The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 05/16/2021 | Report No: ESRSAFA169 Jun 09, 2021 Page 1 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Liberia AFRICA WEST Republic of Liberia Ministry of Health Project ID Project Name P176336 Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines Parent Project ID (if any) Parent Project Name P173812 Liberia COVID-19 Emergency Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 5/24/2021 6/25/2021 Population Financing Public Disclosure Proposed Development Objective The development objective is to prepare and respond to the COVID-19 pandemic in Liberia Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The Liberia COVID-19 response project aims to strengthen the Government of Liberia’s immediate capacity to respond to the COVID-19 outbreak and in the longer-term strengthen its capacity to respond to disease outbreaks and emergencies. The project will have fivecomponents: Emergency Preparedness and Response , Laboratory system Jun 09, 2021 Page 2 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) strengthening, Case management and clinical care , Risk communication, community engagement and advocacy and Project management and coordination including monitoring and evaluation. 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 primary objectives of the AF are to enable the affordable and equitable access to COVID-19 vaccines and to ensure effective vaccine deployment in Liberia through vaccination system strengthening. The Liberia COVID-19 ERP additional financing seeks to support the Government of Liberia to procure COVID-19 vaccines to vaccinate its eligible population in phases with a strategy of targeting sub-groups using a risk-based approach and subsequently rollout the exercise to all segments of the population depending on the availability of additional vaccines and the evolution of the pandemic. Specifically, the prosed AF and restructuring will include (i) support to operationalize COVID-19 rollout, including data collection, of the priority populations, in-country transportation, cold chain system strengthening, training of vaccinators, and waste management for COVID-19 vaccination; (ii) case detection, diagnostics, contact tracing, and vaccine safety monitoring, (iii) COVID-19 case containment and management in health facilities, schools and other public places, (iv) scale up of COVID-19 purchase beyond 20 percent of the total population, subsidized within the framework of COVAX and under other agreements; (v) intensify risk communication to increase vaccine literacy, intensify community engagement for vaccination and establish a reporting system of adverse events following immunization. (vi) engagement with other government agencies to regulate and evaluate COVID-19 for in- country use. Public Disclosure The proposed additional financing will help vaccinate 52 % of the country’s population. This is inclusive of the 20% coverage that will be provided by the COVAX facility vaccines initiative. Bank financing for the COVID-19 vaccines and deployment will follow Bank’s VAC. The availability and terms of vaccines remain fluid and prevent the planning of a firm sequence of vaccine deployment, especially as the actual delivery of vaccines is unlikely to be immediate. Rather, the proposed financing enables a portfolio approach that will adjust during implementation in response to developments in the country pandemic situation and the global market for vaccines. Priority Groups: The AF will support four priority groups in Liberia and will be implement in four phases. The first phase will target 45,265 Health Care Workers (i.e., clinicians who primary intent is to deliver health services). The second phase will target 226,325 Elderly people (i.e., people 60 + years as defined by their age-based risk and mortality). The third phase will target People with co-morbidities (people with pre-existing health conditions especially those associated significantly with higher risk of death), The fourth phase will target 181,060 others (essential workers who cannot social distance due to the work they performed or carried out daily e.g., teachers, bartenders, waiters, and waitresses). Access to Vaccine: There are no cost barriers anticipated to access the vaccines by the priority groups, since the government is providing the vaccine free of charge. However, there could be barriers relating to physical access, gender, and geographic and functional proximity to sites for vaccination. There could also be potential supply chain issues relating to the disruptions to or constraints on the distribution, and delivery of vaccines to some hard-to-reach locations. Many of these barriers need to be identified and are addressed by the Ministry of Health (MOH). Jun 09, 2021 Page 3 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Vaccine Deployment Plan: The national COVID-19 vaccine deployment plan notes that, in order to ensure the viability and integrity of the COVID-19 vaccine, and to address the identified CCE gap, the COVAX Facility for CCE will be used to procure: i) walking-cold room (30 square meters), ii) on grid ILR with freezer component, iii) remote temperature monitoring, iv) standard vaccine carrier, and v) standard vaccine cold boxes on or before the deployment of the vaccine in Liberia at the primary and secondary levels. Vaccine Readiness Assessment: Liberia has conducted a vaccine readiness assessment to identify gaps and options to address them, as well as to estimate the cost of vaccine deployment, with the support of international organizations (WBG, WHO, UNICEF/PAHO, GAVI, other). Considering the uncertainties related to the COVID vaccine market, including testing, approval, availability and pricing, which require flexibility and close monitoring and strong Bank support during implementation, the assessment will continue to be an evolving process and will be dynamically revised and updated as necessary to continue to improve project implementation. Under the parent project, the MOH prepared an Environmental and Social Management Framework (ESMF) and a Stakeholder Engagement Plan (SEP) to mitigate E&S risks. The ESMF and SEP was updated and disclosed on 29th March 2021 and 08th September, 2020 respectively. To effectively manage E&S risks related to the deployment and rollout of vaccines and other activities under this AF, the ESMF, SEP and Environmental and Social Commitment Plan (ESCP) have been updated and will be redisclosed prior to appraisal. ESMF is updated to provide information on cold chain management, training and deployment of vaccinators and volunteers at the community level, Infection Prevention and Control (IPC) materials at the vaccination sites and Vaccine Waste Management. The ESMF will require the preparation of ESMPs for vaccine cold chain temperature monitoring plan, occupational health and safety Public Disclosure and surveillance of adverse Events following immunization plan when required. Liberia reported its first confirmed case of COVID 19 on March 14, 2020 in Monrovia, the country’s capital and by March 15, 2021, a staggering 2045 COVID-19 cases, including 85 deaths, were reported . 49 (11%) health care workers have been infected with COVID-19, and 4 (8%) have died. Most cases are concentrated in the capital city, Montserrado county (374 cases, 84%), where more than 45% of the 4.7 million population of Liberia reside (Figure1) . The risk of infection among health care workers and the community remains high, largely due to the frequent and high volume of travel across counties with active transmission. The overall trends in COVID -19 may be going down but the threat of new waves remains and hence the importance of ensuring increased protection measure through vaccination of the population as close to herd immunity as possible. Along with the COVID-19 related morbidity and deaths, Liberia has also experienced significant secondary impacts of the outbreak which include (i) shortages of essential medical supplies and commodities due to disruptions in the global supply chain; (ii) hospitals and health facilities providing routine health services have closed following exposure to cases of COVID-19; (iii) health facilities providing routine health services have turned patients away for fear of the virus and (iv) recovered patients have been stigmatized and shunned by their communities when returning home. The social distancing measures and lockdown implemented by the Government to reduce the spread of the virus have had a negative social and economic impact, directly impacting the livelihoods of households, especially among the poor. The Ebola Virus Disease (EVD) outbreak of 2014 devasted a health system which was already weakened by conflict, and recovery has been slow. Following the end of the second civil war in 2003, Liberia’s health system slowly recovered to the point where health outcomes started improving. Between 2003-2012, life expectancy increased from 54 to 61 years, child deaths declined from 149 to 88 deaths per 1,000 live births, and Liberia became one of the Jun 09, 2021 Page 4 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) first countries in Sub-Saharan Africa to achieve the child-related Millennium Development Goal11. However, the EVD crisis devastated the healthcare system and severely constrained the GOL’s ability to deliver essential health services, which led to many preventable deaths. D. 2. Borrower’s Institutional Capacity The parent COVID-19 Emergency Preparedness and Response Project, including this proposed AF is being implemented through the Project Implementation Unit (PIU) of the Health, Nutrition & Population (P173812) under the Ministry of Health (MoH). The MoH is the primary implementing agency for the ERP and intends to appoint both a Social & Community specialist and an Environment specialist to lead E&S implementation. MoH will designate E&S focal persons at the regional, district and community levels to monitor and supervise safeguards activities. MoH will also coordinate with the relevant stakeholders with respect to environmental and social management of the ERP and the treatment and disposal of solid and liquid waste. Extensive stakeholder engagement and consultation will be undertaken to provide insight regarding the scope of coordination. Further, the country has limited experience in handling social concerns around COVID-19 as well as related measures, including quarantine and vaccinations. The Project will provide funding to address some of these shortcomings and it will be important that the Project source international expertise to achieve international best practices on these matters in line with WHO guidelines. To this end, the government has updated ESMF prepared for the Liberia COVID- 19 Emergency Response Project (P173812) incorporating the WHO standards on COVID-19 response particularly on vaccinations. It will also outline the processes, which will be followed to ensure compliance with the ESF. Facilities to be supported by the Project will apply international best practices in COVID-19 diagnostic testing and other COVID-19 Public Disclosure response activities. This will also include further identification of capacity gaps and detailed measures to address any gaps identified. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The Environmental Risk Rating is Substantial. The risk ratings take into consideration the E&S risk and impacts associated with the proposed activities under the AF EPRP and the institutional capability of MoH and other implementing agencies to manage them. The activities under AF EPRP include the (i) support to operationalize COVID-19 rollout, including data collection, of the priority populations, in-country transportation, cold chain system strengthening, training of vaccinators, and waste management for COVID-19 vaccination; (ii) case detection, diagnostics, contact tracing, and vaccine safety monitoring, (iii) COVID-19 case containment and management in health facilities, schools and other public places, (iv) scale up of COVID-19 purchase beyond 20 percent of the total population, subsidized within the framework of COVAX and under other agreements; (v) intensify risk communication to increase vaccine literacy, intensify community engagement for vaccination and establish a reporting system of adverse events following immunization; (vi) engagement with relevant agencies of government and other institutions to regulate and evaluate COVID-19 for in-country use. The potential risks and impacts include medical waste generation, infections and pollutions from medical waste, hazardous and liquid waste generation from treatment and vaccination centres, air pollution from incineration, road safety hazards, public health and safety issues, occupational health and safety hazards and discrimination of disadvantaged or vulnerable groups and Jun 09, 2021 Page 5 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) adverse events following vaccinations. These expected risks and impacts are, however, are less adverse, mostly predictable, temporary, reversible, cumulative, transboundary but readily mitigated. Social Risk Rating Substantial The social risk rating for the AF remains substantial, same as the Parent Project and the First AF. The national scale of the planned COVID-19 vaccine rollout under the AF can introduce some social dimensions with potential significant social risks. Negative social risks and impacts will be related to a broad risk of inequality in access to vaccines resulting from exclusion of vulnerable and marginalized groups from vaccination due to gender inequalities, socio-cultural and religious beliefs, disability and geographical location (e.g. people in hard to reach communities and slum communities); and political pressure to provide vaccines to groups not prioritized leading to elite capture. People living in remote or isolated communities, persons with disabilities, the elderly, homeless, slums communities, and women could potentially miss out on vaccination due to elite capture, distance and poor road network to health facilities, and barriers in communication. If not well managed, vaccine targeting may lead to social conflict among interested groups and exclusion of marginalized groups (women, elderly, poor). This risk will be mitigated through transparent and equitable vaccine access plan. GoL’s vaccination approach prioritizes equity and universal health coverage (UHC) principles with the vision to leaving no one behind. The government’s plan is that every person in Libera will receive a free vaccine regardless of residency status. Liberia’s National Deployment and Vaccination Plan (NDVP) for COVID-19 Vaccine does not discriminate against foreign nationals. Communication risk due to disinformation, misperception, rumors, inequitable information dissemination may give rise to COVID-19 vaccine hesitancy, reduce access to vaccine services (especially among vulnerable groups), refusals within communities and reprisals and retaliation especially against healthcare workers. There is also a risk that people may not receive information about access and services unless communication is adequately managed. There is also risk of Public Disclosure commercialization and forced vaccination. This risk wll be mitigated by messaging and communication activities to be supported by Component 4: Surveillance, Community Engagement. Other social risks relate to potential for creating or exacerbating poor conditions with impact on community health and safety due to improper disposal of medical waste (e.g. on open waste dumps and discharge of contaminated water that may contaminate land and surface water or injury to waste pickers). Other potential social risks include increased incidence of reprisals and retaliation, especially against healthcare workers and researchers related to both suspicion of the motives and legitimacy of the vaccinators. There are likely gaps in access to information sources and absorption level of correct information about COVID-19 among women as compared with men as illiteracy rate are higher among women. Some women need to gain authorization from their husbands to get vaccinated. Moreover, pandemics can create or exacerbate the conditions that especially put women and girls at greater risk of SEA/SH. For instance, women and girls may be forced into exchanging sexual favors for access to testing, treatment, vaccines or even supplies. This risk wll be mitigated by messaging and communication activities to be supported by Component 4: Surveillance, Community Engagement. 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: Jun 09, 2021 Page 6 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) The project will consolidate and improve upon the positive impacts made under the parent and AF at improving the capacity for containment of COVID-19 through the provision of the critical supporting medical facilities for rolling out vaccination countrywide. The activities expected to be undertaken to support effective vaccination have the potential to cause substantial risk and impacts. These risks and impacts include infections and pollutions from medical waste, hazardous and liquid waste generation from treatment centres, air pollution from incineration, road safety hazards from transport of vaccines, public health and safety issues, and occupational health and safety hazards. One obvious type of social risk related to this kind of operation is that marginalized and vulnerable social groups including undocumented migrants, groups with health states such as pregnancy/lactation women, groups with comorbidities and disabled population unable to access facilities and services designed to combat the disease, in a way that supports the central objectives of the project. To mitigate this risk, MoH, in the ESCP will commit to the provision of services and supplies based on urgency and need, in line with the current data related to the prevalence of the cases and according to the guidelines of the ESMF. The COVID-19 Vaccine Deployment and Vaccination Plan prepared by the MoH as part of this project will provide arrangement for inclusion and outreach to all vulnerable and disadvantage groups and foreign national. The plan will be consistent with the core principles of the WHO Strategic Advisory Group of Experts (SAGE) values framework for the allocation and prioritization of COVID-19 vaccination and the prioritization roadmap. Also the risk of adverse impacts following vaccinations will be monitored. To tackle this, the AF includes a vaccine safety monitoring component that require the MoH to establish an active surveillance system for adverse events following immunization (AEFI) and adverse events of special interest (AESI) to monitor the safety of vaccines and safeguard the health of the people and communities. The MoH is also making arrangement to use only Auto Destruct Public Disclosure (AD) syringes, which will be provided with safety boxes during vaccinations. Additionally, each vaccination point would be required to carry an emergency kit that includes adrenalin and hydrocortisone. The project implementation will also ensure appropriate stakeholder engagement, proper awareness raising and timely information dissemination to (i) avoid conflicts resulting from false rumors; (ii) ensure equitable access to services for all who need it; and (iii) address issues resulting from people being kept in quarantine. The project will rely on standards set out by WHO as well as international good practice to (i) facilitate noted appropriate stakeholder engagement and outreach towards a differentiated audience (concerned citizens, suspected cases and patients, relatives, health care workers, etc.); and (ii) promote the proper handling of quarantining interventions (including dignified treatment of patients; attention to specific, culturally determined concerns of vulnerable groups; and prevention of Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) as well as minimum accommodation and servicing requirements). The SEP activities will be financed by Component 4: Surveillance, Community Engagement resources/allocation. The project will adopt the ESMF prepared for the parent project (P173812) which provides guidance for the Updating of various safeguards instruments for addressing the environmental and social risks and impacts of the Covid19. This will include a Health Care Waste Management Plan (HCWMP) to guide subsequent development of suitable safeguard instruments. The HCWMP will describe all the practices for handling, storing, treating, and disposing of hazardous and non-hazardous waste, as well as types of worker training required. The plan will also include training of staff to be aware of all hazards they might encounter. This will provide for the application of international best practices in COVID-19 diagnostic testing and handling the medical supplies, disposing of the generated waste, and road safety. The project will also make use of the updated Stakeholder Engagement Plan (SEP) including Grievance Redress Mechanism prepared under the parent project to undertake adequate consultations with stakeholders and Jun 09, 2021 Page 7 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) address project related complaints. The ESMF will include an exclusion list for project activities that may not be undertaken unless the appropriate OHS capacity and infrastructure is available, and the WHO standards on COVID-19 response, which outlines the International best practice for the WHO “Operational Planning Guidelines to Support Country Preparedness and Response”. In addition to the ESMF, it will also implement the SEP and LMP as per the proposed timeline. ESS10 Stakeholder Engagement and Information Disclosure The covid19 vaccine roll outs presents many risks, which include ensuring: (i) public willingness and acceptance to participate in the vaccination campaign; (ii) those in greatest need of health services and vaccinations receive it first and timely; (iii) health services and vaccinations are performed effectively; and (iv) the results of vaccine support services, including beneficiary feedback, are thoroughly captured and used to inform the project. ESS10 is relevant to address these challenges by building public trust through public awareness creation, identifying and reaching those in greatest need (especially those who are often left out of the public health system), timely identification of rollout weaknesses and taking immediate corrective measures to improve the quality of services, and learning from experiences and beneficiary feedback to strengthen the response. In sum ESS10 is relevant to increase vaccine literacy and mitigate misconceptions and rumors around COVID-19 vaccines while continually improving the quality of services. Public Disclosure The project has included a component on “Risk communication and Community Engagement” (RCCE). This component focuses on behavioral and sociocultural risk factors assessment, production of RCCE strategy and training documents, production of communication materials, media and community engagement, and documentation. The project will update the existing SEP to include stakeholder engagement requirements under AF activities as well as relevant WHO guidance on “Pillar 2: Risk communication and community engagement”. The SEP further identifies various stakeholders and establish a structured ways of information disclosure and getting feedback with special reference to vulnerable and disadvantaged parties. The SEP would be used to minimize to close contact in instances where there is a likelihood of more vulnerable groups in attendance, such as women, elderly and those with compromised immune systems or related pre-existing conditions. People affected by project activities should be provided with accessible and inclusive means to raise concerns and grievances through clearly articulated and operationalize grievance redress mechanism. The project will also ensure the establishment of a Grievance Redress Mechanism, including strengthening of the existing and available functional GRM and the establishment of a dedicated hotline. The approaches taken will ensure meaningful consultation and information disclosure as well as timely and accessible information and feedback to all affected stakeholders, including usage of different languages, addressing cultural sensitivities and challenges deriving from illiteracy or disabilities. Due to the expected countrywide implementation of activities, the differences in areas and socioeconomic groups will equally be taken into consideration during the rollout of the RCCE. It will be important that care management in quarantine and isolation centers is managed systematically, allowing patients to access information as well as patients’ relatives to get necessary information about the quarantined; if feasible by enabling two-way-communication. Jun 09, 2021 Page 8 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) The SEP activities will be financed by Component 4: Surveillance, Community Engagement resources/allocation as well as by Risk communication and Community Engagement component under the parent project. Lesson learned from the parent project will be used and the imperative that the 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 will be critical. 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 Health and laboratory workers, i.e. civil servants employed by the Government of Liberia, will conduct most activities supported by the project. Activities encompass thereby treatment of patients as well as assessment of samples. The key risk is contamination with COVID-19 (or other contagious illnesses as patients taken seriously ill with COVID-19 are likely to suffer from illnesses, which compromise the immune system, which can lead to illness and death of workers). Workers under the project could be exposed to OHS risks due to the dangerous nature of the pathogen (COVID-19) and reagents and equipment used in the project-supported activities. Health facilities treating patients administering vaccines may also generate biological, chemical waste, and other hazardous by-products that could be injurious to human health. Transportation of COVID-19 vaccines from one location to the other and operation of light and refrigerated vehicles, use of medical drone technology to supplement rapid delivery of COVID-19 vaccines to hard-to-reach communities also present the risks of accidents to drivers, drone operators; albeit marginal and Public Disclosure insignificant risk. These risks will be mitigated through adherence to occupational health and safety standards and specific infectious- control strategies, guidelines and requirements as recommended by WHO and CDC and other recommended OHS measures based on the World Bank EHS guidelines provided in the updated parent project ESMF. In line with WHO Interim Guidance (February 12, 2020) on “Laboratory Biosafety Guidance related to the novel coronavirus (2019- nCoV)”, and other guidelines, the parent project developed a Hospitals’ Waste Management Plan as part of the parent project ESMF. The plan includes training of staff to be aware of all hazards they might encounter in the COVID- 19 response and provides for the application of international best practices in COVID-19 diagnostic testing and handling of medical supplies, disposing of the generated waste, and road safety. Other measures include posting of signages in all public spaces mandating hand hygiene and use of PPEs (particularly face mask, gowns, gloves, hand washing soap and sanitizers). The project will ensure the application of OHS measures as outlined in the ESMF (including HCWMP) as well as WHO guidelines already noted. 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; and post signage in all public spaces mandating hand hygiene and PPEs. The project may outsource minor works to contractors. The envisaged works will thereby be of minor scale and thus pose limited risks. The workers will not work in contaminated areas. Also, no large-scale labor influx is expected due to the same circumstance. There could be some SEA and GBV risks associated with labor. Jun 09, 2021 Page 9 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) In line with ESS2 as well as the applicable laws of Liberia, use of forced or child labor is prohibited both for construction and operation of health care facilities. The project will also ensure a basic, responsive grievance mechanism to allow workers to quickly inform management of labor issues, such as a lack of PPEs or any other grievances they may to MoH. To manage labor related risks, project will prepare Labor Management Procedures based on WB ESF. ESS3 Resource Efficiency and Pollution Prevention and Management Medical wastes and chemical wastes (including water, reagents, infected materials, etc.) from the, quarantine, and screening posts to be supported (drugs, supplies and medical equipment) can have significant impact on the environment and human health. Wastes that may be generated from medical facilities/ laboratories could include liquid contaminated waste, chemicals and other hazardous materials, and other waste from laboratories and quarantine and isolation centres including of sharps, used in diagnosis and treatment. Each beneficiary medical facility/lab, following the requirements of the ESMF and the HCWMP to be updated for the Project, WHO COVID-19 guidance documents, and other best international practices, will prepare and follow the updated Health Care Waste Management Plan (HCWMP) to prevent or minimize such adverse impacts. The updated ESMF will include guidance related to transportation and management of samples and medical goods or expired chemical products. Resources (water, air, etc.) used in quarantine facilities and labs will follow standards and measures in line with US-Center for Disease Control (CDC) and WHO environmental infection control guidelines for medical facilities. The movement and distribution of COVID-19 related supplies especially vaccines will require enormous amount of Public Disclosure fuel for which the project will adopt best practice measures to optimize the use of fuel. ESS4 Community Health and Safety Relevant. Community health and safety risks identified for the COVID-19 Vaccine deployment include: (i) environmental and community health related risks related to the inadequate storage, transportation and disposal of infectious medical waste; (ii) community health and safety risks given close social contact and limited sanitary and hygiene services (clean water, soap, disinfectants); (iii) possible risks around social exclusion related to access to healthcare facilities and services, especially for the poorest, those living far from health facilities, the elderly or those living with disability who may not have access to the vaccination centers; (iv) risks of corruption that could lead to diversion of vaccine from the most marginalized and SEA/SH risks for women and girls; (v) sociopolitical risks related to residency requirements and demands of citizenship for vaccination; (vi) potential adverse side effects from the vaccine; (vii) requirement of vaccination record/certification for any health, occupational, education and travel purposes; and (vi) Disinformation and conspiracy theories about vaccine efficacy coupled with low trust in the government which could lead to the rejection of public health intervention/information and violence against those providing services. Protecting the safety of communities from increased risk of COVID-19 transmission and adverse events following vaccination is a central part of the nation-wide vaccination exercise. The deployment of safe and efficacious vaccines against COVID-19 in Liberia is expected to protect livelihood, restore economic activities and put the country on course to recovery. Jun 09, 2021 Page 10 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) These identified risks will be managed in several ways through the ESMF, a robust risk communication strategy, SEP, (SRA and SEA/SH action plan) where applicable. ESMF will be expanded following WHO and CDC guidelines for assuring quality control of the vaccines during storage, transportation, handling, and disposal throughout the country. The vaccine Deployment Plan of Action includes a safety monitoring system for new vaccines that would employ enhanced spontaneous reporting, active surveillance of adverse events of special interest and post authorization studies by marketing authorization holders. The MOH will closely monitor the potential side effects of vaccines. Capacity building sessions for health workers on AEFI (Adverse Events Following Immunizations) will be conducted. Emergency drugs for AEFI management will be available at each post. Supervisors at all levels will monitor investigation and management of AEFIs during the campaign. Laboratories, health and vaccination centers and screening posts, will have to follow respective procedures with a focus on appropriate waste management of contaminated materials as well as protocols on the transport of samples and workers cleaning before leaving the workplace back into their communities. The MOH will address concerns of health care professionals and maintain community confidence by creating and sharing a COVID-19 vaccine safety communication plan with communities and relevant stakeholders. The various stakeholders and the appropriate communication channel and format will be outlined in the Stakeholder Engagement Plan (SEP) and in the Risk Communication Strategy. Residency requirements – including official documentation in the form of an identification or residency card prior to receiving the vaccine might not only affect undocumented migrants and refugees but also nationals in rural areas who may not be able to produce the required documentation. Such requirement will be in non-compliance with the Public Disclosure ESF’s provisions on social inclusion under ESS1 and under this Standard - Community Health and Safety, and might affect the productive purposes and objectives of the project to prevent and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness. Whereas the Vaccine Deployment Plan does not clearly outline need for residency requirements for vaccination, the project will ensure that neither such requirements nor forced vaccination are included in the Bank financed vaccination project. Training will be provided for all community workers involved in the vaccination campaign as well as stakeholders involved in the safety monitoring of COVID-19 vaccines to ensure the safety of the vaccine recipients and also obtain accurate data for decision. Supportive supervision to ensure that activities are being carried out as expected and data generated will be performed. The project is not likely to employ security forces to ensure law and order around the Vaccination Centers or to force vaccination; but if the situation changes, the project will undertake a Security Risk Assessment (SRA) to review the security force’s rules of engagement with the community and identify the specific risks related to providing increased security at the various health and vaccination centers. The project would then propose adequate mitigation measures, and strengthen existing measures, where necessary, to ensure that the use of the security forces will not result in adverse consequences to community health and safety, including in matters relating to GBV and SEA/SH. The project will ensure that the security personnel follow a strict code of conduct and avoid any escalation of situation, taking into consideration the protocols included in the ESMF and SEP, and the guidance provided in the World Bank technical note, “USE OF MILITARY FORCES TO ASSIST IN COVID-19 OPERATIONS SUGGESTIONS ON HOW TO MITIGATE RISKS. Jun 09, 2021 Page 11 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) The project will continue to promote the avoidance of SEA/SH by relying on the WHO Code of Ethics and Professional Conduct for all workers in the quarantine facilities. The risks and mitigation measures are addressed in the ESMF, drawing on input from project stakeholders, as documented in the SEP. The ESMF will also incorporate an accountability and response framework, including a worker code of conduct, worker and community training and sensitization, and adaptation of the project GRM to ensure the ethical and confidential management and resolution, including timely service referrals, of SEA/SH claims. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Based on the scope of the AF project activities, this standard is considered not relevant. Under the AF, the renovations and civil works such as covid19 vaccination centers, vaccine storage facilities, and vaccine materials disposal sites, minor rehabilitation of existing facilities will take place in order to install equipment to store the COVID-19 vaccine and for the proper disposal and management of vaccine waste materials, vaccination points and mobile teams to reach remote locations will be established are expected to be undertaken within existing government health facilities. Thus, the AF is not expected to lead to any additional land acquisition as it is not expected to invest in activities that will cause land acquisition and involuntary resettlement or restrictions on land use and access to natural resources. In the unlikely event of land acquisition and involuntary resettlement leading to displacement of people and their livelihood in connection with any project activities that have not yet been identified. This standard will become relevant and used to inform the preparation and implementation of Resettlement Action Plan(s) (RAPs to address compensation and livelihood needs of Project-Affected Persons (PAPs), if any decisions may be made to convert land uses or acquire land for construction of separate quarantine and Public Disclosure isolation centers, vaccine storage rooms, and sites for the disposal of vaccine waste materials. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This Project is not anticipated to affect or involve activities with negative impact on biodiversity or natural resources. However, minor construction or rehabilitation activities may be anticipated in this project and all works will be conducted within existing facilities. Hence, likely impacts of the project on natural resources and biodiversity are low and so this standard is not considered relevant. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard is not considered relevant. The preliminary assessment suggests that there are no distinct social and cultural groups in the project area who exhibit characteristics akin to the criteria for indigenous or traditionally under-served communities as spelled out in the ESS7. ESS8 Cultural Heritage This standard is currently considered Not Relevant as the project is not expected to support major construction or rehabilitation activities that would involve the movement of earth (thereby potentially having an impact on tangible cultural heritage), or other activities that could have an impact on intangible cultural heritage. In the unlikely event of major construction or the movement of earth in connection with any project activities that have not yet been identified, a chance finds procedure will be prepared and integrated into the ESMF for the project. Jun 09, 2021 Page 12 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) ESS9 Financial Intermediaries This stand is not relevant for the suggested project interventions, as no financial intermediaries will be used. 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 parent COVID-19 Emergency Preparedness and Response Project, including this proposed AF is being implemented through the Project Implementation Unit (PIU) of the Health, Nutrition & Population (P173812) under Public Disclosure the Ministry of Health (MoH). The MoH is the primary implementing agency for the ERP and intends to appoint both a Social & Community specialist and an Environment specialist to lead E&S implementation. MoH will designate E&S focal persons at the regional, district and community levels to monitor and supervise safeguards activities. MoH will also coordinate with the relevant stakeholders with respect to environmental and social management of the ERP and the treatment and disposal of solid and liquid waste. Extensive stakeholder engagement and consultation will be undertaken to provide insight regarding the scope of coordination. Further, the country has limited experience in handling social concerns around COVID-19 as well as related measures, including quarantine and vaccinations. The Project will provide funding to address some of these shortcomings and it will be important that the Project source international expertise to achieve international best practices on these matters in line with WHO guidelines. To this end, the government has updated ESMF prepared for the Liberia COVID- 19 Emergency Response Project (P173812) incorporating the WHO standards on COVID-19 response particularly on vaccinations. It will also outline the processes, which will be followed to ensure compliance with the ESF. Facilities to be supported by the Project will apply international best practices in COVID-19 diagnostic testing and other COVID-19 response activities. This will also include further identification of capacity gaps and detailed measures to address any gaps identified IV. CONTACT POINTS World Bank Jun 09, 2021 Page 13 of 14 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Contact: Noel Chisaka Title: Senior Health Specialist Telephone No: +1-202-473-1317 Email: nchisaka@worldbank.org Contact: Anthony Theophilus Seddoh Title: Senior Health Specialist Telephone No: 5269+4612 / 233-30-221-4612 Email: aseddoh@worldbank.org Contact: Opope Oyaka Tshivuila Matala Title: Senior Health Specialist Telephone No: 5331+3483 Email: otshivuilamatala@worldbank.org Borrower/Client/Recipient Borrower: Republic of Liberia Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Public Disclosure Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Noel Chisaka, Anthony Theophilus Seddoh, Opope Oyaka Tshivuila Matala Practice Manager (ENR/Social) Senait Nigiru Assefa Cleared on 16-May-2021 at 05:50:33 GMT-04:00 Jun 09, 2021 Page 14 of 14