The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 03/15/2022 | Report No: ESRSAFA346 Mar 15, 2022 Page 1 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) El Salvador LATIN AMERICA AND Republic of El Salvador, Ministry of Health CARIBBEAN Ministry of Health Project ID Project Name P178315 Second AF El Salvador COVID-19 Emergency Response Project Parent Project ID (if any) Parent Project Name P173872 El Salvador COVID-19 Emergency Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 3/28/2022 4/20/2022 Population Financing Public Disclosure Proposed Development Objective To respond to and mitigate the threat posed by COVID-19 and strengthen the national system for public health preparedness in El Salvador. Financing (in USD Million) Amount Current Financing 20.00 Proposed Additional Financing 100.00 Total Proposed Financing 120.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] To respond to and mitigate the threat posed by COVID-19 and strengthen the national system for public health Mar 15, 2022 Page 2 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) preparedness in El Salvador. The project includes the support for the prevention and mitigation measures to COVID- 19 D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The Parent Project, the El Salvador COVID-19 Emergency Response Project (P173872) and its first Additional Financing (AF1, P176033) were prepared under the World Bank’s Multiphase Programmatic Approach (MPA). The Parent Project financed a US$20 million loan approved on April 17, 2020, to support COVID-19 preparedness and response activities. The AF1 for US$50 million was approved on April 16, 2021, to expand the scope of the Project to include vaccination against COVID-19. The proposed AF2 will continue to support preparedness, response, and vaccination activities under the Project. The AF2 aims to support the Government of El Salvador’s (GoES) response efforts to manage the impacts of the COVID-19 pandemic, which have evolved from focalized acquisitions and activities to a broad, national-level strategy that oversees vaccination and other supporting activities. The parent project initially focused on strengthening the national COVID-19 response by supporting the Hospital San Salvador, the reference COVID-19 health facility in the country. No major civil works have been developed under the parent project; if any works are supported, they are expected to entail minor refurbishments and to take place in existing facilities within existing footprints, and the use of all equipment and medical supplies will be within the existing Hospital San Salvador and its laboratories. The AF1 continues and expands these actions by supporting the COVID-19 vaccination roll-out, which started on February Public Disclosure 2021 and which remains ongoing across the country. The GoES has arranged different means to access vaccines, both through direct purchases with pharmaceutical companies and through the COVAX platform mechanism. The Project and the AF1 also finance and support a communications strategy which aims to slow the spread and mitigate the impacts of the virus. The primary objectives of the AF2 are to further strengthen preparedness and response activities under the Project and to help ensure equitable and effective vaccine deployment through enhanced vaccination system strengthening. The Project includes two components: (i) Emergency COVID-19 response for prevention, detection, and treatment; and (ii) Project management and monitoring. The Project mainly finances medical and non- medical equipment and supplies, including PPE, as well as the national communications strategy, incorporating health prevention campaigns and training materials for health personnel and the public. The AF2 will provide support to scale-up activities under the first component and no changes will be made to the other components. The AF2 is also seeking an exception to increase the retroactive financing limit from 20 percent to up to 100 percent, and a waiver to provisions of Section III Paragraph 16 (d) of the Bank’s directive related to Investment Project Financing (IPF) to extend the maximum retroactive financing period from 12 months to 18 months. At the time of preparation of the AF1, the GoES had set an initial target of vaccinating 4.5 million people (69 percent of the population), starting with frontline health workers, and successively incorporating other priority groups. The targets were revised on September 22, 2021, to include children above 6 years of age and other eligible populations for a total of 5.9 million people (91 percent of the population). Following new medical guidelines, the third dose or the booster shot was authorized on September 27, 2021. As of February 15, 2022, 70 percent of the population has received at least one dose and 20 percent of the population has received a booster dose. Thanks to the high rates of COVID-19 vaccination, combined with stringent measures to contain the pandemic early, El Salvador has weathered the pandemic better than other countries in the region. As of February 24, 2022, there were 0.023 cumulative cases Mar 15, 2022 Page 3 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) per person in El Salvador, compared to world average of 0.548 and South American average of 0.124. In terms of deaths, there were 0.62 deaths per thousand people in El Salvador compared to 0.75 globally and 2.89 in South America. El Salvador has prepared and disclosed a National Vaccination Roll-out Plan (NVRP), which sets out the institutional frameworks for the safe and effective deployment of vaccines, including the phased prioritization of vaccination groups. The NVRP lays out the coordinating entities that hold responsibilities during the vaccination roll- out, led by the Ministry of Health (MoH) and supported by the National Center of Pharmaceuticals, the National Directorate of Medicines and the National Institute of Social Security, all of which operate at national and local level. During the vaccination campaign the MoH has received support from UNICEF and PAHO, who have supported previous vaccination campaigns in the country. It is expected that the AF2 will continue supporting this strategy, which has included setting up regulatory standards for vaccine selection; guidelines for minimum standards for vaccine management including cold chain infrastructure; and policies to ensure robust governance, accountability, and citizen engagement mechanisms. At this stage, vaccines are freely available to anyone regardless of citizenship or origin in health centers, dedicated vaccination hubs managed by the MoH which include walk-on sites and drive- throughs. In this context, the AF2 will mostly consist of retroactive financing related to vaccine purchases (approximately 65%) whilst the remainder (approximately 35%) is expected to finance medicines, medical supplies, PPE, small refurbishments to support vaccination and ancillary activities, as well as to strengthen and broaden communication efforts and campaigns. The environmental and social risks associated with the generation and handling of medical waste, including expired and used vaccine vials, worker and community health and safety, and equitable access to the vaccine have been identified and assessed in the updated Environmental and Social Management Framework (ESMF), the Stakeholder Public Disclosure Engagement Plan (SEP), which were disclosed after the approval of the AF1 on September 23rd 2021, and Labor Management Procedures (LMP), disclosed on October 14, 2021. The ESMF includes an Infection Control and Waste Management Plan (ICWMP) for the vaccination program as well as a Medical Waste Management Plan (MWMP) for those vaccination centers located outside of existing health facilities such as schools. A recent World Bank project (Strengthening Public Health Care System, P117157) worked with selected hospitals to develop and implement bio- hazard waste management systems, including the establishment of environmental regulations that now provide biohazard diagnostics and norms that health facilities must follow nationwide. All 30 national hospitals in El Salvador follow an existing legal framework: El Salvador Technical Regulation for the Management of Bio-infectious Waste. National hospitals and regional offices have a Bio-infectious Waste Management Plan, updated every three years. Waste management for hospitals and local clinics is covered in the facilities’ allocated budgets, although a large increment in waste volume would compromise the management plans and would require additional funding to manage the increased biological risk. All activities under the AF2 will take place within existing facilities and footprints with no new land acquisition or involuntary resettlement and no impacts on natural habitats or cultural sites expected. El Salvador’s population is disproportionately at risk to the effects of natural disasters and contextual crime and violence – aspects which may impact vaccination roll-out. The MoH has built decades of experience with nation-wide vaccination campaigns in complex territories, which are usually accepted in areas with criminal presence. To date, the vaccination roll-out has no record of disputes or safety risks related to contextual crime and violence. During the preparation process for the AF1, several vulnerable groups were engaged to assess the need for adapted messaging and information regarding acces to vaccines. Among these are Indigenous People, who are less than one percent of the population and are distributed across the country. IP groups have been historically discriminated and were not recognized in the Constitution until 2014. This discrimination is critical in the health sector, where traditional health Mar 15, 2022 Page 4 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) practices are disregarded or misunderstood. LGBTI people have also faced exclusion from health provision systems and often experience mistreatment from health authorities. The AF2 SEP assessed these risks and carried out significant consultations with these groups, including the first systematic engagement between the MoH and LGBTI groups as part of WB projects. The AF2 will update the SEP and the Environmental and Social Commitment Plan (ESCP) to show the current state of E&S commitments and include any complementary or relevant information. D. 2. Borrower’s Institutional Capacity The Parent Project, the AF1, and the AF2 are implemented by the Ministry of Health (MoH) of El Salvador. The MoH has established a Project Coordination Unit (PCU) which will be responsible for the implementation, management, monitoring and reporting of project activities as well as for ensuring compliance with the project’s environmental and social requirements. Since October 14, 2021, the PCU has as part of its full time staff, one environmental specialist and one social specialist, responsible for the implementation and monitoring of the measures contained in the E&S instruments. These dedicated specialists were hired within the dated covenant specified in the updated ESCP. Where relevant, the PCU could obtain the services of an Occupational Health and Safety and/or Waste Management consultant(s) to support the PCU in the definition of appropriate management and mitigation actions. The MoH has prior experience implementing World Bank financed projects in compliance with the World Bank’s environmental and social safeguards policies. This experience draws upon a number of already completed health related projects, such as the Earthquake Emergency Recovery and Health Services Extension Project (P067986) and the Strengthening the Public Health Care Project (P117157). More significantly, over the past two years, the MoH has developed a robust experience preparing projects under the Bank’s Environmental and Social Framework (ESF). This includes preparing and updating the COVID-19 response projects, as well the ESF instruments for the Growing Up Public Disclosure Healthy Together Project (P169677), which are close to final disclosure and adoption. For the AF1, the MoH updated, consulted, disclosed and adopted the ESMF, the SEP, and the LMP within the ESCP’s timeframes. All information related to the Project, including the E&S instruments, is publicly available on the MoH’s website. The project’s E&S performance remains rated as Satisfactory. Between October and November 2021, and under the first AF, the PIU prepared an E&S Audit to describe the E&S management measures taken by the MoH during a determined period of vaccination for a proposed retroactive financing. The Rapid Assessment included a thorough analysis of E&S management of El Salvador’s vaccination strategy, including information centered on: (i) waste management, (ii) inclusion of vulnerable groups, (iii) health workers safety measures, and (iv) handling of grievances. The audit included a series of conclusions and recommendations namely i) opportunities to strengthen differentiated messages for vulnerable groups; ii) the need to improve management of biomedical waste (onsite storage prior to final disposal and frequency of removal of waste); iii) whereas a workers’ GRM is established, there is the opportunity for stronger socialization of its reach and purpose; and iv) the opportunity to improve the registers relating to the purchase and distribution of personal protective equipment (PPE) to workers, ensuring that they are kept up to date and available for inspection. The recommendations of the audit, in conjunction with the E&S instruments, detail actions to strengthen and improve E&S management and performance. The E&S Audit was approved by Bank management in January 2022 and an action plan is in place to address audit findings. The Bank’s E&S team continues to guide and support the MoH team to ensure the E&S risks associated with the project are managed in a proactive manner. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS Mar 15, 2022 Page 5 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The Environmental risk rating is considered substantial given the fact that existing resources and capacity of health facilities continue to be stretched as the pandemic evolves. The parent project aims to support the government’s response to the pandemic and to strengthen national systems for public health preparedness by investing in the provision of medical equipment and supplies as well as investing in communication activities. Under the the first AF, the project aimed to further strengthen preparedness and response activities to enable affordable and equitable vaccine access, ensuring effective vaccine deployment. Whereas no civil works are planned under the parent project, under the AF1, minor refurbishments to existing facilities are being executed to meet logistical and vaccine storage, handling and deployment needs. Identified environmental risks and impacts of the project include (i) environmental and community health related risks from inadequate handling, storage, transportation and disposal of infected medical waste and expired and used vaccine vials; (ii) occupational health and safety issues related to the availability, supply and appropriate use of personal protective equipment (PPE) for healthcare workers; (iii) community health and safety exposure risks in the immediate vicinity of health care facilities associated with increased risks of contagion from Covid-19, and (iv) ambient pollution and human health and safety risks stemming from cleaning and disinfection products, chlorine and other hazardous byproducts, including those associated with cold chain storage for the ultra-cold vaccine. The AF2 envisages a scale-up of component 1 activities and as such, no new environmental risks are expected. For the activities under the AF1, the ESMF for the parent project was updated to include an Infection Control and Waste Management Plan (ICWMP) for the vaccination program, including corresponding training and monitoring requirements. A Medical Waste Management Plan (MWMP) for Public Disclosure vaccination centers located outside of existing health facilities such as schools was also developed. The updated ESMF (September 2021) outlines comprehensive procedures and requirements for the safe handling, transportation, storage, and processing of COVID-19 treatment, testing and vaccination materials, safety of medical workers and hospital staff, as well as safe management of wastes, including biohazardous wastes, resulting from project activities. The relevant parts of the WHO COVID-19 guidelines and COVID-19 biosafety guidelines, and the World Bank Group’s Environment, Health and Safety (EHS) Guidelines were reviewed so that relevant occupational and community health and medical worker safety risks and mitigation measures are reflected in the updated instrument. The E&S Audit in respect of retroactive finance for the purchase of vaccines approved by the Bank in January 2022 identified a number of areas for improvement including the management of biomedical waste (especially the need for improvement of onsite storage prior to final disposal). An action plan has been reviewed by the Bank and remedial actions are under implementation. Social Risk Rating Substantial The social risks are considered Substantial. The AF2 will not involve resettlement or land acquisition. Among the key social risks is the potential for vulnerable and high-risk social groups to be unable to access facilities, services and vaccination, due to their income, discrimination, lack of information and/or distance from health centers. The Government of El Salvador has planned and implemented measures to execute the national vaccination roll-out, including setting-up a phased approach for the deployment of vaccination as response to COVID-19. Although the response has been robust by regional parameters, there is potential to develop adequate preparedness actions to ensure disadvantaged and vulnerable groups have awareness and are able to receive appropriate preventive support, including people living in rural communities with difficult access to the national health system, Indigenous People who face discrimination and have a historical mistrust of traditional health approaches, and other Mar 15, 2022 Page 6 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) discriminated minorities such as LGBTI people, and persons with disabilities, particularly those living in poverty. The MoH’s National Plan for Vaccination Roll-out against SARS-COVID-19’ (National Vaccination Plan has established the parameters for vaccine deployment, priority groups phases, and rollout to vaccinate the country’s population. Under the parent Project Emergency Response, there are several project activities concerned with communication strategies, including (a) supporting public health information and communication campaigns for disease prevention and management through mass media platforms; (b) instituting infection control guidelines and service standards in the San Salvador Hospital, which is the dedicated national hospital to manage COVID-19; and (c) training of key front-line staff, including emergency doctors, nurses and paramedical staff. The MoH has an ongoing communications strategy, producing infographics, media spots and social media information. Mobile networks send frequent information on prevention of the COVID-19 and exceptional measures in place during quarantine. However, the implementation of these activities have yet to explicitly show diversity and inclusive messages. Component 2 of the Project will support the national communication campaign, which will promote an inclusive language and differentiated messaging that addresses groups at risk. The PIU has planned for these communication activities and specialized messages to start between March and April 2022. As of March 2022, Parent Project and AF1 activities have not documented any systematic cases of discrimination among vulnerable populations, neither in the GRM nor in interviews carried out for the E&S audit. However, the recommendations from the audit suggest that tailored messaging on the benefits of the vaccines can be strengthened, particularly among those skeptical of the vaccines’ safety and efficacy. Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) Risk Rating Moderate This risk is moderate at this stage as no civil works or labor influx are foreseen. The Project will continue to promote the avoidance of SEA/SH by including the appropriate language in any TOR developed for the project and by relying Public Disclosure including on the WHO Code of Ethics and Professional Conduct for all workers related to the Project who will work as part of the emergency response, which is already documented in the ESMF for the Parent Project. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: This standard is relevant. The Project will have positive environmental and social impacts by improving the surveillance, monitoring and response capacity of El Salvador’s health system to respond to the COVID-19 and other emergencies. Adverse environmental, health and safety risks and impacts could arise from exposure to the corona virus itself following the inadequate provision and use of personal protective equipment by health workers, increased risk of exposure to communities in the immediate vicinity of health care facilities and vaccination centers, and health and pollution impacts associated with the inadequate handling, treatment and disposal of cleaning products, biomedical waste and expired or open vaccine vials, including risks and impacts associated with incremental waste volumes resulting from large scale vaccination activities. To address environmental and social risks and impacts associated with the AF1, which focused on supporting the GoES’ vaccination strategy, the MoH updated the ESMF prepared for the Parent Project (P173872), which was redisclosed and adopted on September 2021. The revised ESMF describes comprehensive procedures and Mar 15, 2022 Page 7 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) requirements for the safe handling, transportation, storage, treatment and disposal of COVID-19 treatment, testing and vaccination materials, the safety of medical workers, hospital staff, workers involved in vaccination activities and communities, as well as safe management of biohazardous wastes resulting from project activities, including provisions for the safe management of vaccination waste generated outside of health care facilities (such as for vaccination centers set-up in schools – to date, no such centers have been set-up). The ESMF references the World Bank Group’s Environment, Health and Safety (EHS) Guidelines, the WHO’s specific COVID-19 guidelines on laboratory biosafety, the WHO’s Vaccine Management Handbook “How to Monitor Temperatures in the Vaccine Supply Chain” (2015) and other WHO and international good practice guidelines on COVID-19 medical waste management, diagnostic testing, administration of COVID19 health services, quarantine guidelines, handling of medical supplies, and healthcare occupational health and safety (OHS), including those requirements to support vaccination activities. The ESMF includes measures to assess the role of security forces, which may be mobilized for transportation and delivery of vaccines at health sites. Additionally, the ESMF specifies measures to identify risks associated with the deployment of such personnel (including sexual exploitation and abuse (SEA), sexual harassment (SH) or excessive use of force) and required mitigation measures. For the AF1, the ESMF was updated to outline the implementation arrangements to support vaccination activities with regards to environmental and social risk management, training programs focused on COVID-19 biosafety as well as compliance monitoring and reporting requirements. The updated ESMF considers the potential social risks for the parent project and the AF1, including situations where access to vaccines and their corresponding allocation to priority groups are not adequately communicated or not Public Disclosure fairly distributed. The updated ESMF determines how these risks will be mitigated, including measures to ensure: a (i) robust and coordinated national communication strategy promoting the Project’s objectives, including the vaccination roll-out, tailored to various audiences to address issues of access, discrimination, and ethnicity; (ii) continuous education and awareness raising campaigns based on the information included in the NVRP; (iii) development of materials (radio, infographics, TV broadcasts) in an inclusive and culturally sensitive manner, particularly when discussing the benefits of vaccination; (iv) consult and inform the public of the content in the NVRP, including the strategies that will be adopted regarding information disclosure, informed consent and measures of transparency; and (v) a grievance redress mechanism that will provide real time feedback. These aspects are also complemented with the actions included in the project Stakeholder Engagement Plan. In addition, the updated ESMF includes provisions to support non-discrimination in provision of services and equal treatment to all project beneficiaries, as well as identifying the barriers faced by poor, marginalized and ethnic minorities in accessing healthcare centers and treatment. The MoH prepared an Environmental and Social Audit to describing E&S management measures during a determined period of vaccination for retroactive financing under the AF1. The audit centered its assessment on: (i) waste management, (ii) inclusion of vulnerable groups, (iii) health workers safety measures, and (iv) handling of grievances. The audit also included a series of findings and recommendations that, in conjunction with the E&S instruments, would signal actions to strengthen and improve E&S management and performance. The audit was approved by Bank management in January 2022, with the request of preparing an Action Plan describing specific actions to respond to the audit’s findings. The MoH drafted an Action Plan in February 2022, detailing corrective actions and timelines to address identified areas for improvement. Actions are currently under implementation. Mar 15, 2022 Page 8 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) Regarding the proposed AF2, the project envisages the scaling-up of component 1 activities, involving the likely financing of retroactive payment for the purchase of vaccines, medicines, medical supplies, PPE, minor refurbishments and services to support the vaccination program and to strengthen and broaden communication efforts. As such, the WB's E&S specialists assessed that the environmental and social risks evaluated in the current ESMF for the project will be maintained. Thus, given the Project components remain the same and no new activities introduced, there is no need to update the ESMF currently being implemented. For the purpose of the AF2 E&S evaluation, an addendum to the existing E&S Audit will be developed, in addition to updating the Environmental and Social Commitment Plan (ESCP) and the Stakeholder Participation Plan (SEP) of the project. The addendum to the audit shall be completed by 30 March 2022 and will be a disbursement condition for the AF2 as defined in the updated Environmental and Social Commitment Plan (ESCP). The ESCP specifies that the MoH agrees to implement the recommendation of the revised Action Plan in accordance with the timelines agreed with the Bank. ESS10 Stakeholder Engagement and Information Disclosure ESS10 is relevant. The MoH has prepared, consulted, disclosed and adopted a Stakeholder Engagement Plan (SEP) for the Parent Project. An updated draft has been prepared and its final version will be disclosed, consulted and adopted before AF2 approval. The AF2 updated SEP will include minor additions to the existing instrument, centered on the findings and engagement developed for the E&S Audit prepared between October and November 2021. The Parent Project includes a subcomponent focused on strengthening national communication strategies and information support resources as part of project design. Activities for this subcomponent will begin implementation in March 2022. In this context, the Project’s SEP has identified affected and interested parties as well as vulnerable groups, and Public Disclosure outlines an initial strategy that includes timelines and methods for consultations and continuous engagement throughout project implementation that is based upon meaningful consultation and disclosure of information, but which also takes into account the realities of advised physical distancing during the COVID-19 outbreak. The AF1 and AF2 will support the expansion of communication activities to inform the public of the rationale for vaccinating and providing booster shots for selected target populations; vaccine safety; the process for vaccine deployment; and possible side-effects to foster confidence in a new vaccine or the different types of vaccines that would become available. Effective communication and outreach will be imperative to increase awareness and “vaccine literacy”, build trust, and reduce stigma around COVID-19 vaccines. Various approaches will be used to improve vaccine literacy among the general Salvadoran population, specially disadvantaged or vulnerable groups identified by the project. Some of the key priorities will include conducting online consultations regarding beneficiary perceptions and obstacles to vaccine uptake; sensitization to counter misconceptions about the disease, vaccine introduction and any negative perceptions and disseminating in due time vaccination-related information such as overview of the COVID-19 vaccine program, priority risk groups, commodity availability, and tracking of those who need to receive a second dose, etc. The AF will support activities targeted at the primary health care services, towards improving two-way communication with the public to reach targeted beneficiaries as well as citizens across the country. It will also target messages to prevent and respond to the risk of gender-based violence (GBV) or LGBTI discrimination, and/or train frontline health workers on how to identify, appropriately handle incidents and refer patients for additional services. During preparation of the AF1, stakeholder engagement and consultation built a significant relationship between MoH staff and organizations representing vulnerable groups, including several rounds of dialogue with Indigenous Peoples and LGBTI representatives. Among Mar 15, 2022 Page 9 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) these discussions, the SEP describes recommendations and feedback to build trust in the prevention and response of misinformation that may interfere with decision-making in the population and to adhere to public health advice. The parent project’s GRM responds to complaints throughout the project lifecycle and has been designed to respond to any project grievances. The PCU has been monitoring the performance of the GRM which is supported by the MoH’s own grievance platforms; it defines ways in which users can submit their grievances, which may include submissions in person, by phone, text message, mail, email or via a website. The GRM also sets out the length of time users can expect to wait for acknowledgement, response and resolution of their grievances, transparency about the grievance procedure, governing structure and decision makers; and an appeals process (including the national judiciary) to which unsatisfied grievances may be referred when resolution of grievance has not been achieved. The project GRM is also enhanced by placing additional channel to register and respond to complaints/feedback linked with supply of vaccinations as the primary objectives of the AF1 and AF2 is to enable affordable and equitable access to COVID vaccines in El Salvador. To this date, no project specific grievances have been received; however, the E&S audit developed in November 2021 showed that the existing GRM channels reported numerous requests for information regarding vaccination sites, appointments and general information about availability. These inquiries have been usually addressed immediately. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions Public Disclosure This Standard is relevant. Labor provisions, risk assessments and requirements are included in the current Labor Management Procedures (LMP), redisclosed and adopted in October 2021. Given the activities of the AF2 align with the provisions taken for AF1, there is no need to update the LMP at this stage. Activities supported by the Parent Project and the AFs will be conducted by publicly employed health and laboratory workers. Additional project workers include contracted suppliers (including those involved in transport, handling and delivery of procured goods), as well as potentially other contract staff to support vaccination activities. The key risk is contamination with COVID- 19 (or other contagious illnesses as patients taken seriously ill with COVID-19 are likely to suffer from illnesses which compromise the immune system, which can lead to illness and death of workers). Emerging risks related to declining mental health and fatigue may impact project workers’ capacity to carry out core functions. Staff of health facilities, workers involved in vaccination activities, as well as all other workers involved in the procurement, delivery, training, use, supervision/monitoring, and/or handling and disposal of medical supplies, equipment, or waste products within the scope of the project will receive necessary training on protecting themselves and others from COVID-19 infection, as well as other relevant OHS and mental health risks and management measures as part of project design. The Project ensures the application of OHS measures as outlined in WHO guidelines which are referred to in the disclosed LMP and ESMF. This includes procedures for entry into health care facilities; procedures for protection of workers in relation to infection control precautions; provision of immediate and ongoing training on the procedures to all categories of workers, and mandating hand hygiene and personal protective equipment (PPE); ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General EHSGs and industry specific EHSGs and following evolving international best practice in relation to protection from COVID-19. The worker-specific GRM is operating, Mar 15, 2022 Page 10 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) with no registered grievances to date. The E&S audit prepared in November 2021 showed the need to better socialize the existence of the worker-specific GRM and make health staff aware of its functionality and operation. The PCU will start this communication process in March 2022. ESS3 Resource Efficiency and Pollution Prevention and Management This Standard is relevant. Pollution prevention and management – specifically medical waste management – remain an important aspect of the Project. Medical wastes and chemical wastes (including water, reagents, infected materials, etc.) from the health centers and home quarantine (drugs, supplies and medical equipment) can have an adverse impact on the environment and human health if not properly handled, transported and disposed. These wastes could include liquid contaminated waste, chemicals and other hazardous materials, and other waste from labs and quarantine and isolation centers including sharp items used in diagnosis and treatment. Despite recent investments in selected hospitals to develop and implement bio-hazard waste management systems, existing capacity for ensuring proper medical waste management at hospitals across El Salvador varies, and will therefore be a key area of focus of capacity building and supervision under the project, considering in particular the risks of further COVID-19 spread if waste is not handled properly. The recent E&S Audit (January 2022) found the need to improve temporary medical waste storage and handling prior to final disposal and actions are being implemented to ensure that facilities are upgraded and procedures updated. The ESMF for the AF1, updated and disclosed by the MoH in September 2021, includes an Infection Control and Waste Management Plan (ICWMP) for the vaccination program as well as a Medical Waste Management Plan Public Disclosure (MWMP) for those vaccination centers located outside of existing health facilities (to date, no schools or similar facilities have been used as vaccination centers). And finally, under the AF2, the project proposes to retroactively finance the purchase of climate-smart technologies and the procurement and mobilization of energy efficient equipment (cold-chain equipment). ESS4 Community Health and Safety This Standard is relevant. In line with safety provisions in ESS2, it is equally important to ensure the safety of communities from infection with COVID-19. Medical wastes and general waste from the labs, health centers, and quarantine and isolation centers have a high potential of being contaminated with the coronavirus or other micro- organisms that can infect the community at large if they are not properly disposed of. There is a possibility for these infectious microorganisms to be transmitted to members of the public if not well contained within laboratories or appropriately isolated areas of hospitals and medical centers, or due to accidents or emergencies (i.e. a fire or disasters such as seismic events). The ESMF updated and disclosed for the AF1 in September 2021, defines waste managed measures in line with international good practice and WHO protocols. Specifically, it describes: i) how Project activities involving the COVID-19 pathogen or waste generated in its identification and treatment will be carried out in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (such as WHO guidelines) ii) defines measures to prevent or minimize the spread of infectious diseases, and iii) defines emergency preparedness measures. Information on preventive health measures to communities surrounding health facilities will be provided periodically through continuous stakeholder engagement. Mar 15, 2022 Page 11 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) Sexual Exploitation and Abuse (SEA)/ Sexual Harassment (SH) risks have been assessed and addressed in the ESMF, including screening measures to prevent and mitigate any relevant SEA/SH risks associated with Project activities. The Project will promote the avoidance of SEA by relying on the WHO Code of Ethics and Professional Conduct for all workers related to the Project who will work as part of the emergency response. Regarding security forces, the PIU shall take SEA/SH and other relevant measures as described in the updated ESMF (disclosed in September 2021) and the disclosed ESCP. All allegations of unlawful or abusive acts of any military/security personnel, should be reviewed, acted (or request appropriate parties to take action) to prevent recurrence and, where necessary, report unlawful and abusive acts to the relevant authorities through the project’s Grievance Redress Mechanism. During project implementation, security personnel have been deployed to support transport, storage, hanlding and distribution of vaccines. Security personnel are also tasked with providing logistical assistance to mobilize older persons or persons with disabilities during vaccination activities. A strict code of conduct is in place and training and awareness sessions will include sensitization on the need to avoid any escalation of situations. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This standard is not currently relevant. The project will not support major construction or rehabilitation works and an initial E&S screening did not identify any potential risks and/or impacts relevant to ESS5. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard is not currently relevant. The Project will not support any construction activities that might jeopardize Public Disclosure the integrity of biodiversity or living natural resources. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is relevant. Since this is a national Project, Indigenous Peoples are present in the project’s scope of implementation. It is not expected that any of the activities related to the Project will have either direct or indirect negative impacts on Indigenous Peoples beyond providing support to any individual IPs who are at risk or have been exposed to COVID- 19 and will be provided access to project resources. Since the Parent Project’s effectiveness, no documented issues related to access have emerged from IP groups. Consultations with IP representatives carried out during the E&S audit showed that no discriminatory practices have occurred during vaccination activities. According to the national census, El Salvador’s IP population accounts for less than one percent, although IP organizations estimate that percentage is higher. The Nahuat-Pipil comprise the most numerous of the three main indigenous groups in El Salvador today, which also include Lencas and Kakawiras. While virtually all of El Salvador’s Indigenous groups speak Spanish as their main language, Nahuat is the only indigenous language still spoken in the country, particularly in some traditional groups living in the western highlands near the border with Guatemala. All the activities financed by the Project must ensure to respect the dignity, aspirations, identity, culture and livelihoods of Indigenous People. These groups have been historically underserved and are often living in rural and remote areas, where access to information and health services is limited. As outlined in the SEP, the Project and the AFs will set up communication channels to appropriately inform these communities of the risks posed by COVID-19 and recommended preventive measures, and will provide information that is culturally sensitive, respectful and inclusive. The redisclosed SEP and ESMF were consulted upon in a manner consistent with ESS7, including meaningful Mar 15, 2022 Page 12 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) consultations with IP communities and their representative bodies and organizations; culturally appropriate engagement processes; providing sufficient time for IPs decision making processes; and allowing their effective participation in the design of project activities or mitigation measures that could affect them either positively or negatively. ESS8 Cultural Heritage ESS8 is not currently relevant. Project activities will not have any adverse impact on tangible or intangible cultural heritage. The potential works to refurbish health facilities to support vaccination activities will be minor and limited to existing footprints. However, some of the project beneficiaries will be IPs who may have distinct cultural health practices. Official health providers should recognize these traditional methods when working with IP communities in health-related matters, which includes recognition of their own traditional governance structures and traditional medicine agents. The project will ensure these customs are taken into consideration when communicating with and treating these communities. ESS9 Financial Intermediaries This standard is not relevant. C. Legal Operational Policies that Apply Public Disclosure OP 7.50 Projects on International Waterways OP 7.60 Projects in Disputed Areas B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: None. IV. CONTACT POINTS World Bank Contact: Roberto F. Iunes Title: Senior Economist, Health Telephone No: +1-202-473-3427 Email: riunes@worldbank.org Mar 15, 2022 Page 13 of 14 The World Bank Second AF El Salvador COVID-19 Emergency Response Project (P178315) Contact: Aakash Mohpal Title: Senior Economist, Health Telephone No: +1-202-473-6614 Email: amohpal@worldbank.org Borrower/Client/Recipient Borrower: Republic of El Salvador Borrower: Ministry of Health Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Public Disclosure Task Team Leader(s): Aakash Mohpal, Roberto F. Iunes Practice Manager (ENR/Social) Genevieve Connors Cleared on 15-Mar-2022 at 13:34:50 GMT-04:00 Mar 15, 2022 Page 14 of 14