The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 02/01/2023 | Report No: ESRSAFA511 Feb 15, 2023 Page 1 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) South Sudan EASTERN AND SOUTHERN UNICEF, International World Health Organization, AFRICA Committee of the Red UNICEF, International Cross, World Health Committee of the Red Organization Cross Project ID Project Name P180277 Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project Parent Project ID (if any) Parent Project Name P176480 South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 2/22/2023 3/31/2023 Public Disclosure Population Financing Proposed Development Objective The objective of the project is to prevent, detect, and respond to the threat posed by COVID-19 in South Sudan, increase access to an essential package of health services in the states of Upper Nile and Jonglei, and develop South Sudan government health sector stewardship and system preparedness capacity. Financing (in USD Million) Amount Current Financing 263.93 Proposed Additional Financing 70.00 Total Proposed Financing 333.93 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes Feb 15, 2023 Page 2 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The Project Development Objective (revised PDO) is to “prevent, detect, and respond to the threat posed by COVID- 19, increase access to an essential package of health and nutrition services including for refugee and host communities in selected states, and to develop South Sudan health sector stewardship and health system preparedness capacity”. The CERHSPP was approved on June 28, 2021, in the total amount of US$63.93 million as follows: (i) IDA grant in the amount of US$51.5 million to UNICEF; (ii) IDA grant in the amount of US$8.0 million to the International Committee of the Red Cross (ICRC); and (iii) IDA grant in the amount of US$500,00 to the World Health Organization (WHO). A restructuring and first AF of US$200 million were approved on March 31, 2022 and declared effective on April 25, 2022. The AF1 was approved to scale up the response to COVID-19 nationwide and expand the provision of essential health services in selected states in the country and has a financing envelop of US$110 million of IDA grants, a US$40 million grant from the IDA Crisis Response Window (CRW) and a US$50 million grant from the IDA-19 Window for Host Communities and Refugees (WHR). The project (parent + AF1) has five components. The first component, implemented by UNICEF, supports COVID-19 vaccination, cold chain, and delivery and community engagement. The second component, implemented by UNICEF and ICRC, supports the provision of essential health and nutrition services in selected states (Upper Nile and Jonglei). The third component, implemented by UNICEF and WHO, supports strengthening the MoH’s institutional capacity and health emergency preparedness. The fourth component, implemented by UNICEF and WHO, supports project management and monitoring. The fifth component is a zero allocation Contingent Emergency Response Component Public Disclosure (CERC). Due to the food insecurity and malnutrition crisis in the Greater Upper Nile Region, the project requested to trigger the CERC to allow a reallocation of US$50 million from component 2 (subcomponent 2.1) to component 5 to enable a timely and integrated health and nutrition response to the crisis. Following the review of the package and the fulfillment of IDA conditions, the WB approved the request for activating the CERC on October 10, 2022. The activation of the CERC has allowed the project to provide rapid expansion of provision of an integrated health and nutrition package to a larger number of people in food insecure areas in Jonglei, Upper Nile and Unity. The provision of micronutrients through blanket and supplementary feeding programs (BSFP and TSFP) was rolled out in the Greater Upper Nile region. The systems for delivery of support are well-established and disbursed efficiently through UNICEF under the current project as well as the recently closed Provision of Essential Health Services Project. The proposed second AF (P180277) in the amount of US$70 million to the South Sudan COVID-19 Emergency Response and Health System Preparedness Project (CERHSPP- P176480) will (i) replenish the US$50 million which was reallocated from Component 2 to CERHSPP’s Contingent Emergency Response Component (CERC) which was triggered on October 10, 2022, to respond to the declared food insecurity emergency in the Greater Upper Nile Region; and (ii) support the scale up of the provision of health and nutrition services to refugees and host communities in project supported areas, which will be expanded to include Unity state. This AF would be in the form of an additional International Development Association (IDA) grant in the amount of US$70 million equivalent to the United Nations Children’s Fund (UNICEF) financed through (i) US$50 million from the Crisis Response Window (Emergency Response Fund); and (ii) US$20 million from the Window for Host Communities and Refugees (WHR). Feb 15, 2023 Page 3 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) Component 1 supports COVID-19 vaccine deployment in South Sudan. Both systems strengthening to support COVID- 19 vaccination and delivery of the vaccine to the population will be financed by the project. Systems strengthening will encompass climate friendly cold chain procurement, training, waste management, and monitoring. Vaccine delivery will include health worker allowances and supervision, risk communication, and procurement of vaccination supplies such as syringes and waste management equipment. - No additional funds will be allocated through AF2 and no changes apply. Component 2 is based on lessons learned from delivery of essential health services through PEHSP and maintains the delivery of essential health services through the predecessor project, with some adjustments to improve service availability. Additional funds through AF2 are only provided to subcomponent 2.1 and 2.3. The package of services to be delivered through Component 2 includes maternal and child health services such as vaccinations, prenatal care, skilled birth attendance, neonatal care and preventive and curative health and preventive nutrition services. Priority services also included in the package include mental health and psycho-social support services and services serving victims of sexual and gender-based violence (GBV). Component 2 supports the delivery of these services at primary care facilities and strategically identified secondary hospitals, complemented with community outreach and mobile health services to increase and expand equitable coverage and access, especially for remote or hard to reach communities. The work under this component maintains health service delivery arrangements under the predecessor project, which have seen notable service delivery achievements and provide core essential services to target populations. Public Disclosure Component 2 channels resources through UNICEF and ICRC, two of the project implementing agencies. The two organizations coordinate to deliver of the package of essential health services in the two states and other areas in the country acutely affected by the conflict. Implementation strategies include: (i) direct service provision of said agencies using their own staff; and (ii) sub-contracting local and international NGOs to support the coordination and delivery of health services. To align with other donor financing in the country such as the HPF and fill critical resource gaps the geographical focus for component 2 has been Upper Nile and Jonglei States and has expanded to Unity State as part of the CERC, a scope expansion to be stabilized during AF2. To ensure continuity of care at secondary-level in conflict-prone Akobo county, the project will also support hospital level services, implemented by ICRC in Akobo County Hospital. The World Bank will facilitate close coordination with the two partner agencies for best service coverage and to respond to anticipated movement of population given the security situation context. Subcomponent 2.1. Delivery of high impact essential health services in Upper Nile and Jonglei States. Under this subcomponent, UNICEF will ensure the delivery of cost-effective, high impact essential health services to the general population. AF2 will support the replenishment of the project funds for this subcomponent to ensure that some critical originally planned activities are financed and implemented. No changes to the activities or the implementation arrangements are envisaged. Under this subcomponent, the project supports the delivery of cost-effective, high impact essential health services to the general population living in the states of Upper Nile and Jonglei implemented by UNICEF. This package of services includes, but not limited to: (i) maternal, neonatal, and child health services; (ii) basic and comprehensive emergency obstetric and newborn care; (iii) sexual and gender-based violence (GBV) Feb 15, 2023 Page 4 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) services; (iv) climate emergency preparedness and response activities; (v) disease surveillance and outbreak response; (vi) quality improvement and supervision; and (vii) procurement and distribution of essential drugs, medical equipment and supplies for essential health services. The subcomponent is also supporting the piloting of strengthened supervision and management of health service delivery by financing several critical areas. This includes (i) support basing at least one high level supervisor with management and coaching expertise within each project county to help support improvements in health service delivery coverage and quality with a focus on support for planning and implementation; and (ii) finances additional senior level staff at the State level to conduct field visits to the project sites. This intensified supervision mechanism at the county level aims to (i) provide additional oversight and support to the health service delivery in the country; and (ii) strengthen capacity of and expand the Boma Health Initiative (BHI) workers, that serve as the community-based service providers and referral services, within the current coverage areas to ensure the target communities have adequate population coverage of the BHI services, including WASH and nutrition. In addition, with the subcomponent supports strengthening the health system resilience and ensure the delivery of essential health and nutrition services to the populations affected by the flooding. Specifically, the subcomponent finance: (i) expanding the scope of services provided to include an enhanced nutrition package of services and for climate-sensitive diseases with customized modes of delivery to the affected population in the states of Upper Nile and Jonglei; and (ii) sustaining the service provision to the affected population through setup of health tents next to the communities displaced by the floods and rehabilitation of flood-affected health facilities in the states of Upper Nile and Jonglei. Public Disclosure Subcomponent 2.2. This subcomponent will remain unchanged. The subcomponent supports delivery of hospital level services to vulnerable, conflict-impacted populations in Akobo County, Jonglei State. Akobo is a remote, highly climate vulnerable county which is severely impacted by intercommunal violence. Hospital level services in Akobo provides conflict sensitive secondary level services including: (i) outpatient and emergency services; (ii) surgical service (including obstetrics emergencies); (iii) non-surgical clinical care services (including non-surgical obstetrics, pediatrics, therapeutic feeding services, physiotherapy); (iv) clinical support services (pharmacy, laboratory, and imaging); and (v) non-clinical support services. The AF will extend the closing date until July 31, 2025. The subcomponent will continue to support, among other areas: (i) incentives for the hospital staff; (ii) transport costs including support for patients in some cases to reach the hospital, transfers from other facilities and transport back to residence due to challenging context; (iii) essential drugs, medical equipment, medical supplies, and medical consumables; (iv) healthy meals and diets required for admitted patients at the hospital; (v) the cost of fuel for the generators to ensure sustained electricity supply for the hospital and fuel for aircrafts, vehicles and boats to facilitate travel and transport; (vi) the cost of housing for the involved ICRC staff in Akobo; and (vii) the purchasing of required information technology equipment, telecommunication, and office and general supplies. Climate sensitive planning will be incorporated in the subcomponent to help ensure delivery of health services at the hospital throughout the year, given access challenges during rainy season. Subcomponent 2.3: Provision of an integrated package of health and nutrition services to refugee and host communities via UNICEF. This subcomponent will be expanded through AF2 to support the delivery of essential health and nutrition services in Unity state. Facilities based services, and establishment and expansion of the BHI community health worker program in Unity state will be financed through the subcomponent. The services will mirror the services provided for refugees and host communities in Pariang County in the Ruweng Administrative Area and Feb 15, 2023 Page 5 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) Maban County in Upper Nile State. The services that will be delivered will be similar to those health services delivered in Upper Nile and Jonglei States as described in Subcomponent 2.1 and include maternal and child health services such as vaccinations, prenatal care, skilled birth attendance, neonatal care and preventive nutrition services. Priority services will also include mental health and psycho-social support and services for victims of sexual and GBV, which is particularly crucial in refugee contexts, where women face elevated vulnerability. In addition, an integrated nutrition package will be provided to refugees and host communities and include: (i) Community-based Management of Acute Malnutrition which focuses on saving the lives of acutely malnourished children under five and acutely malnourished pregnant and lactating women (PLW) by providing curative treatments and preventing deterioration; (ii) Blanket and Targeted Supplementary Feeding Program (BSFP) and (TSFP) for PLW and children of 6 to 23 months; and (iii) scaling up and ensuring the national coverage of the Integrated Nutrition Surveillance System. Provision of essential health services, including nutrition services, to refugees and host communities in South Sudan will contribute to the improved health and well-being of these populations and consequently their ability to cope with climate shocks, to which they are highly vulnerable, particularly the country’s intense floods. Taken together, the package of assistance for refugees and host communities will put their health services situation on a firmer footing, facilitating the transition from humanitarian to development approaches to refugee issues in South Sudan and the local integration of refugees as a durable solution. Component 3 focuses on building institutional capacity and strengthening health emergencies preparedness. - No additional funds will be allocated through AF2 and no changes apply. Public Disclosure Component 4 finances costs related to a national unified monitoring approach as well as monitoring of project activities. The proposed approach builds on experience from PEHSP and incorporates monitoring of the COVID-19 response. The monitoring entities’ roles will include working with implementing partners and UNICEF to explain results, providing guidance on improved methods, proposing context-appropriate solutions, and ex-post fact verification of results provided by project reporting mechanisms. Subcomponent 4.1 will be expanded to finance third-party monitoring of the delivery of health and nutrition services in Unity state (UNICEF) including the refugees and host communities. The project will draw on the TPM to capture information on CE. In addition, the project will continue to support (i) analytical work and knowledge management activities on the project generated data to inform the implementation of the future projects; (ii) capitalize on the innovative digital platforms to facilitate supervision and monitoring activities; and (iii) monitor the implementation of climate change response and resilience. Component 5: Contingent Emergency Response Component (CERC). D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Key activities of the project are being implemented in Jonglei and Upper Nile, two states in the north east of the country. These states have been heavily impacted by violent conflict over the last decades, but equally by environmental shocks such as regular floodings. Although political violence reduced since the latest peace agreement, communal and criminal violence continues to mare the area. Potentially, the project may also extend into other conflict-affected areas, such as Unity State, following a due diligence process with the Bank. As for most of South Feb 15, 2023 Page 6 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) Sudan, apart from the larger urban areas, the areas of intervention are difficult to reach; requiring long travels, including by foot and leading to inaccessibility during rainy season. This has impacts on implementation as well as equally on monitoring of project activities. The project includes outreach activities to ensure that the most vulnerable are reached, even if they cannot come to health facilities on their own. The vaccination deployment system and infrastructure strengthening is also envisioned to strengthen South Sudan’s core Expanded Program for Immunization (EPI) infrastructure in support of strengthened childhood immunization. This part of the project will be implemented by UNICEF throughout the entire country with a short time of intervention, different from the activities in Jonglei and Upper Nile. Thus, they have to use approaches which are adjusted to this type of outreach. The technical assistance focuses on central government capacity and thus will be implemented in the capital and remotely. The project is not expected to have any adverse impact on modifying the physical environment; though relevant provisions on waste management shall ensure that not indirectly environment and communities would be affected. The first AF (P178102) has provide additional funding to support the government of South Sudan to deploy COVID-19 vaccines that meet Bank regulatory standards and are financed by the COVAX facility for 20% of South Sudan’s population and strengthen relevant health systems that are necessary for a successful deployment. Vaccination deployment system and infrastructure strengthening is also strengthening South Sudan’s core Expanded Program for Immunization (EPI) infrastructure in support of strengthened childhood immunization. This part of the project is being implemented by UNICEF throughout the country. The first AF has also continued to support delivery of essential health services in Jonglei and Upper Nile States of South Sudan, as well as insecure locations of South Sudan in line with earlier support since May of 2019, via the parent project, South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (CERHSPP, P176480) and its predecessor, South Sudan’s Provision of Essential Public Disclosure Health Services Project (PEHSP, P168926), which has delivered essential health services to the three million people living in Jonglei and Upper Nile States of South Sudan. UNICEF is the implementing agency for delivery of essential health services in Upper Nile and Jonglei and has remained the implementing agency for service delivery to the two states in this Project. To facilitate a return to Government management of health service delivery, the first AF has also continued to support Government capacity development to strengthen Health Sector Administration and stewardship, led by WHO. The PDO has been amended during the first AF to to reflect the expanded scope of activities to include the provision of essential health and nutrition services to the refugee and host communities. On October 10, 2022 the CERC has been activated to provide expedited emergency health and nutrition services in Upper Nile and neighboring Unity State. The second Additional Financing, discussed here, is being prepared to (i) replenish the US$50 million which was reallocated from Component 2 to CERHSPP’s Contingent Emergency Response Component (CERC) noted above, to respond to the declared food insecurity emergency in the Greater Upper Nile Region; and (ii) support the scale up of the provision of health and nutrition services to refugees and host communities in project supported areas, which will be expanded permanently to include Unity state. Insofar will the geographic scope of AF2 not expand beyond AF1, considering the expansion during the CERC activation. The areas addressed by the project are high-risk in terms of security as well as difficult to access geographically. This has impacts on implementation as well as equally on monitoring of the project. It is not expected to have any adverse impact on modifying the physical environment though relevant provisions on waste management shall ensure that not indirectly environment and communities would be affected. As noted under ESS7, beneficiaries in South Sudan are considered falling under the categories for which ESS7 is relevant. Given high vulnerability of the majority of the Feb 15, 2023 Page 7 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) population, an ongoing history of local grievances and violent conflict, and limited institutional structures, it will be important that the project takes the context strongly into consideration and ensure effective community structures. D. 2. Borrower’s Institutional Capacity Key implementing agencies for the project are UNICEF and ICRC; with AF2 funds being allocated solely to the activities implemented by UNICEF. Over the last years, these agencies, in close cooperation with the Bank, have established effective structures to implement the provision of basic services in Jonglei, Upper Nile, and Unity State, with the latter benefitting from more sustainable investments under AF2, following the CERC-funded works under AF1. The CERHSPP parent project, and consequently AF1, successfully transitioned into the ESF application from the safeguards policies approach implementing in the predecessor project PEHSP. Important to note is that UNICEF, different from ICRC, works with local partners (Implementing Partners) in the rollout of the activities. Experience from PESHP and CERHSPP is that these partners show different levels of capacity and close support and supervision by UNICEF will continuingly be necessary. Respective capacity building activities have been included in the project. Such capacity building will also be extended to members of the Boma Health Initiative teams (sourced from local communities) as well as public health personnel, incentivized by the project. UNICEF is using this capacity also for the deployment of COVID19 vaccines in the national rollout. Enhanced monitoring procedures have been required in the rollout plans to ensure that UNICEF compensates for any potential gap in more stable structures in comparison to Jonglei and Upper Nile. Given that vaccine rollout is a very mobile and short-term activity, equal flexibility will be applied in ensuring the rollout in line with ESF requirements. As with AF1, also AF2 will continue to have a strong focus to strengthen the Ministry of Health in technical and cross-cutting areas. This will include environmental and social risk management, which will be included in the respective component with the vision of transitioning to government leadership in future interventions. The parent project and AF1 show satisfactory environmental and social risk management with good Public Disclosure progress on community outreach via the Boma Health Initiative; trainings on IPC, water supply and sanitation standards, waste management plans; the strengthening of grievance redress; and trainings and material development on the SEA/SH Action Plan. The parent project got advised to further strengthen oversight on implementing partners which also the AF will support. The highest contextual risk remains security, for which monitoring and reporting considerably improved. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) High Environmental Risk Rating Substantial The ERR for AF1 has not changed from AF1. Potential adverse environmental impacts are expected to be limited, site- specific, and reversible. The activities associated with AF2 project will complement the positive impacts of AF1 and the parent project by facilitating COVID-19 containment, reducing Covid-19 related hospital admissions, vaccine procurement, its deployment and administration. The predicted environmental risks associated with the AF project include (i) the generation of additional Covid-19 related healthcare waste in the form of sharps, swabs and PPE; (ii) OHS risks linked to healthcare workers involved in handling and administering vaccines, those working in the health care waste stream and logistical workers involved in the cold storage chain; (iii) risks and impacts from loss or spoiled vaccines due to a mismanaged vaccine cold chain and poor vaccine handling and transportation practices; (iv) Community Health and Safety risks from the handling, transport and disposal of vaccine associated healthcare waste; and (v) risks to a successful country wide vaccination program due to a hesitancy or a refusal to receive the Covid- 19 Feb 15, 2023 Page 8 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) vaccine because of religious, traditions, beliefs or negative online influences. The current plan is not to increase the capacity of vaccine related infrastructure (vaccine centers, additional storage) either by construction or renovation of existing facilities or increase the cold storage capacity by the procurement of refrigeration or refurbishment of equipment. In the parent project CERHSPP, UNICEF’s Environmental and Social Management Framework (ESMF) from the predecessor project (PEHSP) was modified to incorporate new ESF standards, including additional potential risks if plans evolve and/or additional capacity is required. Improved health care waste management under the parent project will support waste segregation, storage, transportation and safe disposal of healthcare waste generated by COVID-19 laboratory and medical activities. The additional healthcare waste generated by the AF activity will include sharps, vials, expired vaccines, swabs and PPE and should be managed under the previous project’s Medical Waste Management Plan (MWMP). Relevant risks identified and managed under the parent project includes healthcare worker’s exposure to COVID 19, testing and handling of supplies, healthcare waste management and community health and safety issues related to the handling and transportation and disposal of healthcare waste and procurement and use of sub-standard PPEs. There are many risks inherent within the cold chain that includes poorly maintained refrigeration equipment, theft, lack of security or law enforcement availability, mishandling, unavailability of climate control vehicles, technical failures in temperature and coolant, human error, road infrastructure and accessibility to rural areas, vaccine accountability and tracking of deliveries and shipments, etc. The risks to cold chain logistical workers are from transportation risks (vehicle licensing, training, accidents) and contact with ultra-low temperatures. All health workers involved in the implementation of Covid-19 vaccines should possess adequate knowledge and skills to ensure safe and efficient Covid-19 vaccination administration. There are OHS risks with using untrained vaccine administrators because of wasted vials, breakages, a lack of needles and no dedicated vaccine storage or poorly maintained refrigeration equipment and a lack of vaccine administration areas at health care Public Disclosure facilities. The environmental risk rating is assessed as Substantial due to the baseline capacity of health care facilities to manage medical waste management. This baseline capacity will continue to be improved through UNICEF supervision, capacity building, and continued investment in minor physical upgrades and materials within footprints of health care facilities. AF2 as AF1 carries the same risks as the parent intervention. Social Risk Rating High As with the ERR, the SRR of AF2 has not changed from AF1. Social risks are above all the result of the FCV context in the project area, including Jonglei, Upper Nile, and Unity. This includes risks resulting from (i) intra-communal tensions over implementation issues, and (ii) assets and staff becoming targets of violent groups. Violence (political, criminal, ethnic, etc.) and GBV are two areas of concern as a result of escalating social risks. Further key identified risks include equity issues as well as elite capture, ethnicity of project staff, exclusion of nomadic pastoralists to other vulnerable and disadvantaged groups, and grievances from people related to beneficiaries, especially pertaining to medical procedures going wrong and challenges on referral to secondary treatment. It will continuingly be important to ensure for the covid vaccine rollout support i) the implementation of a fair, equitable and inclusive policy for in- country vaccine access and allocation; ii) voluntary consent for vaccination and no forced vaccination; iii) increased risk of COVID-19 transmission and adverse events following immunization; and iv) addressing capacity constraints in national system to monitor, investigate and respond to adverse events following immunization. As such, the risk is considered High. The GBV risk has also been rated High. A social assessment is included in the ESMF, meeting the requirements of ESS7. Mitigation measures encompass, among others, awareness campaigns, transparent disclosure of project activities, analysis of risks throughout the project lifecycle, meaningful consultations and participatory approach towards project activities on the ground, Codes of Conduct, integration of women into boma health committees, and constant enhancing of the GRM. The Project will also build in an iterative social/conflict monitoring Feb 15, 2023 Page 9 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) in line with the security management plan throughout the project period to see how the support for local facilities interacts with local social dynamics, so that the project activities/approach can be adjusted in real-time, including in case of hiring of security personnel. The Additional Financing carries the same risks as the parent intervention. Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) Risk Rating High Pervasive incidence of GBV in South Sudan is a significant challenge. Assessment of project-related sexual exploitation and abuse (SEA)/GBV have been conducted during project preparation. Given the context of pervasive insecurity, the project adopts a robust approach to address potential GBV risks including site-specific assessments of the availability of referral systems and its establishment if insufficient. Relevant mitigation measures to address these risks (e.g., integrating Codes of Conduct into contracts with contractors and subcontractors, in combination with SEA/GBV- related protections into community consultations and mapping activities to identify service providers, and establishment of a GRM with procedures and channels to enable safe, confidential and ethical reporting of GBV incidents) are articulated in the ESMF. The project also includes capacity building and training of relevant stakeholders with a focus on primary health facilities; risks will be monitored throughout project implementation through regular re-assessment with the risk screening tool, particularly as new project locations are determined, and through regular monitoring engagement. A GBV Action Plan has been prepared and its implementation is a requirement in the ESCP. The Additional Financing #2 carries the same risks as the parent intervention and AF1. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment Public Disclosure ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: Environmental and social risks are above all the result of the FCV context in the project area, assessed under ESS1. This includes risks resulting from (i) intra-communal tensions over implementation issues and (ii) assets and staff becoming targets of violent groups. Violence (political, criminal, ethnic, etc.) and GBV are two areas of concern as a result of escalating social risks. Potential adverse environmental impacts related to ESS1 are expected to be limited, site-specific, and reversible. These impacts are expected to fall within one or more of the following categories: (i) provision, transport, storage, use and disposal of medicines and vaccines; (ii) medical waste management; (iii) worker health and safety; (iv) community health and safety; and (v) rehabilitation/renovation of multiple public health facilities. Minor rehabilitation will only occur within the existing footprint of public health facilities and will be limited to works critical to the functioning of the center, e.g., plastering and retiling; replacement of doors, windows, locks; repair of electrical wiring, water pipe inflow and outflows; climate-proofing to reduce the impact of seasonal flooding, etc. There is to be no new construction of health facilities; any small-scale construction is expected to be of latrines, water storage, medical waste management sites, solar panel installation, flooding-related drainage and will be confined within the existing health facility footprint. Regarding vaccine access, the project will continue to ensure access for the most vulnerable to the vaccination process, with the targeting methodology and, equally, the logistical structure to take this target into consideration; a respective global discussion is included in the WHO Framework for Allocation and Prioritization of COVID-19 Vaccination, noting the following groups: • Homeless people and those living in informal settlements or urban slums • Disadvantaged or persecuted ethnic, racial, gender, and religious groups, and sexual minorities and people living with disabilities • Low-income migrant workers, refugees, internally displaced persons, asylum seekers, populations in conflict setting or those affected by humanitarian emergencies, Feb 15, 2023 Page 10 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) vulnerable migrants in irregular situations, nomadic populations • Hard to reach population groups. A second aspect are vaccine-tailored outreach activities to address potential rumors and ensure that the vaccination campaign is being ring-fenced from political tensions in the country. UNICEF’s ESMF from the previous project was modified in order to shift from the Safeguards Policies to incorporate Environmental and Social Framework (ESF) standards and holds also for the AFs. The ESMFs also now include risks and mitigation measures associated with Covid-19 vaccine storage, administration, and waste management. Each of the health care facilities to be funded as a continuation from the previous project have a site-specific Medical Waste Management Plan (MWMP) in place. The project makes use of the Environmental and Social Management Framework of UNICEF, including management sections, which includes in line with the ESF the (i) overall project-wide Environmental and Social Risks assessment in line with ESS1- ESS10; (ii) generic management and mitigation procedures for handling environmental and social risks resulting from the project in the South Sudan context; (iii) a social assessment including risks of discrimination, community tensions, and violence and respective measures in a social management plan; (iv) a Gender-Based Violence Action Plan; (v) Labor-Management Procedures including a workers Grievance Redress Mechanism; (vi) organizational structure and resource planning; (viii) waste management; and the (viii) monitoring and reporting system. It also includes a summary of the Security Management Plan, which has been developed separately. the Stakeholder Engagement Plans including a community Grievance Redress Mechanism and security instruments have been prepared separately. The AF2 makes use of the instruments developed for the original project (parent+AF1) with no modifications necessary. The geographical expansion to Unity State, which materialized during the CERC activation after the approval of AF1 and now being formalized into the main components under AF2, has during the CERC activation been assessed as not posing characteristically different risks compared to activities in Jonglei and Upper Nile; as such, they can be managed by the existing instruments. Implementation commitments with binding timelines were agreed to in Public Disclosure the parent project ESCP of UNICEF, ICRC and WHO; these ESCP elements have been complied with so far and will continuingly be monitored. ESS10 Stakeholder Engagement and Information Disclosure Stakeholder engagement is essential in this project due to the contextual risks resulting from political and communal violence where it is important that project activities can be updated in real time to changing -conditions. At the same time, this context does not allow for more traditional, stable stakeholder engagement structures but needs to be more pro-active and adjustable. The project will continue to strengthen the approach established in the parent as well as the previous project to engage with stakeholders based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with COVID-19, including the vaccination campaign. In instances where there is a likelihood of more health-related vulnerable groups in attendance, such as the elderly and those with compromised immune systems or related pre-existing conditions, stakeholder engagement shall minimize close contact. Meanwhile, the project will also ensure inclusion of overall vulnerable groups as outlined under ESS1. People affected by Project activities shall be provided with accessible and inclusive means to raise concerns and grievances. At the center of community engagement is the Boma Health Initiative (BHI), which establishes strong linkages between primary health facilities and the local communities to identify people in need as well as any potential grievances. A challenge for the BHI are security as well as COVID-19 impacts, which are normally first felt by the BHI. Recent experience has been that for ensuring a smooth operational environment, close consultations with local government structures as well as other power groups, including youth, is important, above all in relation to employment opportunities as well as security of project structures. Specific provisions must be included in relation to Feb 15, 2023 Page 11 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) the COVID-19 vaccine rollout. Global and regional experience has highlighted the importance of outreach activities in relation to the pandemic; countering rumours as well as stigmata in terms of the disease, the general mitigation measures, as well as specifically the vaccine to ensure collaboration of communities in the fight against the pandemic. Also, as noted above, as the vaccine campaign will be rolled out with support by UNICEF nationally, it will be important that proportionally efficient and effective provisions are in place beyond Jonglei, Upper Nile, and Unity. Both SEPs include GRMs which appear to have been operational for a long time, sensitive to GBV/SEA/SH as well as accessible for vulnerable people. Respective details are outlined in the existing Stakeholder Engagement Plans of UNICEF and ICRC. 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 ESS2 is above all relevant in terms of occupational health and safety of health system workers as well as in regard to the overall security of workers. The project encompasses direct project workers under UNICEF and ICRC, contracted workers as members of the Implementing Partners (NGOs), as well as incentivized civil servants (MoH workers). OHS provisions with a focus on infectious diseases in health facilities are to be implemented for all workers. This includes the provision of PPE, adequate health waste management, etc. OHS incidents in the parent project relate foremost to impact of contextual security issues (see ESS4). Provisions are included in the ESMF / Labor Management Procedures. More differentiated are provisions related to security, also dependent on the familiarity and integration of workers into local areas, ranging from international to national to local personnel. Provisions are included in the Project's Public Disclosure security management plan which outlines provisions for workers as well as requirements for the different organizations, including support and referral structures in case of incidents, insurance, etc. A worker-specific grievance redress system allows the different workers to raise their concerns. ESS3 Resource Efficiency and Pollution Prevention and Management Medical wastes and chemical wastes from the COVID 19 supported activities (drugs, vaccines, clinical supplies and medical equipment) can have substantial impact on the environment or human health. Pollution prevention and management will be an important activity under the Project. Medical waste, including chemicals, contaminated PPE and equipment, and lab testing kits from healthcare facilities will need to be safely stored, transported and disposed. During transportation of goods or supplies, including delivery, handling and storage of vaccines, there are additional risks of COVID-19 spread by drivers and risks of traffic accidents, which will be covered in the updated ESMF and Medical Waste Management Plan (MWMP). Wastes generated from labs, screening posts and treatment facilities could include contaminated waste (e.g. blood, other body fluids and contaminated fluids) and infected materials (used water; lab solutions and reagents, syringes, bed sheets, the majority of waste from labs and isolation centers, etc.) require special handling and awareness, as they may pose an infectious risk to healthcare workers in contact with the waste. Proper sustainable management of the medical and hazardous waste is constrained by the limited access to appropriate infrastructure, facilities and specialized companies for collection and treatment which operate in the country. Each site has a simple site-specific MWMP which takes account of the specific features of each facility and the available waste management services and systems. The ESMF has also been updated to include protocols for Feb 15, 2023 Page 12 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) the disposal of used panels and batteries from solar installation to assist with health care facility functioning in remote locales. ESS4 Community Health and Safety Key Community Health and Safety issues relate to (i) infectious diseases, (ii) GBV, and (iii) security of beneficiaries. The project follows WHO guidelines in terms of management of COVID19-related risks of infection. This includes the preparation of related management plans (e.g., limiting exposure in closed rooms, social distancing, etc.) as well as the usage of PPE. It also needs to pro-actively address stigmata to ensure that PPE are being used uniformly. General safety provisions for the vaccination campaign need to be in place, e.g., the single use of needles, sterile environments, effective cold chains, monitoring of vaccine expiration dates, response to adverse events following immunization, etc. Effective waste management will be also relevant, including for materials used for the vaccination campaign such as needles. Pervasive incidence of GBV in South Sudan is a significant contextual challenge. In combination with project-related activities, sexual exploitation and abuse (SEA)/GBV is a risk during the provision of benefits. The project adopts a robust approach to address potential GBV risks; including site-specific assessments of the availability of referral systems and its establishment if insufficient. Relevant mitigation measures to address these risks (e.g., integrating Codes of Conduct with SEA/GBV-related protections into community consultations and mapping activities to identify service providers, and establishment of GRM with procedures and channels to enable safe, confidential and ethical reporting of GBV incidents) are articulated in the ESMF. The project also includes capacity building and training of relevant stakeholders with a focus on primary health facilities; risks will be monitored throughout project implementation through regular re-assessment with the risk screening tool, Public Disclosure particularly as new project locations are determined, and through regular monitoring engagement. A GBV Action Plan has been prepared and its implementation is a requirement in the ESCP. The third aspect under ESS4 is security. The project does not envision the hiring of project-specific security beyond unarmed guards and accordingly the respective requirements under ESS4 on Security Personnel is not relevant beyond the general behavior of project staff (see GBV Action Plan). However, the high contextual risk threatens public health facilities and thus also beneficiaries. Specific provisions are included in the security management plan, but in general security measures focus strongly on stakeholder engagement and close coordination with local institutions and provisions on engagement with weapon bearers. This allows timely reaction including the temporary closure and evacuation of facilities if necessary. It must be noted that a significant residual risk remains for, both, communities and project. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not currently relevant as no construction activities, other than minor rehabilitation or upgrading of existing facilities, will be financed. As such, no land acquisition needs are expected. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources No construction or rehabilitation activities are expected in this project that could affect protected areas or flora or fauna. Hence, likely impacts of the project on natural resources and biodiversity are low. However, if supplies transportation or medical and chemical wastes generated are not properly disposed of, they can have impact on living natural resources. The procedures to be established in the ESMF describe how these impacts will be minimized. Feb 15, 2023 Page 13 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 applies to all beneficiaries of the project area as assessed earlier by the Bank in line with the application of OP 4.10. As such, no Indigenous Peoples’ Plan is required and the social assessments in the ESMFs apply to all beneficiaries. Measures are outlined in the Social Development and Monitoring Plans, addressed and mainstreamed into the overall project activities included in the ESMFs prepared for the parent project. This includes the GRM, which is outlined under ESS10. Many health facilities have been mapped to enable the selection of NGO partners. The selection process will take into account ethnic considerations. The Expressions of Interest (EOI) stipulate that each NGO partner has to: (1) show understanding of local context and conflict sensitivity risks which differ from County to County and within different groups and demonstrated ability to translate contextual understanding into effective interventions, including community engagement; and (2) outline access constraints and security considerations and how the NGO will manage these, whilst integrating conflict sensitivity into the proposed interventions. The poor and underserved will remain central to the project in prioritization, with the restoration of services in the areas most affected the conflict and consequently least provided for, and monitoring will assess the coverage and inclusiveness of the health service provision and thus provide information that will constitute a basis for corrective actions, if necessary. The Boma Health Initiative enables adequate outreach to local communities in adequate and culturally sensitive ways, ensuring avoidance of discrimination in the provision of benefits which will be provided culturally appropriate and adapted to the respective needs and structures of the vulnerable groups involved. ESS8 Cultural Heritage Not currently relevant as no new construction activities will be financed by the project. Public Disclosure ESS9 Financial Intermediaries Not currently relevant as no financing will provided for financial intermediaries. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No 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: Not applicable. Feb 15, 2023 Page 14 of 15 The World Bank Second Additional Financing to the South Sudan COVID-19 Emergency Response and Health Systems Preparedness Project (P180277) IV. CONTACT POINTS World Bank Contact: Moustafa Mohamed ElSayed Title: Senior Health Specialist Mohamed Abdalla Telephone No: 5345+3012 / 002-02-24614403 Email: mmabdalla@worldbank.org Contact: Abeyah A. Al-Omair Title: Public Health Specialist Telephone No: +1-202-458-7244 Email: aalomair@worldbank.org Contact: Chiho Suzuki Title: Senior Health Specialist Telephone No: 5355+3252 Email: csuzuki@worldbank.org Borrower/Client/Recipient Borrower: UNICEF Borrower: International Committee of the Red Cross Borrower: World Health Organization Public Disclosure Implementing Agency(ies) Implementing Agency: World Health Organization Implementing Agency: UNICEF Implementing Agency: International Committee of the Red Cross 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 Task Team Leader(s): Moustafa Mohamed ElSayed Mohamed Abdalla, Abeyah A. Al-Omair, Chiho Suzuki Practice Manager (ENR/Social) Helene Monika Carlsson Rex Cleared on 01-Feb-2023 at 21:35:17 EST Feb 15, 2023 Page 15 of 15