines. ▪ 24 hours during the hot season. ▪ 48 hours during the cooler season ▪ For pathological waste, is susceptible to the growth of pathogens and is biologically active waste, and gas formation during storage should be expected, thus immediate treatment is recommended. • As the Trinidad and Tobago culture, body parts are passed to the family for ritual procedures or are buried in designated places. They should be autoclaved and placed in sealed bags to reduce infection risks before release to the public. 164 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y 4.3 Procedure for decontamination of • At all times cleaning staff should be equipped HCWs, On generation HCF HCF Reusable storage containers and with the requisite PPE, including at minimum, HCWWs, Operational Management, storage areas to prevent the risk of masks, plastic puncture proof gloves and boots budget PIU, MoH continuous contamination and residue and covered clothing, including aprons. accumulation. • Discarded spoiled PPE should be included in the waste stream as part of hazardous waste. • Reusable secondary containers (garbage cans, bins, etc.) should be decontaminated each time they are emptied unless they are protected from contamination by disposable liners, bags, or other devices removed with the waste. • These containers should be maintained in a clean and sanitary manner. • Approved methods of decontamination include, but are not limited to, agitation to remove visible soil combined with one of the following procedures: • Exposure to hot water of at least 82 °C (180 °F) for a minimum of 15 seconds • Exposure to chemical sanitizer by rinsing with, or immersion in, one of the following for a minimum of 3-5 minutes at minimum: ▪ Hypochlorite solution (500 ppm available chlorine) ▪ Phenolic solution (500 ppm of active agent) ▪ Iodoform solution (100 ppm available iodine) ▪ Quaternary ammonium solution (400 ppm active) 4.4 Pharmaceutical waste should be • Pharmaceutical waste with non-hazardous HCWs, On generation HCF HCF segregated from other wastes and characteristics that can be stored in a non-hazardous HCWWs, Operational Management, local regulations followed for final storage area include the following. budget PIU, MoH disposal. General, pharmaceutical • ampoules with non-hazardous content (e.g. vitamins); wastes can be hazardous or non- • fluids with non-hazardous contents, such as hazardous, and liquid or solid in vitamins, salts (sodium chloride), amino salts; nature, and each should be handled • solids or semi-solids, such as tablets, capsules, differently. The classification should granules, powders for injection, mixtures, creams, be carried out by a pharmacist or lotions, -- aerosol cans, including propellant-driven other expert on pharmaceuticals. sprays and inhalers. • Hazardous waste that should be stored in accordance with their chemical characteristics and instructions specifically assigned as per regulations include (e.g. genotoxic drugs) or specific requirements for disposal (e.g. controlled drugs or antibiotics), include the following. • controlled drugs (should be stored under government supervision); • disinfectants and antiseptics; • anti-infective drugs (e.g. antibiotics); 165 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y • genotoxic drugs (genotoxic waste); • gels and suppositories; • ampoules with, for example, antibiotics. • Genotoxic waste is highly toxic and should be identified and stored carefully away from other formers of HCW in a designated secure location. It can be stored in the same manner as toxic chemical waste, although some cytotoxic waste may also carry a risk of infection. 4.5 Specific measures for • When planning storage places for hazardous HCWs, On generation HCF HCF hazardous chemical waste chemical waste, the characteristics of the different HCWWs, Operational Management, storage chemicals to be stored and disposed of must be budget PIU, MoH considered (inflammable, corrosive, explosive). • The storage place should be an enclosed area and separated from other waste storage areas. • When storing liquid chemicals, the storage should be equipped with a liquid- and chemical-proof sump. • If no sump is present, catch-containers to collect leaked liquids should be placed under the storage containers. • Spillage kits, protective equipment and first aid equipment (e.g. eye showers) should be available in the central storage area. • The storage area itself should have adequate lighting and good ventilation to prevent the accumulation of toxic fumes. • To ensure the safe storage of chemical wastes, the following separate storage zones should be available to prevent dangerous chemical reactions. • The storage zones should be labelled according to their hazard class. If more than one hazard class is defined for a specific waste, use the most hazardous classification: ▪ explosive waste ▪ corrosive acid waste ▪ corrosive alkali waste (bases) ▪ toxic waste ▪ flammable waste ▪ oxidative waste ▪ halogenated solvents (containing chlorine, bromine, iodine or fluorine) ▪ non-halogenated solvents. • Liquid and solid waste should be stored separately. 166 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y • If possible, the original packaging should be taken for storage too. • Packaging used to store, and transport chemical wastes offsite should also be labelled. • This label should have the following information: hazard symbol(s), waste classification, date, and point of generation (if applicable). • The storage area for explosive or highly flammable materials must be suitably ventilated above and below, with a bonded floor and constructed of materials suitable to withstand explosion or leakage. 4.6 Specific measures for storage of • Storage areas must be equipped with sufficient HCWs, On generation HCF HCF Radioactive Waste in order to shielding material, either in the walls or as movable HCWWs, Operational Management, mitigate shielding budget exposure risks. screens. 167 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y • The storage area must be clearly marked with PIU, MoH RADIOACTIVE WASTE�, and the international hazard label should be placed on the door and entry should be restricted unless for authorized personnel. • The storage place should be constructed in a manner that renders it flame-proof and should have such surfaces on floors, benches and walls that allow proper decontamination. • An air-extraction system and radioactive monitoring system should be put in place. • The International Atomic Energy Agency provides comprehensive guidance on all aspects of the safety of radioactive waste management in the Safety Standards Series and should be referred to. • Storage within storage areas should follow the following best practice norms. • Radioactive waste should be stored in containers that prevent dispersion of radiation and stored behind lead shielding as indicated above. • Waste that is to be stored during radioactive decay should be labelled with the type of radionuclide, date, period of time before full decay and details of required storage conditions. • The decay storage time for radioactive waste differs from other waste storage, because the main target will be to store the waste until the radioactivity is substantially reduced and the waste can be safely disposed of as normal waste. • A minimum storage time of 10 half-life times for radioisotopes in wastes with a half-life of less than 90 days is a common practice. • Infectious radioactive waste should be decontaminated before disposal. • Liquids associated with solid materials, such as assay tube contents, should be decanted or removed by decay time. • Radioactive waste with a half-life of more than 90 days must be collected and stored externally in accordance with national regulations. 4.7 Documentation of the operation of • As best practice the following forms of HCWs, On generation HCF HCF storage places. Keeping clear records additional documentation are suggested to be HCWWs, Operational Management, of the wastes stored and their maintained. budget PIU, MoH treatment and disposal dates is • a written spill contingency plan; important to ensure a good control of • a weekly store inspection protocol; 168 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y waste management not only during • protocols for using, repairing and replacing COVID Response but during emergency equipment; overall operations. • training system and documentation (names of trained staff, job descriptions, form of training, date of training, date for refresher or revalidation training); • hazardous waste storage documentation; • collection of relevant material safety data sheets. 5. Onsite Treatment and Disinfection of Waste Prior to Final Disposal 5.1 Recommended treatment options for • Human Anatomical Waste (Human tissues, organs, HCWs, On generation HCF HCF various types of waste generated via body parts) HCWWs, Operational Management, the COVID-19 response and care • Via Incineration at temperatures above 800°C budget PIU, MoH activities as per WHO guidelines • Infectious Waste (Wastes from clinical samples, during an emergency. pathology, bio-chemistry, hematology, blood bank, laboratory cultures, stocks or specimens of micro- organisms, live or attenuated vaccines, human cell culture, infectious agents, dishes and devices used for transfer of cultures, items contaminated with blood and body fluids including cotton, dressings, soiled plaster-casts, linen, bedding, other materials contaminated with blood. Wastes generated from disposable items other than the waste sharps, such as tubing, hand-gloves, saline bottles with IV tubes, catheters, glass, intravenous sets etc. • Via Disinfection at source by chemical treatment or by autoclaving/microwaving followed by mutilation/shredding and after treatment final disposal in secured landfill or incinerated at temperatures above 800°C • Waste Sharps (Needles, glass syringes or syringes with fixed needles, scalpels, blades, glass, etc. that may cause punctures and cuts. This includes both used and unused sharps) • Disinfection by chemical treatment or destruction by needle and tip-cutters, autoclaving or microwaving followed by mutilation or shredding, whichever is applicable, and final disposal through disposal in secured landfill, contained waste parallels that are sealed if open dumping is the only option in country or designated concrete waste sharps pit where possible. • Discarded Pharmaceuticals (Wastes comprising of outdated, contaminated and discarded medicines) 169 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y • Disposal in secured land fill or incineration incinerated at temperatures above 800°C • Hazardous Chemical Waste (Chemicals used in production of biological toxins, chemicals used in disinfection, as insecticides etc.) 5.2 Disinfection via the use of Chemicals • Waste to be Autoclaved should not be chemically HCWs, On generation HCF HCF such as Characteristics of sodium treated unless post autoclaving as an additional HCWWs, Operational Management, hypochlorite (NaOCl), bleach and measure. budget PIU, MoH other substances may lead to • Disinfection via chemical substance should irritation of skin, only be conducted eyes and the respiratory track, and in designated area or where not available a cause burns due to associated toxic designated bathroom or lab area that has adequate properties and there need to be ventilation and wash facilities available. handled with care. o Storage and use areas as a best practice should have facilities should always have sinks or facilities and access to portable water for washing. • Only individuals trained to carry out chemical disinfection should be involved, and the chemicals should be handled, stored and disposed in line with the guidance provided by the manufacture. • Gloves and protective eyeglasses should be worn at all times during handling of such substances to protect skin and eyes. • In the case of contact with eyes, the eyes should be rinsed abundantly with water and due medical care provided. • Storage and Disposal • Aqueous solutions of hypochlorite and other chlorine based substances are corrosive to metals and should always be stored in plastic containers in well ventilated, dark and leakage- proof rooms; • All Cleaning substances should be stored separately from acids. • Unused solutions should be reduced with substances such as sodium bisulfite or sodium thiosulfate and neutralized with acids before discharge into sewers as per the WHO guidelines for management. • Large quantities of concentrated solutions should be treated as hazardous chemical waste and treated as per the requirements of the KEPA 5.3 Autoclave operation for disinfection of • General Operational Requirements HCWs, On generation HCF HCF waste poses a number of potential • Autoclaves should be operated only by trained HCWWs, Operational Management, risks which can impact operators. personnel or certified operators. budget PIU, MoH These include heat and steam burns, • Waste treated with hypochlorite should not be 170 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y hot fluid scalds, injuries to hands and autoclaved, while it can be used to further disinfect arms from the door, and bodily injury in waste post autoclaving. the event of an explosion. Exposure to • Onsite training on how to use the autoclave biohazardous material may occur if properly and safely is essential for all new biohazardous waste is improperly employees to prevent injury should be conducted packaged or manipulated and documented (as a best practice training should be documented and training records should be maintained in an autoclave training log). • Autoclaves should be placed in designated areas with the HCF with hazard signage duly places with only authorized personnel allowed to enter. • Desktop autoclaves at waste management points should be placed in secure areas away from other equipment and care and testing areas. • The use of heat-insulating gloves, lab coat, and closed- toe shoes help prevent burns and scalds during loading and unloading the autoclave must be worn by all personnel prior to operation. • Follow the manufacturer’s specific user manual and guidance and HCF laboratory SOPs • Specific areas where autoclaves should be locked, and users should ensure the door is secure before starting a cycle. • Record cycle information on autoclave log sheet or logbook. • Precautions during Loading • The top of waste bags shall be handles as per the handling instructions. • Be sure that the autoclavable red bag or yellow Infectious waste bags can withstand the autoclave cycle without melting. • Inspection of the door gasket (seal) for any cracks or bulges should be conducted. Typically, the gasket should be smooth and pliable. • Ensure that the jacket has reached sufficient pressure to start a cycle • The following steps should be followed when loading ▪ Inspect for spills or debris inside the autoclave; ▪ Place items in an autoclave tub on rack. ▪ Never place items directly on the autoclave bottom or floor. ▪ Do not overload the autoclave. ▪ Allow sufficient space between items for steam. ▪ Always use secondary containment in case of 171 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y spillover ▪ Users should check about 20 minutes into the cycle to verify the respective autoclave being operated has reached sterilization temperature (typically 121°C). ▪ The autoclave door during a cycle should not be opened during the process at all. ▪ If it is necessary to open the door, the cycle should be aborted, and the time should be allowed for the chamber depressurizes. ▪ If cycle fails immediate assistance from trained personnel or the manufacture should be taken as the waste inside may not be sufficiently decontaminated if the cycle did not complete. ▪ If any problems are found, contact the responsible person before using the autoclave • Unloading and Repacking Waste ▪ During the unloading and packaging autoclaves waste the following steps must be taken by operated to ensure good management: ▪ When the cycle is complete, verify that chamber temperature has dropped, and pressure is zero. ▪ Wear appropriate PPE to protect yourself from heat and steam (e.g. heat-resistant gloves, lab coat, safety glasses). ▪ The door should be opened slowly to allow steam to escape gradually. ▪ At all times the face should be kept away from the door. ▪ Allow items to stand in the autoclave for 10 minutes- both desktop and larger units- unless a specific time has been instructed in the manufactures Manuel. ▪ Maintain caution when removing items, and place in a safe area to cool. ▪ Do not agitate containers as boiling or superheated liquids can explode if moved too quickly. ▪ Carefully move the remains of waste into the transport bins for final disposal. ▪ Clean the drain screen of debris if necessary. ▪ Record cycle information on autoclave log sheet or logbook. • Maintenance Requirements • A regular implementation schedule should be maintained to ensure safe 172 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y operation. • The contact information for maintenance technician available should be recorded and made available near the units for emergencies. • Management of Unforeseen Accidents- in the event an accident occurs the following mediate measures will be undertaken at the HCF. • An Exposure Response Poster must be posted near the autoclave. • In the event of an accident, first aid should be immediately provided first aid and help should be taken in accordance with the according to the instructions on the poster immediately. • Report any accidents or near misses in the log and to hospital authorities, so that they can be investigated and hopefully prevented in the future. • Personal protective equipment (PPE) use for autoclave operation • Operators are required to always use PPE when using an autoclave. • The basic attire should be a lab coat, heat- resistant gloves, and safety glasses. • Workers must ensure via the attire that arms are covered by a lab coat and longer heat-resistant gloves to prevent burns from heat and steam. • Precautions on Items that can be autoclaved and process • Autoclave should not be used for sterilizing waterproof materials, such as oil and grease or dry materials, such as glove powder • Materials are loaded in, such a way that it allows efficient steam penetration (do not overfill the chamber). It is more efficient and safer to run two separate, uncrowded loads than one crowded one. • Wrapping objects in aluminum foil is not recommended because it may interfere with steam penetration. Articles should be wrapped in materials that allow steam penetration. • Materials should not touch the sides or top of the chamber • The clean items and the wastes should be autoclaved separately. • Polyethylene trays should not be used as they may melt and cause damage to the autoclave. • Do not autoclave flammable, combustible, 173 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y reactive, corrosive, toxic, or radioactive materials. • Contact EH&S for disposal of hazardous materials. • Check that plastics are compatible with the autoclave as not all plastics can be autoclaved. • Prior to loading inspect glassware for cracks. Do not autoclave cracked or compromised glassware when disinfecting for reuse. • For liquids, leave caps loose or cover with foil to allow steam penetration and prevent explosion. • For bagged items, loosely tape or tie closed. ▪ Leave an opening for steam to penetrate the bag. 5.4 Management of Liquid Medical Waste • Treated medical waste in liquid or semi-liquid state HCWs, On generation HCF HCF such a chemical as improper can be discharged to the sanitary sewer, i.e. a sewer HCWWs, Operational Management, management of liquid waste can lead that leads to a treatment facility if available if it is not budget PIU, MoH to exposure risks and contamination of a mixed waste containing radioactive, hazardous, or land environments. untreated medical waste. • Medical waste of the following types must be treated by a chemical disinfection if the medical waste is liquid or semi-liquid and the chemical disinfection method as per Infection Control guidance. • The medical waste that may be treated by chemical disinfection includes, but not limited to, the following: Cultures and stocks of infectious agents from research and industrial laboratories. • Wastes from the production of bacteria, viruses, and spores, discarded live and attenuated vaccines used in human health care or research, and discarded animal vaccines. • Disposal of Disinfectants • Only hypochlorite bleach has been pre- approved for disposal down the drain for discharge into the public sewer system as per best practice standards. • Other disinfectants may be approved on a case- by-case basis. It should be verified that the disinfectant is a certified, approved method. The default mode of disposal (for disinfectants other than bleach) is as chemical hazardous aqueous waste. • All other chemical disinfectants or waste with any additional hazardous properties must be included for disposal as hazardous waste, unless otherwise approved. • Prior approval must be obtained prior to 174 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y disposing of these solutions down the sink by the relevant authority. There is a list of chemicals that can be imported without permit and a list of chemicals that needs permit under Administrative Instruction 03/21 on hazardous waste administration. • Liquid medical waste containing bio-toxins on the select agent list will be autoclaved and then disposed of as chemically hazardous waste, via the processes outlined in the HCWMP. 6. Transport of Health Care Waste by Service Providers for Treatment in another HCF or For End Disposal 6.1 Transport of Health Care Waste for • Standards for Suitable Vehicles/Vessel HCWs, On generation HCF HCF Sterilization by Waste Service • Any vehicle used to transport health-care waste HCWWs, Operational Management, Providers. can place both workers should fulfil several design criteria: budget PIU, MoH and communities on risk if not ▪ The body of the vehicle should be of a suitable transported and managed as per size commensurate with the design of the standards from the collection point to vehicle final disposal. A fundamental ▪ There should be a bulkhead between the driver’s requirement is for the vehicle cabin and the vehicle body, which is designed to transporting hazardous waste to be retain the load road worthy and labelled to indicate ▪ if the vehicle is involved in a collision. its load, and its payload to be secured ▪ There should be a suitable system for securing to minimize the risk of accidents and the load during transport. spillages. ▪ Empty plastic bags, suitable protective clothing, cleaning equipment, tools and disinfectant, together with ▪ special kits for dealing with liquid spills, should be carried in a separate compartment in the vehicle. ▪ The internal finish of the vehicle should allow it to be steam-cleaned and internal angles should be rounded to ▪ eliminate sharp edges to permit more thorough cleaning and prevent damage to waste containers. ▪ The vehicle should be marked with the name and address of the waste carrier. ▪ An international hazard sign should be displayed on the vehicle and containers, as well as an emergency telephone number. ▪ The driver should be provided with details of the waste being carried. The transport vehicle should be labelled according to the type of waste that is being transported. • Vehicle/Vessel Operators • Drivers of vehicles carrying hazardous health-care waste should have appropriate training about risks 175 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y and handling of hazardous waste. Training on the following issues should be included: ▪ relevant legal regulations ▪ waste classifications and risks ▪ safe handling of hazardous waste ▪ labelling and documentation ▪ emergency and spillage procedures. o In addition, drivers should be declared medically fit to drive vehicles and have valid licenses for waste vehicle operation. o In case of accident, contact numbers or details of the emergency services and other essential departments should be carried in the vehicles. o For safety reasons, vaccination against tetanus and hepatitis A and B is recommended and vaccination and training details of staff should be recorded. • Vehicle/Vessels Operations o Vehicles should be operated as per the speed regulations of the country. o A routing plan via routes that avoid densely populated areas and high traffic zones where possible should be used. 7. Occupational Health and Safety Management for Health Care Waste Workers 7.1 Management of exposure to infectious • Adequate awareness and training should be HCWs, On generation HCF HCF waste from COVID-19 patient care, provided in line with OHS WHO guideline HCWWs, Operational Management, other forms of toxic health care waste, • Only trained personnel should be allowed to budget PIU, MoH chemicals, and partaking in risky operate machinery such as autoclaves and activities such as operation of incinerators as these reduce the risk operational autoclaves and incinerators during the injuries. health care waste management cycle • Minimum PPE to workers involved on Health Care • Gloves should be worn at all times during HCWM Waste Management. operations to protect from exposure to blood, other potentially infectious materials and chemicals, particulate masks (respirators) to protect from respiratory infections hazards and particulates from burning waste; and boots for waste handlers to protect from sharps injuries to the foot. • Industrial boots with thick soles should be worn as they offer protection in the storage area, as a precaution from spilt sharps, and where floors are slippery. • As it is likely that health-care waste bags will come into contact with workers’ legs during handling, leg protectors may also need to be worn 176 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y • Workers should have access to soap and water, and alcohol hand rub, for hand hygiene are also important to maintain cleanliness and inhibit the transfer of infection via dirty hands. • The type of protective clothing used will depend to an extent upon the risk associated with the health- care waste, but the following should be made available to all personnel who collect or handle waste: • obligatory disposable gloves (medical staff) or heavy duty gloves (waste workers) • industrial aprons • overalls (coveralls) • leg protectors and/or industrial boots • depending on type of operation eye protectors (safety goggles) • face masks (if there is a risk of splash into eyes) • helmets, with or without visors. The following preventive measures can also be implemented during an emergency response phase such as the COVID-19 Response to reduce public and occupational health risks (in an emergency response period, some activities, such as awareness raising, may not be implemented): • Provide hepatitis B vaccination to all health-care staff and waste handlers. • Encourage hand hygiene (washing, preferably followed by disinfection) • Raise the awareness of staff about simple post exposure prophylaxis in the event of an occupational injury (e.g. needle-stick injury). • Contain and promptly clean up spillages of infectious materials and disinfect quickly to avoid pathogen transmission. • Conduct onsite awareness-raising activities (whenever possible) to remind health-care staff about occupational exposures and the safe practices for managing health-care waste. 7.2 Reporting accidents and incidents • All health care management staff at the HCF’s and HCWs, On generation HCF HCF waste collectors should be trained in emergency HCWWs, Operational Management, response and made aware of the correct procedure budget PIU, MoH for prompt reporting. • Accidents or incidents, including near misses, spillages, damaged containers, inappropriate segregation and any incidents involving sharps, 177 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y should be reported to the waste management officer (if waste is involved) or to another designated person. • The report should include the following details of: the nature of the accident or incident • the place and time of the accident or incident • the staff who were directly involved • any other relevant circumstances. • The cause of the accident or incident should be investigated by the waste-management officer (in case of waste) or other responsible officer, who should also take action to prevent recurrence. • The records of the investigation and subsequent remedial measures should be maintained at the HCF 8.3 Staff Training-In order to ensure • The training of waste handlers and nurses HCWs, On generation HCF HCF good implementation once the managing medical areas should be more HCWWs, Operational Management, ICHCWMP is developed or where thorough and focus on practical procedures budget PIU, MoH time permits during the development outlined in the HCF specific IC- HCWMP. phase itself HCF managers, medical • Training programs should be practical and staff producing the waste (doctors, undertaken at their own place of work or somewhere nurses and lab technicians), waste similar. workers and waste handlers and • Training and awareness programs help in teams involved in final disposal changing the mindset of the HCF teams and should be trained. Nurses and waste workers towards health- care waste. handlers are key personnel to instill a Regular and ongoing training and awareness disciplined approach in the day- to- programs for all the staff members day management of wastes. • from the top administrator to the housekeeping staff should be organized to reinforce the message of proper waste management practices. • Training for HCWs should be conducted as soon as the ICHCWMP is completed as least via a quick awareness program taking into consideration the nature of operations. • As all HCFs in the Kosovo have at least one HCW personnel as per the MoH, this training can be conducted remotely via video conference or via online reading material. • Training programs should broadly include the following topics: • COVID-19 Related Infection Control Protocols • Hazards of health-care waste • Infection control measures • Bio-Medical Waste (Management and Handling) Rules • Waste management steps: waste collection, segregation, transportation, storage, treatment and 178 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y disposal • Liquid waste management • Cleaning of spills • Waste minimization • Alternatives to hazardous chemicals • Occupational safety issues. • More in-depth face to face training must be conducted immediately after the rapid response phase • Periodic repetition of courses will provide an opportunity to instruct new employees, and “refresher� courses for existing employees can remind them of practices and inform about changes or new responsibilities. • Online based modules are offered by the WHO with already pre-prepared training material that can be used. 8. Emergency Preparedness Plans 8.1 Biohazard, Infectious material • Only staff members who are trained and HCWs, On generation HCF HCF and chemical spills. competent regarding the proper procedures, that HCWWs, Operational Management, have the appropriate spill clean-up equipment and budget PIU, MoH personal protective equipment, are allowed to clean up blood or other potentially infectious materials. • Department heads of the HCF are responsible for ensuring that staff members have been trained regarding spill response procedures for biological materials to which they may be exposed. • Alert people in immediate area of spill to keep away and not to touch the material or walk near it. • Staff trained, need to put on protective equipment including gloves, gown and face and eye protection. The following management steps needs to be followed: o Cover spill with paper towels or other absorbent material. • Carefully pour a hospital-approved germicide around the edges of the spill and then into the spill. Avoid splashing. Avoid making the spill significantly larger. • Wipe up the spill with towels, absorbent material and dispose properly. • Follow other applicable departmental procedures. • Exposed individuals should be immediately referred to the Occupational/Employee Health Facility or Emergency Department within the HCF and provided with due care. 179 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y • All actions should be documented in operational logs 8.2 Contingency Measures for Disruption • In the event that service by the health care waste HCWs, On generation HCF HCF of Service – Transport and Treatment transporter and/or treatment/disposal contractor is HCWWs, Operational Management, and/or final disposal by a service interrupted for any reason, the following actions budget PIU, MoH provider. would be implemented: • Determine when regular service from regular transport and treatment contractor can be resumed. Inquire if contractor has alternative transportation, storage and disposal plan that can be implemented. • Notify the MoH senior officials and HCF management for guidance on next steps. • If the service provider cannot provide services within a reasonable time, then the following actions will be implemented: ▪ Attempt to secure the services of an alternate service provider who may be able to transport and dispose of waste until regular service is restored. ▪ Implement disinfection and contained storage for a minimal period of 48 hours. 8.3 Potential Equipment Failure within • If the primary equipment fails, there should always HCWs, On generation HCF HCF HCFs be an alternate machine or facility identified. HCWWs, Operational Management, • Health care waste will be handled by one budget PIU, MoH of the following methods: • Complete the sterilization at the other autoclave if possible or immediate chemical disinfection • Medical waste can be stored at temperatures greater than 32 °F (0°C) for up to 7 days prior to treatment if refrigeration facilities for waste is available within the facility. • The medical waste may also be stored frozen for up to 90 days. Attempts will be made to complete repair within this time. 8.4 Hindrances to regular operations due In the event of a natural disaster, all activities HCWs, On generation HCF HCF to Natural Disasters generating medical waste should follow guidance on HCWWs, Operational Management, longer storage. budget PIU, MoH • It is recommended that for larger HCFs refrigerators should be explored as a storage option in the event of emergencies. • In the event of an electrical or other problem related to natural disasters, the lab users need to coordinate with the relevant authorities to ensure power supply. 180 | P a g e Activity and Potential E&S Issues Proposed Mitigation Measures Responsibilities Timeline Budget Monitoring and Risks Responsibilit y • Having a backup power supply such as a generator is recommended such as auxiliary generators to provide backup power to autoclaves. 8.5 Potential closure of a waste Upon closure of the facility, all equipment, facilities, HCWs, On generation HCF HCF treatment facility and non-disposable items used in the operation of the HCWWs, Operational Management, treatment process will be decontaminated either by budget PIU, MoH steam sterilization or by disinfection with a commercial quaternary ammonium salt disinfectant, mixed and used per the manufacturer’s directions. 181 | P a g e 9.4: Annex IV - Community Health and Safety Plan (CHSP) World Bank ESS4 addresses the health, safety, and security risks and impacts on project-affected communities and the corresponding responsibility of Borrowers to avoid or minimize such risks and impacts, with particular attention to people who, because of their particular circumstances, may be vulnerable. The ESMP and ESMF for the Project identify several aspects related to community health and safety: • Infrastructure and equipment design and safety • Safety of services • Transport of Vaccines • Community exposure to health issues • Accessibility, social inequity, and risk of exclusion • Management and of hazardous materials • Security Personnel • Emergency preparedness and response This Community Health and Safety Plan (CHSP) and Emergency Response Plan (ERP) provides additional detail on the risks and potential impacts posed by the project, and proposes mitigation measures to avoid or minimize them. Each aspect is discussed in turn below. 1. Equipment Design and Safety The project will not fund any infrastructure, only the procurement of vaccines and related equipment and supplies. To mitigate these risks, due diligence and assessments will be undertaken by MOH regarding purchase of equipment to ensure correct fit for purpose equipment is procured to local standards. As well, energy efficient equipment will be favoured. Sustainable use of goods and materials will be encouraged through capacity building and training of health service personnel. The following specific mitigation measures will be undertaken: • Adhere to the procurement plan for acquisition of all vaccines, medical supplies and equipment from certified suppliers only. • Carry out due diligence for all potential suppliers to guarantee quality equipment and products. 183 | P a g e • The healthcare workers shall be provided with medical personal protective equipment (PPE) which includes: Medical mask, Gown, Apron, Eye protection (goggles or face shield), Respirator (N95 or FFP2 standard), Boots/closed work shoes. Poor quality PPE may exacerbate COVID-19 infection transmission to healthcare workers and cleaners in relation to laboratory procedures, interaction with COVID-19 patients and handling of healthcare waste. The following mitigation measures will be applied: • Adhere to the procurement plan for acquisition of all personal protective equipment from certified suppliers only. • Carry out due diligence for all potential suppliers to guarantee quality supply of personal protective equipment and products. • Abide by the WHO interim guidance on rational use of PPE for coronavirus disease 2019 over the types and quality of PPE required for different functions. • The healthcare workers shall be provided with medical personal protective equipment (PPE) which includes: Medical mask, Gown, Apron, Eye protection (goggles or face shield), Respirator (N95 or FFP2 standard), Boots/closed work shoes and trained on use To mitigate against the misuse or inability to correctly use the installed healthcare systems and equipment, the following will be applied: • Provide requisite training during equipment installation. • Carry out regular supervision, ensure only trained authorized personnel operate equipment, • The manual containing information on how the medical facilities and equipment should be safely handled should be made available to the relevant staff. • Equipment’s should be sanitized and disinfected before use to minimize risks of infections. When improved healthcare facilities and equipment’s installed are not continually maintained, they quickly degenerate. To allow for sustainability of the investments, the following will be adopted: • There shall be adherence to the Facility Maintenance Plans at each healthcare facility. • The respective beneficiary facilities shall ensure there is always a budget to sustain healthcare facilities in the county in a functional state. • Equipment available in the health facilities should be serviced and maintained regularly. 2. Safety of Services 184 | P a g e ESS4 specifies that where the project involves provision of services to communities, the Borrower will establish and implement appropriate quality management systems to anticipate and minimize risks and impacts that such services may have on community health and safety. In such circumstances, the Borrower will also apply the concept of universal access, where technically and financially feasible. Relative to social risks, the ESMP identifies there is a risk that wider public and patients are not treated with respect for their dignity, human rights and fundamental freedoms. Further, marginalized, high- risk and vulnerable social groups (poor, disabled, elderly, migrants, homeless) may be unable to access facilities. To minimize these risks the following measure will be adhered to: • The project’s Stakeholder Engagement Plan (SEP) will ensure widespread engagement with communities – including its more vulnerable groups – to disseminate information related to community health and safety, particularly about social distancing, high-risk demographics, self-quarantine, and mandatory quarantine. All the relevant information will be translated into Spanish and this shall be made accessible to the groups through the appropriate channels including the NGOs who routinely work with migrants. • Project grievance mechanism (GM) enables communities to raise project related concerns and grievances. • The operation of medical centres will be implemented in a way that both the wider public, as well as the patients are treated in line with international best practice as outlined in WHO guidelines. Patients will be treated with respect for their dignity, human rights and fundamental freedoms and minimize any discomfort or distress associated with such measures taking into consideration their gender, sociocultural, ethnic or religious needs. • MOH, in the ESCP, committed to the provision of services and supplies to all people and ensure that individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable, have access to the development benefits. • The MOH will implement WHO guidance tools for COVID-19 risk communication and engagement, including with respect to social stigma: (https://www.who.int/docs/default- source/coronaviruse/COVID19-stigma-guide.pdf). There is a risk that outreach campaigns do not meet the needs of the public. To address these risks, MoH has committed to the implementation of the WHO Code of Ethics and Professional Conduct. In addition: 185 | P a g e • SEP implementation will ensure community awareness and communication activities address potential issues. • Clear communication of risks and prevention measures will be included within stakeholder engagement activities and the project’s Labour Management Procedure (LMP). • Project grievance mechanism (GM) will be available to enable communities to raise project related concerns and grievances. This mechanism will be available on the MoH’s website and other media presence 3. Transport of the Vaccines The Defence Force will be utilised in the transport of vaccines from the airport to the centralized storage area. For Tobago, the vaccines will be transported via air. Once on the ground, the vaccines will be transported via the roads to each health facility. The MoH /TRHA vehicle will be used. The vaccines will be transported in coolers with ice packs and a thermometer inside. The measures put in place for transport include: • To minimize the risk of encountering heavy traffic, the driver will deliver the vaccines at non- peak hours. Additionally, the inventory of each facility will be monitored to ensure that there is no urgent need for vaccines all at the same time. • Drivers will follow all the traffic laws of Trinidad and Tobago and be especially mindful of speed limits to the health facilities. • The Maintenance personnel of the Ministry shall regularly inspect vehicle safety and employ trained drivers to minimize the accidents. • Armed forces shall be trained on the applicable standards and code of conduct in line with the guidance provided in the WB’s Technical Note “Use of Military Forces to Assist in Covid- 19 Operations� 4. Community exposure to health issues The vaccine administration may lead to crowding and violation of physical distancing measures, increasing the risk of exposure of the health workers, the vaccines, and the community, especially the residents within the vicinity of the immunization site. Thus, compliance to minimum public health standards will be pursued. The existing security personnel will also be used to manage crowds. Tents shall be set up outside the facilities so that persons can wait until they are called inside. Infectious health care wastes generated from the vaccination and other COVID-19- related responses 186 | P a g e pose risk to community health and safety if not handled, transported, treated, and disposed of according to the proper health care waste management practices. Section 7 of the ISWMP addresses the issues regarding this. Hospital visitors and other non- COVID-19 patients may also be exposed to the virus as well as the workers. To mitigate this, the storage area for bio-medical waste will be in an enclosed room and access will be limited to authorized staff. 5. Accessibility, social inequity, and risk of exclusion. There is an indirect risk of social exclusion, in particular, the most vulnerable and marginalized groups and also the sexual and gender minorities or refugees. The elderly, those with underlying medical conditions, and people living with disability, though included in the priority populations to be vaccinated as identified in the WHO SAGE Roadmap for Prioritizing Uses of COVID-19 Vaccines in the Context of Limited Supply, may have limited access to the vaccines due to reduced mobility. The vulnerable groups may also be excluded from coverage of the national program and local responses to COVID-19. The vaccine distribution and deployment may also exclude populations based on geographical distribution, and on socioeconomic status, such as less access for the marginalized. To mitigate this, the Stakeholder Engagement Plan includes provisions for engaging affected and interested stakeholders throughout the project implementation. Measures to address concerns of vulnerable groups, including persons with disabilities, are included in the ESMF and SEP. The National Vaccination Deployment Plan identifies groups according to their prioritization (based on risk). 6. Management and safety of hazardous materials Medical wastes from vaccinations can have a potential of carrying micro-organisms that can infect the community at large if not properly managed. There is a possibility for the infectious microorganism to be introduced into the environment if not sustainably contained within the clinical practice, supplies’ transportation and laboratory operation or due to accidents/ emergencies e.g. a fire response or natural phenomena. To manage these risks, the project has prepared an Infection Control and Waste Management Plan (ICWMP) that describes how facilities manage bio-medical waste in a safe manner with appropriate biomedical waste management practices, in line with the established Code of Practice. Sections 5, 7 and 8 specifically address these concerns. 187 | P a g e 7. Security Personnel The larger health facilities have an internal, regular security presence on staff. In the early days of vaccines delivery there were issues with crowd control but these have been mostly addressed by implementing an appointment system. In the case, however, that an external, third-party security company would be needed from time to time, they would be required to follow the relevant guidelines below: • Security personnel shall follow strict rules of engagement and avoid any escalation of the situation. • Training and or implementation of strict guidelines for engagement of armed security personnel. • Monitoring of the behaviour of the security personnel over the rules of engagement. • Community members encouraged to report any concerns through instituted GM. The Trinidad and Tobago Defence Force are part of the logistics team for the vaccine deployment. They will escort the vaccines as they arrive in Trinidad and are also responsible for security at the Couva Medical and Mutlti-Training Facility which is both a hospital that treats with COVID-19 patients as well as the main storage facility for the vaccines. As a result, they shall be trained on the applicable standards and code of conduct in line with the guidance provided in the WB’s Technical Note “Use of Military Forces to Assist in Covid-19 Operations� 8. Emergency Preparedness and Response The major legislative drivers for the development of plans and procedures for emergency response are: Sections 8 (2,3) of the OSH Act 2004 amended states: (2) An occupier of an industrial establishment employing twenty-five or more persons shall prepare or revise, in consultation with worker representatives in the industrial establishment— (a) a written statement of his general policy with respect to the safety and health of persons employed in the industrial establishment, specifying the organisation and arrangements for the time being in force for carrying out that policy and the provisions specified in subsection (1); and (b) an emergency plan in writing based on a risk assessment made in accordance with section 13A which shall include— 188 | P a g e (i) suitable and rapid means of obtaining first-aid help and transportation from the industrial establishment to a hospital for injured workers; and (ii) measures and procedures to be used to control a major fire, to react to serious damage to the industrial establishment, to evacuate the industrial establishment and to notify rescue personnel, and the occupier shall submit the statement or the emergency plan, as the case may be, and any revision thereof to the Chief Inspector and bring them to the notice of all persons employed in the industrial establishment. (3) The Chief Inspector may, having regard to the statement or the emergency plan submitted under subsection (2), direct the occupier to appoint at his own expense, a Safety Practitioner who shall assist in ensuring that the policy and the provisions specified in subsection (1) or the requirements of the emergency plan, as the case may be, are complied with. The Trinidad and Tobago Fire Service Act 35:50 and the Trinidad and Tobago Fire Service Fire/Life Safety Certificate guiding document for SFTH: 6.1 A written Emergency Action Plan that is consistent with the available equipment and personnel shall be established to respond to fires and related emergencies. This plan shall include the following: - 6.1.2 Appointment and training of personnel to carry out assigned duties. Each health care facility has a Disaster Management Plan. The overall purpose of the plan is to define a systematic approach to disaster management at the facility so as to ensure, as far as reasonably practicable, healthcare service continuity in times of disaster. Within this plan is the Emergency Response Plan (ERP). An emergency is defined as an unexpected event that negatively impacts lives and property but differs from a disaster as the affected community, society or country is able to cope using its own resources and normal arrangements, so as not to result in a serious disruption of the functioning of the entity. Emergency incidents occurring in a health facility may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, communities, the facility’s operation and the environment. The following measures should apply for all facilities: • All employees should be educated and trained on the management of biomedical waste and spill management. 189 | P a g e • There should be various procedural methods for containing and isolating each type of spill. • If a spill occurs, staff responsible for clean - up should be notified immediately • There should be proper equipment available for clean – up (such as spill kits) • If a spill involving blood or bodily fluids occurs, the following procedures should be followed: o Put on protective clothing and gloves; o Pour bleach (for small spills use 1:00 dilution; for large spills 1:10) and allow to sit for several minutes; o Put sand, kitty litter or absorbent over spill and wait until absorbed; o Place contaminated waste in bag; o Put on new pairs of gloves, and mop area with soap and water; o Dry area with disposable paper towels and discard of materials; o Wash hands thoroughly, and report the incident o If any accident or spill occurs, there should be a thorough investigation as to the cause of the incident and a report be prepared. 190 | P a g e 9.5 Annex V – Resource List for COVID-19 Guidance WHO Guidance Advice for the public • WHO advice for the public, including on social distancing, respiratory hygiene, self-quarantine, and seeking medical advice, can be consulted on this WHO website: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public Technical guidance • Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, issued on March 19, 2020 • Recommendations to Member States to Improve Hygiene Practices, issued on April 1, 2020 • Severe Acute Respiratory Infections Treatment Center, issued on March 28, 2020 • Infection prevention and control at health care facilities (with a focus on settings with limited resources), issued in 2018 • Laboratory biosafety guidance related to coronavirus disease 2019 (COVID-19), issued on March 18, 2020 • Laboratory Biosafety Manual, 3rd edition, issued in 2014 • Laboratory testing for COVID-19, including specimen collection and shipment, issued on March 19, 2020 • Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios, issued on March 21, 2020 • Infection Prevention and Control for the safe management of a dead body in the context of COVID-19, issued on March 24, 2020 • Key considerations for repatriation and quarantine of travelers in relation to the outbreak COVID-19, issued on February 11, 2020 • Preparedness, prevention and control of COVID-19 for refugees and migrants in non- camp settings, issued on April 17, 2020 191 | P a g e • Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health, issued on March 18, 2020 • Oxygen sources and distribution for COVID-19 treatment centers, issued on April 4, 2020 • Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response, issued on March 16, 2020 • Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19), issued on March 19, 2020 • Operational considerations for case management of COVID-19 in health facility and community, issued on March 19, 2020 • Rational use of personal protective equipment for coronavirus disease 2019 (COVID- 19), issued on February 27, 2020 • Getting your workplace ready for COVID-19, issued on March 19, 2020 • Water, sanitation, hygiene and waste management for COVID-19, issued on March 19, 2020 • Safe management of wastes from health-care activities, issued in 2014 • Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak, issued on March 19, 2020 • Disability Considerations during the COVID-19 outbreak, issued on March 26, 2020 World Bank Group Guidance • Technical Note: Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints on conducting public meetings, issued on March 20, 2020 • Technical Note: Use of Military Forces to Assist in COVID-19 Operations, issued on March 25, 2020 192 | P a g e • ESF/Safeguards Interim Note: COVID-19 Considerations in Construction/Civil Works Projects, issued on April 7, 2020 • Technical Note on SEA/H for HNP COVID Response Operations, issued in March 2020 • Interim Advice for IFC Clients on Preventing and Managing Health Risks of COVID- 19 in the Workplace, issued on April 6, 2020 • Interim Advice for IFC Clients on Supporting Workers in the Context of COVID-19, issued on April 6, 2020 • IFC Tip Sheet for Company Leadership on Crisis Response: Facing the COVID-19 Pandemic, issued on April 6, 2020 • WBG EHS Guidelines for Healthcare Facilities, issued on April 30, 2007 ILO Guidance • ILO Standards and COVID-19 FAQ, issued on March 23, 2020 (provides a compilation of answers to most frequently asked questions related to international labour standards and COVID-19) MFI Guidance • ADB Managing Infectious Medical Waste during the COVID-19 Pandemic • IDB Invest Guidance for Infrastructure Projects on COVID-19: A Rapid Risk Profile and Decision Framework • KfW DEG COVID-19 Guidance for employers, issued on March 31, 2020 • CDC Group COVID-19 Guidance for Employers, issued on March 23, 2020 193 | P a g e 9.6 Annex VI – Environmental and Social Commitment Plan (ESCP) The Republic of Trinidad and Tobago Ministry of Health Trinidad and Tobago: COVID-19 Emergency Response Project (P173989) ENVIRONMENTAL and SOCIAL COMMITMENT PLAN (ESCP) May 24, 2022 194 | P a g e Trinidad and Tobago: COVID-19 Emergency Response Project (P173989): Environmental and Social Commitment Plan (ESCP) ENVIRONMENTAL AND SOCIAL COMMITMENT PLAN 1. The Republic of Trinidad and Tobago (hereafter, the “Borrower�) is implementing the Trinidad and Tobago: COVID-19 Emergency Response Project (the “Project�) through the Ministry of Health (“MoH�). The International Bank for Reconstruction and Development (hereinafter, the “Bank�) has agreed to provide financing for the Project. 2. The Borrower shall carry out the Project in accordance with the World Bank Environmental and Social Standards (ESSs). This Environmental and Social Commitment Plan (ESCP) sets out material measures and actions, to be carried out or caused to be carried out by the Borrower, including time frames of the actions and measures, institutional, staffing, training, monitoring and reporting arrangements, grievance management and the environmental and social assessments and instruments to be prepared or updated, disclosed, consulted, adopted and implemented under the ESCP and the ESSs, all in a manner acceptable to the Bank. 3. The Borrower is responsible for compliance with all requirements of the ESCP even when implementation of specific measures and actions is conducted by the Ministry referenced in 1. above. 4. Implementation of the material measures and actions set out in this ESCP shall be monitored and reported to the Bank by the Borrower as required by the ESCP and the conditions of the Loan Agreement, as amended. 5. As agreed by the Bank and the Borrower, this ESCP may be revised from time to time during Project implementation, to reflect adaptive management of Project changes and unforeseen circumstances or in response to assessment of Project performance conducted under the ESCP itself. In such circumstances, the Borrower shall agree to the changes with the Bank and shall update the ESCP to reflect such changes. Agreement on changes to the ESCP shall be documented through the exchange of letters signed between the Bank and the Minister in charge of MoH on behalf of the Borrower. The MoH shall promptly disclose the updated ESCP. 6. Where there are Project changes, unforeseen circumstances, or Project performance results in changes to the risks and impacts during Project implementation, the Borrower shall provide additional funds, if needed, to implement actions and measures to address such risks and impacts. 195 | P a g e MATERIAL MEASURES AND ACTIONS TIMEFRAME RESPONSIBLE ENTITY/AUTHORITY MONITORING AND REPORTING A REGULAR REPORTING Prepare and submit to the Bank regular monitoring reports on the environmental, Quarterly reporting throughout Project Project Implementation social, health and safety (ESHS) performance of the Project, including but not implementation submitted within 45 days Unit (PIU) within the limited to the implementation of the ESCP, status of preparation and after the end of each reporting period, Ministry of Health (MoH) implementation of E&S instruments required under the ESCP, stakeholder starting from the Effective Date of the engagement activities, and grievances log. Project. Mid-term and completion reports shall also be submitted, as requested by the Bank, during Project implementation. B INCIDENTS AND ACCIDENTS Promptly notify the Bank of any incident or accident related to the Project which Notify the Bank within 48 working hours PIU/MoH has, or is likely to have, a significant adverse effect on the environment, the after learning of the incident or accident. affected communities, the public or workers, including, inter alia, any COVID-19 A report would be provided within a outbreak in the Project area, improper disposal of healthcare wastes from timeframe acceptable to the Bank, as diagnosis, treatment, and immunization activities, cases of sexual exploitation and requested. abuse (SEA), and sexual harassment (SH), and incidents related to security forces/personnel following incident classification defined in the ESMF. Provide sufficient detail regarding the incident or accident, indicating immediate measures taken or that are planned to be taken to address it, and any information provided by any contractor and supervising entity, as appropriate. Subsequently, as per the Bank’s request, prepare a report on the incident or accident and propose any measures to prevent its recurrence. 196 | P a g e MATERIAL MEASURES AND ACTIONS TIMEFRAME RESPONSIBLE ENTITY/AUTHORITY ESS 1: ASSESSMENT AND MANAGEMENT OF ENVIRONMENTAL AND SOCIAL RISKS AND IMPACTS 1.1 ORGANIZATIONAL STRUCTURE The PIU already established under the Ministry of Health (MoH) shall be An environmental and social specialist PIU/ MoH responsible for the implementation of the Project. The MoH shall hire and maintain shall be contracted or assigned before the throughout Project implementation one (1) environmental and social specialist with first disbursement for Component 2 but no qualifications and experience acceptable to the Bank. In addition, the MoH has later than September 26 , 2022. The already assigned and shall maintain officials as the Environmental Focal Point and specialist and the focal points shall be Social Focal Point. The MoH shall ensure adequate time is allocated for the retained throughout Project specialist and the Focal Points for the Project’s environmental and social risk implementation. Before the appointment management. The Project Coordinator shall have overall responsibility for is complete, the Focal Points shall provide coordinating the environmental and social aspects with the support of the the necessary support to the environmental and social specialist and respective focal points. The MoH shall management of E&S risks and impacts. also convene a technical oversight committee with the relevant technical lead for environmental and social risk management. PIU/MoH Adequate resources shall be allocated to support management of the ESHS risks Throughout Project implementation. of the Project. 197 | P a g e 1.2 ENVIRONMENTAL AND SOCIAL ASSESSMENT AND ENVIRONMENTAL AND SOCIAL MANAGEMENT PLANS a. Prepare/Update, adopt and disclose the ESMF to address risks and a. The adoption and disclosure of the PIU/MoH impacts related to the procurement and deployment of vaccines., ESMF, acceptable to the Bank, including the results of a rapid E&S assessment. The ESMF will assess shall occur no later than 60 (sixty) the environmental and social risks and impacts of proposed Project days after the Effective Date of the activities, in accordance with ESS1, including ensuring that individuals amendment to the Loan Agreement, or groups who, because of their particular circumstances, may be and in addition shall be a withdrawal disadvantaged or vulnerable, have access to the development benefits condition for Category 2 of the Loan resulting from the Project including, as relevant, with regards to Agreement. vaccines. The ESMF shall also build on a comprehensive review of the Code of Practice for Bio-Medical Waste Management and a rapid assessment of relevant incinerator facilities to determine whether they currently meet WB/WHO standards. The ESMF shall identify critical gaps (if any) and propose appropriate measures to overcome the gaps. b. The MOH shall ensure, document, and certify through a rapid b. The rapid E&S assessment will be environmental and social assessment, that the activities subject to part of the ESMF, and it will follow retroactive financing comply with the Environmental and Social the same timeframe as 1.2. a. Standards of the World Bank. The rapid E&S assessment shall be undertaken by the GORTT and the final report shall be integrated into the updated ESMF as described in 1.2.an above. The rapid assessment should confirm that adequate waste management practices, appropriate laboratory facilities, training of key staff on the use of the supplies and equipment that follows the Trinidad and Tobago’s ‘Code of Practice for Bio-Medical Waste Management’ and ‘Occupational Safety and Health Management Policy’ and the relevant World Health Organization (WHO) Guidelines for medical waste management, are implemented in a manner consistent with the ESSs. c. Prepare, disclose, adopt, and implement an Environmental and Social c. Plans or instruments prepared, Management Plan (ESMP), Infection Control and Waste Management adopted, and disclosed before the Plan (ICWMP), Community Health and Safety Plan (CHSP), and any carrying out of the relevant Project other environmental and social management plans, measures or other activities, and thereafter instruments required for the respective Project activities based on the implemented throughout the assessment process, in accordance with the ESSs, the ESMF, and carrying out of such activities. other relevant Good International Industry Practice (GIIP) including relevant WHO Guidelines on COVID-19 to, inter alia, ensure access to and allocation of Project benefits in a fair, equitable and inclusive manner, taking into account the needs of individuals or groups 198 | P a g e who, because of their particular circumstances, may be disadvantaged or 199 | P a g e MATERIAL MEASURES AND ACTIONS TIMEFRAME RESPONSIBLE ENTITY/AUTHORITY vulnerable, including, as relevant, with regards to vaccines. This includes access to Project benefits for non-nationals, as set out in the Stakeholder Engagement Plan (SEP). d. Incorporate the relevant aspects of this ESCP, including, inter alia, any d. Before initiating the procurement environmental and social management plans or other instruments, process for the relevant activities ESS2 requirements, and any other required Environmental, Social, and thereafter throughout the Health and Safety (ESHS) measures, into the ESHS specifications of implementation of such Project the procurement documents and contracts with suppliers. Thereafter activities. ensure that the suppliers comply with the ESHS specifications of their respective contracts. e. Before initiating the vaccination e. Adopt procedures, protocols and/or other measures to ensure Project program and thereafter beneficiaries that receive vaccines under the Project do so under a implemented throughout the carrying program that does not include forced vaccination and is acceptable to out of such activities. the Bank, as set out in the ESMF. 1.3 EXCLUSIONS: Exclude the following types of activities as ineligible for financing under the During the assessment process PIU/MoH Project: conducted under action 1.2.c. above. • Activities that may cause long term, permanent and/or irreversible (e.g., loss of major natural habitat) adverse impacts. • Activities that have high probability of causing serious adverse effects to human health and/or the environment not related to COVID-19 treatment. • Activities that may have significant adverse social impacts and may give rise to significant social conflict. • Activities that may involve any resettlement or land acquisition/use restriction or adverse impacts on cultural heritage. • All the other excluded activities set out in the ESMF of the Project. 1.4 AVAILABILITY OF RESOURCES FOR WASTE MANAGEMENT Throughout Project implementation. PIU/MoH Ensure that resources, including human and financial resources, are available to cover the incremental costs associated with the management of increased waste volumes, including biomedical waste, and vaccination related waste (expired and opened vaccine vials), resulting from Project activities. 200 | P a g e MATERIAL MEASURES AND ACTIONS TIMEFRAME RESPONSIBLE ENTITY/AUTHORITY ESS 2: LABOUR AND WORKING CONDITIONS 2.1 LABOUR MANAGEMENT PROCEDURES Prepare, disclose, adopt, and implement Labor Management Procedures (LMP) Same timeframe as 1.2. a. Until then, the PIU/MoH as part of the ESMF, in accordance with the applicable requirements of ESS2, in recommendations referenced in the a manner acceptable to the Bank, including, inter alia: interim guidelines for workplace safety and infection control and existing • Implementing adequate occupational health and safety measures (including grievance mechanism shall apply. personal protective equipment, emergency preparedness and response measures) to ensure the health and safety of Project workers. World Health LMP to be implemented throughout Organization (WHO) guidelines on COVID19 shall be followed in all facilities, Project implementation. including laboratories, quarantine and isolation centers, and screening posts. • Establishing and maintaining a Grievance Mechanism (GM) for health workers and any other Project. • Incorporating labor requirements into the ESHS specifications of the procurement documents and contracts. 201 | P a g e MATERIAL MEASURES AND ACTIONS TIMEFRAME RESPONSIBLE ENTITY/AUTHORITY ESS 3: RESOURCE EFFICIENCY AND POLLUTION PREVENTION AND MANAGEMENT 3.1 MEDICAL AND HAZARDOUS WASTE MANAGEMENT: a. Relevant aspects of this standard shall be considered, as needed, under action a. Throughout Project implementation. PIU/MoH 1.2 above, including, inter alia, measures to: carry out the purchase, storage, transportation, handling and deployment of vaccines (including, ultra-cold chain management) in a safe manner and in accordance with the ESHS, and other relevant GIIP including relevant WHO guidelines. b. Prepare, disclose, adopt, and implement the Infection Control and b. Same timeframe as for the Waste Management Plan (ICWMP) as per the requirements of the preparation and implementation of ESMF. the ESMP, under action 1.2.c. c. Throughout Project implementation. c. Adequately manage and dispose of health care wastes (including vaccines) and other types of hazardous and non-hazardous wastes, including appropriate selection and safe usage and disposal of personal protective equipment (PPE) and relevant medical evaluation and health surveillance of PPE users following actions 1.2a-d. MoH shall adopt technologies and procedures on medical waste management including rapid assessment for appropriate treatment and disposal. Given the potential resource scarcity in the face of an outbreak, MoH shall commit to the provision of services and supplies based on the urgency of need, in line with the latest data related to the prevalence of the cases. 202 | P a g e MATERIAL MEASURES AND ACTIONS TIMEFRAME RESPONSIBLE ENTITY/AUTHORITY ESS 4: COMMUNITY HEALTH AND SAFETY 4.1 COMMUNITY HEALTH AND SAFETY a) Relevant aspects of this standard shall be considered, as needed, under action a) Throughout Project implementation PIU/MoH 1.2 above including, inter alia, measures to: minimize the potential for community exposure to communicable diseases; ensure that the public is safe from potential wastes, especially disposed biohazardous materials and PPE; reduce risk associated with visits to health centers; ensure that individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable, have access to the development benefits resulting from the Project; manage the risks of the use of security personnel; manage the risks of labor influx; and prevent and respond to sexual exploitation and abuse, and sexual harassment (SEA/SH). b) A Community Health and Safety Plan (CHSP) shall be developed as part of the b) Same timeframe as for the PIU/MoH ESMF. preparation and implementation of the ESMF, under action 1.2.a 203 | P a g e MATERIAL MEASURES AND ACTIONS TIMEFRAME RESPONSIBLE ENTITY/AUTHORITY 4.2 USE OF SECURITY FORCES: In case the Borrower’s security forces (e.g., PIU/MoH Trinidad and Tobago Defense Force) are used in the implementation of Project activities and/or for provision of security to Project workers, sites and/or assets, the MoH shall adopt the following measures, in coordination with other competent authorities, as needed and as relevant: a. Assess the risks and impacts of engagement of the security forces, as part a) Assessment carried out in the same of the assessment referred to in action 1.2 a above, and implement timeframe than action 1.2 a) above and measures to manage such risks and impacts, guided by the principles of any required measures shall be adopted proportionality and GIIP, and by applicable law, in relation to hiring, rules of before deploying security forces under conduct, training, equipping, and monitoring of such forces. the Project and thereafter implemented throughout Project implementation. b. Adopt and enforce standards, protocols, and codes of conduct, in b) and c) before deploying security or coordination with other competent authorities, for the selection and use of military personnel under the Project and such forces, and screen such personnel to verify that they have not thereafter throughout engaged in past unlawful or abusive behavior, including SEA/SH or Project implementation. excessive use of force. c. Ensure that such forces are adequately instructed and trained, prior to deployment and on a regular basis, on the use of force and appropriate conduct (including in its relations to civilian, SEA and SH, and other relevant areas) d) and e) as set out under actions 10.1 and 10.2 respectively. d. Ensure that the stakeholder engagement activities under the Stakeholder Engagement Plan (SEP) include a communication strategy on the involvement of such forces under the Project. e. Ensure that any concerns or grievances regarding the conduct of such forces are received, monitored, documented (taking into account the need to protect confidentiality) and resolved through the Project’s grievance mechanism (see action 10.2 below) and reported to the Bank no later than 5 days after being received. ESS 5: LAND ACQUISITION, RESTRICTIONS ON LAND USE AND INVOLUNTARY RESETTLEMENT ESS5 is not currently relevant. ESS 6: BIODIVERSITY CONSERVATION AND SUSTAINABLE MANAGEMENT OF LIVING NATURAL RESOURCES ESS6 is currently not relevant 204 | P a g e MATERIAL MEASURES AND ACTIONS RESPONSIBLE TIMEFRAME ENTITY/AUTHORITY ESS 7: INDIGENOUS PEOPLES/SUB-SAHARAN AFRICAN HISTORICALLY UNDERSERVED TRADITIONAL LOCAL COMMUNITIES ESS7 is currently not relevant. ESS 8: CULTURAL HERITAGE ESS8 is currently not relevant. ESS 9: FINANCIAL INTERMEDIARIES ESS 9 is currently not relevant ESS 10: STAKEHOLDER ENGAGEMENT AND INFORMATION DISCLOSURE 10.1 STAKEHOLDER ENGAGEMENT PLAN PREPARATION AND PIU/MoH IMPLEMENTATION A draft SEP was already prepared and Update, consult, adopt, disclose, and implement a Stakeholder Engagement Plan disclosed prior to project appraisal and (SEP) consistent with ESS10, which shall include measures to, inter alia, provide updated for the restructuring of the stakeholders with timely, relevant, understandable, and accessible information, Project. and consult with them in a culturally appropriate manner, which is free of manipulation, interference, coercion, discrimination, and intimidation. The SEP shall be consulted, finalized and redisclosed no later than 60 (sixty) days after the Effective Date of the amendment to the Loan Agreement, and in addition shall be a withdrawal condition for Category 2 of the Loan Agreement. The SEP shall be implemented throughout Project implementation. 10.2 PROJECT GRIEVANCE MECHANISM PIU/MoH An accessible grievance mechanism shall be established, publicized, maintained, The GM is already in place and shall be and operated to receive and facilitate resolution of concerns and grievances in adjusted, maintained, and implemented relation to the Project, promptly and effectively, in a transparent manner that is throughout Project implementation. The culturally appropriate and readily accessible to all Project-affected parties, at no existing GM arrangements are described cost and without retribution, including concerns and grievances filed anonymously, in the SEP. in a manner consistent with ESS10. The grievance mechanism shall also receive, register, and address concerns and grievances related to the SEA/SH in a safe and confidential manner, including through the referral of survivors to gender-based violence service providers. 205 | P a g e CAPACITY SUPPORT (TRAINING) CS1 TRAINING PIU/MoH The PIU and other relevant implementing support staff responsible for the No later than one month after adoption Project shall receive training on the Project’s ESHS plans and E&S of this ESCP, SEP and ESMF and instruments as well as on fair, equitable and inclusive access and allocation periodically with the addition of new of Project benefits, including with regards to vaccines, and the roles and Project team members as they join the responsibilities of different key agencies in the ESF implementation. Project and throughout implementation. Project workers shall receive training on the contents and requirements detailed in the ESMF, the Infection Control and Waste Management Plan and Emergency Preparedness and Response Plan to ensure compliance with environmental and social requirements. The MoH shall ensure that the Regional Health Authorities are aware of the Project GM and its functioning and contact points for referrals. Security forces shall be trained on the applicable standards and code of conduct in line with the guidance provided in the Bank’s Technical Note “Use of Military Forces to Assist in Covid-19 Operations� and as defined in the updated ESMF and stated under 4.2. The Borrower shall ensure that resources, including human and financial resources, are available to cover costs associated with such training requirements. 206 | P a g e 9.7 Annex VII – Labour Management Procedures (LMP) TRINIDAD AND TOBAGO: COVID-19 EMERGENCY RESPONSE PROJECT (P173989) MINISTRY OF HEALTH LABOUR MANAGEMENT PROCEDURES (LMP) 1.0 INTRODUCTION This document represents the Labour Management Procedures (LMP) for the Trinidad and Tobago: COVID-19 Emergency Response Project (P173989). These procedures ensure that the measures are established and implemented to manage any risks associated with employment under the project. The LMP identifies the main labour requirements and ensures that the engagement of project workers is completed in accordance with the requirements established in both the Labour Laws of the Republic of Trinidad and Tobago and ESS2 (Labour and Working Conditions) of the World Bank’s Environmental and Social Framework (ESF). The labour risks for the project, including Covid-19 risks are understood and will be adequately managed by the procedures outlined in this document. On a continuous basis, throughout the project’s life cycle, the government of the Republic of Trinidad and Tobago is committed to evaluating risks and impacts and to having in place adequate measures and procedures to manage any adverse impacts that may arise. This LMP is a living document and may be updated throughout the project’s life cycle, when necessary. World Bank Environmental and Social Standard (ESS2) Labour and Working Conditions ESS2 recognizes the importance of employment creation and income generation in the pursuit of poverty reduction and inclusive economic growth. Borrowers can promote sound worker-management relationships and enhance the development benefits of a project by treating workers in the project fairly and providing safe and healthy working conditions. ESS2 objectives are: • To promote safety and health at work. • To promote the fair treatment, non-discrimination and equal opportunity of project workers. • To protect project workers, including vulnerable workers, • To support the principles of freedom of association and collective bargaining of project workers in a manner consistent with national law. • To provide project workers with accessible means to raise workplace concerns. 207 | P a g e 2.0 OVERVIEW OF LABOUR USE ON THE PROJECT Use of Labour in the Project ESS2 defines four categories of project workers: Categorization of the Workforce ESS2 a) Direct workers - people employed or engaged directly by the Borrower (including the project proponent and the project implementing agencies) to work specifically in relation to the project. b) Contracted workers - people employed or engaged through third parties to perform work related to core functions of the project, regardless of location. These could be either international or national workers. c) Primary supply workers - Primary suppliers are those suppliers who, on an ongoing basis, provide directly to the project goods or materials essential for the core functions of the project. Core functions of a project constitute those production and/or service processes essential for a specific project activity without which the project cannot continue. d) Community workers - people employed or engaged in providing community labour, generally voluntarily. There will be no community workers engaged on the Project. * Civil Servants- those employed directly by the Government. Categorization of the Workforce in the Project a) Direct workers – The Trinidad and Tobago COVID-19 Project will employ the following direct workers Project Implementation Unit (PIU) staff: • A Project Manager in charge of overseeing the implementation of the proposed Project (including the management of the contract with the Pan American Health Organization (PAHO), monitoring, evaluation and reporting); • Financial Specialist; • Procurement Specialist; • Environmental and Social (E&S) Specialist; and • Administrative Assistant. b) Contracted workers will be involved in the following activities under the project:– o Sanitization o Waste management o Construction ▪ Cold Storage 208 | P a g e ▪ Quarantine/Facilities o Information Technology o Transportation o Security Administrative staff Temporary contract employment o o Contact tracing All contracted workforce will be sourced in accordance with: 1. MoH/ RHA Human Resource Management Guidelines (individual labour) 2. MoH/ RHA Procurement Rules/ Regulations (for business or contractor labour) 3. Ministry of CARICOM and Foreign Affairs (for foreign migrant labour) 4. Ministry of Labour guidelines (for On-the-Job Trainees) c) Primary supply workers – Regionally- PAHO PAHO will be responsible for procurement for the project. This will be facilitated through a contractual arrangement. Furthermore, PAHO will be providing technical assistance to the MOH to assist with capacity development, third party monitoring and assistance with translation services. Locally- NIPDEC NIPDEC is providing the storage facilities for the vaccines at their storage site in Chaguaramas. d) Community workers – Volunteers Support Staff and Volunteers: Support from the following areas have been identified in a volunteer or other current arrangement capacity: o Ministry of National Security (Trinidad and Tobago Defence Force, Trinidad and Tobago Police Service, Trinidad and Tobago Fire Service, the Office of Disaster Prevention and Management)- transport, logistics and security o Trinidad and Tobago Red Cross- contact tracing o Trinidad and Tobago Registered Nurses Association- vaccine administration and COVID-19 treatment 209 | P a g e o Trinidad and Tobago Medical Association- vaccine administration and COVID-19 treatment o The University of the West Indies- research and technical expertise o Trinidad and Tobago Chambers of Commerce o Trinidad and Tobago Scouts Association Medical Health Care Workers Most activities supported by the project will be conducted by health care workers, laboratory workers, i.e., civil servants employed by the Government of the Republic Trinidad and Tobago. ESS2 recognizes that they remain subject to the terms and conditions of their existing public sector employment agreement or arrangement. Nevertheless, their occupational health and safety will to be considered, and the measures adopted by the project for addressing occupational health and safety issues, including those specifically related to COVID-19, will apply to them as documented in the LMP. The Ministry of Health (MoH) will ensure that the staff are aware of and able to comply with relevant health and safety protocols and procedures and kept up to date on WHO advice (https://www.who.int/emergencies/diseases/novel- coronavirus-2019/technical-guidanceand recommendations on the specifics of COVID-19. Medical Health Care Workers are key stakeholders identified in the SEP. If they have any grievances with the project, they can make use of the GM described in the SEP, and their grievances will be logged in the SEP database. The GM for project workers is separate from the GM of stakeholders, (see health care workers grievance form attachment 2 and general public grievance form attachment 3) The principles and practices of good industrial relations are universally applicable to all workers and classification of workers in the Republic of Trinidad and Tobago, especially as it relates to grievance handling. The IRA chapter 88:01 define worker as: “worker�, subject to subsection (3), means— (a) any person who has entered into or works under a contract with an employer to do any skilled, unskilled, manual, technical, clerical or other work for hire or reward, whether the contract is expressed or implied, oral or in writing, or partly oral and partly in writing, and whether it is a contract of service or apprenticeship or a contract personally to execute any work or labour; (b) any person who by any trade usage or custom or as a result of any established pattern of employment or recruitment of labour in any business or industry is usually employed or usually offers himself for and accepts employment accordingly; or (c) any person who provides services or performs duties for an employer under a labour only contract, within the meaning of subsection (4)(b); and includes (d) any such person who— (i) has been dismissed, discharged, retrenched, refused employment, or not employed, whether or not in connection with, or in consequence of, a dispute; or 210 | P a g e (ii) whose dismissal, discharge, retrenchment or refusal of employment has led to a dispute; or (e) any such person who has ceased to work as a result of a lockout or of a strike, whether or not in contravention of Part V, as the case may be.� Therefore, all workers’ grievances during the project will be addressed using the same grievance procedure, which is made accessible to workers of the MoH/RHAs via their Human Resource departments, as defined in attachment 2 ESMF. As a general principle of good industrial relation, grievances are defined as: “Informally: a grievance may be defined as any real or imagined factor which causes irritation, dissatisfaction or misunderstanding on part of the employee [worker] in the work situation. When Industrial Relations operate in a formal sense the definition is somewhat different. Thus formally, a grievance “is the violation of a contract between the Union and the Employer and any laid down practices and procedures in Industrial Relation.� or “it is the difference of opinion concerning the interpretation of alleged breach of an Industrial Agreement and any laid down practices, principles or procedures in Industrial Relations.� Gabriel L. Yeates “Grievance Handling and Discipline.� All grievances associated with the project will be treated with equal due attention and addressed to bring amicable resolution. Whether such grievances are from project workers, contractor workers, or stakeholders as outline in the SEP, the GM process is a high priority. This section describes the following, based on available information: Number of Project Workers: It is estimated that approximately 2,000 contracted persons will be employed on this project across the following categories. This represents the persons to be employed for all sectors of the COVID-19 response and not limited to vaccinations. Some labour may be contracted for multiple purposes. Characteristics of Project Workers: The MoH will fairly and equitably distribute labour mindful of gender, age and ethnicity considerations. Clinical/Medical Staff 1. Local staff redirected to work on project 211 | P a g e 2. Foreign staff e.g. Cuban nurses 3. Tertiary level graduate students 4. Retired medical and clinical professionals Timing of Labour Requirements: The number of persons hired will vary based on need and risk evaluation. Some labour maybe be repurposed across different tasks as the need arises. Contracted Workers: Security Personnel Health facilities supported by the project, is expected to use some security personnel. Military and security personnel may also be involved in the deployment and administration of the COVID-19 vaccines. Normally a security agency is contracted on a long-term basis by health care facilities to ensure safety of employees and the facility, including the equipment and supplies The potential scope of such security measures, and potential risks surrounding them, will be assessed and monitored during implementation and this LMP may be revised accordingly to manage environmental and social risks concerning project activities. The World Bank’s ESS4 on Community Health and Safety encourages disclosure of government security arrangements and that clients ensure that government personnel act in a manner consistent with the provisions of the standard. In case project activities are supported by private or government security personnel, it will be ensured that the security personnel follow a strict code of conduct and avoid any escalation consistent with the ESF and IFC guidance on the use of security personnel (IFC Good Practice Handbook on the Use of Security Forces: Assessing and Managing Risks and Impacts). In these cases, the PIU will assess the risks posed by these security arrangements to project workers and the local community. Security personnel will provide security services in a manner consistent with the applicable laws and code of practices and will be consistent with the relevant requirement of the World Bank’s ESS4. The PIU will ensure that the workers and local community are informed about the arrangements and the project’s GM. The PIU will also review any allegations of unlawful or abusive acts of security personnel, take action (or urge appropriate parties to take action) to prevent recurrence and, where necessary, report unlawful abusive acts to the relevant authorities. Any incidents, concerns or grievances regarding the conduct of security personnel will be received, monitored, documented (taking into account the need to protect confidentiality), and resolved through the Project’s grievance mechanism following incident classification: Indicative, serious and severe. Any severe incidents with such personnel need to be reported to the Bank no later than 48 hours with basic information and a detailed incident report within 10 working days. 212 | P a g e o Migrant Workers: Foreign workers may be sourced to augment local clinical and medical needs. These will include specific numbers of doctors and nurses from Cuba, which will not result in any large influx of migrant labour. 3.0 ASSESSMENT OF KEY POTENTIAL LABOUR RISKS Persons engaged to work in the Trinidad and Tobago COVID-19 project may come into contact with people diagnosed with COVID-19. It is therefore extremely important that all project workers that are in direct contact with patients and/or medical or any other hazardous waste, follow strict protocols as recommended by the World Health Organization (WHO) and Occupational Health and Safety (OHS) measures highlighted in the Environmental and Social Management Framework (ESMF). Most environmental and social impacts of the project resulting from activities directly under the control of the MoH will be mitigated directly. As such, the approach is to ensure that MoH effectively mitigate project related impacts. Health workers, waste management and security personnel will be more at risk of infection. These risks may be minimized and addressed through: • conducting pre-employment health checks • controlling entry and exit from site/workplace • reviewing accommodation arrangements, to see if they are adequate and designed to reduce contact with the community • reviewing contract durations, to reduce the frequency of workers entering/exiting the site • rearranging work tasks or reducing numbers on the worksite to allow social/physical distancing, or rotating workers through a 24-hour schedule • providing appropriate forms of personal protective equipment (PPE) • putting in place alternatives to direct contact, like telemedicine appointments and livestream of instructions. Another example of potential risk is where the project activity is the treatment by health care workers of COVID-19 patients. In this case the risks could include pathogen exposure, infection and associated illness, death, illegal and untenable overtime, psychological distress, fatigue, occupational burnout, stigma and passing on infections to family and community. The table below summarizes the key labour risks and the recommended mitigation measures. Assessment of Key Labour Risks and Mitigation Measures. 213 | P a g e Project Activity Key Labour Risks Mitigation measures General project Exposure to people who The E&S specialist will ensure that project administration and could have COVID-19 workers have access to the MOH protocols implementation. and guidelines to prevent transmission of Abuse and Stigmatization COVID-19. from public. The E&S specialist will ensure that project workers Discrimination and are provided with/have access to the relevant harassment in the Personal Protective Equipment (PPE), workplace. including face masks, and sanitizing liquids or General workplace injuries. gels. During consultations, the stakeholders will be informed about the type of project workers and their key functions. Consultations will be part of community engagement activities to promote sensitization and ensure that there is no discrimination or abuse against project workers. Implement and maintain a Code of Conduct. Implement adequate occupational health and safety protocols. Ensure that all project workers have access to GM for project workers. Specifically, within this Risk of Accidents, include The E&S specialist will ensure that direct component, activities traffic accidents. project workers have access to the MoH related to transport of protocols and guidelines to prevent Exposure to hazardous Medical Equipment, transmission of COVID-19. substances Supplies and vaccines The E&S specialist will ensure that project workers are provided with/have access to the relevant Personal Protective Equipment (PPE), including face masks, alcohol based hand sanitizer, to reduce the spread of COVID-19. Pr project workers including contractors and primary supply workers will need to observe the Project Occupational Health and Safety Measures to prevent accidents related to 214 | P a g e Project Activity Key Labour Risks Mitigation measures hazardous materials. Project workers will need to follow manufacture guidance related to equipment installation to prevent accidents. Adherence to the GORTT road code to ensure safe driving protocols followed. Specifically, within this Exposure to people who The E&S specialist will ensure that project component, activities could have COVID-19 workers have access to the MoH protocols and related to guidelines to prevent COVID-19. strengthening the The E&S specialist will ensure that project epidemiology and Discrimination and workers are provided with/have access to the surveillance capacity in stigmatization from relevant Personal Protective Equipment the MoH. Also includes community members and (PPE), including face masks, antibacterial gel, contact tracing within the workplace. to prevent the spread of COVID-19. During consultations, the stakeholders will be Workers at risk of informed about the type of project workers and psychological distress and their key functions. Consultations will be part fatigue due to the nature of of community engagement activities to their work promote sensitization and ensure that there is no discrimination or abuse against project workers. General workplace injuries MoH Mental health unit will offer physio-social support for workers that need help Discrimination and Implement adequate occupational health and harassment in the safety protocols workplace Implement and maintain a Code of Conduct. Ensure that all project workers have access to GM for project workers. Promoting preventative Exposure to people who The E&S specialist will ensure that project actions and increasing could have COVID-19 workers have access to the MoH protocols and community awareness guidelines to prevent COVID-19. Community members may and participation. discriminate and abuse The E&S specialist will ensure that project trainers. workers are provided with/ have access to the relevant Personal Protective Equipment 215 | P a g e Project Activity Key Labour Risks Mitigation measures (PPE), including face masks, alcohol-based hand sanitizer, to prevent the spread of Direct project workers, COVID-19. contracted, primary supply workers and civil workers During consultations, the stakeholders will be can also be victims informed about the type of project workers and discrimination and their key functions. Consultations will be part harassment. of community engagement activities to promote sensitization and ensure that there is General workplace injuries. no discrimination or abuse against project workers. The Project will take into consideration the WB technical note on Sexual Exploitation and Abuse/Harassment (SEA/H) for COVID Response Operations to implement the relevant mitigation measures. Communication materials developed under this project can also include the development of communication materials outlining unacceptable behaviour on SEA/H. Key messages should be disseminated focusing on: i) No sexual or other favour can be requested in exchange for medical assistance; ii) Medical staff are prohibited from engaging in sexual exploitation and abuse; iii) Any case or suspicion of sexual exploitation and abuse can be reported as follows: • By telephone: 627-0010 • In person at Ministry of Health Trinidad and Tobago, #63 Park Street, Port of Spain • In writing to the Customer Relations Officer/Representative at the following address: hospitalcomplaints@health.gov.tt The complainant can also contact their respective RHA Implement and maintain a Code of Conduct. 216 | P a g e Project Activity Key Labour Risks Mitigation measures Project workers will have access on the information on what facilities provide psychosocial and emergency medical services/. Where relevant, this would also include sharing information on specialized facilities (One Stop Centres, Centres of Excellence on Gender Based Violence (GBV), and available helplines) where services can be accessed. Project workers will also have access to a GM for workers where they can submit their complaints. The complaints will be received by the E&S specialist who will ensure anonymity and protection of the survivor. Implement adequate occupational health and safety protocols. Vaccine administration Risk of contracting COVID- The E&S specialist will ensure that direct 19 project workers have access to the MoH protocols and guidelines to prevent COVID- Crowds 19. Discrimination and Decentralize vaccines deployment so there is harassment in the no major build-up of crowds workplace. The E&S specialist will ensure that project General workplace injuries. workers are provided with the relevant Language and Personal Protective Equipment (PPE), communication barriers including face masks, alcohol-based hand sanitizer, to reduce the spread of COVID-19. Foreign Migrant labour (nurses and doctors) are required to possess a minimum English Language Proficiency before being deployed. Have a translator or bilingual staff members Have communication materials in another language Work with Non-governmental organizations (NGOs) and faith-based organizations who have experience working with migrants Implement adequate occupational health and 217 | P a g e Project Activity Key Labour Risks Mitigation measures safety protocols Implement and maintain a Code of Conduct. Ensure that all project workers have access to GM for project workers. Specific activities eg waste Risk of contracting COVID- The E&S specialist will ensure that project management and 19 workers have access to the MOH protocols sanitization, transport of and guidelines to prevent transmission of Accidents, including traffic sick patients COVID--19. accidents The E&S specialist will ensure that project Exposure to hazardous workers are provided with/have access to the substances relevant Personal Protective Equipment General workplace injuries (PPE), including face masks, alcohol based hand sanitizers, to reduce the spread of Discrimination and COVID-19 harassment in the workplace. Only approved contractors will be hired Implement adequate occupational health and safety protocols Implement and maintain a Code of Conduct. Ensure that all project workers have access to GM for project workers. Additional COVID-19 Guidance: The Project will also adhere to international guidelines related to Covid-19. These include: • ILO Occupational Safety and Health Convention, 1981 (No. 155) • ILO Occupational Health Services Convention, 1985 (No. 161) • WHO International Health Regulations, 2005 • WHO Emergency Response Framework, 2017 • WHO Guidance on COVID-19, 2020 218 | P a g e The project will also ensure that adherence is made to the WHO’s specific guidelines on COVID-19 (see https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public), along with the World Bank’s guidance provided through “ESF/SAFEGUARDS INTERIM NOTE:COVID-19 CONSIDERATIONS IN CONSTRUCTION/CIVIL WORKS PROJECTS (April 1, 2020) 34�, especially as it relates to the application of such guidance to project workers, contractors and subcontractors. The note recommends assessing the current situation of the project, understanding the obligations of contractors under existing contracts, requiring contractors to put in place appropriate organizational structures and developing plans and procedures to address different aspects of COVID-19. 4.0 BRIEF OVERVIEW OF LABOUR LEGISLATION: TERMS AND CONDITIONS Project workers will be paid on a regular basis as required by national laws and labour management procedures. Should there be gaps between the national legislation and ESS2 the ESS2 will apply. Deductions from payment of wages will be made as allowed by national laws or labour management procedures and project workers will be informed of the conditions under which such deductions will be made. Project workers will be provided with adequate periods of rest per week, annual holiday, sick, maternity and family leave, as required by national laws and labour management procedures. The following sections outline the details of national labour legislation as it regards terms and conditions. The Constitution of Trinidad and Tobago recognizes and guarantees citizens certain basic human rights and freedoms, such as the right to life, liberty and security, the right to equality before the law and the right to freedom of expression. The right to freedom of association and assembly is also a fundamental right protected by the Constitution. This right translates into the right of a person to form and join a trade union or association. There is no constitutional right to bargain collectively or to strike. The Industrial Relations Act (IRA) does however make provisions for collective bargaining between employers and workers and allows industrial action, including strike action, once taken in accordance with the IRA. The general industrial relations policy in Trinidad and Tobago is based on voluntary collective bargaining between employers and workers, via their representative associations, for the settlement of terms and conditions of employment. The employment relationship in Trinidad and Tobago may be governed by either or a combination of both industrial relations principles and practices, and legislation. While the Government has ratified several International Labour Organization (ILO) Conventions, including the Tripartite Consultation (International Labour Standards) Convention, 1976 (No. 144), these Conventions only become effective when they are legislatively implemented. A 144 Tripartite Committee, comprising 34 https://worldbankgroup.sharepoint.com/sites/wbunits/opcs/Knowledge%20Base/ESF%20Safeguards%20Interim%20Note%20Const ruction%20Civil%20Works%20COVID.pdf 219 | P a g e all of the social partners, trade unions, employers, and Government, is in operation in Trinidad and Tobago with the responsibility of considering and recommending the ratification of ILO Conventions. State employees include civil servants, teachers and members of the Protective Services (Fire, Police and Prison Services). The employment relationship between the State and its employees is governed generally by legislation, which makes provisions for terms and conditions of employment including recruitment, hours of work, leave entitlements, payment of remuneration, pensions, allowances and other benefits. There is legislation which deals specifically with each group, such as the Civil Service Act and Regulations for all civil servants, the Police Service Act, Chap. 15:01, as revised by the Police Service Bill (2003), the Fire Service Act, Chap. 35:50 and the Education Act, Chap 39:01 for teachers. In the private sector collective bargaining is generally engaged between individual companies with the respective recognized majority unions, rather than on an industry wide basis. Many companies have industrial relations or human resources managers who handle negotiations. Companies which do not have industrial relations professionals may hire private negotiators or practitioners to conduct negotiations on their behalf. Trade unions have negotiators on their staff. Those aspects of the employment relationship which could not be left to collective bargaining such as employee health and safety, minimum age of employment and workers' compensation, retrenchment and severance benefits and maternity leave are set down in legislation which bind the State and private employers. The most important of these set the standards for employee health and safety at the workplace. The Employment Injury and Disability Benefits Bill provides compensation where employees are injured on the job, while the Retrenchment and Severance Benefits Act guarantees the payment of severance pay to retrenched employees. The Maternity Protection Act provides maternity leave and related benefits to female employees. The Government has also recognized the need to implement legislation which sets minimum terms and conditions of employment so that employees are guaranteed a basic level of rights and protection. The IRA sets the stage for the practice of industrial relations in Trinidad and Tobago. It is the legal framework within which parties bargain collectively, settle disputes and come before the Industrial Court for arbitration. Minimum wage The Minimum Wages Act Chap. 88:04 provides for a national minimum wage for all workers generally. This minimum wage was recently increased, effective January 2015, to $15 per hour. Employees can report non-compliance by their employer to their trade union or the Minister of Labour. Health and safety Workers have often downed tools in dissatisfaction with workplace conditions. Under the Occupational Health and Safety Act Chap. 88:08 employers must provide a safe and healthy work environment, protective clothing and equipment at no extra cost, and adequate training and supervision. Employees 220 | P a g e can refuse to work in unsafe environments. The Act covers both public sector and private sector employees. Injury at work When injuries occur at work because of an employer's wrongful or negligent act the Workmen's Compensation Act Chap. 88:05 provides for an employee injured on the job to make a claim–Section 4. Where death results from the injury a dependent of the deceased may also bring a claim–Section 9. Funeral expenses may also be recovered. National Insurance The national insurance system (NIS) provides employed persons with many benefits including assistance with maternity, sickness, funeral grants, survivorship, invalidity and employment injury. A worker paid more than $180 per week must register and contribute to NIS. Employers who do not pay contributions for their employees will be liable under the National Insurance Act Chap. 32:01. Leave Vacation leave with pay is a right. Paid sick leave, normally 14 days per year, is also a right. Under the Maternity Protection and the Masters and Servants Ordinance Bill a woman is entitled to 14 weeks paid leave and to return to work in a position no less favorable than that she left. If her baby died before she left for maternity leave or in childbirth, she is still entitled to the rest of her maternity leave. A non- unionised employee alleging non-compliance has recourse to the Minister of Labour. Paternity leave is not mandatory by law but some institutions have made it a part of their regulations. Male teachers, for example, are permitted four days leave around the time their partner or spouse is about to deliver. Non-discrimination The Constitution guarantees citizens equal treatment from public authorities. The Equal Opportunity Act Chap. 22:03 adds another layer of protection for all workers against discrimination in the workplace. An employer cannot refuse employment or discriminate against employed persons on grounds of sex, race, ethnicity, origin, marital status, religion or disability. Employees alleging a breach may bring a complaint to the Equal Opportunity Commission. Dismissal A worker is entitled to severance pay if he is dismissed from employment in certain circumstances. Where an employee claims to have been wrongfully or unfairly dismissed, ultimate resort may be had either to the Industrial Court or High Court. Sexual Harassment In Trinidad and Tobago recourse can be sought through the following legislation: 221 | P a g e • Constitution of the Republic of Trinidad and Tobago Act, Chapter 1:01 • Equal Opportunity Act, of the Laws of Trinidad and Tobago, Chapter 22:03 • Common Law and Decisions of the Industrial Court of Trinidad and Tobago • Occupational Safety and Health Act Chapter 88:08 • Sexual Offences Act, Chapter 11:08 • Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) • International Labour Organisation (ILO) Convention (No.111) 1958 on Discrimination in Respect of Employment. Workers’ Rights The Labour Inspectorate Unit of the Ministry of Labour and Small Enterprise Development ensures that both employers and employees are aware of the rights and responsibilities, respectively. Workers' rights are protected by law in Trinidad and Tobago. Some of these rights include minimum wage, hours of work, payment of overtime rates, meal and rest breaks, vacation leave, sick leave, and maternity benefits. Clarification on the rights of workers according to the terms and conditions of work and the relevant legislation can be sought at the Labour Inspectorate Unit of the Ministry of Labour and Small Enterprise Development. Industrial Relations Act (IRA), 1972, Chapter 88:01 The IRA provides for the following: • free collective bargaining between employer and workers through their representative associations, • the development of a peaceful and expeditious procedure for the settlement of disputes, • the recognition and registration of trade unions, • the freedom to be represented by a trade union and the right not to associate, • industrial action which may be taken by both employer and employee. The general industrial relations policy in Trinidad and Tobago is based on voluntary collective bargaining between employers and workers, via their representative associations, for the settlement of terms and conditions of employment. The employment relationship in Trinidad and Tobago may be governed by either or a combination of both the principles and practices of good industrial relations, and legislation. Other labour regulations are summarized in the table below: Summary of Labour related Acts 222 | P a g e Act Description Maternity Protection provides maternity leave and related benefits to Act No. 4 of 1998 female employees. Retrenchment and guarantees the payment of severance pay to Severance Benefits retrenched employees Act No. 32 of 1985 The Equal Opportunity prohibits discrimination of persons on grounds of Act, No. 69 of 2000 sex, race, ethnicity, origin, marital status, religion, or disability. Part III of the Act deals specifically with employment discrimination Minimum Wages Concerns minimum wages and terms and (Amendment) Act, conditions of employment. The Act relies on orders No.11 of 2000 issued by the Minister to set actual minimum wages Workmen’s Provides for the payment of compensation to Compensation Act, workers for injuries suffered in the course of 1960 their employment Criminal Injuries Sets up a Criminal Injuries Compensation Unit Compensation Act, which pays compensation to people injured as 1999 a result of criminal activities Trade Disputes and Makes provisions in respect of trade disputes and for Protection of Property the protection of property and public utility services Act, 1943 Public Health These have been continually amended based on the Regulations Chapter severity of the national situation with respect to 12 (No 4) COVID-19. These regulations affect labour as they regulate opening and closing hours of businesses: describe essential workers and determine what businesses can stay open during the pandemic The following international conventions, and directives may also support measures for addressing health and safety issues relevant to COVID-19: • ILO Occupational Safety and Health Convention, 1981 (No. 155) • ILO Occupational Health Services Convention, 1985 (No. 161) 223 | P a g e • ILO Safety and Health in Construction Convention, 1988 (No. 167) • WHO International Health Regulations, 2005 • WHO Emergency Response Framework, 2017 5.0 BRIEF OVERVIEW OF LABOUR LEGISLATION: OCCUPATIONAL HEALTH AND SAFETY The main provisions on occupational safety and health in Trinidad and Tobago can be found in the Occupational Safety and Health Act 2004 as amended, and more details can be found in other regulations such as the Tobacco Control Act of 2009, and the legislation brought forward from the Factories Ordinance Act such as the Occupational Safety and Health (Prescribed Forms) Order, the Distillery (Safety) Regulations, the Boilers Regulations, the Special Provisions for Safety in the Case of Air Pressure Containers, the Occupational Safety and Health – Cleaning of Machinery in Motion, the Woodworking Machinery, the Occupational Safety and Health (Electricity) Regulations, the Occupational Safety and Health (Welfare) Regulations, the Electric Accumulator (Manufacture and Repair) Order, and the Occupational Safety and Health (Protective Measures) Regulations. Occupational Safety and Health Act, 2004 as amended. The Occupational Safety and Health Act, 2004 as amended is a comprehensive law governing all aspects of health and safety in the workplace, and it replaced earlier laws such as the Factories Ordinance, the Employment of Women (Night Work) Act, and the Factories (Boilers) Regulations. The scope and applicability of the OSH Act is to ensure that industrial establishments manage safety, health and welfare in the workplace, using the legal compliance requirements as a minimum standard. The duties of an employer centre on the general duty to provide, as far as is reasonably practicable: the safety, health and welfare of all employees; adequate and suitable protective equipment at no cost to the employee; and adequate training, instruction and supervision. Employees have the right to refuse unsafe work where there is exposure to imminent danger or a perceived risk to health and safety in the workplace. Section 3: Rights of employees to refuse work where safety or health are in danger (Part III of the Occupational Safety and Health Act 2004 as amended) An employee can refuse to work if he has the following reasons: • There is serious and imminent danger to himself • Any machine, plant or device is likely to endanger himself or another employee. • The physical condition of the workplace or the part in which he works or is to work is likely to endanger himself. • Any machine, plant, device or thing he is to use or operate or the physical condition of the workplace or part thereof in which he works or is to work is in contravention of this Act or the Regulations made under it and such contravention is likely to endanger himself or another employee. Establishment of Safety and Health Committees (Sections 25E. of the Occupational Safety and 224 | P a g e Health Act 2004 as amended) 25E. Every employer in consultation with the representatives of his employees shall establish a safety and health committee at an industrial establishment in accordance with this section where— (a) there are twenty-five or more persons employed at that establishment; or (b) the Chief Inspector on the basis of prescribed criteria, directs the establishment of such a committee at the industrial establishment where fewer than twenty-five persons are employed. Health Surveillance (Sections 25K of the Occupational Safety and Health Act 2004 as amended) (1) Every employer shall ensure that his employees are provided with such health surveillance as is appropriate having regard to the risks to their safety and health which are identified by the annual risk assessment. (2) Every employer shall keep a record of the health surveillance referred to in subsection (1) in accordance with section 75 The importance on conducting risk assessment is once again emphasized here in this section and throughout this ESMF as an essential tool in managing all ESS risks. The following international conventions, and directives may also support measures for addressing health and safety issues relevant to COVID-19: • ILO Occupational Safety and Health Convention, 1981 (No. 155) • ILO Occupational Health Services Convention, 1985 (No. 161) • ILO Safety and Health in Construction Convention, 1988 (No. 167) • WHO International Health Regulations, 2005 • WHO Emergency Response Framework, 2017 • WHO SAGE Values Framework for the Allocation and Prioritization of COVID-19 Vaccination (Sept 2020) • WHO SAGE Roadmap for Prioritizing Uses of COVID-19 Vaccines in the Context of Limited Supply (Nov 2020) • WHO Target Product Profiles (TPP) for COVID-19 Vaccines (2020) • EU OSH Framework Directive (Directive 89/391) 6.0 RESPONSIBLE STAFF The Project Coordinator will be responsible for Project management, implementation and coordination 225 | P a g e with other government ministries and stakeholders. The Project Coordinator will lead project management and implementation, supported by one E&S Specialist. The Project Coordinator, with support of the E&S specialist, will be responsible for the following within their responsibility area: Implementing this LMP; Ensuring that contractors comply with this LMP; Monitoring to verify that contractors are meeting labour and OHS obligations toward contracted workers as required by national legislation and ESS2; Monitoring contractors’ implementation of this LMP; Monitoring compliance with occupational health and safety standards at all workplaces in line with the national occupational health and safety legislation; Monitoring compliance with COVID-19 related health and safety measures including making workplaces ready for COVID-19; Monitoring and implementing training on LMP,OHS and mitigating the spread of COVID-19 for Project workers as described in the Project ESMF; Ensuring that the grievance mechanism for Project workers is implemented and that workers are informed of its purpose and operation. Have a system for regular monitoring and reporting on labour and occupational safety and health performance; and data collection, monitoring, and analysis of the LMP as part of the Project’s M&E activity. Raising awareness and training workers in the mitigation against the spread of Covid-19. The Ministry of Health (MoH) is responsible for engagement of project workers including contractors and compliance with contract conditions (payment of invoices). The MoH will address all LMP aspects as part of procurement for works. The Project Implementation Unit (PIU) established at the MoH will be responsible for overseeing all aspects of implementation of the project, including compliance of direct workers and contractors, and monitoring and evaluation. 7.0 POLICIES AND PROCEDURES Terms and Conditions of Employment Terms and conditions of project direct workers are determined by their individual contracts. Full time and part time staff will have individual agreements (labour contract or service contract) with fixed monthly wage rates. All the recruiting procedures will be documented and filed in accordance with the requirements of Trinidad and Tobago labour legislation and the ESS2. Forty hour per week employment 226 | P a g e should be practiced. Requirements and conditions of overtime and leave entitlements are agreed as part of individual contracts. All terms and conditions as outlined in the World Bank Environmental and Social Framework (ESF) ESS2, paragraphs 10 to 15 and Trinidad and Tobago labour laws will apply to workers. In addition, • In line with national law, the maximum working hours are limited to 8 hours per day, unless there is payment of overtime, however this may be amended during a COVID-19 outbreak as prescribed by national directives or legislation. • Employment opportunities will be available to all. This includes equal pay for equal work, regardless whether the person performing the work is male or female. • The wages paid by the employers to the workers shall not be lower than the national minimum wage. • All workers to be covered by insurance against occupational hazards and COVID-19, including ability to access medical care and take paid leave if they need to self-isolate as a result of contracting COVID- 19. Age of Employment For this project, the minimum age will be 18 years. This rule will apply for both national and international workers. Workers will be required to provide proof of their identify and age before commencing any works on site. Contractors are responsible of sharing with the PIU list of employers with official identification to prove the absence of child labour. Occupational Health and Safety (OHS). The OHS measures of the Project are based on the requirements of the relevant sections of ESS2 as well as World Health Organization (WHO) guidelines. These will particularly address the key identified risks, including infection of Project workers with COVID-19 and of psychological distress (Work-related Stress), fatigue and stigma due to the nature of their work. The Management Standard on work-related stress (HSG 218) will be used to carry out work-related stress risk assessment to determine the levels of exposure to workers and develop measure to avert in the first instance, and reduce the exposure to those psychosocial hazards/risks. Psychosocial hazards are defined as: “Workplace psychosocial hazards are related to the psychological and social conditions of the workplace rather than just the physical conditions. These include stress, fatigue, bullying, violence, aggression, harassment [i.e. sexual harassment] and burnout, which can be harmful to the health of workers and compromise their wellbeing.� Code of Practice 227 | P a g e Psychosocial Hazards in the Workplace, WorkSafe Western Australia35 The Environmental and Social Safeguard Specialist will establish OSH guidelines for all Project workers, monitor and implement training on OHS for Project workers and establish a system for regular monitoring and reporting on OSH performance including documentation and reporting of occupational accidents, diseases and incidents. The Project Coordinator will ensure effective methods are put in place for responding to identified hazards and risks, establishing priorities for taking action and evaluating outcomes. WHO‘s guidance for health workers details both the rights of health workers and expectations of employers and managers in health facilities, as well as the responsibilities of health workers. These guidelines include preventive and protective measures (such as the use of PPE), emergency prevention and preparedness and response arrangements to emergency situations, and remedies for adverse impacts as requires under the ESS2. The Project guidelines will require compliance with the following provisions: • Ensure workplace health and safety standards in full compliance with national law, ESS2 and WHO Guidelines and include: o Basic safety awareness training to be provided to all persons as well as on COVID-19 prevention and related measures. o All Project vehicle drivers to have appropriate licenses. o Safe management of areas around operating equipment inside or outside hospitals/ laboratories/ treatment facilities/ isolation centres. o All workers to be equipped with all necessary PPE (particularly facemask, gowns, gloves, handwashing soap, and sanitizer) to protect from COVID-19. o First aid equipment and facilities to be provided in accordance with labour legislation. • Compliance with national legislation, WB’s ESS2 requirements and other applicable requirements which relate to OHS hazards, including WHO specific COVID-19 guidelines at all times. • All workplace health and safety incidents to be properly recorded in a register detailing the type of incident, injury, people affected, time/place and actions taken. 35 https://www.hse.gov.uk/stress/standards/index.htm https://www.commerce.wa.gov.au/sites/default/files/atoms/files/221154_cp_psychosocialhazards.pdf 228 | P a g e • All workers (irrespective of contracts being full-time, part-time, temporary or casual) to be covered by insurance against occupational hazards and COVID-19, including ability to access medical care and take paid leave if they need to self-isolate as a result of contracting COVID-19. • All work sites to identify potential hazards and actions to be taken in case of emergency. • Any on-site accommodation to be safe and hygienic, including provision of an adequate supply of potable water, washing facilities, sanitation, accommodation and cooking facilities. • Laminated signs of relevant safe working procedures to be placed in a visible area on work sites, in English and Spanish, including on hand hygiene and cough etiquette, as well as on symptoms of COVID-19 and steps to take if suspect have contracted the virus. • Fair and non-discriminatory employment practices. The employment of project workers will be based on the principle of equal opportunity and fair treatment, and there will be no discrimination with respect to any aspects of the employment relationship, such as recruitment and hiring, compensation (including wages and benefits), working conditions and terms of employment. • Under no circumstances will contractors, suppliers or sub-contractors engage forced labour. • Equipment and reagents materials to be procured only from suppliers able to certify that no forced labour or child labour has been used in production of the materials. • Sexual harassment, gender-based violence (GBV), sexual exploitation and abuse (SEA) will not be tolerated. All workers under the project will adopt a code of conduct (Attachment 1) and all workers will sign and will be informed on Code of Conduct provisions. • Given that there are direct workers under PIU, the PIU will adapt and receive training on Code of Conducts as well as on OHS measures required under ESS2. • All employees to be aware of their rights, including the right to organize. • All employees to be informed of their rights to submit a grievance through the Project Worker Grievance Mechanism. All employees to be provided training on appropriate behaviour with communities, gender- based violence and violence against children. Project workers will receive OHS training at the start of their employment or engagement, and thereafter on a regular basis and when changes are made in the workplace, with records of the training kept on file. Training will cover the relevant aspects of OHS associated with daily work, including the ability to stop work without retaliation in situations of imminent danger (as set out in paragraph 27 of ESS2) and emergency arrangements. There will be adequate supplies of medical PPE, including gowns, aprons, curtains; medical masks and respirators (N95 or FFP2); gloves (medical, and heavy duty for cleaners); eye protection (goggles or face screens); hand washing soap and sanitizer; and effective cleaning equipment. Where relevant PPE cannot be obtained, the plan should consider viable alternatives, such as cloth masks, alcohol-based 229 | P a g e sanitizers, hot water for cleaning and extra handwashing facilities, until such time as the supplies are available All Project workers will also receive training on COVID-19 prevention, social distancing measures, hand hygiene, cough etiquette and relations with local community. Training programs will focus, as needed, on COVID-19 laboratory bio-safety, operation of quarantine and isolation centres and screening posts, communication and public-awareness strategies for health workers and the general public on emergency situations, as well as compliance monitoring and reporting requirements, including on waste management, the Project’s labour-management procedures, stakeholder engagement and grievance mechanism. The space in all vaccination sites will be organized in a safe and socially distant manner, and necessary logistical controls and waste management are planned for in advance. Enhanced cleaning arrangements, including thorough cleaning (using adequate disinfectant) of catering facilities/canteens/food/drink facilities, latrines/toilets/showers, common areas, including door handles, floors and all surfaces that are touched regularly will be conducted All parties who employ or engage Project workers will actively collaborate and consult with Project workers in promoting understanding of, and methods for, implementation of OHS requirements, as well as in providing information to Project workers, training on occupational safety and health, and provision of personal protective equipment without expense to the Project workers. Employees at all levels have the authority to stop any activity they consider to be a danger to themselves or other workers, the public or the environment. There will be no retaliation to project workers for stop-work whistle blowing. 8.0 AGE OF EMPLOYMENT • The minimum age for employment on the project is 18 • The process that will be followed to verify the age of project workers are use of proof of identification. Birth certificates, passports, national identification/registration cards or driver’s licenses will be accepted as proof of identification. • While is not anticipated that underage workers will be engaged by the project, the following actions will be taken if any underage workers are discovered. o Termination of the contract and services agreement immediately as per the Labour Act; o Schedule a meeting with the child and seek to determine the reasons for seeking employment; o Refer the child to other support services including social services and the Ministry of Education; o Leverage the services of Non-government and Community Based Organizations to assist the child. 230 | P a g e • The procedure for conducting risk assessments for workers aged between the minimum age and 18. Is not anticipated that this will be applicable 9.0 TERMS AND CONDITIONS This section sets out details regarding: • Specific wages, hours and other provisions that apply to the project • Maximum number of hours that can be worked on the project • Any collective agreements that apply to the project. When relevant, provide a list of agreements and describe key features and provisions • Other specific terms and conditions COVID-19 CONSIDERATIONS: Any requirements to work outside of the normal regulated working conditions the worker will be guided by the terms and conditions outlined in their Terms of Employment. 10.0 GRIEVANCE MECHANISM There will be a specific Grievance Mechanism (GM) for project workers as per the process outlined below. Processes for documenting complaints and concerns have been specified, including time commitments to resolve issues. In addition, this GM will be communicated to all relevant category of workers as part of project engagement. All project workers will be informed of the Grievance Mechanism process as part of their contract and induction package. The Environmental Social and Safeguard Specialist will be in charge of the GM implementation. This specialist will be responsible for monitoring the correct implementation of the project GM and for resolving all grievances in a timely and appropriate manner. The Ministry of Health already operates a complaint handling system across its health facilities to respond to issues pertaining to the quality of care received. The system does not make it clear if anonymous complaints can be submitted and investigated, but the final GM for the project will allow anonymous complaints to be submitted. There are several ways to lodge a complaint. These are: • By telephone: 627-0010 • In person at Ministry of Health Trinidad and Tobago, #63 Park Street, Port of Spain • In writing to the Customer Relations Officer/Representative at the following address: 231 | P a g e Walk-ins may register a complaint on a grievance logbook at healthcare facility, vaccination site or suggestion box at clinic/hospitals For non-quality of care related complaints the project will promote the Inter-American Development Bank (IDB) Health Sector Program’s GM • Toll-free telephone hotline: 800-WELL (9355); 877-WELL (9355) Once a complaint has been received, it will be recorded in the complaints logbook or grievance excel- sheet/grievance database. Grievances will be handled at the regional level by the respective Regional Health Authorities and at the national level by the Ministry of Health which will also be in charge of keeping a database of grievances and monitoring their resolution. The GM will include the following steps: Step 1: Submission of grievances either orally or in writing to the Regional Health Authorities. This can be done either orally, via telephone, email or written (through suggestion boxes). Suggestion boxes at the health centres shall be opened weekly. Step 2: Recording of grievance and providing acknowledgement, immediately for oral complaints and within two working days for written complaints. The complaints shall be recorded on a complaint register at each facility and then submitted to the MoH. These are then logged in a central database. Step 3: The complaints will be sorted and then forwarded to the respective departments for investigation. The resolution and communication to the complainant (if they identified themselves) shall take place within 7 days Step 4: Complainant Response: either grievance closure or taking further steps if the grievance remains open. If grievance remains open, complainant will be given opportunity to appeal to Regional Health Authorities first and if needed at the national level. Once all possible redress has been proposed and if the complainant is still not satisfied then they should be advised of their right to legal recourse. At no time should the complainant be given the impression that legal recourse is not available because they are using the GM. 11.0 CONTRACTOR MANAGEMENT The tendering process for contractors will require that contractors can demonstrate their labour 232 | P a g e management and OHS standards, which will be a factor in the assessment processes. Contractual provisions will require that contractors: The tendering process for contractors will require that contractors can demonstrate their labour management and OHS standards, which will be a factor in the assessment processes. Contractual provisions will require that contractors: • Monitor, keep records and report on terms and conditions related to labour management, including specific aspects relating to COVID-19; • Provide workers with evidence of all payments made, including benefits and any valid deductions; • Provision of medical insurance covering treatment for COVID-19, sick pay for workers who either contract the virus or are required to self-isolate due to close contact with infected workers and payment in the event of death • Specific procedures relating to the workplace and the conduct of the work (e.g. creating at least 6 feet between workers by staging/staggering work, limiting the number of workers present) • Specific procedures and measures dealing with specific risks. • Ensuring there is a health and safety focal point, responsible for monitoring OHS issues and COVID- 19 prevention and any cases of the virus; • Keep records regarding labour conditions and workers engaged under the Project, including contracts, , hours worked, remuneration and deductions (including overtime); • Record safety incidents and corresponding Root Cause Analysis (lost time incidents, medical treatment cases), first aid cases, high potential near misses, and remedial and preventive activities required (for example, revised job safety analysis, new or different equipment, skills training, etc.); • Report evidence that no child labour is involved; • Training/induction dates, number of trainees, and topics; • Insurance for workers against occupational hazards and COVID-19, including ability to access medical care and take paid leave if they need to self-isolate as a result of contracting COVID-19. • Details of any worker grievances including occurrence date, grievance, and date submitted; actions taken and dates; resolution (if any) and date; and follow-up yet to be taken. Grievances listed should include those received since the preceding report and those that were unresolved at the time of that report; Monitoring and performance management of contractors will be the responsibility of MoH. The MoH will be responsible for oversight of labour management provisions as well as contract supervision. The MoH Focal Point will have overall responsibility for data collection, monitoring, and analysis of the LMP as part 233 | P a g e of the Project’s M&E efforts. The MoH Focal Point will monitor the implementation of, and compliance with, this LMP, including management of worker-related grievances. Monitoring reports should be reviewed and submitted regularly to Manager of the PIU, who will submit with other monitoring reports to the World Bank. Workers’ Rights to Refuse Unsafe Work Environments Workplace processes are in place for Project workers to report work situations that they believe are not safe or healthy. These measures will be reinforced. Project workers can remove themselves from a work situation which they have reasonable justification to believe presents an imminent and serious danger to their life or health. Project workers who remove themselves from such situations will not be required to return to work until necessary remedial action to correct the situation has been taken. Project workers will not be retaliated against or otherwise subject to reprisal or negative action for such reporting or removal. (PART III OSH Act 2004 as amended) Engagement and Management of Sub-Contracted Workers. The Contractor is responsible for management of their workers or subcontracted workers in accordance with this LMP, which will be supervised by MoH. This includes ensuring compliance with key aspects, in particular those relating to COVID-19 prevention and general OHS. Labour and Working Conditions. Contractors will keep records in accordance with specifications set out in the National Laws. MoH may at any time require records to ensure that labour conditions are met and that prevention mechanisms and other safety issues, general to OHS and specific to COVID-19, are being followed. MoH may review records against actuals at a minimum and can require immediate remedial actions if warranted. A summary of issues and remedial actions will be included in quarterly reports to the World Bank if there is any. Training of Workers. Contractors are required to have a designated safety officer. The contractor must train staff on OHS measures, hygiene practices, precautions against COVID-19, and other aspects of this LMP as appropriate. Contractors must make staff available for any mandatory trainings required by MOH, as specified by the contract. Mean while MoH must ensure adequate training and materials are provided to direct workers, such as those working on communication materials, screening, etc. Addressing Worker Grievances. MoH will be required to implement a Grievance Mechanism (GM) for workers which responds to the 234 | P a g e minimum requirements in this LMP. The MoH may review records if it is necessary. MoH will keep abreast of GM complaints, resolutions and reflect in quarterly reports to the World Bank. Occupational, Health and Safety. Contractors on civil works must designate a minimum of one safety representative to ensure day-to-day compliance with specified safety measures and OHS, including on precautions against COVID-19, and record any incidents to MoH on a monthly basis; serious incidents should be reported immediately. Cases of COVID-19, and actions taken, should also be reported immediately. Minor incidents should be reflected in the quarterly reports to the World Bank, and major issues should be flagged to the World Bank immediately. Further to enforcing the compliance of environmental and social management, contractors will be responsible and liable for the safety of site. Community Workers The project will engage with community workers in the form of volunteers from various organizations as described in section 2 of the LMP. These persons will contribute their work as part of the project therefore ESS2 applies to them. Their main risks because they will be involved in contact tracing, vaccine administration and Covid-19 treatment, they will be at risk of contracting Covid-19. Therefore, the requirements described under the Occupational Health and Safety section of the LMP along with the age of employment will be applied to them, including ensuring that they are provided with adequate PPE to protect against Covid-19. The Environmental Social and Safeguard Specialist will supervise the working conditions to ensure that they meet the standards and guidelines of the WB. These volunteers will be obliged to follow the training sessions prior to their engagement to ensure that they become fully familiar with all E&S safety procedures and regulations. It will be during the training sessions that project team will communicate to community volunteers on the nature of volunteering under project and to ascertain if volunteers agree to work on a voluntary basis. The training will make clear that people are free to opt out without fear of reprisal, that work is not mandatory and that no resources from the project can be withheld as a result of not participating in the volunteer work. The training will also review the code of conduct. The PIU will register all participants who attend the training session. 12.0 PRIMARY SUPPLY WORKERS The Contractor will be responsible for conducting due diligence on the primary supply workers (those providing medical equipment and supplies), if there is a significant risk of child or indentured labour in the supply chain. In conducting due diligence, the contractor (or contractor’s staff) should: 235 | P a g e • Inform the provider, that the Contractor will not engage a provider who has forced or child labourers; • When possible, and where a high risk exists, visit the company/factory, and conduct interviews with key personnel about their working conditions, as well as informal random interviews with workers; • Conduct secondary due diligence, by asking information from others who may be familiar with the provider, to make sure there are no reported instances of forced or child labour; • If necessary, and possible, engage the Ministry of Labour to conduct checks on supplier to ensure no child labour or forced labour; Keep records of the information and include in reporting to MoH. ATTACHMENT 1- CODE OF CONDUCT FOR CONTRACTOR’s PERSONNEL/ PROJECT WORKERS We are the Contractor, [enter name of Contractor]. We have signed a contract with [enter name of Employer], for [enter description of the Works]. These Works will be carried out at [enter the Site and other locations where the Works will be carried out]. Our contract requires us to implement measures to address environmental and social risks related to the Works, including the risks of sexual exploitation, sexual abuse and sexual harassment. This Code of Conduct is part of our measures to deal with environmental and social risks related to the Works. It applies to all our staff, labourers and other employees at the Works Sites or other places where the Works are being carried out. It also applies to the personnel of each subcontractor and any other personnel assisting us in the execution of the Works. All such persons are referred to as “Contractor’s Personnel� and are subject to this Code of Conduct. This Code of Conduct identifies the behaviour that we require from all Contractor’s Personnel. Our workplace is an environment where unsafe, offensive, abusive or violent behaviour will not be tolerated and where all persons should feel comfortable raising issues or concerns without fear of retaliation. REQUIRED CONDUCT Contractor’s Personnel shall: 1. Carry out his/her duties competently and diligently; 2. Comply with this Code of Conduct and all applicable laws, regulations, and other requirements, including requirements to protect the health, safety and well-being of other Contractor’s Personnel and any other person. 3. Maintain a safe working environment including by: 236 | P a g e a) ensuring that workplaces, machinery, equipment and processes under each person’s control are safe and without risk to health; b) wearing required personal protective equipment (PPE); c) using appropriate measures relating to chemical, physical and biological substances and agents; and d) following applicable emergency operating procedures. 4. Report work situations that he/she believes are not safe or healthy and remove himself/herself from a work situation which he/she reasonably believes presents an imminent and danger to his/her life or health; 5. Treat other people with respect and not discriminate against specific groups such as women, people with disabilities, migrant workers or children; 6. Not engage in Harassment (sexual or non-sexual in nature), which means unwelcome (sexual) advances, requests for sexual favours, and other verbal or physical conduct (of a sexual or non-sexual nature) with other Contractor’s or Employer’s Personnel; 7. Not engage in Exploitation (sexual or non-sexual in nature), which means any actual or attempted abuse of position of vulnerability, differential power or trust, for sexual or non-sexual purposes, including, but not limited to, profiting monetarily, socially or politically from the sexual or non-sexual exploitation of another. In Bank financed operations/projects, sexual or non-sexual exploitation occurs when access to or benefit from Bank Financed Goods, Works, Consulting or Non-consulting services is used to extract sexual or non-sexual gain; 8. Not engage in Sexual Abuse, which means the actual or threatened physical intrusion of a sexual nature, whether by force or under unequal coercive conditions; 9. Not engage in any form of sexual activity with individuals under the age of 18 10. Complete relevant training courses that will be provided related to the environmental and social aspects of the Contract, including health and safety matters, Sexual Exploitation and Abuse (SEA), and Sexual Harassment (SH); 11. Report violations of this Code of Conduct; 12. Not retaliate against any person who reports violations of this Code of Conduct, whether to us or the Employer who makes use of the grievance mechanism for Contractor’s Personnel or the project’s Grievance Redress Mechanism. RAISING CONCERNS If any person observes behaviour that he/she believes may represent a violation of this Code of Conduct, or that otherwise concerns him/her, he/she should raise the issue promptly. This can be done in either of the following ways: 1. Contact [enter name of the Contractor’s Social Expert with relevant experience in handling sexual exploitation, sexual abuse and sexual harassment cases, or if such person is not required under the Contract, another individual designated by the Contractor to handle these matters ] in writing at this address [ ] or by telephone [ ] or in person at [ ]; or 237 | P a g e 2. Call [ ] to reach the Contractor’s hotline (if any) and leave a message. The person’s identity will be kept confidential, unless reporting of allegations is mandated by the country law. Anonymous complaints or allegations may also be submitted and will be given all due and appropriate consideration. We take seriously all reports of possible misconduct and will investigate and take appropriate action. We will provide warm referrals to service providers that may help support the persons who experience the alleged incident, as appropriate. There will be no retaliation against any person who raises a concern in good faith about any behaviour prohibited by this Code of Conduct. Such retaliation would be a violation of this Code of Conduct. 238 | P a g e CONSEQUENCES OF VIOLATING THE CODE OF CONDUCT Any violation of this Code of Conduct by Contractor’s Personnel may result in serious consequences, up to and including termination and possible referral to legal authorities. FOR CONTRACTOR’S PERSONNEL: I have received a copy of this Code of Conduct written in a language that I comprehend. I understand that if I have any questions about this Code of Conduct, I can contact [enter name of Contractor’s contact person(s) with relevant experience (including for sexual exploitation, abuse and harassment cases) in handling those types of cases] requesting an explanation. Name of Contractor’s Personnel: [insert name] Signature: ____________________________________________________________________ Date (day/month/year/): _________________________________________________________ Countersignature of authorized representative of the Contractor: Signature: _____________________________________________________________________ Date (day/month/year/): ________________________________________________________ 239 | P a g e ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN (ESMP) CHECKLIST The Republic of Trinidad and Tobago Emergency COVID-19 Response Project P173989 ATTACHMENT 2 Health Care Worker Grievance Form Do you have a complaint/grievance with: Working Condition? Yes No Health and Safety Conditions at Work (e. g. harassment/bullying/Hazardous Substances)? Yes No Personal Protective Equipment? Yes No COVID-19 Precautionary Conditions? Yes No Accommodation Facilities? Yes No Salary/Contract? Yes No Transportation to Work? Yes No Any Injury at Work (what happened/how it happened? Yes No Other Issues? Yes No If yes, please explain: Date of Incident/Grievance: One time incident/grievance? Date: Happened more than once? How many times: On going (Currently experiencing the problem) Do you have any suggestions how to solve the problem (grievance) Do you wish to receive an answer to your grievance Yes No If yes, please mark Post Telephone E-mail Other how you wish to be Address: Contact Number: E-mail Address: Please Specify: contacted Preferred language of English Spanish Other (Please specify) Communication: French I Prefer to Remain Anonymous Title: Name: (Please do not fill this field if you wish to remain anonymous) Signature: (Please do not fill this field if you wish to remain anonymous) Date: Please return this form to: Customer Relations Officer/Representative (respective RHA) Email Address: hospital.complaints@health.gov.tt Ministry of Health Trinidad and Tobago. #63 Park Street, Port of Spain (or address of respective RHA) 240 | P a g e ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN (ESMP) CHECKLIST The Republic of Trinidad and Tobago Emergency COVID-19 Response Project P173989 ATTACHMENT 3 General public Grievance Form Description of Incident or Grievance (What happened? Where did it happen? Who did it happen to? What is the result of the problem?) (Be brief, state the facts) Date of Incident/Grievance: One time incident/grievance? Date: Happened more than once? How many times? On-going (currently experiencing problem) Do you have suggestions on how to solve the problem? (Be brief, state the facts) Do you wish to receive an answer to your grievance? Yes No If yes, please Mail Telephone E-mail Others mark how you wish to be Address: Contact number: E-mail address: Please specify: contacted Preferred French Spanish English Other language for Please specify: communication I prefer to remain anonymous Title: Name: (Please do not fill this field if you would like to remain anonymous) Signature: (Please do not fill this field if you would like to remain anonymous) Date: Please return this form to: Customer Relations Officer/Representative (respective RHA) Email Address: hospital.complaints@health.gov.tt Ministry of Health Trinidad and Tobago. #63 Park Street, Port of Spain (or address of respective RHA) 241 | P a g e 9.8 Annex VIII Training Conducted by the Environnmental and Social Specialist of the PIU. 242 | P a g e RHA : 1 Eastern RHA 243 | P a g e RHA : 2 South-West RHA 244 | P a g e RHA : 3 Noth West RHA 245 | P a g e RHA : 4 Tobago RHA 246 | P a g e