The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
Additional Financing Appraisal Environmental and
Social Review Summary
Appraisal Stage
(AF ESRS Appraisal Stage)
Public Disclosure
Date Prepared/Updated: 02/21/2022 | Report No: ESRSAFA336
Feb 21, 2022 Page 1 of 13
The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
BASIC INFORMATION
A. Basic Project Data
Country Region Borrower(s) Implementing Agency(ies)
Bhutan SOUTH ASIA Kingdom of Bhutan Ministry of Health, Royal
Government of Bhutan
Project ID Project Name
P178656 Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems
Preparedness Project
Parent Project ID (if any) Parent Project Name
P173787 Bhutan: COVID-19 Emergency Response and Health Systems Preparedness Project
Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date
Health, Nutrition & Investment Project 3/4/2022 4/22/2022
Population Financing
Public Disclosure
Proposed Development Objective
To prevent, detect and respond to the threat posed by COVID-19 and to strengthen national systems for public health
preparedness in Bhutan
Financing (in USD Million) Amount
Current Financing 5.00
Proposed Additional Financing 10.00
Total Proposed Financing 15.00
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]
Feb 21, 2022 Page 2 of 13
The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
The project development objective is to prevent, detect and respond to the threat posed by COVID-19 and to
strengthen national systems for public health preparedness in Bhutan. It will achieve this objective by supporting
Bhutan, and specifically the Ministry of Health, to (i) provide emergency COVID-19 response, including case detection,
confirmation, contact tracing, recording, reporting; health system strengthening; and COVID-19 vaccination; (ii)
enhance community engagement and risk communication; (iii) in implementation management and monitoring and
evaluation; and (iv) contingency emergency response, when needed.
D. Environmental and Social Overview
D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic,
environmental, social]
Bhutan is on the southern slopes of the eastern Himalayas, landlocked between the Tibet to the north and the Indian
states of Sikkim, West Bengal, Assam to west and south and the Indian state of Arunachal Pradesh to the east. The
land consists mostly of steep and high mountains crisscrossed by a network of swift rivers that form deep valleys
before draining into the Indian plains. Elevation rises from 200 m (660 ft) in the southern foothills to more than 7,000
m (23,000 ft). Bhutan's climate varies with elevation, from subtropical in the south to temperate in the highlands and
polar-type climate with year-round snow in the north. The 12 recognized protected areas of Bhutan are its national
parks, nature preserves, and wildlife sanctuaries and they cover more than 42% of the country, mostly in the northern
regions. Bhutan is divided into twenty districts, administered by a body called the Dzongkhag Tshogdu.
This AF project will be implemented throughout Bhutan and will mainly contribute to COVID-19 vaccination. The
specific locations where project sub-components will be implemented have not yet been identified but the project
Public Disclosure
will be implemented in urban as well as rural areas.
The RGOB had prepared a National Vaccination and Deployment Plan, covering 79 percent of population, and targets
all population in four different phases. The MOH has been using the existing supply chain mechanism to deploy the
vaccines to the various health centers, primary health centers and the vaccination sites especially for vaccines
requiring conventional storage temperature at 2 to 8 degrees and vaccines requiring -20 degree as it can be still
stored at 2 to 8 degrees for one month. The proper handling, storage and administration of vaccines including cold
chain management will be in accordance with WHO guidance and relevant provisions of GIIP. UNICEF is proving
support to procure and install quality cold chain rooms at national level. Ultra-cold chain (-70 degree) storage and its
supply chain has been established for Pfizer and Moderna vaccines. There are helicopter services for deploying
vaccines requiring -70 degrees to remote areas.
The parent project will continue to strengthen the Health Emergency Operation Centers (HEOC) at the center and
sentinel surveillance sites; strengthen the ports of entry (Paro Airport and various border points); establish a well-
equipped health desk including equipment, transportation and referral mechanisms and strengthen risk
communication. It will also strengthen Hub and Spoke Hospitals for Diagnosis, Treatment, Infection Control and
Waste Management. No major civil works are expected in this project; if any works are supported, they would be
minor and take place in existing facilities within existing physical footprints. However, should there be a need for
major refurbishments and/ or construction of any new structures, Environmental and Social Management Plans
(ESMPs) will be prepared based on the provisions of the updated Environmental and Social Management Framework
(ESMF). There could be broader social risk of inequity in access to vaccines, such as due to political pressures to
provide vaccines to groups that are not prioritized due to need or vulnerability or should target groups be misaligned
Feb 21, 2022 Page 3 of 13
The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
with available vaccines. This includes possible exclusion of population groups based on gender, race, ethnicity,
refugee status, religion, or others. The project is not expected to impact natural habitats or cultural sites.
D. 2. Borrower’s Institutional Capacity
Ministry of Health (MOH) is responsible for implementing the project. There is no change in implementation
arrangement due to the AF. Overall, MOH is responsible for the execution of activities under the project. It will use its
existing Expanded program of Immunization (EPI) units to deliver the COVID- 19 vaccination. Although the parent
project is the first WB financed IPF project in the health sector in recent years, Bhutan has made good socioeconomic
progress, with the assistance from United Nations agencies; the Japan International Cooperation Agency; the Japan
Children’s Vaccine Initiative; Gavi, the Vaccine Alliance. To implement these operations environment and social due
diligence, the implementing agencies have followed applicable national laws, and relevant provisions of Royal
Government of Bhutan (RGOB).
Bhutan has a Waste Prevention and Management Act of Bhutan, 2009. This Act covers all forms of waste whether
solid, liquid, gaseous, hazardous or non-hazardous, organic or inorganic, from residential, agricultural, commercial,
medical or industrial sources, produced by any person, including materials being stored for recycling or in the process
of recycling, including the transportation of waste in any form, and import and export of waste in Bhutan. The Waste
Prevention and Management Regulation, 2012 is also a comprehensive regulation for the waste minimization and
management. It establishes various agencies and monitoring authorities for the effective implementation of this
regulation and is applied to all point sources and/or point of origin of different types of waste and their management.
This regulation classifies wastes into four categories (Medical, Municipal, Industrial and E-Waste) for the purpose of
clearly demarcating the roles of implementing agencies under respective waste categories for the effective waste
management.
Public Disclosure
A project management and policy support unit (PIU) has been established in MOH to coordinate and manage the
overall activities under this project. Also, the environmental safeguards aspects in Bhutan are overseen by the
National Environment Commission (NEC) which is a high-level autonomous agency of the RGOB and is mandated to
look after all issues related to environmental safeguards including waste management, emission standards etc.
Overall, the capacity of the IA may be considered as adequate.
The PIU has recruited an Environment and Social Specialist, who is assisting the development of a long-term E&S
capacity building program for the Ministry, especially those under emergency situations and will support
implementation of the E&S instruments prepared for the project, successfully. The E&S specialist is also assisting with
ESMP preparation and implementation, monitoring, and reporting requirements. The Bank’s E&S team has provided
support the E&S specialist to update the ESMF, ESCP, SEP and LMP of the parent project for this restructuring They
were also provided training by the E&S team. The hired specialists at PIU will focus on the implementation of the
ESCP, SEP, LMP, ESMPs and ESMF during project implementation phase.
Bhutan will use its existing Expanded program of Immunization (EPI) units to deliver the COVID- 19 vaccines. The
relevant unit has been strengthened with human resource and equipment to fulfill the objective.
Approximately 241.7 tons of COVID-19 waste (PPEs, food wastes and packages) were accounted for throughout the
country and were disposed of as per the established standard procedures of National Guideline on Infection Control
and Medical Waste Management for waste management. At present, the infectious waste in the health facilities in
Bhutan are treated by autoclave and chemical disinfection. Autoclave facility is available in eight hospitals across the
country and the three referral hospitals. Management practices against the risks related to medical waste
management and the exposure to COVID-19 in the project has been strengthened through the implementation of the
Feb 21, 2022 Page 4 of 13
The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
updated ESMF, the occupational health and safety standards and specific infectious-control strategies, guidelines and
requirements as recommended by WHO and CDC. Environment and Social Management Plan and labor management
plan was developed for minor civil works and were implemented and followed and monitored for compliance.
Activities described under stakeholder engagement plan were implemented and a Grievance Redressal Mechanism
has been established. There was no grievance received from the workers. The workers were using proper
Occupational Health Safety (OHS) measures and wearing proper PPEs at the site. There were no child workers and
forced laborers employed at the site.
II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS
A. Environmental and Social Risk Classification (ESRC) Substantial
Environmental Risk Rating Substantial
The AF will support the provisions for procurement, transportation, storage, and application of around 130,000
vaccines. Like the parent project the key environmental risks for these activities will continue to revolve around
properly managing, transporting, and disposing the medical waste generated by the vaccination. In addition, there
will be a risk of exposure to a wide range of potentially affected communities and individuals, starting with medical
and health care workers, and extending from there to a wide swath of the professional and civic community.
Vaccines must be continuously stored in a limited temperature range and distributed to local cold storage facilities
by refrigerated vehicle. Moreover, any escalation of risks due to the AF will be continually monitored and efforts will
be made to access hard to reach populations, fatigue of the health workers diminishing their capacity to manage
Public Disclosure
COVID 19 pandemic. The measures to address social and environmental risks in the parent project remain relevant,
including infection prevention and control improvements in health facilities, such as assessment and mitigation
measures for medical waste risk management that will be expanded as inoculation sites expand. The Environmental
risk is rated Substantial. The main environmental risks are: (i) the occupational health and safety (OHS) issues
related to testing and handling of supplies and the possibility that they are not safely used by laboratory technicians
and medical crews; (ii) medical waste management and community health and safety issues related to the handling,
transportation, and disposal of healthcare waste. The vaccination will generate medical wastes that may include
syringe, vials, used medical supplies, masks, and used PPEs, various disinfectant chemicals etc. If not treated, stored,
disposed in adherence to GIIP, these may have impact on human health and on the surrounding environment. As
the vaccination will cover the whole nation, it is expected that the volume of waste will grow substantially with time
and generation of wastes will be from multiple locations/ vaccination sites, and (iii) minor/moderate scale
construction impacts related to air, water, noise emissions and waste. Safety boxes will be used to keep sharps
(syringes) produced from the COVID vaccination. Based on the existing procedure for routine vaccination, each
health facility will follow the same procedure for disposal of safety box like as incineration, pit burn etc. The disposal
of safety box must be done in presence of the waste management committee. Besides, the risks of the parent
project the additional risks identified under the proposed AF, are (i) difficulty in accessing the last remaining
unreached populations with the final dose of primary series or booster doses; and (ii) COVID-19 fatigue amongst
health workers extending over 24 months severely depleting health workers drive to manage the pandemic and its
health consequences. These risks are being systematically managed by MOH by leveraging previous experience from
deployment of COVID-19 vaccines as well as strategically planning for the vaccination campaigns so as to not
overwhelm the health system. Civil works may also cause noise and emissions from vehicles and machinery, waste
Feb 21, 2022 Page 5 of 13
The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
generation and may involve risks regarding workplace and community health and safety. The ES screening will be
required for civil works to evaluate if sub-project activities require specific environmental assessment and necessary
ESMP prepared/updated as per screening. This proposed risk classification will be reviewed on a regular basis and
changed (if necessary). Any change to the classification will be disclosed on the World Bank’s website.
Social Risk Rating Substantial
The social risk is anticipated to be substantial in Bhutan because in addition to the existing risk of the parent project
activities there could be broader social risk of inequity in access to vaccines, such as due to political pressures to
provide vaccines to groups that are not prioritized due to need or vulnerability or should target groups be
misaligned with available vaccines. This includes possible exclusion of population groups based on gender, race,
ethnicity, religion, or others. These risks will be mitigated through several measures to ensure vaccine delivery
targets the most vulnerable populations, including poor, refugees, and minorities in accordance with criteria
specified in this AF. Bank will support Bhutan to develop and adapt an explicit, contextually appropriate, and well-
communicated targeting criteria and implementation plan (e.g., the national vaccination program and any subsidiary
programs) including criteria for access to vaccines. RGOB will ensure that this plan is subject to timely and
meaningful consultations in accordance with ESS 10. MOH will also target population in high-population density
locations. The Bank will continue to provide technical and implementation support to mitigate this risk. Another
potential risk is the increased incidence of reprisals and retaliation especially against healthcare workers and
researchers. The mitigation of this risk will be benefit from continuous information disclosure and consultation
processes. The parent project already has a comprehensive GRM in place to address relevant issues including labor
& working conditions and SEA/SH, which will fully apply to the AF project.
Public Disclosure
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:
The project will have positive environmental and social impacts as it will improve surveillance for infectious epidemic
diseases (including COVID 19), monitoring, containment and vaccination. At the same time the project could also
cause significant environmental, health and safety risks due to the dangerous and highly infectious nature of the
pathogen and vaccines and other materials to be used in the project-supported health care facilities and vaccine
distribution centers. ESS1 will apply and will clarify the government’s responsibilities in identifying and managing the
environmental and social risks of the project. The proposed project will provide health services in response to the
global COVID-19 outbreak. Given the nature of how the disease spreads and the medical requirement and resources
needed to address the issue, the health-care workers, the community members and the environment are likely to be
exposed to health risks from medical, solid and liquid wastes generated from the health facilities if not properly
treated and managed. In addition, the health facilities which will be used as vaccination centers can generate
infectious waste, pathological waste, chemical waste, and other hazardous health care waste. These facilities to be
supported by the project will have potential exposure to COVID-19 and will therefore have the potential to cause
serious illness or potentially lethal harm to the health care workers, laboratory staff and to the community. In
addition, the proposed cold chain management is important not to lose the potency of the vaccines.
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The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
These risks will be mitigated with the implementation of the updated ESMF, the occupational health and safety
standards and specific infectious-control strategies, guidelines and requirements as recommended by WHO and CDC.
Effective administrative and infectious-controlling and engineering controls would be put in place to minimize these
risks. Climate change can affect the trajectory of the COVID-19 pandemic and impact groups that are most
susceptible to the virus including healthcare workers, the elderly, those with pre-existing conditions, people with
disabilities and other disadvantaged groups. These vulnerabilities will be addressed through targeting and improving
health care interventions as well as the surveillance monitoring. International best practice is outlined in
the WHO “Operational Planning Guidelines to Support Country Preparedness and Response”, which will be followed
in the updated ESMF.
The MOH has been using the existing supply chain mechanism to deploy the vaccines to the various health centers,
primary health centers and the vaccination sites especially for vaccines requiring conventional storage temperature
at 2 to 8 degrees and vaccines requiring -20 degree as it can be still stored at 2 to 8 degrees for one month. Ultra-cold
chain (-70 degree) storage and its supply chain has been established for Pfizer vaccines. There are helicopter services
for deploying vaccines requiring -70 degrees to remote areas.
Key social issue entails risk of inequity in access to vaccines, such as due to political pressures to provide vaccines to
groups that are not prioritized due to need or vulnerability or should target groups be misaligned with available
vaccines. This includes possible exclusion of population groups based on gender, race, ethnicity, refugee status,
religion, or others.
These risks will be mitigated through several measures to ensure vaccine delivery targets the most vulnerable
Public Disclosure
populations, including poor, refugees, and minorities in accordance with criteria specified in this AF. MOH will also
target population in high-population density locations. The Bank will continue to provide technical and
implementation support to mitigate this risk.
Another potential risk is the increased incidence of reprisals and retaliation especially against healthcare workers and
researchers. The mitigation of this risk will be benefit from continuous information disclosure and consultation
processes. The parent project already has a comprehensive GRM in place to address relevant issues including labor &
working conditions and SEA/SH, which will fully apply to the restructured project.
ESS10 Stakeholder Engagement and Information Disclosure
From the very outset of the project, MOH is engaged in meaningful consultations with all stakeholders and continue
throughout the project life cycle, paying special attention to the inclusion of women and vulnerable and
disadvantaged groups. Home-based vaccination services were provided for people with reduced mobility, such as
people with visual disabilities and the elderly citizens.
Implementing agencies will apply the SEP prepared for this project, to engage citizens (affected and interested parties
and vulnerable groups) and provide them with information related to project activities. The preliminary SEP for the
project has been updated in line with the revised project components and also includes relevant measures related to
the provision of the Covid-19 vaccine. The updated SEP also includes details of the GRM for addressing any concerns
and grievances raised across all components.
Feb 21, 2022 Page 7 of 13
The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
The project implementation will ensure appropriate stakeholder engagement, proper awareness raising and timely
information dissemination. This will help: (i) avoid conflicts resulting from rumors; (ii) ensure equitable access to
services for all who need it; and (iii) address issues resulting from people being kept in quarantine. (iv) Targeted
engagement and use of diverse channels for information disclosure to curb Vaccine hesitancy. These will be guided
by standards set out by WHO as well as other international good practices including social inclusion and prevention of
Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH).
The parent project’s SEP includes a comprehensive project wide GRM which enable a broad range of stakeholders to
channel concerns, questions, and complaints to the various implementation agencies and COVID-19 Call centers. The
project supports the COVID-19 Call Centers with call-free numbers. These numbers have been publicly disclosed
throughout the country in the broadcast and print media. The GRM is equipped to handle cases of SEA/SH, as rapid
guidance on how to respond to these cases are developed and shared with operators. This will follow a survivor-
centered approach. The GRM has not received any complaints to date.
The SEP is a living document and will continuously be updated throughout the life cycle of the project when needed.
SEP also focuses on the needs and requirement of indigenous people who may need a differentiated measure for
consultation and participation.
B.2. Specific Risks and Impacts
A brief description of the potential environmental and social risks and impacts relevant to the Project.
Public Disclosure
ESS2 Labor and Working Conditions
Healthcare workers and other staff and relevant workers will be assigned by MoH for the vaccination campaign that
will be financed by the proposed AF. The project workers are likely to be exposed to the virus from the general public.
Training for the workers and communication program for the public adherence to COVID-19 preventive protocols
(using mask, PPEs, hand washing, maintenance of social distancing, etc.) will be arranged.
The recruitment and assignments of the workers will be done in an inclusive manner, following labor practices, and
keeping in mind the risks of discrimination towards women and marginalized and disadvantaged groups, and avoiding
child and forced labor. All conditions of contracts will be explicitly spelled out and agreed and abided by both the
employers and the employees. Workers will be trained on specific codes of conduct including expected interaction
formalities with the communities and vaccine seekers, issues of misuse and abuse of their role, theft and wastages of
logistics, sexual exploitation and abuse and sexual harassment issues.
Project workers will be working in the COVID-19 environment; hence PPE (particularly facemask, gowns, gloves, hand
washing soap and sanitizer) and training on their usage will be provided to them free of charge, and training on
procedure of entry and exit the health facilities, continuous monitoring of their health condition (especially
symptoms of COVID-19) will need to be ensured. There may be situation of firing the health workers for refusing to
get vaccinated, to curb this tendency continuous motivation, communication and training to be arranged. So far, no
such incidence is reported under the parent project and the updated LMP will include the discussion on the likelihood
of this risk to emerge and how it would be handled. No workers below the age of 18 will be assigned, given the
hazardous nature of work. Adequate OHS protections in accordance with General EHSGs and industry specific EHSGs
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Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
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and GIIP in relation to protection from COVID-19 will be adhered to. The project developed LMP which include types
and number of workers, legal frameworks, nature of their assignment, OHS issues, Grievance Redress Mechanism
(GRM) etc. The LMP also include summaries of National Labor Law, as applicable, and gap filling measures to be
consistent with the objective of ESS2. The LMP include the assessment and required mitigation measure to ensure
health and safety of the workers that may be exposed to health risks as well as a GRM for workers. Issues such as
child labor, forced labor and safety issues in the supply chain, gender and GBV/SEA/SH issues, occupational health
and safety will be addressed in the bidding and contract documents as well in line with the World Bank procurement
regulations.
ESS3 Resource Efficiency and Pollution Prevention and Management
The project is likely to generate medical, solid and liquid wastes (used sharps and syringes, PPE contaminated by body
fluid, infectious waste, pathological waste, chemical waste and wastewater etc.). This may result in potentially
significant environmental risks and impacts such as air pollution and soil and groundwater contamination due to the
release of chemical substances to the environment. In addition, if vaccines are not properly stored, transported and
handled, and cold chain management is not in place during transportation, effectiveness of vaccines may be
adversely affected. To mitigate such potential environmental pollution, each HCF will apply relevant national
guidelines and international best practices in infection prevention and control, storing and handling vaccine and the
medical supplies involved, and disposing of generated wastes. The updated ESMF will also include guidance related to
transportation and management of vaccines, samples and medical supplies or expired chemical products at
distribution centers and health care facilities to be followed by the project.
Public Disclosure
MOH will ensure the execution of the waste management plans throughout the project implementation period. MoH
will also ensure sustainable design for minor renovating/ refurbishment of health facilities and will consider energy,
water efficiency measures where possible. The construction contractor will make arrangements for water required
for construction in such a way that the water availability and supply to nearby communities remains unaffected. The
construction contractor will be required to treat wastewater before discharging the same into any stream or natural
water bodies. Innovative solution will be sought for biomedical waste to be processed as close as possible to its
generation place. The waste generated by the renovation works will be disposed of at approved sites according to the
national laws and regulations.
ESS4 Community Health and Safety
Project activities under this project may give rise to a number of risks for community health and safety. The project
would support the provision of health services to deter the COVID-19 outbreak through various health facilities. The
anticipated non- hazardous wastes would include construction material and debris, solid waste and waste water.
Hazardous waste may include medical wastes including syringe, used medical supplies, masks and used PPEs, unused/
expired medicines, various disinfectant chemicals etc. If not treated, stored, disposed of following GIIP, these might
have impact on human health and on the surrounding environment.
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Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
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A Community Health & Safety Plan is developed as part of the ESMF. Health workers were trained on Covid-19
prevention measures such as handling of PPEs, social distancing. Communities were sensitized to Covid-19
preventative measures through mass communication.
The possible spread of the virus due to interaction between non COVID and COVID patients in the health facilities will
also be extremely serious, given the nature of how the disease spreads from human to human. A public interaction
protocol, good practices, use of PPE, good hygiene protocol will have to be posted in various locations and people
made aware of how to contain and eradicate the likelihood of transmission. This community engagement on how to
avoid the risk of COVID- 19 is part of the project design.
In addition, life and fire safety (L&FS) risk associated to activities involving oxygen therapy (e.g. concentration,
cylinders transport, and supply) specially when near or around open fires, including enhancement of pressure swing
adsorption (PSA) oxygen plants is addressed in the updated ESMF. These could be effectively managed by providing
training/capacity building to workers/users/health care professionals, provision and use of appropriate PPEs,
implementation of good international L&FS practices especially around oxygen therapy related activities and open
fires near or around hospital and health care centers, emergency response, safe transport and storage of materials
and waste management following of hygiene practices and protocols suggested by product manufacturers. The
hospitals and other healthcare facilities must update their fire safety measures and ensure that all medical gas, PSA
plants, and vacuum system zone valves are (i) functional; (ii) have appropriate access restrictions / controls; (iii) are
correctly labeled; and (iv) are included in a routine inspection / maintenance program. Hospitals and other healthcare
facilities must confirm that building designs comply with earthquake specifications, fire escapes, and other fire
Public Disclosure
prevention requirements, have proper smoke exhaust and detectors, drainage, etc. as required in line with the
Bhutan Building Code 2018 (Part 6- Fire Safety) and international standards e.g., the US NFPA (National Fire
Protection Association) code. The hospitals must maintain a plan to deal with fire emergencies, including evacuation
protocols, operation of medical gas, oxygen, and vacuum system zone valves, and incident reporting root cause
analysis and corrective actions and audit. Given the expected increase in storage and handling of oxygen cylinders
and proposed PSA plants enhancement, staff shall be trained in the safe handling of oxygen. Similarly, all hospital
staff should be trained on the emergency response plans, and evacuation drills should take place periodically,
including a well-defined protocol allowing availability of emergency supplies for patient during evacuation or
relocation, especially for the elderly, vulnerable patients, and/or those connected to life support equipment.
Project healthcare workers and volunteers deployed to carryout vaccination campaigns may also demand money,
sexual favors, etc. in exchange of providing preferential treatment/ vaccines. Code of Conduct will be developed,
training will be provided, and strict implementation will be ensured to address the issue of inappropriate interaction
with the beneficiaries. Project GRM is designed to receive SEA/SH related grievances.
For storage of COVID-19 vaccines, the existing cold chain facilities will be used with required upgrading to ensure they
are ready for COVID-19 vaccines. The NDVP details out the various options for storage, distribution and transport of
vaccines across the country, assuming the temperature ranges that would be required by the different vaccines. The
NVDP is being amended to guide Bhutan’s intent to vaccinate eligible populations <12 years of age.
Safety measures and protocols will also be included in the plan. Various Good International Industry Practices will be
adopted to monitor cold chain so that temperature and other necessities are maintained at optimum scale for
storage, transportation, handling, and delivery of vaccinations. The project includes interventions to scale up and
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Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
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strengthen the implementation of effective NPIs. In addition, through robust monitoring, any risks related to
improper storage of vaccines, delays in delivery and vaccination caused by shortage of human resources and needed
supplies will be identified and addressed. The vaccination will be on completely voluntary basis. Though extensive
campaign has been planned and being run by the Government to encourage citizens to take vaccination, it has not
become mandatory. The registration of vaccination is also on completely voluntary basis and people who do not opt
for vaccination will not be marginalized. Information on voluntary vaccination is also being informed to citizens
through campaign.
While use of military or security personnel (Security Personnel) is not anticipated, in the event that they do need to
be engaged in carrying out Project activities, the ESCP outlines the measures to be taken to mitigate the associated
risks.
As part of the updated ESMF, a Community Health & Safety Plan was developed, which includes emergency
preparedness and response procedures, community awareness raising activities. Efficient waste management system
is also developed accordingly. Approximately 241.7 tons of COVID-19 waste (PPEs, food wastes and packages) were
accounted for throughout the country and were disposed off as per the established standard procedures of National
Guideline on Infection Control and Medical Waste Management for waste management.
ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement
In this project, no land acquisition is envisaged since only civil work involved at the moment will be refurbishment
Public Disclosure
and rehabilitation of a number of hospitals. No new infrastructure has been planned to be built either on public or
private property. Existing waste management facilities will be used for waste disposal and no additional waste
management facilities/ dumpsite/ landfill will be established as part of the project.
ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources
The project is not likely to affect any biodiversity of living natural resources, given the information at the moment.
ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities
There are four major ethnic groups in Bhutan: Ngalong in the west, Sharchop in the east, Khengpas in the central
region, and Lhotshampa in the south. There are also a few indigenous groups with distinct religion, language, and
culture. Since this is a national project, Indigenous Peoples (IPs) are present in the overall project implementation
area. No specific direct negative impacts on IP groups (that meet the criteria of ESS7 i.e., self-identification, collective
attachment, distinct customary culture and distinct dialect in varying degrees)) are envisaged at the moment.
However, the potential of exclusion is a concern. Interaction with these groups to share information on the benefits
of vaccination through community engagement will be done in a culturally appropriate manner and using virtual
platforms —respecting the tradition and social environment the ethnic communities might be living under. Ensuring
the inclusion of beneficiaries from IP groups, meeting beneficiary criteria will have to be ensured through
communication campaign in their own language, project and healthcare workers deployed to areas with ethnic
communities will be trained on cultural norms and sensitivities of these groups and people. Targeted and culturally
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Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
appropriate consultations will be conducted for any vaccination campaigns where IP groups are beneficiaries.
Stakeholder engagement and vaccinations will be conducted with extra cautions to minimize COVID-19 transmission
risks, especially for IP communities living in more remote areas or in voluntary self-isolation.
ESS8 Cultural Heritage
This project is unlikely to adversely affect any cultural heritage.
ESS9 Financial Intermediaries
The proposed project will not involve any financial intermediaries.
B.3 Other Relevant Project Risks
Given the existing state of the disease and its transmission mechanism, it is likely that schools, offices, public place,
shopping centers/ bazars, places of large gathering may be subject to closure. Forced/ self-isolation may also become
a common phenomenon. These may give rise to the price hike of essentials, disruption of supply chain mechanism,
travel restriction, isolation from family support, social tension and rumors—all of which will add to the risk potential
of the environment the project will operate in. As the overall area of influence of the disease rise, the healthcare
facilities may come under serious stress with shortage of manpower and equipment, causing pressure on social
stability. People living in close proximities (hostels, prisons etc) are likely to be more vulnerable than other
Public Disclosure
populations and the need for special arrangements for isolation, initial case diagnosis and referral for these groups.
C. Legal Operational Policies that Apply
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:
N/A
IV. CONTACT POINTS
World Bank
Feb 21, 2022 Page 12 of 13
The World Bank
Additional Financing to Bhutan COVID-19 Emergency Response and Health Systems Preparedness Project
(P178656)
Contact: Sangeeta Carol Pinto Title: Senior Operations Officer, Human
Development
Telephone No: 5770+6136 / 977-1-4236136 Email: spinto@worldbank.org
Borrower/Client/Recipient
Borrower: Kingdom of Bhutan
Implementing Agency(ies)
Implementing Agency: Ministry of Health, Royal Government of Bhutan
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): Sangeeta Carol Pinto
Practice Manager (ENR/Social) Christophe Crepin Cleared on 17-Feb-2022 at 17:19:9 GMT-05:00
Feb 21, 2022 Page 13 of 13