The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 12/21/2021 | Report No: ESRSAFA309 Dec 21, 2021 Page 1 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Guinea-Bissau AFRICA WEST Republic of Guinea Bissau Office of the High Commissioner for COVID- 19 Project ID Project Name P178198 Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project Parent Project ID (if any) Parent Project Name P176721 GUINEA-BISSAU COVID-19 VACCINE PROJECT Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 12/8/2021 12/23/2021 Population Financing Public Disclosure Proposed Development Objective The Project Development Objective is to prevent, detect and response to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Guinea-Bissau. Financing (in USD Million) Amount Current Financing 5.00 Proposed Additional Financing 2.20 Total Proposed Financing 7.20 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 Dec 21, 2021 Page 2 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The proposed Project will support the Government of Guinea-Bissau efforts to further strengthen its response to COVID-19 pandemic by purchasing COVID-19 vaccines, preparing the immunization system for the deployment of the COVID-19 vaccine, and supporting the distribution of these vaccines. The proposed project will strengthen the national immunization and related health delivery system in a way that will promote an effective COVID-19 response and generate, as far as feasible, long-lasting resilience. Purchasing vaccines is just one step in a complex, multi- dimensional effort that involves detailed planning and implementation of a vaccine deployment program in Guinea- Bissau. This includes a variety of issues such as effective microplanning, safe and appropriate transportation, storage, training, ancillary materials, registration, and effective vaccine logistics and a suitable information management system. The Project is structured around the two complementary components, which will support the Guinea-Bissau to continue mitigation measures to contain the spread of the pandemic in the country and to implement its National COVID-19 Vaccination Plan. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The AF will target at national level, like its parent project. The specific locations where project sub-components will be implemented include health facilities such as national and regional hospitals and health centers in urban and rural areas. The deployment in rural areas is expected to be more difficult due to cold chain logistics and potential vaccine hesitancy among some of the rural areas, where the population has less exposure to health services including other Public Disclosure vaccinations. Waste management is a main environmental risk in the country whereby the disposal system and recycling of solid waste are undeveloped. There is only one single landfill present in the country and too small in relation to its increasing population growth and waste production. Large amounts of waste are therefore discharged directly into soils and large waterways causing contamination. Treatment and disposal of healthcare waste may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment. The disposal of untreated healthcare waste in landfills can lead to the contamination of drinking, surface, and groundwaters if those landfills are not properly constructed. Waste resulting from vaccine delivery, such as sharps and the disposal of used and expired vaccine vials, can pose health risks through the potential for infectious disease transmission, or release of toxic pollutants into the environment, whereas sharps pose risk to injuries. Civil works expected in this project are considered of minor scale, focusing on the installment of incinerators. No natural habitats or cultural sites are expected to be impacted by the project. Vaccination operations are being carried out using primarily fixed points (national and regional hospitals, health centers, private and religious health care providers). Advanced and mobile strategies are also used to reach out to beneficiaries living at a distance of more than 5 km (advanced) and 15 km (mobile) from the nearest health structure and who cannot reach the fixed points and frontline workers (like entry points). The strategy is built on previous experience of SIVE (Serviço Imunização Vigilância Epidemiológica) in the immunization campaigns in the country. The COVID-19 Vaccination campaign started in SAB (Setor Autonomo Bissau) in April 2021, followed by Bafata and Biombo Health Regions. The operations were extended to the other 8 Health Regions of the country in August 2021, including the islands (Bijagos and Bolama Health Regions). Moreover, starting from August 2021, vaccination centers managed by Military Health Services in Bissau’s urban area and in Biombo Health Regions (Safim) are operational on a Dec 21, 2021 Page 3 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) daily basis. These vaccination centers are located strategically in crowded areas, like markets and high circulation spots. Training of vaccination teams started in the capital Bissau (SAB) on March 29th, 2021 and has been carried out at all levels: central, regional, and local level. Further training was organized in Bafata and Biombo health regions in May 2021. For the remaining 8 Health Regions technicians were trained starting from August 2021. Due to general strike of healthcare workers, medical students and recent graduates have been trained to support the October 2021 vaccination campaign. D. 2. Borrower’s Institutional Capacity The Ministry of Public Health (MINSAP) has been implementing two World Bank-financed projects in the health sector: Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) and Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954). The PIU responsible for these two projects is also implementing the COVID Vaccine Project. The PIU has limited capacity to screen, implement, monitor, and report on environmental and social commitments as part of Bank-financed activities. In addition, COVID-19 poses a unique set of challenges given the importance of immediate action synchronized over a broad geographic space. There were several positions within the PIU that needed to be filled and the recruitment of the Social Specialist is ongoing. The PIU developed the Environmental and Social Management Framework (ESMF) for the parent project. Further support will be needed for project monitoring of environment and social risks and impacts linked to the vaccination roll-out such as cold storage, waste management, distribution, and communication. A third-Party Monitoring (TPM) firm is in progress of being recruited under the parent project, which will also include monitoring of Public Disclosure waste management issues throughout project implementation. Institutional capacity has yet to be strengthened as the implementation of projects under the ESF is new to the PIU. The parent project became effective on October 20, 2021 and therefore there is no disbursement at this time. No training events to support the implementation of the ESF have yet taken place. The project is being implemented in close coordination with other development partners such as WHO, UNICEF, GAVI/COVAX and AU/AVAT aiming to provide technical assistance to SIVE, MINSAP, the Health Emergency Operation Center (Centro Operações Emergências em Saúde) and the Office of the High Commissioner for COVID-19 in the deployment of vaccination plans, logistics for cold chain supply, communication strategies among others. To mitigate risks related to the Borrower’s capacity, going forward, and throughout project implementation in particular, Borrower’s institutional capacity will be strengthened in a coordinated approach between all Project partners. Interventions will include training, additional recruitment, and support from third-party entities to deliver on the objectives of the COVID-19 response operation including cold storage, waste management, distribution and communication. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial Dec 21, 2021 Page 4 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) The scaled-up activities financed by the AF are expected to contribute to a higher distribution of COVID-19 vaccines across the country, to prevent further spread of COVID-19 and deaths caused by the virus. However, vaccination- related risks linked to the distribution of vaccines, as identified under the parent project remain, namely: (i) community health and safety risks linked to improper transportation, storage, handling, and disposal of vaccines and cold chain storage which can lead to vaccine quality deterioration, especially in remote areas, away from major transport links and refrigeration facilities, and places with unstable power supply (ii) occupational health and safety issues related to the availability and supply of personal protective equipment (PPE) for healthcare workers, the logistical challenges in transporting vaccines and materials such as PPE across the country in a timely manner, and close social contact and limited sanitary and hygiene services (clean water, soap, disinfectants), and (iii) environmental and community health issues from inadequate storage, transportation, and disposal of infected medical waste. This includes generated waste from vaccine delivery, such as sharps, and used and expired vaccine vials. Risks related to gaps in healthcare and hazardous waste management include health risks and injuries resulting from sharps for medical staff, other ancillary workers, nearby communities and individuals who scavenge on waste disposal sites, and contamination of soils and groundwater (on open dump sites). The environmental risk rating remains Substantial due to the above- mentioned risks, which will need to be properly mitigated. Social Risk Rating Substantial The social risk remains substantial, given that the activities financed by the AF will lead to higher distribution of COVID-19 vaccines under the parent project. Risks include the possibility of exclusion from vaccination due to discriminatory targeting, vaccine hesitancy and/or elite capture, which, in turn, could result from broader misinformation and public distrust. Other potential social risks include the increased incidence of reprisals and retaliation, especially against healthcare workers and researchers related to both suspicion of the motives and Public Disclosure legitimacy of the vaccinators and the vaccine itself as well as Sexual exploitation, abuse, and harassment risks (SEAH), which – based on the World Bank screening tool – has been determined to be substantial for the COVID-19 parent and AF projects together, especially with regard to vaccine deployment-related initiatives. The health crisis such as COVID-19 and the response measures put in place to contain it can increase inequalities and vulnerabilities, affecting women and girls disproportionately, as well as gaps with the health workers contributing to boost SEAH incidents. For instance, in similar contexts it has been reported that male health workers offered health services, including vaccination in exchange for sexual favors from women and girls. This is particularly worrying taking into consideration that women are often in care roles and are the ones arranging when and how children and wider family members, such as older relatives, get immunized paying with their own depleted funds for transport and other small, related expenses. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: This Standard is relevant. The AF will have overall positive environmental and social impacts in that its primary objective is to increase the availability of affordable and equitable COVID-19 vaccines in Guinea-Bissau. Nonetheless, there are environmental and social risks and impacts that will need to be assessed and managed through a risk-based approach. The environmental and social risks were already assessed as part of the parent project and this AF is Dec 21, 2021 Page 5 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) limited to financing the purchase of additional doses of COVID-19 vaccines, to be distributed under the parent project. The COVID-19 Vaccination campaign began on April 2, 2021 with priority groups as planned in the National Deployment and Vaccination Plan (NDVP). The main challenges identified during the campaign include: (i) low turnout for COVID-19 vaccinations, which led the country to open vaccination to the population over 18 years of age since the first campaign (April 2021) and to recently (as of November 2021) require vaccinations for use of public transportation, entry into schools and universities and travel between regions; (ii) the weakness in communication and community sensitization which has also led to low turnout due to the lack of information of safety and efficacy; (iii) the short shelf-life of the vaccines received through COVAX, including the bilateral donations, have in some cases led to vaccine waste due to low vaccination turnout; (iv) vaccine storage challenges and cold chain capacity at central and regional levels in the last few weeks have stopped the country from accepting new vaccine donations; (v) active surveillance to detect and report adverse events following immunization (AEFIs) needs to be strengthened; (vi) the coordination challenges between the main national stakeholders involved (MINSAP and the Office of the High Commissioner of COVID-19) is hampering COVID-19 vaccination efforts; and (vii) the national strike of healthcare workers in the public sector has impacted the availability of health professionals as of October 2021. As mentioned in the A-ESRS of the parent project, the primary risks identified include: (i) environmental and community health-related risks from inadequate storage, transportation, and disposal of infected medical waste. This includes generated waste from vaccine delivery, such as sharps and used and expired vaccine vials, as a result of the project activities (see A-ESRS from parent project for more information). Public Disclosure A waste management plan is included in the NDVP but not operationalized yet, priorities include the installation of new incinerators. At present only two incinerators are fully operational (in Clininca Madrugada (Bissau) and Cumura Hospital (Biombo Health Region). The incinerators in SIVE premises (Bissau), Buba (Quinara Region, south), and Bafata (Bafata Region, east) are not operational due to lack of protection and septic tank. The Global Fund recently funded one incinerator to be installed in Central das Compras de Medicamentos (CECOME) premises. Furthermore, the installation of the new 8 incinerators in the Health Regions purchased with WB REDISSE II project will be covered under the COVID-19 Vaccine parent project, during Q1-2- 2022. Additionally, there are companies that are active in the field of handling of waste, which often work with health facilities in the collection and disposal of biomedical waste. Under the parent project, the PIU drafted an ESMF to provide guidance for the screening and management of E&S risks associated with the project activities. The ESMF contains template for development of Infection Control and Medical Waste Management Plan (ICWMP) which sets out details of the procedures to be implemented to manage infection control and waste management. The ICWMP template is to be used by each health facility to prepare specific ICWMPs. Given the emergency of the distribution of the vaccines received through COVAX, its short shelf- life, including the expected increased volume of vaccine purchase under this AF, the ESMF will be revised and disclosed by effectiveness date of AF, and include measures to strengthen storage and handling waste in the short- term, to ensure that the medical waste generated by the parent project and the AF is adequately managed, building on best international practices and WHO protocols for its collection, storage, transportation and final disposal. The short-term measures to be included are proper storage facilities for hazardous waste such as expired vaccine vials Dec 21, 2021 Page 6 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) and sharps, as a result of the project activities, and establishing Memorandum of Understanding (MOU) with Clinica Madrugada, a private clinic in Bissau, which has an operational incinerator in place. On the social side, the risks of exclusion due to vaccine hesitancy and/or elite capture are mitigated through the following measures: First, the Government has developed explicit, contextually appropriate, and well communicated criteria for access to vaccines. There is consensus to first target health workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly and people with comorbidities. All targeting criteria and implementation plans are reflected in the country’s national vaccination program. Second, the Government will actively use the National COVID Risk Communication and Community Engagement strategy to address misinformation and distrust as a main barrier to vaccination. The risks of SEA/SH are mitigated by specific measures outlined in a SEAH Prevention and Response Action Plan (SEAH AP), which is part of the ESMF, taking into account the recommendations of the Technical Note on SEAH for HNP COVID Response Operations and the Interim Technical Note on Protection from Sexual Exploitation and Abuse (PSEA) during COVID-19 response. These prevention, mitigation, and response measures incorporate an accountability and response framework, including codes of conduct to be signed by all individuals engaged in the project activities (including if possible MoH relevant partners, health staff, and all suppliers linked to the execution of project activities) outlining prohibited SEAS conduct and applicable sanctions, procedural adaptations to the project grievance mechanism to ensure safe and confidential management of SEAH claims with timely referrals to appropriate survivor care, as well as training and sensitization activities for workers and community members. In addition, SEAH risk is addressed through robust stakeholder identification and consultation processes, which take into account separate consultations with women Public Disclosure and vulnerable groups in safe and enabling, sex-segregated environments (including with same-sex facilitators). ESS10 Stakeholder Engagement and Information Disclosure ESS10 Stakeholder Engagement and Information Disclosure Project activities under the AF do not require any changes in the Stakeholder Engagement Plan (SEP) which was developed under the parent project. The project will establish a structured approach to stakeholder engagement and public outreach that is based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with combating COVID-19. The SEP is underpinned by a broader National Risk Communication and Communication Engagement Plan for COVID-19, which focuses on community mobilization and behavioral change objectives and aims to combat false rumors about COVID-19 and vaccines and to ensure equitable access to services. The SEP identifies stakeholders, especially disadvantaged or vulnerable groups who have barriers to access to health services or health information campaigns, groups who may have a distrust of government health programs, and groups who may be hesitant of health interventions such as vaccinations for cultural reasons. It highlights the importance of clear and accessible messaging on vaccine safety, principles of fair, equitable, and inclusive access and allocation, as well as a rationale for prioritizing certain groups. It includes a Grievance Mechanism with specific procedures and channels for SEA/SH issues. B.2. Specific Risks and Impacts Dec 21, 2021 Page 7 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions Project activities financed will be performed by mostly healthcare, laboratory personnel, and construction workers involved in minor civil works under the parent project. As part of the ESMF of the parent project, the Borrower prepared Labor-Management Procedures (LMP). Key issues addressed in the LMP include the prohibition of child labor in hazardous work situations and the use of forced labor; rights (such as overtime compensation, annual or sick leave, or severance) for healthcare workers or other essential workers and their limitations due to COVID-19 emergency measures; grievance redress to allow workers to quickly inform management of labor issues, such as a lack of PPE and unreasonable overtime; adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); adequate OHS protections in accordance with General EHSGs and industry-specific EHSGs and follow evolving international best practice in relation to protection from COVID-19 The LMP also addresses risks in relation to SEAH in the workplace, both for project personnel and workers. Likewise, it includes details of the grievance mechanism (GM) for workers and the roles and responsibilities for monitoring such workers. For more information, refer to the ESMF of the parent project. For the AF, no additional LMP will be required. ESS3 Resource Efficiency and Pollution Prevention and Management The AF will purchase an additional 300,000 Johnson & Johnson vaccines, which will lead to an increment of medical Public Disclosure waste production. The ESMF of the parent project was developed to provide guidance for the screening and management of E&S risks associated with the project activities. The ESMF contains template for development of Infection Control and Medical Waste Management Plan (ICWMP), which sets out details of the procedures to be implemented to manage infection control and waste management. Each health facility targeted under the project will develop and implement its own ICWMP based on the template. For the AF, the existing ESMF will be revised and disclosed by effectiveness date of AF to include short-term immediate Infection Control and Medical Waste Management measures and ensure that the medical waste generated by the parent project and this AF is adequately managed, building on best international practices and WHO protocols for its collection, storage, transportation and final disposal, until each health facility has developed and implemented its own ICWMP. Measures that would need to be included are proper storage facilities for hazardous waste, such as used and expired vaccine vials and sharps, as a result of the project activities, and establishing Memorandum of Understanding with private clinic in Bissau (Clinica Madrugada) with an operational incinerator in place. According to the AF, the parent project will finance the installation of 8 incinerators in each region of the country. Before the start of these specific activities, the ESMF will be revised to include an assessment of the potential air pollution generated by the operation of the incinerators, including an estimate of gross Greenhouse Gas Emissions (GHG) resulting from the project and will consider technically and financially feasible measures to minimize project-related air emissions. ESS4 Community Health and Safety Dec 21, 2021 Page 8 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) Protecting the health and safety of communities from infection with COVID-19 is a central part of the parent project and the AF. The AF potential community health and safety risks are the same as those in the parent project and are adequately addressed in the existing ESMF for the parent project. Based on the experiences of the REDISSE and Maternal Health Projects, the existing ESMF addresses: (i) how project activities will be carried out in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (WHO guidelines); (ii) measures in place to prevent/minimize mitigate and response the risks of SEAH; (iii) emergency preparedness measures; and iv) monitoring of adverse impacts and side effects of vaccines on recipients of the vaccinations. The existing ESMF also includes best practice measures for assuring quality control of the vaccines during storage and transportation throughout the country. The client is also planning to employ Military Health Services, which will be used to augment MINSAP health personnel for vaccination campaigns. As stipulated in the Financing Agreement, the client will be providing further details on the modalities of these deployments by 30 November. At this point it is not envisaged to conduct a security assessment as the military staff are not providing security services but their involvement will be reflected in updates to the SEP and LMP. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This standard is not relevant as the project will not finance any activity that could lead to involuntary resettlement. Public Disclosure ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The additional purchase of vaccines financed by this AF will not directly lead to pressure on sensitive ecosystems and habitats. Management of generated waste will be handled under the parent project as described in the parent project’s A-ESRS. The specific locations where project sub-components will be implemented include health facilities such as national and regional hospitals and health centers in urban and rural areas. There will also be mobile units to reach out to beneficiaries living at a distance of more than 5 km (advanced) and 15 km (mobile) from the nearest health structure and who cannot reach the fixed points and frontline workers (like entry points). Infectious Medical Waste could reach critical habitats if not properly managed and disposed, and impact endangered and vulnerable species such as primates among other fauna and contamination of ecosystems. The ESMF will screen targeted health care facilities and mobile facilities in relation to its proximity to critical habitats, including endangered species. To mitigate the risk of contamination of critical habitats, the project must strictly comply with the requirements delineated in the ESCP the ESMF/ESMPs and Medical Waste Management Plan to ensure safe handling and disposal of medical and hazardous waste. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard is not relevant as there are no Indigenous Peoples/Sub-Saharan Histrorically Underserved Traditional Local Communities in Guinea-Bissau. Dec 21, 2021 Page 9 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) ESS8 Cultural Heritage No major civil works are planned in this project; therefore this standard is not relevant. ESS9 Financial Intermediaries This standard is not relevant, as no financial intermediaries will be involved. 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: Public Disclosure The borrower framework is not being considered IV. CONTACT POINTS World Bank Contact: Fatoumata Binta Maama Barry Title: Health Specialist Telephone No: +1-202-473-3908 Email: fbarry1@worldbank.org Contact: Yemdaogo Tougma Title: Economist, Health Telephone No: 473-7891 Email: ytougma@worldbank.org Borrower/Client/Recipient Borrower: Republic of Guinea Bissau Implementing Agency(ies) Implementing Agency: Office of the High Commissioner for COVID-19 V. FOR MORE INFORMATION CONTACT Dec 21, 2021 Page 10 of 11 The World Bank Additional Financing for the Guinea-Bissau COVID-19 Vaccine Project (P178198) 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): Yemdaogo Tougma, Fatoumata Binta Maama Barry Practice Manager (ENR/Social) Maria Sarraf Cleared on 21-Dec-2021 at 09:42:29 GMT-05:00 Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Concurred on 08-Dec-2021 at 16:55:13 GMT-05:00 Public Disclosure Dec 21, 2021 Page 11 of 11