The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 04/15/2022 | Report No: ESRSAFA383 Apr 20, 2022 Page 1 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Ethiopia AFRICA EAST Democratic Republic of Ministry of Health Ethiopia Project ID Project Name P178821 Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project Parent Project ID (if any) Parent Project Name P173750 Ethiopia COVID-19 Emergency Response Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 4/27/2022 5/19/2022 Population Financing Public Disclosure Proposed Development Objective To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Ethiopia. Financing (in USD Million) Amount Current Financing 495.60 Proposed Additional Financing 250.00 Total Proposed Financing 745.60 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 C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The third AF will support investments to bring immunization systems and service delivery capacity to the level required to successfully deliver COVID-19 vaccines at scale, through all the 5 Components of the parent project. Apr 20, 2022 Page 2 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) Component 1: Medical Supplies and Equipment [proposed AF3 allocation US$41.0 million equivalent] Under this component, AF3 will finance: (i) the procurement of COVID-19 vaccine doses to cover an additional 10 percent of the population; (ii) procurement of vaccination supplies needed to vaccinate the additional 10 percent of the population such as diluents, syringes, and all medical supplies associated with the vaccination response; (iii) infection prevention and waste management; (iv) vaccine storage and transportation through EPSA, including purchase of spare parts for climate friendly cold chain equipment and; (v) procurement and distribution of COVID-19 ICU supplies; and (vi) laboratory equipment and consumables. These frontline health workers will be expected to conduct house-to-house visits hence the project will procure additional PPEs in adequate supply designed specifically for female health workers and volunteers. Component 2: Preparedness, Capacity Building and Training [proposed AF3 allocation US$142.0 million equivalent] finances (i) coordination at the national, subnational and regional/cross-country levels, which will require substantial strengthening to prepare for and effectively manage the roll out of vaccines; (ii) Emergency Operations Center (EOC) functionalization (including sub-national coordination and support for preparedness, training, and supervision) (iii) deployment of health workers and other personnel required for COVID-19 preparedness and response, human resources for supportive supervision and subnational support, including logistics management, delivery and supervision and monitoring; (iv) operating costs for Public Health Emergency Management (PHEM) and Incident Management functions; (v) screening at designated points of entry; (vi) strengthening call/hotline centers; (vii) strengthening PHEM and community- and event-based surveillance for COVID-19; and (viii) building diagnostic capacity for COVID-19 at the subnational (regional/state) level, including preparation of guidelines and standard operating procedures (SOPs). Public Disclosure Component 3: Community Discussions and Information Outreach [proposed AF3 allocation US$5.0 million equivalent] include: (i) risk communication and community engagement; (ii) behavioral and sociocultural risk factors assessments; (iii) production of a Risk Communication and Community Engagement strategy to address the key gaps for the expected behavioral change for COVID-19 response; (iv) production of communication materials; (v) establishing a production center for information and communication tools to support media and community engagement; and (vi) monitoring and evidence generation; and (vii) human resources for risk communication. Component 4: Quarantine, Isolation and Treatment Centers[proposed AF3 allocation US$57.0 million equivalent]: through the rehabilitation of existing facilities and setting up temporary structures, establishes and equips quarantine, isolation, and treatment centers; provision of nutrition and dignity kits. Component 5: Project Implementation and Monitoring [proposed AF3 allocation US$5.0 million equivalent]includes: (i) support for procurement, financial management, environmental and social safeguards, monitoring and evaluation, and reporting; (ii) recruitment and training of Grant Management Unit (GMU) and Ethiopia Public Health Institute (EPHI) staff and technical consultants; and (iii) operating costs specifically for the project staff under the GMU and COVID-19 hazard pay /risk allowance for staffs who will be involved in COVID-19 response at different levels. Vaccine purchasing will be done through Component 1 of Ethiopia COVID-19 Emergency Response and Preparedness project. The support for vaccines when available, which was anticipated in the initial Global COVID-19 MPA, will be added as part of the containment and mitigation measures to prevent the spread of COVID-19 and deaths under Component 1: Emergency COVID-19 Response. Ethiopia will use options the AVAT platform and/or direct procurement through UNICEF for vaccine purchase and financing mechanisms. Given the recent emergence of COVID- 19, there is no conclusive data available on the duration of immunity that vaccines will provide. While some evidence suggests that an enduring response will occur, this will not be known with certainty until clinical trials follow participants for several years. As such, this additional financing will allow for re-vaccination efforts if they are Apr 20, 2022 Page 3 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) warranted by peer-reviewed scientific knowledge at the time. In the case that re-vaccination is required, limited priority populations (such as health workers and the elderly) will need to be targeted for re-vaccination given constraints on vaccine production capacity and equity considerations (i.e., tradeoffs between broader population coverage and re-vaccination). As a prudent and contingent measure, budget for funding has been retained for re- vaccination, if needed, of such a subset of the population. To support the Government of Ethiopia’s vaccination planning, the AF will finance upfront technical assistance to support Ethiopia to establish institutional frameworks for the safe and effective deployment of vaccines. These will include: i) establishment of policies related to ensuring that there is no forced vaccination and that any mandatory vaccination program (such as for entry to schools) is well designed including regarding consent and follows due process for those who choose to opt out; ii) acceptable approved policy for prioritized intra-country vaccine allocation; iii) regulatory standards at the national level, including pharmacovigilance; iv) appropriate minimum standards for vaccine management including cold chain infrastructure (with financing as well for the investment to meet those standards as described below); and v) the creation of accountability, grievances, and citizen and community engagement mechanisms. The policies for prioritizing intra-country vaccine allocations will follow principles established in the WHO Allocation Framework, including targeting an initial coverage of 20 percent of a country’s population; focusing first on workers in health and social care settings; and then focusing on the elderly and younger people with an underlying condition which places them at higher risk. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, Public Disclosure environmental, social] As it has been the case for the parent Project and the preceding AFs, the third additional financing to Ethiopia COVID- 19 Emergency Response Project will be implemented throughout Ethiopia and will contribute to improved COVID-19 surveillance and response.. Ethiopia has considerable geographical diversity and as a result, is endowed with great diversity of plant, animal and microbial genetic resources. Ethiopia also encompasses different World Heritage Sites. Apart from rehabilitation works, no major civil works are expected in this project, and any rehabilitation works will take place in existing facilities. As result, the project is not expected to endanger natural habitats or cultural sites. However, COVID-19 Preparedness and Response activities such as the operation of laboratories (equipment, reagents /chemicals) as well as quarantine and isolation centers (which have been used since the parent project and which may be rehabilitated by this AF) can have considerable environmental and social impacts . Such activities will be implemented in urban as well as remote areas (including border areas and areas of potential communal conflicts); above all in the latter quality control will be essential. Ethiopia’s proximity to multiple fragile states and as a major land and air transportation hub greatly exacerbate the vulnerabilities to epidemics. Given the importance of limiting the spread of COVID-19 to both health and economic recovery, further supporting health system improvements and providing access to COVID-19 vaccines will be critical to accelerate economic and social recovery in Ethiopia. D. 2. Borrower’s Institutional Capacity The Ethiopian Ministry of Health (MOH) is the implementing agency for the project, including this third AF. The Minister’s Office will be responsible for leading the execution of project activities as the Partnership and Cooperation Directorate (PCD) is currently moved from the State Ministers office to the Ministers Office. A National and Sub National Coordinating Committee (NCC) for COVID-19 vaccine introduction has been established and respective. Apr 20, 2022 Page 4 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) Technical Working Group has also been established to serve as a technical wing of the NCC. The Grant Management Unit (GMU) of the MoH’s PCD in collaboration with Maternal and Child Health (MCH) directorate [is] responsible for the day-to-day management of activities supported under the project, as well as the preparation of a consolidated annual workplan and a consolidated activity and financial report for the parent and AF project components. The PCD already manages and coordinates several donor-funded projects in the health sector, including the Sustainable Development Goal Program for Results (P123531) and the Ethiopia component of the Africa CDC Regional Project. The Government of Ethiopia and Ministry of Health (MoH) has experience in managing environmental and social risks associated with Bank Projects along the Bank’s E&S Safeguards Policies and the ESF. The country also has relevant legal framework and established institutions for environmental and social risk management. One of the implementing agencies, the Ethiopian Public Health Institute (EPHI), has existing safety manuals and standard operational procedures for waste handling and disposal. EPHI has a regular training program on biosafety and biosecurity and waste management. Most of the staff are trained on biosafety and biosecurity and waste management. Staff working in the EPHI’s laboratories are vaccinated according to the specific risk group. In addition, EPHI has been implementing a quality management system including biosafety and biosecurity. However, the ESSs has been used to fill any gaps in the E&S country system. The project has a moderately satisfactory E&S performance. An ESMF, LMP, and SEP were prepared for the AFs which were used to guide the EHS risk management activities. The Ministry of Health is the key project implementing agency. The Ethiopian Public Health Institute (EPHI) has been providing technical guidance during implementation and undertaking surveillance. The MoH’s latest environment, health and safety (EHS) report for the parent project shows Public Disclosure that considerable attention has been given to meet the EHS compliance requirements of the project. This, according to the report, is evidenced by the following activities: i. EHS focal persons have been assigned at each COVID-19 facility (isolation, treatment and quarantine centers) and trained on the EHS requirement of the project so that they could provide appropriate oversight on the functionality of the EHS risk management system. ii. A range of activities have been implemented to ensure adhere to standard precautions for infection prevention and control (IPC) at COVID-19 facilities which among others include: i) preparation of guidelines for rational use of personal protective equipment, proper health care waste management, environmental cleaning and disinfection, health care worker protection, dead body management during COVID-19, etc.; ii) health care workers (medical professionals, cleaners, porters, security staff, waste handlers and morgue workers) were trained on infection prevention and control; iii) procurement of pedal hand washing facilities and deployment of dedicated and trained IPC-WaSH officer for each Quarantine, Isolation and Treatment center; iv) deployment of trained spray man for COVID-19 facility and v) sanitary supplies procured and distributed. iii. Health care waste/general waste management at COVID-19 facilities. In order to ensure proper medical waste handling and management, waste handlers and cleaners were trained and provided with appropriate personal protective equipment. Color coded dust bins and biohazard bags were procured and distributed to each regional state. Finally, the health care wastes were incinerated. iv. Occupational Health and Safety and Personal Protective Equipment (PPE). In addition to training the health care workers, appropriate PPE has been provided. The adequacy and appropriateness of PPE has monitored by forecasting and planning PPE use. The use of PPE at COVID-19 facilities was monitored and mentored by using standardize check list. Trainings on rational use of PPE and donning and doffing steps have been given to health care workers. A video demonstrating PPE donning and doffing steps was prepared and distributed to regional states. Apr 20, 2022 Page 5 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) v. EHS Compliance at COVID-19 testing laboratories. COVID-19 testing and processing of samples have been carried out under validated BSc or primary containment materials. All health care workers use PPE by abiding with recommended national protocol during specimen collection. Laboratory professionals who collect and transport specimens took a minimum of two days training on sample collection, safe handling practices and spill decontamination procedures. Twenty wards are under renovation at St. Paul (95 % complete) and Black lion ( 92 %) hospitals by the parent. The main and mini-ICU of S.t Paul hospital and D4 ward, which can accommodate up to 40 patients who need intensive care services, are among those under renovation. No oxygen storage facilities are installed yet. No fire or explosions have been encountered. Some healthcare workers were infected with COVID-19 which was the major OHS issue during implementation of the parent and AF projects. The client has been implementing various infection prevention and control measures as indicated above to minimize such incidents. As indicated above, the improvements to PPE, water and sanitation facilities at health facilities could play an important role infection control activities. Further, the project made considerable progress in the implementation the Risk Communication and Community Engagement Strategy (RCCES) as well as the Stakeholder Engagement Plan. The following are the key activities conducted for parent and 1st AF project: i. Activities to ensure two-way communications, including rapid assessments, use of toll-free numbers, rumors and media monitoring, and live TV programs were undertaken. The following rumors were identified and addressed: Association of COVID vaccine with 666 or microchips; the vaccine has no quality or produced in short period and may not effective; people die after vaccination; AstraZeneca will case blood clotting etc. Public Disclosure ii. Ministerial level engagements, regular daily and weekly briefings have been provided by the minister and EPHI authorities about the pandemic. iii. Different radio spots on ‘Mask Ethiopia’ have been translated into different languages of the country including Afan Oromo, and Somaligna. Both Oromifa and Somaligna are languages for the pastoralist and underserved communities in Oromia and Somalia regions. iv. Several communication materials targeting different audiences (including persons with hearing difficulties) were developed and shared with the public. However, the quantity of the developed materials was lower than planned and the contents lacked such topics as gender-based violence and protection of vulnerable groups v. Several communication channels tailored to different population groups including pastoralist communities have been used. Trusted sources were involved in disseminating messages including in pastoral communities. vi. Regional and woreda level RCCE focal persons in all regions including pastoralist and underserved regions were assigned/deployed/recruited and were provided orientation and/or training vii. Orientation on school reopening and prevention and control of COVID19 was given to relevant stakeholders through several meetings. viii. 24,000 stickers, 136, 913 posters and banners, 18 audio and video spot messages have been produced and disseminated / broadcasted including on top of COVID-19 preventative messages, physical, mental health, psycho- social support, non-stigma, and continuity of services key messages; 2491 volunteers has been trained and deployed in 6 regions ix. Behavioral and social risk factors assessments were undertaken, and a national survey is underway However, EHS staff turnover at the federal ministry was one of the major challenges during implementation of the project. Besides, there were delays in the EHS performance reporting. The client’s periodic reports did not adequately Apr 20, 2022 Page 6 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) cover COVID-19 vaccine activities. The MoH has agreed to address these gaps during the latest implementation support mission. Hence, the activities that have been implemented in the parent and the first additional financing projects have been of great help to improve the capacity of the client. MoH has gained some experience and capacity to manage, train staff and conduct communication campaigns for vaccine distribution and provision in different vaccination programs. However, both the AF and the parent project has been facing challenges in documentation and reporting. Besides there has been continuous turnover of E&S focal persons. At Federal GMU, there was turnover over of EHS focal persons at least three times last year. The Ministry has assigned E&S focal person and agreed to report in compliance with the requirements of the ESCP. The Ministry will therefore make sure that qualified E&S specialists will be maintained from federal to operation level implementation units as per the requirements of the Environmental and Social Commitment Plan and ensure that proper monitoring and reporting mechanism is in place. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The third AF to the Ethiopia COVID-19 Emergency Response Project will have considerable positive outcomes as it aims to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness. However, the COVID-19 vaccination activities can also have potential adverse environmental, Public Disclosure health and safety (EHS) risks if an appropriate system for collection, transportation and disposal of medical wastes is not put place. The parent project’s EHS risks was rated as high whereas the EHS risks of the preceding two AFs and this third AF is rated as substantial. The environment, health, and safety risks that may result from the project are mainly associated with Component 1 (which will finance Medical Supplies and Equipment including procurement and deployment of COVID19 vaccines; vaccine storage and transportation; supplies needed to vaccinate the additional population such as diluents, syringes, and all medical supplies associated with the vaccination response) and Component 4 (which will finance quarantine, isolation and treatment centers). Vaccination programs or vaccines (from Component 1) are not entirely without risk as adverse reactions /adverse events following immunization might sometimes occur following vaccination which may be due to the vaccine or by an error in the administration or handling of the vaccines. Hence, there should be an appropriate COVID-19 vaccines safety monitoring system to respond to adverse events following immunization (AEFIs) cases, if any. Furthermore, an appropriate cold chain system should be in place so as to maintain the potency of the vaccines and the quality of the immunization service. Immunization programs also entail safe injection practices so that potential risks to the patients, healthcare personnel, and others could be avoided or minimized as unsafe injection practices that can result in disease transmission. Vaccines should also be properly stored and transported. The vaccine must only be transported using appropriate packing materials that provide maximum protection. The potency is reduced every time a vaccine is exposed to an improper condition. This includes overexposure to heat, cold, or light at any step in the cold chain. It is essential to monitor and comply with COVID-19 vaccine expiration dates. Expired vaccines and diluents must be removed immediately from storage units to avoid inadvertently administering them (WHO Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19 (2020)) (Component 1). Refurbishing and renovation of vaccine stores and vaccination rooms (Component 4) can also have small scale EHS risks such as generation of wastes from renovation activities. The MoH should therefore maintain an Apr 20, 2022 Page 7 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) EHS risk management system for monitoring and surveillance of AEFIs; safe injections; for proper collection, transportation, and disposal of hazardous medical wastes; and for minimization of community and occupational health and safety risks. Considering the client’s capacity to manage the EHS risks associated with the AF activities, the environmental risk of the third AF is rated as substantial at this stage. Social Risk Rating Substantial The third AF COVID-19 emergency response project will continue to support activities included in the2nd AF which includes vaccine purchasing; service delivery of COVID-19 vaccination, including trainings and deployment of technical assistants; cold chain equipment and logistics; surveillance and monitoring; infection prevention and waste management. Hence, the risks for this AF are similar with the risks identified in the second A. The key social risks related to the third AF will be public and occupational health risks deriving from engagement with people and samples contaminated with COVID-19. Accordingly, provisions need to be in place for proper safety systems, with a focus on quarantine and isolation centers, screening posts, vaccination centers and laboratories to be funded by the project; encompassing all OHS and waste management procedures. Beyond this immediate concern, project implementation needs also to ensure appropriate stakeholder engagement to (i) avoid conflicts by anticipating and preempting false rumors, and (ii) support vulnerable groups to access service and manage a risk of exclusion of vulnerable groups such as internally displaced persons, populations in conflict settings or those affected by humanitarian emergencies, and vulnerable migrants in irregular situations. The project as it did for the first and second AF, will mitigate these risks through several measures to ensure vaccine delivery targets the most vulnerable populations, particularly women, elderly, poor, IDPs, and minorities and people in conflict affected areas. The project will use different approaches/mechanisms to reach vaccine eligible community members: Static, vaccine delivery at health facilities; Outreach, fixed and mobile community outreach, on fixed date and place or variable Public Disclosure date and place, respectively; and house-to-house, to reach to those who are identified as vaccine defaulters or to reach to those who are immobile for different reasons. The project will mitigate potential risks of Gender-Based Violence and Sexual Exploitation and Abuse at the isolation, quarantine and treatment centers and vaccination sites . The client will continue building the capacity/ awareness of health care providers and others working in health facilities including vaccination sites. The training materials prepared for the first AF will be updated and used for the third AF. Another risk will be reaching communities in the conflict affected areas, IDPs and refugees where the functionality of public health facilities is compromised as well as accessing the place is difficult. In areas where access is difficult the the project will engage the third party implementers the private health facilities and non- governmental organizations such as UN agencies. The project will ensure that these implementers are implementing the project in compliance with the ESF. The Environment and Commitment Plan (ESCP) will provide explicitly the requirements of the ESF and the responsibly of their party involvement. However, in active conflict areas, even the private health facilities and CSOs will face challenges to access them and therefore, there is a risk that people in active conflict areas may not be reached. Besides, the project will finalize and adopt the security management plan being prepared for the 2ndAF. Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) Risk Rating Low 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 Apr 20, 2022 Page 8 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) Overview of the relevance of the Standard for the Project: The AF expected to have a range of positive outcomes. However, there are also potententisl adverse environmental and social risks that may result from the project activities if appropriate risk management measures are not put in place. The potential adverse environment, health and safety risks and impacts associated with the third AF activities include: i) risks associated with inappropriate collection, transportation and disposal of medical wastes; ii) Adverse Events Following Immunization (AEFIs) which may be caused by the vaccine or by an error in the administration or handling of the vaccine; iii) unsafe injection practices that can result in disease transmission; iv) COVID-19 infections due to inadequate adherence to occupational and community health and safety standards that can lead to illness among healthcare workers and the community; v) drawbacks in the cold chain system of the country, if any, that could compromise the potency of the vaccines; and vi) there are also environmental, occupational health and safety risks associated with the rehabilitation of medical facilities. There is considerable risk of vaccines being rendered impotent if a proper cold chain transport system is not put in place. The COVID-19 vaccine cold chain should be designed to keep vaccines within World Health Organization (WHO) recommended temperature ranges from the point of manufacture to the point of administration. To ensure optimal performance, cold chain equipment used for COVID-19 immunization programs must comply with relevant technical specifications such as WHO standards. The WHO Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19 (2020) shall be to identify and manage potential health and safety risks during vaccination campaigns. Immunization activities shall be undertaken in alignment with WHO Infection Prevention and Control (IPC) guidance on minimizing COVID-19 transmission and by adhering to IPC good practices to protect health workers against COVID-19 and other pathogens transmitted via person-to-person as per WHO Public Disclosure recommendations. In order to address the anticipated risks, the MoH shall adopt the Environmental and Social Management Framework (ESMF) and including Infection Control and Waste Management Plan as was the case for the preceding additional financings which covers among others a vaccine cold chain temperature monitoring plan, Surveillance of Adverse Events Following Immunization plan, COVID-19 vaccine handling and storage in line with the WHO/CDC guidelines. The Ministry will adopt and use COVID-19 Vaccines Safety Surveillance Manual (2020) developed by the WHO. The MoH will finalize adopt and implement security management plan for locations where there are security concerns. In event that a third party will be engaged for implementation or monitoring of the project activities, the client will make sure the activities implemented in compliance with the requirements of the ESF. Furthermore, the Stakeholder Engagement Plan updated for the second AF will also be applicable for this AF. The SEP has been updated to provide information on what has been done and the engagement of stakeholders to date . Thus, no major update is required for the SEP. As noted in Section D.2., the MoH has implemented various activities to ensure compliance with the ESMF and LMP. EHS focal persons have been assigned at each COVID-19 facility (isolation, treatment and quarantine centers) and trained on the EHS requirement of the project so that they could provide appropriate oversight on the functionality of the EHS risk management system. A range of activities have been implemented to ensure adhere to standard precautions for infection prevention and control (IPC) at COVID-19 facilities which among others include: i) preparation of guidelines for rational use of personal protective equipment, proper health care waste management, environmental cleaning and disinfection, health care worker protection, dead body management during COVID-19, etc.; ii) health care workers (medical professionals, cleaners, porters, security staff, waste handlers and morgue workers) were trained on infection prevention and control; iii) procurement of pedal hand washing facilities and deployment of dedicated and trained IPC-WaSH officer for each Quarantine, Isolation and Treatment center; iv) Apr 20, 2022 Page 9 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) deployment of trained spray man for COVID-19 facility and v) sanitary supplies procured and distributed. In order to ensure proper medical waste handling and management, waste handlers and cleaners were trained and provided with appropriate personal protective equipment. Color coded dust bins and biohazard bags were procured and distributed to each regional state. In addition to training the health care workers, appropriate PPE has been provided. The adequacy and appropriateness of PPE has monitored by forecasting and planning PPE use. The use of PPE at COVID-19 facilities was monitored and mentored by using standardize check list. Trainings on rational use of PPE and donning and doffing steps have been given to health care workers. A video demonstrating PPE donning and doffing steps was prepared and distributed to regional states. COVID-19 testing and processing of samples have been carried out under validated BSc or primary containment materials. All health care workers use PPE by abiding with recommended national protocol during specimen collection. Laboratory professionals who collect and transport specimens took a minimum of two days training on sample collection, safe handling practices and spill decontamination procedures. In sum, there has been a very good progress to implement the project activities as per the requirements of the E&S risk management tool. However, there have also been some gaps such as EHS staff turnover and delays in the EHS performance reporting. The MoH has agreed to address these gaps during the latest implementation support mission. MoH shall ensure that vaccine prioritization within the country takes into account the vulnerabilities, risks and needs Public Disclosure of groups who, because of underlying societal, geographic or biomedical factors, are at risk of experiencing greater burdens from the COVID-19 pandemic. Furthermore, following WHO Framework for Allocation and Prioritization of COVID-19 Vaccination, MoH ensures the establishment of a system that enables equal access to everyone who qualifies under a priority group, particularly socially disadvantaged populations such as: • People living in poverty, especially extreme poverty • 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, vulnerable migrants in irregular situations, nomadic populations • Hard to reach population groups • Older adults defined by age-based risk • Older adults in high risk living situations (examples: long term care facility, those unable to physically distance) • Groups with comorbidities or health states (e.g. pregnancy/lactation) determined to be at significantly higher risk of severe disease or death from Covid-19 • Sociodemographic groups at disproportionately higher risk of severe disease or death from Covid-19 • Social groups unable to physically distance (examples: geographically remote clustered populations, detention facilities, dormitories, military personnel living in tight quarters, refugee camps) • Groups living in dense urban neighborhoods • Groups living in multigenerational households Apr 20, 2022 Page 10 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) ESS10 Stakeholder Engagement and Information Disclosure The third AF of this project will continue in recognize the need for an effective and inclusive engagement with all of the relevant stakeholders and the population at large. This AF will further strengthen the approach established in the 2nd AF 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 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. People affected by Project activities shall be provided with accessible and inclusive means to raise concerns and grievances. The ongoing RCCE intervention is providing sufficient reliable information to communities to understand the vaccination component and to address related concerns, but the project will need to remain vigilant to addressing rumors and have emergency plans in place in case they would threaten the operation. The RCCE strategy outlines how rumors and misinformation are identified and addressed. Particularly, rumors and misinformation monitoring, analysis and response have been done and this will continue to be implemented. There is a dedicated team who monitors media platforms and public feedback and quickly develop countering messages to defuse and dispel such rumors. In addition, community radio phone-ins and conversations, social media, free toll lines, feedback from health extension workers and community volunteers and risk perception surveys will be used to gather rumors and Public Disclosure misinformation. A rumor and misinformation monitoring sheet which was developed during the parent project will be used for this AF to monitor and analyze rumors. Media monitoring and community engagement will be increased, and rumors will be addressed immediately, usually within 24-hours. The SEP updated for the 2nd AF address how to equip medical personnel with the necessary information to engage pro-actively with beneficiaries. The project will continue to be guided by the SEP updated and adopted for the 2nd AF. Different community mobilization activities have been implemented to address vaccine hesitancy due to misinformation. Health education campaigns using religious institutions and religious leaders, media campaign using both print and digital media and mainstream medias (television and radios) which broadcasts using different local languages are among the key activities implemented to address misinformation about COVID19 vaccines. There has been a significant increase in vaccine uptake. However, there was no study (assessment) done to measure the impact of these public communication activities on the increasing trend of vaccine uptake. The project will ensure that information is meaningful, timely, and accessible to all affected stakeholders, including usage of different languages, addressing cultural sensitivities, as well as challenges deriving from illiteracy or disabilities. The project will ensure that information disclosure takes place in an on-going and satisfactory manner, with clear and accessible messaging on safety of vaccines, principles of fair, equitable and inclusive vaccines access and allocation, as well as rationale for prioritizing certain groups where stakeholder engagement takes place in an on- going manner, at different levels, with different partners, and in a culturally appropriate manner. The client has put in place a GRM to enable stakeholders to air their concerns/ comments/ suggestions, if any. The national COVID-19 hotline has been established and is serving the public, with people calling to access information. Apr 20, 2022 Page 11 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) Based on the experience of the national hotline, the project, with financing from the AF, has established regional COVID-19 hotlines to provide more in-depth information about COVID-19 (i.e., symptoms, testing options, referrals, vaccine related information and so forth) and information about how to access other essential health services during the pandemic. The project hotline is functional and receive a huge of calls from several people throughout the country, mostly in seeking information about the prevention methods, where they can go if they suspect COVID case and others. About 39594 people called using the hotline numbers. This AF will also ensure the continued functioning of a Grievance Redress Mechanism, including the operation of a hotline. The operators of the hotlines will be equipped with the knowledge that is required to provide information about the vaccines. 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 As it has been the case the parent Project and the preceding AFs, the third AF will be implemented in accordance with the applicable requirements of ESS 2, in a manner acceptable to the Association, including through, inter alia, implementing adequate occupational health and safety measures (including emergency preparedness and response measures), and setting out grievance arrangements for different categories of workers. Most activities supported by the third AF will be undertaken by health workers, i.e. civil servants employed by the Government of Ethiopia. Activities encompass treatment of patients as well as assessment of samples and provision of vaccines. The key risk is contamination with COVID-19 (or other contagious illnesses as patients taken seriously ill with COVID-19 are likely to Public Disclosure suffer from illnesses which compromise the immunes system), which can lead to illness and death of workers. The project will have low gender-based violence and sexual exploitation and abuse (GBV/SEA/SH) risks. To mitigate and reduce any of the project risk at the isolation, quarantine and treatment centers and vaccination sites, the client will continue using the training and communication materials prepared for both the parent project, the 1st AF and 2nd AF project The project will ensure the application of OHS measures as outlined in the ESMF noted under ESS1 , LMP as well as WHO guidelines related to COVID-19 infection prevention and control . This encompasses procedures for entry into health care facilities, including minimizing visitors and undergoing strict checks before entering; procedures for protection of workers in relation to infection control precautions; provision of immediate and ongoing training on the procedures to all categories of workers, and post signage in all public spaces mandating hand hygiene and PPE; ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General EHSGs and EHSG for Health Care Facilities and follow evolving international best practice in relation to protection from COVID-19. Also, the project will regularly integrate any latest guidance about COVID-19 risk management by WHO as it develops over time and experience addressing COVID-19 globally. Some health care workers were infected with COVID-19 which was the major OHS issue during implementation of the parent and AF projects. Child labor is forbidden in accordance with ESS2 and Ethiopian law, i.e. due to the hazardous work situation, for any person under the age of 18. In line with ESS2 as well as the Ethiopian law, the use of forced labor or conscripted labor in the project is prohibited. The project may outsource minor works to contractors. The envisaged works will thereby be of minor scale and thus pose limited risks. Also, no large-scale labor influx is expected. The LMP procedure prepared for the first AF identifies issues related with all type of workers and hence, this AF will continue implementing the LMP prepared for the first AF. Apr 20, 2022 Page 12 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) The third AF will also ensure a basic, responsive grievance mechanism to allow workers to quickly inform management of labor issues, such as a lack of PPE and unreasonable overtime via the Ministry of Health. The existing LMP provides an estimated number of workers; detailed information on the work terms and conditions; and procedures to address workers grievances. It also includes a requirement that MoH shall notify to the Bank if certain rights (such as overtime compensation, annual or sick leave, or severance) have been suspended for healthcare workers or other essential workers due to COVID-19 emergency measures. ESS3 Resource Efficiency and Pollution Prevention and Management Resource efficiency and pollution risks may result from the activities to be financed by Component 1 and Component 4. Activities to be financed by Component 1 can result in generation of medical wastes and chemical wastes (including reagents, infected materials, etc.) from the health facilities can have significant impact on environment and human health. Wastes that may be generated from medical facilities/ labs could include liquid contaminated waste, sharps, chemicals and other hazardous materials.New beneficiary medical facilities that may be rehabiliated by the AF3, if any,/, following the requirements of the ESMF, WHO COVID-19 guidance documents, shall prepare and follow the Infection Control and Medical Waste Management Plan (ICMWP) to prevent or minimize such adverse impacts. The MoH has been managing healthcare wastes following the requirements of Medicines Waste Management and Disposal Directive (in addition to relevant WHO guidelines and the WB Health Care Facility EHSG) which provides a clear guidance of on collection, sorting, storage, transportation, and disposal of medical wastes. The directive prohibits dumping medical waste in uncontrolled non-engineered landfill. Depending on the nature of the medical Public Disclosure waste, the directive recommends final disposal of such wastes shall be undertaken through controlled non- engineered landfill (for non-hazardous wastes), engineered sanitary landfill, medium-temperature combustion process (850-1,0000C), and high-temperature incineration. Waste expected from vaccination, quarantine, treatment and isolation centers among others include : i) Chemical Waste (chemicals used in the laboratory reagents, disinfectants that are expired or no longer needed; solvents; outdated, contaminated and discarded chemicals); ii) Pathological waste (e.g. unused blood products); iii) Biohazard solid waste (e.g, patient samples and specimens); iv) Disposables ( e.g. disposables other than sharps, e.g. Gloves, valves, and any other infected); vi) Sharps (e.g. Needles; syringes) etc.. The cold chain system should be energy efficient and should also try to rely on sustainable energy sources whenever practicable. The Project activities will consider alternatives and implement technically feasible activities to reduce project related GHG emissions such as use of the renewable energy sources and implementation of the energy efficiency measures in health care facilities. Every vaccine storage unit/container must have a temperature monitoring device. CDC recommends digital data loggers (DDLs). One vaccine product is stored at ultra-cold temperatures and will require a DDL that can register these temperatures. The MoH shall continue to identify options to obtain DDLs for use with ultra-cold vaccines, in addition to the DDLs needed for storage of refrigerated and frozen (-20°C) vaccines. MoH shall comply with CDC requirements for vaccine management, including storage and handling, temperature monitoring at all times, complying with instructions for dealing with temperature excursions, and monitoring expiration dates (CDC- COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, Oct 2020). If vaccines, sharps, vaccine vials and other supplies have to discarded/disposed of, the client shall follow the medical waste management procedure specified in the ESMF. MoH shall use the Logistics Monitoring Information System (LMIS) which is designed to track and trace Vaccine Vial Monitor (VVM) status, batch numbers, manufacturer, Apr 20, 2022 Page 13 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) etc. If any damage happens, those specific lots will be separated and accounted in the LMIS and finally properly disposed of. To maintain temperature during transportation to health care facilities, the distribution of vaccines from central vaccine store to all provinces (regions) will be delivered by refrigerated trucks (diesel fueled cooling system). The trucks to be used for this purpose should be fuel efficient so that potential small scale emissions could be minimized. Solar powered and diesel-powered refrigerators will be used as a back-power sources if the electricity from hydropower interrupts as appropriate. All Walk in Cold Rooms (WICRs) and Walk in Freezers (WIFRs) are equipped with standard Remote temperature Monitoring Device (RTMD)which enables to alert via email and text messages. Some 1400 health facilities in Ethiopia are also equipped with RTMDs which can alert excursions. However, bulk of vaccine swill be stored only at national and subnational levels with appropriate temperature. Ethiopian pharmaceutical supply Agency (EPSA) center and the 17 EPSA hubs are fully equipped with backup generators. EPSA will be delivering vaccines to districts only for the first dose at a time and the second dose will be consigned at the regional hubs. The health facilities will be consigning stock only for the first-round dose, most of the health facilities are equipped with modern Solar Direct Derives (SDDs) with autonomy up to 84 hours. Ethiopian pharmaceutical supply Agency (EPSA) has a working modality to ensure accountability for each transaction, each vial is captured in the STV (Stock transfer voucher) and receive POD (proof of delivery). Small rehabilitation works to be financed under Component 4 can also lead to generation of wastes from rehabilitation activities that should be managed following the procedures that have been specified in the ESMF.The ESMF that has been prepared for the preceding AF project has a template for preparation of site-specific instruments Public Disclosure (ESMPs) and hazardous medical waste plans and provides guidance related to transportation and management of medical wastes, and medical goods or expired products. It also has a guideline related to the transport, storage, handling and disposal of COVID-19 vaccines. The third AF activities should therefore be implemented following the requirements of the ESMF and other relevant WHO guidelines. ESS4 Community Health and Safety There are potential community health concerns during vaccination campaigns. To identify and manage potential community health and safety risks during immunization campaigns, the MoH shall adopt and use the WHO Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19 (2020). There is a risk of COVID-19 transmission in vaccination clinic settings unless appropriate risk management measures are put in place. To this end, it is important to consider the following infection control measures that are currently necessary when selecting COVID-19 vaccination clinic settings: • Providing specific appointment times or other strategies to manage patient flow and avoid crowding and long lines. • Ensuring sufficient staff and resources to help move patients through the clinic flow as quickly as possible • Limiting the overall number of clinic attendees at any given time, particularly for people at higher risk for severe illness from COVID-19 • Setting up a unidirectional site flow with signs, ropes, or other measures to direct site traffic and ensure physical distancing between patients • When feasible, arranging a separate vaccination area or separate hours for people at increased risk for severe illness from COVID-19, such as older adults and people with underlying medical conditions Apr 20, 2022 Page 14 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) • Making available a point of contact for any reasonable accommodation needs for people with disabilities • Selecting a space large enough to ensure a minimum distance of 6 feet between patients in line or in waiting areas for vaccination, between vaccination stations, and in postvaccination monitoring areas The quantity of COVID-19 vaccine transported to a satellite, temporary, or off-site COVID-19 vaccination clinic should be based on the anticipated number of COVID-19 vaccine recipients and the ability of the vaccination provider to store, handle, and transport the vaccine appropriately. This is essential to minimizing the potential for vaccine wastage and spoilage. • COVID-19 vaccines may be transported—not shipped—to a satellite, temporary, or off-site COVID-19 vaccination clinic setting using vaccine transportation procedures outlined in the upcoming COVID-19 addendum to CDC’s Vaccine Storage and Handling Toolkit. The procedures will include transporting vaccines to and from the provider site at appropriate temperatures, using appropriate equipment, as well as monitoring and documenting temperatures. • Upon arrival at the COVID-19 vaccination clinic site, vaccines must be stored correctly to maintain appropriate temperature throughout the clinic day. There will also inspection of the receiving facility to ensure correct storage and a set up protocol in case the conditions are not appropriate. • Temperature data must be reviewed and documented according to guidance in the upcoming COVID-19 addendum to CDC’s Vaccine Storage and Handling Toolkit. • At the end of the clinic day, temperature data must be assessed prior to returning vaccine to fixed storage units to prevent administration of vaccines that may have been compromised. • As with all vaccines, if COVID-19 vaccines are exposed to temperature excursions at any time, the temperature excursion should be documented and reported according to the national immunization program’s procedures. The vaccines that were exposed to out-of-range temperatures must be labeled “do not use” and stored at the required Public Disclosure temperature until further information on usability can be gathered or further instruction on disposition or recovery is received. The MoH will strengthen its immunization pharmacovigilance system to minimize potential risks to community health and safety. Specifically, the capacities to identify, report, investigate, and analyze adverse events following immunization and determine the cause of and respond to safety issues shall be strengthened the details of which will be described in the updated ESMF. The MoH will adopt COVID-19 vaccines safety surveillance manual developed by the World Health Organization. It will also put an appropriate arrangement for vaccine cold chain temperature monitoring in line with GIIP which should cover the whole vaccine chain transport, storage and handling. The updated ESMF has an emergency preparedness and response (EPR) measures to address a plan for safe cold chain management during power outages and natural disasters. The COVID-19 vaccine to be procured shall be deemed safe and approved by 3 Stringent Regulatory Authorities in three regions or one with WHO pre-qualification and approval by 1 Stringent Regulatory Authority according to its Project Appraisal Document for the COVID-19 Multi Phase Programmatic Approach Additional Financing. The MoH shall put measures /protocols in place to ensure voluntary consent for vaccination and to ensure that there is no forced vaccination. The operation of quarantine and isolation centers needs to be implemented in a way that both, the wider public, as well as the quarantined patients are treated in line with international best practice. This includes addressing avoidance of any form of Sexual Exploitation and Abuse as well as protocols in case of use of security personnel. Further, a security management plan will be prepared by MoH in compliance with ESS4 to address potential security risks before disbursement for Component 1 and 4 activities. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Apr 20, 2022 Page 15 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) This AF will not finance civil works requiring land acquisition, restriction on land use and involuntary resettlement. However, should the need arise for the project to acquire land, appropriate plans in accordance with ESS5 guidelines will be prepared and cleared by the Bank prior to any displacement. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources No major construction activities are expected in this project and the rehabilitation works will be conducted within existing facilities. Hence, likely impacts of the project on natural resources and biodiversity are low. However, if medical and chemical wastes are not properly disposed of, they can have impacts on living natural resources. Site specific waste management plans, which will be prepared following the requirements of the ESMF(in event that new healthcare faciltities will be engaged), will cover risk mitigation measures for potential risks to biodiversity, if any. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities Due to the country-wide rollout of activities, it is likely that the Project will also affect people meeting the criteria of ESS7, notably in the emerging regions and potentially pastoralists at its borders. The project will continue ensuring respect of human rights, dignity, aspirations, identity, culture and livelihoods of SSAHUTLC and avoid adverse impacts on them or, when avoidance is not possible, minimize, mitigate or compensate for such impacts. On the vaccine campaign, for this AF it is expected to be in all areas that the vaccination will be distributed (both urban and rural part of the county) and in case SSAHUTLC will be targeted, respective engagement on the demand side (i.e. potential cultural concerns around vaccines) as well as supply side (i.e. cold chain towards remote or Public Disclosure pastoralist communities) will need to be ensured by the client. This will be ensured via the Project’s communication and outreach strategy as well as stakeholder engagement plan as outlined under ESS10: the project will ensure that such communities are appropriately informed and can share in the benefits of the project in an inclusive and culturally appropriate manner (i.e. prevention and treatment). Consultations and vaccination campaigns in these areas will be conducted through partnership with relevant SSAHUTLC organizations and traditional authorities. Consultations will clearly communicate that there is no forced vaccination. Stakeholder engagement and vaccinations will be conducted with extra precautions to minimize COVID- 19 transmission risks, especially for SSAHUTLC living in more remote areas or in voluntary self-isolation. At the same time, the ESMF will ensure functioning cold chain requirements throughout the country. The project under the parent project and the Afs has been implementing several activites in pastoral communities. Risk communication and community engagement strategy and other related strategies prepared and used for the previous projects including parent project considers the context of pastoralist and underserved communities. Different radio spots on ‘Mask Ethiopia’s has been translated in to different languages including Afan Oromo , Somaligna. Both Oromifa and Somaligna are languages for the Pastural and underserved communities in Oromia and Somalia regions.No situations which would require FPIC are foreseen. The project activities are not expected to impact intangible cultural heritage of IP/SSAHUTLC, who may have certain traditional medicinal practices. ESS8 Cultural Heritage No construction activities are expected in this project. Hence, likely impact of the project on cultural heritage is low. Apr 20, 2022 Page 16 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) ESS9 Financial Intermediaries Not applicable 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: The project will not use Borrower Framework. Public Disclosure IV. CONTACT POINTS World Bank Contact: Enias Baganizi Title: Senior Health Specialist Telephone No: 5358+6069 / 251-011-51766069 Email: ebaganizi@worldbank.org Contact: Roman Tesfaye Title: Senior Operations Officer Telephone No: 5358+6140 / 251-011-5176140 Email: rtesfaye@worldbank.org Borrower/Client/Recipient Borrower: Democratic Republic of Ethiopia Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT Apr 20, 2022 Page 17 of 18 The World Bank Third Additional Financing for the Ethiopia COVID-19 Emergency Response Project (P178821) 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): Roman Tesfaye, Enias Baganizi Practice Manager (ENR/Social) Iain G. Shuker Cleared on 15-Apr-2022 at 11:13:23 GMT-04:00 Public Disclosure Apr 20, 2022 Page 18 of 18