FOR OFFICIAL USE ONLY Report No: PAD4732 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT PROJECT APPRAISAL DOCUMENT ON A PROPOSED LOAN IN THE AMOUNT OF US$6.2 MILLION TO BELIZE FOR BELIZE COVID-19 RESPONSE PROJECT UNDER THE COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROGRAM (SPRP) USING THE MULTIPHASE PROGRAMMATIC APPROACH (MPA) WITH A FINANCING ENVELOPE OF UP TO US$6 BILLION APPROVED BY THE BOARD ON APRIL 2, 2020 AND UP TO US$12 BILLION ADDITIONAL FINANCNG APPROVED BY THE BOARD ON OCTOBER 13, 2020 Health, Nutrition & Population Global Practice Latin America and Caribbean Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Exchange Rate Effective January 31, 2021 Currency Unit = BZ dollar BZ$1= US$0.5 FISCAL YEAR April 1 – March 31 Regional Vice President: Carlos Felipe Jaramillo Country Director: Lilia Burunciuc Regional Director: Luis Benveniste Practice Manager: Michele Gragnolati Task Team Leader: Laura Di Giorgio ABBREVIATIONS AND ACRONYMS AEFI Adverse Event Following Immunization AVAT African Vaccine Acquisition Trust BHIS Belize Health Information System CE Citizen Engagement COVAX Facility COVID-19 Vaccines Global Access Facility COVID-19 Coronavirus Disease 2019 CPF Country Partnership Framework DA Designated Account DFIL Disbursement and Financial Information Letter DP Development Partner EUL Emergency Use Listing EPI Expanded Program for Immunization ESCP Environmental and Social Commitment Plan ESMF Environmental and Social Management Framework FM Financial Management FTCF Fast Track COVID-19 Facility GAVI Global Alliance for Vaccines and Immunizations GBV Gender-based Violence GDP Gross Domestic Product GHSI Global Health Security Index GoB Government of Belize GRID Green, Resilient, and Inclusive Development GRM Grievance Redress Mechanism GRS Grievance Redress Service HCWMP Health Care Waste Management Plan IBRD International Bank for Reconstruction and Development IDA International Development Association IDB Inter-American Development Bank IFRs Interim Financial Reports IPC Infection Prevention Control IPF Investment Project Financing Instrument IRI Intermediate Results Indicator MCH Maternal and Child Health M&E Monitoring and Evaluation MOHW Ministry of Health and Welfare MPA Multiphase Programmatic Approach i NCD Non-communicable disease NHIS National Health Insurance Scheme NTWG National Technical Working Group NVSF National Vaccine Storage Facility PAD Project Appraisal Document PAHO Pan-American Health Organization PDO Project Development Objective POM Project Operational Manual PPE Personal Protective Equipment PPPMU Policy, Planning and Project Management Unit PPSD Project Procurement Strategy for Development SEP Stakeholder Engagement Plan SOE Statement of Expenditure SPRP Strategic Preparedness and Response Program, also known as Global COVID- 19 MPA SRA Stringent Regulatory Authorities STEP Systematic Tracking of Exchanges in Procurement UNICEF United Nations Children’s Fund VAC Vaccine Approval Criteria (of the World Bank) VIP Vaccine Introduction Plan VRAF Vaccine Readiness Assessment Framework VIRAT Vaccine Introduction Readiness Assessment Tool WHO World Health Organization ii TABLE OF CONTENTS DATASHEET .......................................................................................................................... iv I. PROGRAM CONTEXT ....................................................................................................... 1 A. MPA Program Context .................................................................................................................. 1 B. Updated MPA Program Framework.............................................................................................. 2 C. Learning Agenda ........................................................................................................................... 2 II. CONTEXT AND RELEVANCE ............................................................................................. 3 A. Country Context ............................................................................................................................ 3 B. Sectoral and Institutional Context ................................................................................................ 4 C. Belize’s Response to COVID-19 and Bank’s Support ..................................................................... 6 D. National Capacity and COVID-19 Vaccination Plan ..................................................................... 10 E. Relevance to Higher Level Objectives ......................................................................................... 18 III. PROJECT DESCRIPTION.................................................................................................. 19 A. Development Objectives ............................................................................................................. 19 B. Project Components ................................................................................................................... 19 C. Project Beneficiaries ................................................................................................................... 20 D. Project Cost and Financing.......................................................................................................... 22 IV. IMPLEMENTATION ARRANGEMENTS ............................................................................ 23 A. Institutional and Implementation Arrangements ....................................................................... 23 B. Results M&E Arrangements ........................................................................................................ 24 C. Sustainability ............................................................................................................................... 25 V. PROJECT APPRAISAL SUMMARY ................................................................................... 25 A. Technical, Economic and Financial Analysis................................................................................ 25 B. Fiduciary ...................................................................................................................................... 26 C. Legal Operational Policies ........................................................................................................... 31 D. Environmental and Social Standards .......................................................................................... 31 VI. GRIEVANCE REDRESS SERVICES ..................................................................................... 32 VII. KEY RISKS ..................................................................................................................... 32 VIII. RESULTS FRAMEWORK AND MONITORING ................................................................... 35 ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS .................... 39 ANNEX 2: PROJECT COST ........................................................................................................... 44 ANNEX 3: IMPLEMENTATION SUPPORT PLAN ............................................................................ 45 . iii DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Belize Belize COVID-19 Response Project Project ID Financing Instrument Environmental and Social Risk Classification Investment Project P177987 Substantial Financing Financing & Implementation Modalities [✓] Multiphase Programmatic Approach (MPA) [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [✓] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made Disaster [ ] Alternate Procurement Arrangements (APA) [ ] Hands-on Enhanced Implementation Support (HEIS) Expected Project Approval Expected Project Closing Expected Program Closing Date Date Date 24-Feb-2022 30-Apr-2024 31-Mar-2025 Bank/IFC Collaboration No MPA Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness MPA Financing Data (US$, Millions) Financing MPA Program Financing Envelope 18,000.00 iv The World Bank Belize COVID-19 Emergency Response Project (P177987) Proposed Project Development Objective(s) To support the Government of Belize in the acquisition and deployment of Project COVID-19 vaccines. Components Component Name Cost (US$, millions) Component 1: COVID-19 Response 5.80 Component 2. Project Management and Monitoring 0.40 Organizations Borrower: Belize Implementing Agency: Ministry of Health and Wellness MPA FINANCING DETAILS (US$, Millions) MPA FINA NCI NG DET AILS (US$, Millions) Approve d Board Approved MPA Financing Envelope: 18,000.00 MPA Program Financing Envelope: 18,000.00 of which Bank Financing (IBRD): 9,900.00 of which Bank Financing (IDA): 8,100.00 of which other financing sources: 0.00 PROJECT FINANCING DATA (US$, Millions) FIN_SUMM_NEW SUMMARY -NewFin1 Total Project Cost 6.20 Total Financing 6.20 of which IBRD/IDA 6.20 Financing Gap 0.00 v The World Bank Belize COVID-19 Emergency Response Project (P177987) DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 6.20 Expected Disbursements (in US$, Millions) WB Fiscal 2022 2023 2024 2025 Year Annual 1.50 2.90 1.20 0.60 Cumulative 1.50 4.40 5.60 6.20 INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance ⚫ Moderate 2. Macroeconomic ⚫ Substantial 3. Sector Strategies and Policies ⚫ Low 4. Technical Design of Project or Program ⚫ Low 5. Institutional Capacity for Implementation and Sustainability ⚫ Moderate 6. Fiduciary ⚫ Substantial 7. Environment and Social ⚫ Substantial 8. Stakeholders ⚫ Low vi The World Bank Belize COVID-19 Emergency Response Project (P177987) 9. Other ⚫ Substantial 10. Overall ⚫ Substantial Overall MPA Program Risk ⚫ High COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No Does the project require any waivers of Bank policies? [✓] Yes [ ] No Have these been approved by Bank management? [✓] Yes [ ] No Is approval for any policy waiver sought from the Board? [ ] Yes [✓] No vii The World Bank Belize COVID-19 Emergency Response Project (P177987) Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance Assessment and Management of Environmental and Social Risks and Impacts Relevant Stakeholder Engagement and Information Disclosure Relevant Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and Management Relevant Community Health and Safety Relevant Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant Biodiversity Conservation and Sustainable Management of Living Natural Resources Not Currently Relevant Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Relevant Communities Cultural Heritage Relevant Financial Intermediaries Not Currently Relevant NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). Legal Covenants Sections and Description [Schedule 2.Section I.A.2] No later than 60 days after the Effective Date, the Borrower shall recruit the following additional staff for the PMU: a project officer, a monitoring and evaluation officer, a senior accounts officer and an environmental and social officer, under terms of reference and with qualifications and experience satisfactory to the Bank. Sections and Description [Schedule 2. Section I.B.1] No later than sixty (60) days after the Effective Date, the Borrower, through the MOHW, shall prepare and adopt, an operational and Project COVID-19 Vaccine delivery and distribution manual (Operational and Vaccine Delivery and Distribution Manual, OVDDM) in form and substance satisfactory to the Bank. viii The World Bank Belize COVID-19 Emergency Response Project (P177987) Conditions Type Financing source Description Disbursement IBRD/IDA [Schedule 2. Section III.B.1(a)] No withdrawal shall be made for payments made prior to the Signature Date, except that withdrawals up to an aggregate amount not to exceed $4,340,000 may be made for payments made prior to this date but in no case more than one year prior to the Signature Date, for Eligible Expenditures. Type Financing source Description Disbursement IBRD/IDA [Schedule 2. Section III.B.1(b)] No withdrawal shall be made: under Category (1) until the Environmental and Social Due Diligence Review has been carried out and found in form and substance satisfactory to the Bank. This project is being processed using the following waivers granted through the Global SPRP MPA Projects (COVID- 19 SPRP - P173789 and COVID-19 MPA Vaccination AF - P175450): (i) Waiver on flexibility to enable Management approval of individual projects under SPRP rated Substantial for Environmental and Social (ES) risks. Management can approve individual SPRP projects of US$100 million or less that are rated Substantial (or less) for ES risks; and (ii) Waiver on flexibility in application of Anti-Corruption Guidelines to Bank-financed procurement where retroactive financing is used. Consistent with the Bank’s procurement policy, all contractors, suppliers and consultants receiving financing under SPRP projects will have to comply with the Bank’s Anti-Corruption Guidelines (ACGs). ix The World Bank Belize COVID-19 Response Project (P177987) I. PROGRAM CONTEXT 1. This Project Appraisal Document (PAD) describes the health response to Belize under the Coronavirus Disease 2019 (COVID-19) Strategic Preparedness and Response Program (SPRP) using the Multiphase Programmatic Approach (MPA). The Project’s primary objectives are to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccine deployment in Belize through vaccination system strengthening. A. MPA Program Context 2. The COVID-19 pandemic has had massive global impact and continues to spread. Since December 2019, following the diagnosis of the initial cases in Wuhan, Hubei Province, China, the number of COVID-19 cases has increased rapidly. On March 11, 2020, the WHO declared a global pandemic. As of February 15, 2022, there have been 413.7 million confirmed cases of COVID-19, including 5.8 million deaths, reported to WHO.1 The pandemic has caused the largest global economic contraction since the Great Depression in 1929, driving millions of people into poverty. The economic recovery is expected to be slow. Furthermore, many countries, including Belize, are seeing new waves of cases with the spread of the Delta and Omicron variants. 3. The World Bank’s response to the pandemic was quick. On March 3, 2020, the World Bank’s Board of Executive Directors endorsed urgent actions supporting client countries’ response to the COVID -19 pandemic. Subsequently, the Board approved the establishment of a US$12 billion WBG Fast Track COVID-19 Facility (FTCF or “the Facility”) to assist IBRD and International Development Association (IDA) countries in addressing the global pandemic and its impacts. Of this amount, US$6 billion came from IBRD/IDA (“the Bank”) and US$6 billion from the International Finance Corporation For Official Use (IFC). The IFC subsequently increased its contribution to US$8 billion, bringing the FTCF total to US$14 billion. On March 17, 2020, the World Bank’s Board granted approval of specific waivers and exceptions required to enable the rapid preparation and implementation of country operations under the FTCF. On April 2, 2020, the World Bank’s Board approved the SPRP with a US$6 billion financing envelope of which up to US$4 billion for health financing (up to US$1.3 billion IDA Only and up to US$2.7 billion under IBRD). The SPRP utilizes MPA, to be supported by the FTCF. 4. The Global COVID-19 MPA provides a critical and highly effective operational programmatic framework for the World Bank’s emergency health response to COVID-19 with FTCF resources. The Program development objective of the Global MPA is “to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness.” At the time of the approval of the Global MPA, and in the absence of a safe and effective COVID-19 vaccine, immediate needs were focused on early detection, diagnosis, confirmation, and treatment of patients (including those afflicted with other chronic conditions that increase the risk of COVID-19 severity and mortality). The Global MPA provided a common operational framework to support individual countries’ specific needs in preventing the spread of the disease and limiting immediate socioeconomic losses, as well as strengthening public health and essential medical care structures and operations to build resilience and reduce the risk from emerging and re-emerging pathogens. 5. The Additional Financing (AF) to the SPRP approved by the World Bank’s Board of Executive Directors on October 13, 2020 to the existing COVID-19 SPRP utilizing the MPA (“Global COVID-19 MPA”) will significantly expand the World Bank support to client countries for COVID-19 vaccination, with the aim to support vaccination of one billion people globally. An effective and safe COVID-19 vaccine is the most promising path forward for the world to reopen safely, building on global efforts to develop treatments and to expand testing capacity. The timing of potential vaccine development was not known when the Global COVID-19 MPA was approved, but global vaccine development efforts have progressed rapidly. Production is underway of several vaccines that have been approved for use since the end of 2020. Many high-income countries have made large-scale advance purchases to reserve supply for their populations and have 1 https://covid19.who.int/ Page 1 of 46 The World Bank Belize COVID-19 Response Project (P177987) the systems in place to get people vaccinated efficiently. The approval of an envelope of US$12 billion (US$6 billion from IDA and US$6 billion from IBRD) in financing was critical to expand affordable and equitable financing for vaccine purchase and deployment. It also sent a signal to potential suppliers that World Bank financing is available for the demand of vaccines from low- and middle-income countries, providing an incentive for production capacity at levels that can also supply developing economies at affordable prices, not only high-income countries. The World Bank’s Global COVID-19 MPA AF is expected to enable vaccination for up to 750 million people, with potential surge capacity for an additional 250 million people in the poorest countries (depending on the delivered price of approved vaccines) while scaling up support to strengthen immunization delivery, with design flexibility at the country level. This COVID-19 Response Project will enable support to the GOL’s COVID-19 vaccination and response efforts and will be a key contribution to the World Bank Group overall COVID-19 response. 6. Since the initial FTCF response, the WBG has significantly expanded its support for countries as they respond to the COVID-19 pandemic and its overall impacts. In March 2020, the WBG announced that the institution has the capacity to provide up to US$160 billion in total financial support through June 2021 to help countries address the social and economic impacts of the pandemic. On June 16, 2020, the World Bank’s Board endorsed the COVID -19 Crisis Response Approach Paper, outlining priorities for supporting countries in the longer term, including: a continued focus on saving lives; protecting the poor and vulnerable; ensuring sustainable business growth and job creation; and strengthening policies, institutions, and investments for rebuilding better. As of February 15, 2022, a total of 87 MPA-funded projects are being implemented ($4.2 billion), whereas 84 operations have been approved to support vaccine procurement (AF MPA) and rollout in 70 countries, amounting to $7.6 billion. B. Updated MPA Program Framework For Official Use 7. The MPA Program framework for the proposed Project is as follows: Box 1. MPA Program Framework Only Estimated Estimated Phase’s Estimated Estimated Estimated Phase Project Sequential or IPF or Other Environment Proposed IBRD Amount IDA Amount Approval # ID Simultaneous PforR Amount al & Social DO* ($ million) ($ million) Date ($ million) Risk Rating 2 P177987 See PAD IPF 6.20 0.00 0.00 02/24/2022 Substantial Total 6.20 0.00 0.00 C. Learning Agenda 8. The proposed Project will support adaptive learning throughout implementation, as well as from international organizations, including the WHO/Pan-American Health Organization (PAHO), International Monetary Fund (IMF), United States Centers for Disease Control (CDC), United Nations Children's Fund (UNICEF), and others. It will adjust to emerging technical, social, and economic evidence, as applicable, and incorporate lessons learned from the ongoing global vaccine rollout and COVID-19-related service delivery. In particular, the Project will support a survey to understand the drivers of vaccine hesitancy in Belize which will inform the most appropriate messaging under the campaigns/communication sessions to address them. Through engagement in Bank-organized knowledge sharing events, Belize will contribute to and benefit from the experience of other countries on vaccine deployment and strategies to fight vaccine hesitancy, especially in the Caribbean region. In addition, the Project will contribute to improving knowledge and capacity in the Ministry of Health and Welfare (MOHW) on environmental and social management aspects of COVID-19 vaccination and beyond by updating the existing health care waste management plan (HCWMP) and strengthening their grievance redress mechanism (GRM). Page 2 of 46 The World Bank Belize COVID-19 Response Project (P177987) II. CONTEXT AND RELEVANCE A. Country Context 9. Belize is a small country that is highly vulnerable to external economic shocks and climate change. With an estimated 430,191 inhabitants as of 2021, Belize has the smallest population among Central American countries.2 The country is multi-ethnic, with Mestizos/Hispanics forming the most populous group (48 percent), followed by Creoles (26 percent), Mayas (10 percent), and Garifuna (7 percent).3 As a small economy primarily reliant on tourism,4 the exportation of agricultural products, and an energy sector dependent on oil imports, Belize is highly vulnerable to fluctuations in international commodity and energy prices and external economic shocks.5 Due to its dependence on agriculture and low- lying coastline where half the population resides, climate change poses a major economic and social risk to the country, as hurricanes, flooding, droughts, sea level rise, coastal erosion and coral bleaching increase in frequency and intensity.6 10. Belize faced the COVID19-pandemic with a contracting economy, growing fiscal and external deficits, and half of its population living in poverty. With a per capita Gross Domestic Product (GDP) of US$5,079, Belize was classified as an upper middle-income country as of 2019. Annual GDP growth averaged 1.8 percent over the 2009-2019 period, which, combined with a similar rate of population growth, amounted to a near stagnation of GDP per capita over the past decade.7 In the last quarter of 2019, due to a drought and slowing tourism, the country entered a recession with a GDP contraction of 2.2 percent, deepening to 6.3 percent in the first quarter of 2020. Triggered by the sluggish growth, a rise in public investments, and increasing debt service, the average yearly fiscal deficit widened to 4.3 percent of GDP in 2015- 2019, and public debt rose from 79 percent of GDP in 2014 to 98 percent in 2019. As a result of the underperforming economy, the country’s poverty rate rose from 34 percent in 2002 to 52 percent in 2019, with 9 percent of the population living in extreme poverty, a trend that sharply contrasts with poverty reductions in other parts of Latin America. For Official Use 11. The Government of Belize (GoB) acted swiftly and decisively to dampen the pandemic’s epidemiological and economic impacts.8 In an early effort to contain the spread of COVID-19, in March and April 2020, Belize closed its schools, non-essential sectors of the economy and international airport, and imposed stay-at-home orders. To aid employees in Only the sectors most affected by the restrictions on international travel and internal containment measures, in March 2020, the GoB announced a fiscal stimulus amounting to 1 percent of GDP. The relief effort included introducing a temporary unemployment program and the expansion of transfers to the most vulnerable population groups through the Boost Conditional Cash Transfer. To stabilize the financial sector, authorities, among other things, lowered statutory cash reserves and extended the period for classifying targeted non-performing loans. 12. Despite the GoB’s stabilizations efforts, GDP contracted by 14 percent in 2020. As a consequence, a sharp increase in poverty is expected. Driven by an over 70 percent drop in tourism arrivals, the direct and indirect effects of containment and mitigation on manufacturing, a severe drought, and tropical storm Eta’s impacts on agricultural production, the Belize economy shrunk by 14 percent in 2020. The resulting drop in per capita GDP from US$5,079 to 2 Besides Belize, the Central America region includes Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama. 3 Statistical Institute of Belize. 2021. Abstract of Statistics 2020. http://sib.org.bz/wp-content/uploads/2020_Abstract_of_Statistics.pdf 4 Tourism is estimated to directly and indirectly account for 37 percent of GDP in 2019 (World Travel and Tourism Council. Economic Impact – Belize Country Report, 2019). 5 Carneiro, F. 2016. Belize, Right Choices Bright Future: Systematic Country Diagnostic. The World Bank, Washington DC https://openknowledge.worldbank.org/handle/10986/24046 6 The United Nations Framework Convention on Climate Change (UNFCCC) has identified that Belize is among those countries most vulnerable to the negative effects of climate change. Between 1994 and 2013, for example, losses from hydro-meteorological disasters were estimated at US$71 million, with an annual average loss of approximately 4 percent of GDP. 7 This paragraph sources from the World Bank’s “Macro Poverty Outlook for Belize” of Fall 2021, https://www.worldbank.org/en/publication/macro-poverty-outlook/mpo_lac, and the International Monetary Fund’s “Belize: 2021 Article IV Consultation-Press Release” of June 2021, https://www.elibrary.imf.org/view/journals/002/2021/103/article-A001-en.xml 8 This and the following paragraph source from World Bank’s “Macro Poverty Outlook for Belize” of Fall 2021. Page 3 of 46 The World Bank Belize COVID-19 Response Project (P177987) US$4,250 relegated the country into the lower middle-income group for the first time in ten years. Meanwhile, a drop in tax revenue and increased public spending needs further worsened Belize’s already dire fiscal situation, as public deficit and debt rose to 10.4 percent and 123 percent of GDP in 2020, respectively. The sharp economic decline and rise in unemployment, particularly in sectors employing low-skilled workers, may be contributing to a significant increase in poverty.9 13. The Belize economy has shown signs of recovery in 2021 but continues to be impacted by the pandemic. After five consecutive quarters of contraction, Belize’s GDP increased by a robust 22 and 15 percent in the second and third quarters of 2021, respectively.10 However, key sectors of the economy continue to be affected by the pandemic: in the third quarter of 2021, for example, the number of overnight tourist arrivals remained more than 40 percent below the level of the third quarter of 2019.11 Moreover, the fiscal situation is expected to have worsened further in 2021, with a public deficit of 4.9 percent of GDP according to the government’s most recent budget proposal.12 B. Sectoral and Institutional Context Health Outcomes and Healthcare System 14. Life expectancy in Belize has increased over the past decade with the upward trend mainly driven by reductions in childhood mortality. However, a rapidly rising burden of non-communicable disease (NCD) threatens the financial viability of the healthcare system, putting a large part of the population at risk of severe COVID-19 illness and death. Life expectancy has steadily trended upwards in Belize over the past decade, from 71.5 years in 2009 to 74.6 years as of 2019.13 This increase is in part driven by rapid declines in infant mortality (11 per 1,000 births) and under five mortality (12 per 1,000 births) rates, both of which dropped by over one third since 2009 and now are the second lowest in Central For Official Use America after Costa Rica. The improvements in childhood mortality contrast with a rapidly rising burden of NCDs in a relatively young population.14 Driven by unhealthy lifestyles – high body mass index, blood sugar, blood pressure and alcohol consumption15 – and weak disease management capacity, cardiovascular disease, diabetes, cancers, and chronic respiratory diseases are now responsible for about 40 percent of deaths, half of which are premature and in individuals Only younger than 70 years.16 Diabetes is of particular concern: at 16.5 percent of the population, Belize has the highest prevalence in North America and the Caribbean and about half of females die from diabetes-related causes.17 15. The public sector in Belize primarily provides healthcare, mainly funded through general taxes. As of 2018, current health spending in Belize amounted to US$286 (PPP$506) per capita, equivalent to about 5.7 percent of GDP.18 Despite rapid growth of the private health sector over the past decade, the public sector still accounts substantially for healthcare in Belize.19 Under the auspices of the MOHW, public care provision is decentralized across four regions 9 Poverty impact data from COVID-19 is not yet available. 10 Quarterly GDP by Activity. Statistical Institute of Belize (SIB). https://sib.org.bz/statistics/gross-domestic-product/ 11 Statistical Institute of Belize. GDP release for: Third Quarter of 2021. Published on November 24th, 2021. https://sib.org.bz/wp- content/uploads/GDP_2021_03_Quarter.pdf 12 Government of Belize. Estimates of Revenue and Expenditure for Fiscal Year 2021/2022 as approved by the House of Representatives and by the Senate on April 28, 2021. https://www.mof.gov.bz/uploads/files/2w04luwr.pdf 13 World Development Indicator (WDI) database. 14 The population share age 65 and over remains at a low 4.9 percent. 15 Murray, Christopher JL, et al. "Global burden of 87 risk factors in 204 countries and territories, 1990 –2019: a systematic analysis for the Global Burden of Disease Study 2019." The Lancet 396.10258 (2020): 1223-1249. 16 Figures from PAHO/WHO Country Cooperation Strategy Belize, 2017-2021. The same report has injuries and external causes, in particular interpersonal violence, accounting for 28 percent and communicable diseases for about 20 percent of deaths. Similar estimates come from the Institute of Health Metrics and Evaluation (Vos, Theo, et al. "Global burden of 369 diseases and injuries in 204 countries and territories, 1990 –2019: a systematic analysis for the Global Burden of Disease Study 2019." The Lancet 396.10258 (2020): 1204-1222.) 17 International Diabetes Federation. 2015. IDF Diabetes Atlas 7th Edition. www.diabetesatlas.org 18 The health spending data in this paragraph is sourced from the WHO’s Global Health Expenditure Database (GHED). 19 Arcia, Gustavo. 2016. Efficiency of Public Expenditures in Education and Health in Belize, 2003-2013. IDB Technical Note 972. IDB. Page 4 of 46 The World Bank Belize COVID-19 Response Project (P177987) (Northern, Western, Central, and South). Funding for public healthcare comes almost exclusively from general taxes, and providers are mostly paid based on inputs, except outpatient services received by people enrolled in the National Health Insurance Scheme (NHIS), about a third of the total population. The NHIS is operated by the Social Security Board and contracts private and public outpatient care providers, reimbursing them through a mix of capitation and performance- based payments.20 The health financing mix has been stable over the past decade: as of 2018, 61 percent of current health spending came from general revenue, 8 percent from NHIS contributions, 8 percent from private health insurance, and 23 percent from household out-of-pocket spending. The out-of-pocket share is similar to that of Costa Rica (22 percent), which has the lowest share among Central American countries. 16. There is universal access to essential public care, but quality gaps limit effective coverage. All Belize residents – including undocumented immigrants – are entitled to essential public healthcare for only nominal fees, which are waived for the poor. The low out-of-pocket share in the current health spending, very high use, and small wealth gradients in key reproductive and childhood health services indicate that there are few access barriers to basic primary care.21 Some differences between ethnic groups, however, remain: full childhood vaccination rates are highest among the Mestizo/Spanish (88 percent) and Mayan (87 percent) communities and lagging among Creoles (75 percent) and Garifuna (71 percent). Moreover, long wait times for more specialized services, lacking medical equipment, frequent drug stockouts, a small and inequitably distributed health workforce22, poor protocol adherence, and insufficient integration across the different levels of care undermine effective coverage.23 With a score of 52 of 100 in the Institute for Health Metrics and Evaluation’s Effective Coverage Index, Belize ranked second to last in Central America and 122nd out of 204 countries globally.24,25 With the added fiscal pressure imposed by the COVID-19 pandemic, Belize is unlikely to make substantive investments to address its effective coverage gaps in the near to mid-term. 17. International health emergency preparedness assessments rank Belize poorly in its capacity to prevent, detect For Official Use and respond to infectious disease outbreaks, which are also expected to increase in frequency due to climate change. Recent global health crises have highlighted the need for a system flexible enough to respond to unexpected and climate- related challenges, minimizing disruption in the provision of health services. With an overall self-assessed capacity of 48 Only percent (2020) in the International Health Regulation Capacity Progress report, Belize’s ability to prevent, detect and respond to infectious diseases is substantively below the regional and global averages of 72 percent and 65 percent, respectively. The 2019 Global Health Security Index (GHSI) also suggests that Belize compares poorly with other countries in the region, with an index score of 31.8 out of 100, ranking 23rd among 31 Latin American and Caribbean countries and 135 out of 195 countries worldwide. The country ranks especially poorly in its rapid response capacity to epidemics (155th) and the sufficiency and robustness of its health system to treat the sick and protect health workers (163rd). 20 IanMac Arthur, Jennifer Nelson, Martha Woodye. 2014. Quality improvement of health care in Belize: focusing on results. IDB Technical Note 661. IDB. 21 According to the Belize Multiple Indicator Cluster Survey 2015-16, 93 percent of pregnant women complete 4 or more antenatal care visits and 99 percent give birth in a health facility and poor-rich gaps in the uptake of essential services like antenatal care and childhood vaccinations are of negligible magnitude. 22 As of 2018, the clinical healthcare worker (physicians, dentists and nurses) to 10,000 population ratio was 31.8 (Abstract of Statistics 2020) – about 30 percent short of the 44.5 rate that WHO considers to be the minimum level necessary to provide a Universal Health Coverage benefits package (WHO. 2016. Health workforce requirements for universal health coverage and the Sustainable Development Goals. Human Resources for Health Observer, 17. Geneva: WHO). 23 Effective coverage for a health condition is defined as the share of those in need who receive care of appropriate quality (Shengelia, B., Tandon, A., Adams, O.B., & Murray, C.J.L. (2005). Access, utilization, quality, and effective coverage: An integrated conceptual framework and measurement strategy. Social Science & Medicine 61(1), 97–109). 24 Lozano, Rafael, et al. "Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019." The Lancet 396.10258 (2020): 1250-1284. (Belize Abstract of Statistics 2002). 25 The mobility restrictions and fear of contracting COVID-19 in healthcare settings have likely further worsened coverage of essential interventions in Belize, as outpatient visits to public facilities dropped by one third from 2019 to 2020 (Belize Abstract of Statistics 2020). Page 5 of 46 The World Bank Belize COVID-19 Response Project (P177987) 18. Notwithstanding the gaps revealed in the health emergency preparedness assessment, Belize has a robust immunization program. Belize ranks favorably in the GHSI index regarding its immunization capacity (92.1/100 points) and has successfully introduced vaccines against 12 communicable diseases in the routine vaccination schedule. High child immunization rates reflect this success: according to administrative data from 2018, at least 96 percent of children had received the Bacille Calmette-Guerin (BCG), polio, Diphtheria and Tetanus Toxoids/Acellular Pertussis Vaccine (DTP), and measles, mumps, and rubella (MMR) vaccines, respectively. 19. Belize’s vulnerability to climate change can have significant impacts on the population’s health. According to the Climate and Disaster Risk Screening conducted for this Project, Belize is expected to endure more frequent rainfall with increased intensity, more frequent heat waves and droughts, and rising sea levels as predicted for the rest of the Caribbean consistent with the projected global median.26 Observed and anticipated climate change impacts are expected to cause an increase in the transmission of communicable diseases such as malaria, cholera, leishmaniasis, tuberculosis, and dengue. A large proportion of Belize’s vulnerable population is elderly and poor. Noting their low adaptive capacity, these groups are at the highest risk of both climate change impacts and COVID-19. For example, in 2019, Belize had one of the highest incidence rates of dengue in the LAC region,27 and dengue outbreaks have persisted during the COVID-19 pandemic. The most recurrent and disruptive natural events in Belize are hydro-meteorological, namely droughts and severe rainfalls, leading to floods and landslides. These natural disasters disproportionately affect vulnerable groups and can damage health care facilities and supply chains, including vaccines, sometimes disabling them completely when their services are most required. Several hurricanes and tropical storms have impacted Belize in recent years, damaging infrastructure and affecting transportation and energy systems. 20. Belize is currently implementing investments to strengthen the health sector’s resilience, but a sustained effort is needed. For example, Belize is strengthening the infrastructure resilience of several hospitals such as the Punta Gorda For Official Use and Corazal Community Hospitals.28 The health system needs to be prepared to tackle a higher prevalence of vector and water-borne diseases and respond to heatwaves and droughts, which can cause a high morbidity and mortality among the population. Surveillance and data reporting systems should be strengthened to ensure early warning of these events, Only and the health service delivery model needs to be able to reach those in remote and underserved areas, which are often at higher risk due to climate change. The Project will support such adaptation measures to be deployed widely and swiftly and strengthen the health system’s preparedness to cope with future emergencies to avoid Belize suffering directly or indirectly from the consequences of climate change coupled with the impacts from the COVID-19 pandemic. C. Belize’s Response to COVID-19 and Bank’s Support 21. Belize initially managed to delay the occurrence of COVID-19 (first registered COVID-19 case occurred on June 5, 2020) and contain its spread with decisive public health measures, but after the first peak in December 2020, the country recently experienced its most severe COVID-19 wave. With the lifting of some restrictions from August 2020, cases began to rise. Despite the tightening of containment measures and opening of international borders only under tight controls in October 2020, the pandemic gained momentum and reached its first peak in December 2020. After a subsequent sharp drop and stabilization of cases at a low level between January and June 2021, infections again rose to a current bi-weekly case count of over almost 10,000 per million inhabitants in October 2021. After another drop, cases began to rise steeply in late December 2021 with the arrival of the omicron variant and have since reached a bi-weekly count of 25,000 per million inhabitants. Altogether, as of February 1, 2022, the country has registered 50,285 COVID-19 cases (116,889 per million population) and 629 COVID-19-related deaths (1,462 per million population).29 26 World Bank, 2021, Climate Knowledge Portal 27 PAHO, 2019, Epidemiological Update – Dengue. 28 PAHO. 2021. Building the Punta Gorda Community Hospital in Belize to become Disaster-Resilient and Climate-Friendly 29 Daily updates from the Facebook page of the MOHW. Page 6 of 46 The World Bank Belize COVID-19 Response Project (P177987) 22. Belize has worked with partners to increase the testing and case management capacity for COVID-19. In the initial phase of the pandemic, in particular, Belize lacked testing and case management capacity.30 With the rapid increase in COVID-19 cases in the summer of 2020, testing demand soon exceeded the Central Medical Laboratory’s capacity, resulting in significant lags in test turnaround time and delay in implementing control measures. With the introduction and decentralized application of rapid antigen-based testing with European Union and PAHO/WHO support towards the end of 2020, turnaround time improved substantively. Due to the unpredictable pandemic dynamics, forecasting and securing adequate amounts of antigen tests, reagents, and laboratory supplies continue to be challenging. Regarding case management, rapid assessments PAHO/WHO conducted with the MOHW found gaps in human resources and adequate structural spaces to triage, isolate, examine and manage patients with respiratory symptoms and minimize the possibility of exposing others to COVID-19. For Official Use Only 30 The information in this paragraph comes from PAHO. 2021. Universal Health and the Pandemic. Belize. Annual Report 2020. PAHO/BLZ/21-0001. Page 7 of 46 The World Bank Belize COVID-19 Response Project (P177987) Figure 1. Cumulative and biweekly COVID-19 cases and deaths per million people in Belize and other Central American countries. Page 8 of 46 The World Bank Belize COVID-19 Response Project (P177987) 23. Belize identified and addressed key gaps for a robust response to the COVID-19 pandemic, working closely with key partners. The COVID-19 Country Preparedness and Response Plan guided the country’s response to COVID-19 coordinated by the multi-sectoral National COVID-19 Task Force. Key gaps addressed with partners’ support included: (i) shortages of equipment and supplies for COVID-19 testing in the national laboratory system; (ii) inadequate facilities for case surveillance at point of entry; (iii) critical gaps in the availability of key personnel; (iv) lack of sufficient personal protective equipment (PPE) and medical equipment; and (v) low capacity to properly manage medical waste. Various partners continue to support the COVID-19 response in Belize: The Inter-American Development Bank (IDB) provided US$6.2 million to finance the “Immediate Public Health Response to Contain and Control the Coronavirus and Mitigate its Impact on Service Delivery in Belize”, the European Union reallocated 500 thousand euros (US$567 thousand equivalent) from the Health Sector Support Programme, and the PAHO has provided technical assistance and support from the onset. 24. Prompt support to vaccine purchase and deployment is critical for Belize to reduce the disease burden from COVID-19 and enable economic recovery. Expedient actions to support vaccine procurement and vaccine deployment in Belize are necessary to scale up ongoing immunization efforts and provide the MOHW much needed resources to the health sector during this period of significant fiscal constraints. Moreover, due to the global spread of COVID-19 variants, increasing immunization rates is paramount to contain the spread of the coronavirus. 25. The proposed Project will form part of an expanded vaccination effort led by the GoB and supported by several international partners. The IDB, PAHO, UNICEF, and the European Union have played a key role in supporting the GoB’s financial and technical response to COVID-19, including COVID-19 immunization. Moreover, Belize benefited from COVID- 19 vaccines donated by foreign governments (Barbados, India, Mexico, United Araba Emirates, United Kingdom, United States of America). Close coordination with other partners, under the leadership of the MOHW, will avoid duplication of efforts and maximize synergies. Box 2 provides a summary of partners’ roles in the COVID-19 response and immunization program. Page 9 of 46 The World Bank Belize COVID-19 Response Project (P177987) Box 2. Supportive Roles for Partner Agencies in COVID-19 response and Immunization PAHO/WHO Financing amount COVID-19 immunization: Communications, HIS, Adverse Event Following Technical assistance (Amount TBC) Immunization (AEFI) surveillance system, cold chain Overall COVID-19 response with financing from the European Union Fund reallocation, €500K UNICEF Cold chain equipment, procurement of vaccines Not known Global Alliance for Vaccines and Immunizations (GAVI)-COVAX Facilitation vaccines procurement (Government financed) US$2.5 million IDB COVID-19 response US$ 6.2 million (loan repurposed from an existing project) COVID-19 Immunization US$2.8M vaccine deployment (loan) + US$2.1M guarantee for vaccine procurement Foreign governments (United Kingdom, Mexico, Barbados, United Arab Emirates, India, United States of America) COVID-19 Vaccines Donations Caribbean Regulatory System and CARICOM’s roles Technical approval for importation of COVID 19 vaccines, situation reports, and Not known liaison with African Medical Supplies Platform to procure vaccines United Nations Development Programme (UNDP), United Nations High Commissioner for Refugees (UNHCR) and Red Cross Support through Global Fund, hiring personnel and IT inputs, communications, Not known transportation, volunteers, meals for field workers D. National Capacity and COVID-19 Vaccination Plan (i) Vaccine Readiness Assessment 26. Belize has completed multiple rounds of the Vaccine Introduction Readiness Assessment Tool (VIRAT)/ Vaccine Readiness Assessment Framework (VRAF 2.0) for COVID-19. The country continues to work with PAHO and other stakeholders to address gaps like lacking ultra-cold chain equipment, while the Bank funding would address budgetary shortfalls and help intensify outreach and communication efforts (Table 1). The latest self-assessment validated the strategy outlined in the GoB’s Vaccine Introduction Plan (VIP) that was developed in February 2021 and reflected that overall, the country was well prepared to roll out the COVID-19 vaccine. A key gap currently being addressed with PAHO support is the lack of adequate ultra-cold chain equipment which has been procured and is expected to arrive in the country in March 2022. As Belize continues to find itself in a dire economic and fiscal situation despite signs of recovery in 2021, the proposed Project is essential for the country to finance the continuation and scale-up of their vaccination efforts, including communication and sensitization activities, additional mobile vaccination units for hard-to-reach populations, and digital monitoring of vaccinations. Page 10 of 46 The World Bank Belize COVID-19 Response Project (P177987) Table 1. Vaccination readiness findings from the VIRAT/VRAF 2.0 assessment31 Readiness domain Readiness of Government Key gaps addressed (as of latest assessment on Sept 21, 2021) Planning and coordination Completed No gaps remaining as per self-assessment Budgeting Completed The GoB allocated domestic resources. Funding gaps are being addressed with the proposed Project jointly with support from other partners. Regulatory Completed No gaps remaining as per self-assessment Prioritization, targeting,surveillance Completed No gaps remaining as per self-assessment Service delivery Completed No gaps remaining as per self-assessment (Project to support scale up of outreach activities to hard-to-reach communities) Training and supervision Completed No gaps remaining as per self-assessment Monitoring and evaluation (M&E) Completed No gaps remaining as per self-assessment Vaccine, cold chain, logistics, infrastructure Completed No gaps remaining as per self-assessment (PAHO is supporting procurement of ultra-cold chain equipment) Safety surveillance Completed No gaps remaining as per self-assessment Demand generation and communication Completed No gaps remaining as per self-assessment (Project to support scale up plans) (ii) Belize Vaccine Introduction Plan (VIP) 27. To date, Belize has secured 1,010,810 vaccine doses through COVID-19 Vaccines Global Access Facility (COVAX) 32 , African Vaccine Acquisition Trust (AVAT) and donations (Table 2). On September 18, 2020, the GoB signed a Committed Purchase Agreement with the GAVI Alliance to join COVAX, through which it will have access to a total of 180,360 COVID-19 vaccine doses, namely 100,800 already delivered doses of the AstraZeneca (AZ) vaccine and 79,560 doses of the Pfizer vaccines, payment and shipment of which are currently deferred to the future due to a subsequent large influx of vaccine donations. In addition, after reaching an agreement with the GoB on May 28, 2021, the AVAT facility also delivered 148,800 doses of the Johnson & Johnson's Janssen COVID-19 (J&J) vaccine. Finally, to date, the country has secured 681,650 doses of the AZ, Sinopharm, and Pfizer vaccines through donations from various governments and directly from Pfizer, of which 564,650 doses have already been delivered. Of the total number of vaccines already secured (1,010,810 vaccine doses), 814,250 were already delivered. 28. The vaccine doses Belize has so far secured are sufficient to fully immunize (including booster vaccines for adults) up to 80 percent of the total population. In terms of primary vaccination (no booster), the secured doses are sufficient for primary vaccination of 521,825 people or 121 percent of the total population. When considering that everyone aged 18 and older will be eligible for a booster vaccination during the Project implementation period, the hitherto secured vaccines are sufficient to vaccinate 80 percent of the population, somewhat below the GoB’s target of 88.5 percent (see below for details of vaccination plan). The GoB plans to use donated vaccines for boosters. 29. The Project will finance the procurement of doses sufficient for primary vaccination of 55 percent of the population. This includes retroactive financing for primary vaccination doses of 39 percent of the adult population and 31 A multi-partner effort led by WHO and UNICEF developed the VIRAT to support countries in developing a roadmap to prepare for vaccine introduction and identify gaps to inform areas for potential support. Building upon the VIRAT, the Bank developed the VRAF to help countries obtain granular information on gaps and associated costs and program financial resources for deployment of vaccines. To minimize burden and duplication, in November 2020, the VIRAT and VRAF tools were consolidated into one comprehensive framework, called VIRAT-VRAF 2.0. 32 COVAX is co-led by GAVI, the Coalition for Epidemic Preparedness Innovations (CEPI) and WHO. Page 11 of 46 The World Bank Belize COVID-19 Response Project (P177987) proactive financing for primary vaccination of children ages 5-11, equivalent to 16 percent of the population. The GoB seeks retroactive financing for 228,360 of the secured doses, namely the already delivered 148,800 doses of the J&J vaccine from the AVAT facility (primary vaccination for 31.1 percent of the population) and for the 79,560 currently deferred doses of the Pfizer vaccine from COVAX, which the GoB committed to purchase (primary vaccination for 8.3 percent of the population) if payment for this shipment is made before the signing of the project financing agreement. Moreover, as an adapted formula of the Pfizer vaccine has recently been approved for use among children ages 5-11 years, the GoB is seeking proactive financing for the procurement of an additional 150,000 doses of the child formulation of the Pfizer vaccine with the project financing (primary vaccination for 15.7 percent of the population). With the procurement of the Pfizer vaccines for the children, total vaccine procurement (purchases and donations combined) will reach 1,160,810 doses, sufficient for primary vaccination and booster vaccines (for adults 18+) for 96 percent of the population. The 96 percent exceed the GoB’s 88.5 percent vaccination target (based on those eligible for vaccination), with the oversupply due to the recent influx of Pfizer vaccine donations from the United States. 30. As a central part of its vaccine readiness, Belize developed a comprehensive VIP as of February 2021. The VIP is developed and overseen by the National Coordinating Committee, including representatives from the medical community and civil society organizations. Technical guidance comes from the National Immunization Technical Advisory Group (NITAG) of medical experts from the public and private sectors. The plan describes institutional arrangements, vaccine approval procedures, regulatory framework, budget and procurement planning, plans for storage, cold chain and waste management, health worker training, target populations, and deployment strategy, stakeholder engagement and communication plans, data collection and monitoring arrangements, and the surveillance system for adverse events. The VIP can be updated as new financial, technical, and epidemiological information becomes available and, therefore, should be considered as a living document. Page 12 of 46 The World Bank Belize COVID-19 Response Project (P177987) Table 2. Belize’s National Vaccine Coverage and Purchase Plan People who can be Vaccines Bank’s Vaccines already arrived vaccinated with (to be) Vaccines Number of doses Estimated VAC in the country Source of financing (IBRD, procured doses* (to be) Contract administered total U$ Status of IDA, TF, Govt, Other) % of total procured Status as of Price Shipping** (millions) the population # of people Source Name doses Name Doses November ($/dose) ($/dose) vaccine (430K) 30th, 2021 Phase 1 Govt (through IDB loan) 10.5% 45,360 COVAX AZ 4 0.5 100,800 0.5 Approved Signed AZ 100,800 100,800 Phases 2-5B (population age 12+) Govt 0 8.3% 35,802 COVAX Pfizer 12 0 79,560 1.0 Approved Signed Pfizer 0 (Temporarily (IBRD if loan approved) deferred) Govt 31.1% 133,920 AVAT J&J 7.5 0 148,800 1.1 Approved Signed J&J 148,800 19,142 (IBRD if loan approved) AZ, AZ, 290,237 Countries, AZ: 199,260 Donations 71.3% 306,743 Sinopharm, 0 0 681,650 0 NA Signed Sinopharm, 564,650 Pfizer Sinopharm: 7,931 Pfizer Pfizer Pfizer: 83,046 Phase 1-5B total (1 dose J&J, 2 doses all other 121.3% 521,825 Various Various 2.4 0.0 1,010,810 2.5 NA NA Various 814,250 410,179 vaccination) Phase 1-5B total 80.2% 344,968 (assuming 1 booster for 18+) Phase 5C (population age 5-11)*** Govt (15.7%) (67,500) TBD Pfizer (12) (0) (150,000) (1.8) Approved TBD Pfizer (0) (0) (IBRD if loan approved) NATIONAL TOTAL (1 dose J&J, 2 doses all other (137.0%) (589,325) Various Various (3.7) (0.0) (1,160,810) (4.3) Approved Various (814,250) (410,179) vaccines) NATIONAL TOTAL (95.9%) (412,468) (assumes 1 booster for 18+) * The number and population percentages of people who can be vaccinated with the procured doses takes into account 10 percent wastage (based on current evidence). ** For all vaccines except the AZ vaccine, shipping costs are in included in the dose prices. *** Because no Pfizer vaccines for children have to date been procured, numbers for the population 5-11 and for the national totals that include this group are reported in parentheses. Page 13 of 46 The World Bank Belize COVID-19 Response Project (P177987) 31. The National Technical Working Group (NTWG), with representatives of various units within the MOHW, coordinates activities for vaccine deployment and the Maternal and Child Health (MCH) Units at MOHW headquarters and at the district level implements the vaccine rollout. Under the involvement of local stakeholders and within the framework of the national VIP, coordinating committees in each of the country’s six districts develop local vaccination plans, implementation of which is organized by the districts’ lead rural and public health nurses. Overall responsibility for local deployment lies with the management teams of the four health regions. 32. Belize has established regulations for the importation and use of approved COVID-19 vaccines. For its approval decisions, Belize relies on WHO prequalification, Stringent Regulatory Authorities (SRAs), and recommendations from the Caribbean Regulatory System and the Caribbean Public Health Agency (CARPHA). Once the MOHW places a request for prepayment of foreign purchased vaccines, and these meet the safety and efficacy approval from at least one of the authorities mentioned above, no further testing is required before importation. As part of the vaccine procurement and acquisition process, Belize is addressing indemnity and liability issues as described in Box 3. 33. Belize’s vaccine strategy is to vaccinate everyone eligible – currently 88.5 percent of the population – and willing to get the vaccine for community immunity. The national COVID-immunization rollout followed the VIP’s prioritization framework in line with WHO/Strategic Advisory Group of Experts recommendations in the first phase. The vaccine rollout plan was derived based on WHO recommendations, as well as morbidity and mortality data identifying at-risk populations. It followed five phases in which different populations groups become eligible for the vaccines according to profession, age, and comorbidity status (Table 3). Phase 5B and phase 5C were added later as younger people became eligible for COVID-19 vaccines. To identify eligible populations at the community level, NTWG teams engage with local healthcare providers (including community health workers) to create vaccination schedules for eligible residents. The vaccination campaign officially began on March 1, 2021, with Phase 1A, thus targeting healthcare workers, the elderly and those at high-risk of severe disease. Since June 30, 2021, all adults aged 18 and older have been eligible for vaccination.33 Following the approval of the Pfizer vaccine for younger age groups, on August 23, 2021, COVID-19 vaccine eligibility was extended to children aged 12-17 years. The GoB plans to extend COVID-19 vaccination to children aged 5-11 years as soon as it can procure the vaccines. Moreover, booster vaccinations are now approved for persons whose primary vaccination dates back at least six months. Table 3. Priority groups for vaccination PHASE Target population Numbers % TOTAL 1A Health Care Workers 5,000 1.2 1 1B Persons 60 years and older 25,000 5.8 35,000 Persons at higher risk of complications (cancer, HIV, 1C 5,000 1.2 and requiring dialysis) Essential frontline workers: Teachers and police 2A 8,263 1.9 officers 2 National assembly & judiciary, customs and 16,783 2B 520 0.1 immigration 2C Tourism sector 8,000 1.9 3A Frontline workers (BDF, coast guard, fire service) 2,624 0.6 3 3B Persons with co-morbidities 30,000 7.0 42,824 3C Frontline workers (red cross, utility workers) 10,200 2.4 4A All other public servants 10,000 2.3 4 11,000 4B Transportation workers 1,000 0.2 5 5A All other persons 18-59 years 143,677 33.4 274,904 33 https://www.breakingbelizenews.com/2021/06/30/covid-19-vaccination-open-to-anyone-18-years-and-older/ Page 14 of 46 The World Bank Belize COVID-19 Response Project (P177987) PHASE Target population Numbers % TOTAL 5B Persons 12-17 years (added August 23, 2021) 58,214 13.5 5C Persons 5-11 years (planned) 73,013 17.0 Total 380,511 88.5 380,511 34. Vaccines are administered mainly by public primary care providers. Mobile clinics and home visits are used to vaccinate hard-to-reach and vulnerable communities. Vaccinations are free for all residents, including undocumented immigrants. While several private sector healthcare providers support the deployment efforts, most vaccines are administered by specifically trained rural and public health nurses via (44) public primary care facilities,34 other public venues like schools, and through mobile clinics for hard-to-reach communities.35 Home visits are used to reach persons with mobility restrictions, as identified by community stakeholders, including residents of elderly homes. 35. The GoB has adapted its health information system to accommodate the electronic entry of vaccination data, which allows for near real-time tracking of vaccination progress. The MOHW has an electronic health information system, the Belize Health Information System (BHIS), accessible to most public health facilities and updated to accommodate COVID-19 immunization data. Some rural health facilities without access to the BHIS use a paper-based system to collect vaccination data which are later entered in the system at a BHIS-ready facility. However, in numerous vaccination sites, data entry clerks enter individual-level vaccine data electronically so that the deployment process can be monitored in near real time and accurate daily updates can be published. The proposed Project will support efforts to avoid backlog in data entry, including the MOHW’s plan to fully digitize immunization data entry at vaccination sites. 36. COVID-19 vaccines are distributed to the local vaccination sites according to orders placed via an electronic supply chain management system. Vaccines arrive in Belize City by air and are initially stored at the national vaccine storage facility (NVSF) in the capital Belmopan. Each shipment of vaccines is then distributed to the six districts according to available quantities, the regional distribution of target populations and the orders districts place with the NVSF via hard copy or the BHIS electronic supply chain management module. Vaccine shipments to the districts accommodate an estimated 10 percent wastage. Transport to urban health centers that serve as district vaccines stores, and eventually rural health centers and other public vaccination sites is done by MOHW vehicles and, in areas where land transportation is not an option (e.g., Cayes), by air or sea transport. 37. A cold chain assessment was completed in December 2020, and additional ultra-cold chain equipment is currently being procured with PAHO support. The existing and needed cold chain equipment has been determined for all levels of the health care system and by health facility. The total installed cold chain capacity for 2-8°C is 1,897.38 m3 net available, for -20°C is 1.02m3 net available, and for -70°C (ultra-cold chain) (specifically static ultra-cold freezers or equivalent) 0.72m3 net available (at the NVSF). Additional ultra-cold chain equipment is being procured and expected to be delivered in March 2022. All health workers involved in the vaccination campaign have been trained in COVID-19 vaccine cold chain management, and country-wide, around 100 staff monitor and supervise cold chain effectiveness. Vaccine temperature is monitored twice daily by the Vaccine Technician at the national level and by the public health nurses and rural health nurses in the districts. Of the 44 public primary care facilities in the country, 95 percent (42) have cold chain equipment installed to manage vaccines at the local level, while two are attended through mobile clinics. 38. Belize has strengthened its capacity to monitor adverse events following vaccination through passive, stimulated, and active surveillance. Belize has an established AEFI surveillance system for the documentation and reporting of adverse events following immunization integrated in the surveillance of vaccine preventable diseases managed under the Expanded Program for Immunization (EPI). Persons receiving COVID-19 vaccines are provided with 34 Persons with a history of allergic reactions are vaccinated in large health facilities/hospitals and under the supervision of doctors. 35 People living in extreme poverty, homeless and those living in urban slums; low-income migrant workers; refugees, asylum seekers, vulnerable migrants in irregular situations; and hard-to-reach population groups such as those in rural and remote areas. Page 15 of 46 The World Bank Belize COVID-19 Response Project (P177987) relevant information before leaving the vaccination site. AEFI cases are investigated within 24 hours of notification using the country protocol. The BHIS system is updated manually to record AEFI. 39. The GoB uses a multi-faceted strategy to counter vaccine misinformation and ensure that everyone has access to information regarding the importance of COVID-19 vaccination to stop community spread, and regarding the vaccine’s benefits and risks. According to the latest data from June 2021 on vaccine hesitancy among persons 18 and older, 24 percent of the hitherto unvaccinated individuals are unsure about getting vaccinated, and 21 percent have no intention to get vaccinated.36 A committee was formed to support the development and monitoring of demand generation and communication activities. The communication campaign follows a dedicated communication plan which includes, for example: radio and television talk shows, sensitization sessions with religious and community leaders and with local businesses/universities/unions, daily reporting on data on vaccination and COVID-19 on social media, immunization at home (for disabled people) and at workplaces, and information campaign supporting vaccination sites. Printed information material, such as flyers and pamphlets, are distributed to districts together with the vaccine and immunization supplies, and health educators form part of every vaccination team. More recently, home visits 1 to 2 days prior to the arrival of the vaccination team have been introduced to better reach indigenous people and those living in rural and urban poor areas. Box 3. Liability and Indemnification Issues in Vaccine Acquisition and Deployment General • The rapid development of vaccines increases manufacturers’ potential liability for adverse effects following immunization. • Manufacturers want to protect themselves from this risk by including immunity from suit and liability clauses, indemnification provisions, and other limitation of liability clauses in their supply contracts • Contractual provisions and domestic legal frameworks can all operate to allocate that risk among market participants, but no mechanism will eliminate this risk entirely. For COVAX-financed vaccines for AMC countries • COVAX has negotiated model indemnification provisions with manufacturers for vaccines purchased and supplied under the COVAX AMC. • In providing vaccines through COVAX AMC, COVAX requests COVAX AMC participants to have in place an indemnity agreement directly with manufacturers, and the necessary indemnity and liability frameworks for that purpose – either in the form of the COVAX model indemnification arrangements or prior bilateral arrangements with manufacturers. • The COVAX Facility will have a no-fault compensation scheme for AMC countries as part of its risk mitigation strategy. This will cover vaccines supplied only through COVAX AMC. • Belize will have to consider what it will take to implement these indemnification provisions (including statutory implementation) and how they can avail of the benefits of the no-fault compensation scheme. For vaccines purchased outside of COVAX • Belize will need to enter into direct indemnification arrangements with manufacturers. • Belize does not currently have legislation in place to provide statutory immunity for manufacturers. Belize does not have a national no fault compensation scheme. • Adoption of any such indemnification provisions or compensation scheme would have to be in accordance with Belize own national strategy and framework. Possible Bank support to Belize 36 World Bank, high frequency phone survey, 2021. Page 16 of 46 The World Bank Belize COVID-19 Response Project (P177987) • Information sharing on: (a) statutory frameworks in Organization for Economic Co-operation and Development countries and other developing countries; and (b) overall experience in other countries. • Training and workshops for Government officials to familiarize them with the issues. • For Bank-financed contracts, the Bank can provide hands-on expanded implementation support The VIP and/or Project Operational Manual (POM) will make clear that the country’s regulatory authority is responsible for its own assessment of the Project COVID-19 Vaccines’ safety and efficacy and is solely responsible for the authorization and deployment of the vaccines in the country. (iii) Update on COVID-19 Vaccination Rollout 40. Belize officially launched the rollout of COVID-19 vaccines on March 1, 2021. As of January 24, 2022, 212,480 persons (49.3 percent of the total population) were vaccinated with at least one dose of a COVID-19 vaccine, and 202,878 persons were fully vaccinated.37 To date, Belize has vaccinated 49 percent of its population, the 5th highest vaccination rate among the seven Central American countries, and about half of its target of 88.5 percent of the population. The latest available subregional data indicates that substantive regional differences in vaccination rates remain, with a particularly low rate in the poor and sparsely populated Toledo district (Figure 2). Figure 2. Share of district total population partially and fully vaccinated against COVID-19 (as of November 22, 2021 – latest data) Source: MOHW. Retrieved under: https://www.facebook.com/100076305600375/videos/410500577404649 41. Vaccine misinformation paired with gaps in the GoB’s communication strategy are the main drivers of vaccine hesitancy in the country. The GoB has identified a number of obstacles to a more rapid rollout which include: (i) absence of a vaccination mandate; (ii) vaccine hesitancy due to misinformation through social media and incomplete adherence to the national VIP’s recommendations on early vaccine education in some localities; (iii) limited acceptance of the J&J vaccine; and (iv) inadequate communication strategy with indigenous communities that primarily reside in Toledo: Toledo’s population is small (9 percent of the total population). Eighty percent reside in rural areas where access to media is limited given the constrained geographic reach of Belize-based radio stations. Residents prefer indigenous-language programs from Guatemala stations, while vaccination communication from Belize media is only in English and Spanish. Local teams have revised the vaccination strategy in response to the low uptake in Toledo. Early coordination with local leaders is being enhanced and community health workers of indigenous descent now conduct house-to-house health education visits 1-2 days before the vaccination effort. 42. Aside from vaccine procurement, IBRD financing will be used to bolster GoB deployment and communication efforts. Specifically, project financing will be used to hire and deploy (including vehicles) additional mobile vaccination 37 Belize daily immunization report from Facebook. Retrieved under: https://www.facebook.com/profile.php?id=100076305600375 Page 17 of 46 The World Bank Belize COVID-19 Response Project (P177987) teams to reach hard-to-reach communities and to support communication efforts countering misinformation (media ads, billboards, leaflets, etc.). E. Relevance to Higher Level Objectives 43. The proposed Project is aligned with the Bank’s CPF for Belize FY18-FY22, discussed by the Board of Executive Directors on April 28, 2017 (Report No. 106630). The proposed Project is aligned with one of the CPF areas of focus: Promoting Financial Inclusion and Social Resilience. The Project also supports the GoB’s development vision, Horizon 2030: National Development Framework 2010-2030, which highlights strategies for poverty reduction and longer-terms development issues. The overarching goal of the FY18 -22 CPF is economic resilience, but health was not identified as a key area of support. However, by providing critical resources to support the COVID-19 immunization program, the Project will contribute to managing the pandemic and restoring economic activities which are vital for the country’s economic and social resilience, the second focus area of the CPF. As per the CPF, the Bank will coordinate with critical partners already active in the COVID-19 response, including the PAHO, the European Union, and others. 44. The Project is also aligned with the Bank’s mission and strategic priorities, particularly by supporting Green, Resilient, and Inclusive Development (the GRID approach). The proposed Project would contribute to achieving the Bank’s twin goals by providing timely resources to help the GoB respond to the ongoing public health emergency, with particular emphasis placed on the poor and vulnerable population. The Project would also support GRID in Belize as it would simultaneously improve the overall resilience of the health sector – and therefore of the people of Belize - to natural and man-made disasters, focusing on the most vulnerable population groups. 45. In particular, the Project is aligned with the Bank’s Corporate Commitments on climate change. It incorporates specific actions intended to increase the climate mitigation and adaptation capacity of the Belize health system to reduce climate vulnerabilities identified in the country. The Project contributes to mitigating the negative climate impacts of the health system through investments in green and climate-friendly equipment and processes. It also contributes to increasing the adaptative capacity of the health system to cope with climate-induced events and the emergence of climate-related diseases such as dengue and malaria, through the strengthening of the outreach capacity of the MOHW, improved data reporting in remote areas, inclusion of climate aspects in communication campaigns, and training of human resources on climate awareness and resilience. 46. The Bank remains committed to a fast and flexible response to COVID-19, utilizing all Bank operational and policy instruments and working in close partnership with Government and other agencies. Grounded in the One Health approach, which provides for an integrated approach across sectors and disciplines, the proposed Bank response to COVID-19 will include emergency financing and technical assistance, building on existing instruments to support IDA/IBRD- eligible countries in addressing the health sector and broader development impacts of COVID-19. The Bank’s COVID-19 response is anchored in the WHO’s COVID-19 global SPRP outlining the public health measures for all countries to prepare for and respond to COVID-19 and sustain efforts to prevent future outbreaks of emerging infectious diseases. The economic rationale for investing in the MPA interventions is strong, given that success can reduce the economic burden suffered both by individuals and countries. The Project complements both Bank and development partner investments in health system strengthening, disease control and surveillance, attention to changing individual and institutional behavior. Page 18 of 46 The World Bank Belize COVID-19 Response Project (P177987) III. PROJECT DESCRIPTION A. Development Objectives 47. The Project objectives are aligned to the results chain of the COVID-19 SPRP. Project Development Objective (PDO): The PDO is to support the Government of Belize in the acquisition and deployment of Project COVID-19 vaccines. PDO level indicator: Eligible population fully vaccinated (by sex) (Percentage). Target: 75 percent of the country’s total population. B. Project Components 48. The proposed Project is designed around two components as described below. 49. Component 1: COVID-19 Response (US$5.8 million). The support for vaccines will be financed as part of the containment and mitigation measures to prevent the spread of COVID-19 and deaths and to strengthen the ability of the health system to respond to future health emergencies. Belize has been purchasing COVID-19 vaccines from the COVAX and AVAT facilities. Vaccine purchase and deployment activities carried out under this component will be guided by the Belize COVID-19 VIP. Given the expected impacts of climate change and the country’s high vulnerability as described above, the Project will contribute to climate resilience and mitigation measures through vaccine deployment to increase the resilience of the health system and vulnerable populations. This component will support the Belize COVID-19 response through two subcomponents as follows: Subcomponent 1.1. Vaccine purchase (US$3.9 million). This subcomponent will support the procurement of vaccines from the COVAX and AVAT facilities. Other sources to be determined may be included. Subcomponent 1.2 Vaccine deployment (US$1.9 million). Envisioned support under this subcomponent includes vaccine deployment and supporting the health system emergency response capacity: a. procurement of ancillary supply kits that may include PPE for vaccinators,38 syringes, and other medical supplies; b. scale up the outreach program (e.g., by supporting human resources, procurement of vehicles and operating costs) to strengthen the emergency response and provide critical health services – starting with COVID-19 vaccines - to everyone, with a focus on specific target groups such as poor people living in rural and urban areas, people with vaccine hesitancy and lower uptake for essential health services, women and girls, persons with disabilities, indigenous population groups, and populations groups vulnerable to climate change. The strengthened outreach program will also ensure the continued delivery of essential and emergency services to these populations during climate-induced disasters, such as hurricanes, flooding and others; c. capacity building of human resources to: (i) strengthen infection prevention control (IPC) and waste management practices and updating the MOHW HCWMP, (ii) increase climate awareness and resilience, and (iii) increase awareness and knowledge about gender-based violence (GBV) and better equip male and female frontline workers with leadership and self-care skills; d. strengthen the BHIS through digitizing data reporting systems in hard-to-reach areas (e.g. through support of human resources and the procurement of IT equipment that will consider energy savings and resource-use 38 The PPE procurement plan will consider workforce composition/different sizes and to ensure female/male tailored PPE reaches the most remote areas. It would also include considerations for emergencies, including climate related ones, to aim to make PPE available in shelters and other emergency locations to prevent transmission of COVID-19. Page 19 of 46 The World Bank Belize COVID-19 Response Project (P177987) efficiency measures, contributing to environmentally and climate-smart processes instead of current systems which are heavily reliant on paper records) to monitor vaccines uptake and use of other services provided through mobile clinics. Such system will strengthen early warning systems for disease outbreaks in the future, including climate-induced incidents; e. the development of contingency plans to maintain vaccination campaigns during climate shocks; f. supporting the COVID-19 immunization campaign and the development and distribution of risk communication products for COVID-19 vaccination, including communication on the risks related to climate shocks and respectful attitudes towards male and female health workers, with special attention to the specific needs of women and men, and disadvantaged population groups (e.g., urban poor, indigenous people); g. ensuring adequate and climate and environmentally friendly medical waste management; h. support analytic activities for evidence-based decision making, including a knowledge, attitudes and practices survey around COVID-19 vaccination which will provide critical information to the MOHW on possible interventions to increase uptake of public health services in case of future epidemics and natural disasters, and i. support the procurement of medical equipment to strengthen COVID-19 case management; such equipment will consider energy savings and resource-use efficiency measures. 50. Component 2. Project Management and Monitoring (US$0.4 million). This component will finance the required project management activities and administrative and human resources to manage the Project. The main activities will be carried out by the MOHW team as the Policy, Planning and Project Management Unit (PPPMU) and working closely with the MCH and EPI teams and will include: (i) financial management (FM), procurement, environmental and social requirements, and due diligence; and (ii) monitoring and evaluating the Project. These costs include additional staffing and training of the PPPMU, technical consultants, and other operating costs. These activities will be carried out per Bank’s guidelines and procedures. 51. Through its support to the COVID-19 immunization program, the Project intends to increase long-term climate resilience and the preparedness and response capacity of the health system to tackle future pandemics and climate- related emergencies. Investments in the digitalization of the BHIS, community and vulnerable populations outreach capacity, human resources for immunization, capacity in IPC, and the updating of waste management processes aim to increase Belize’s capacity to prevent and respond to future emergencies, especially climate-driven ones. The Project aims to ensure that this strengthened capacity reaches all populations, and particularly the most vulnerable who experience the greatest health impacts of climate change. For example, digitization of the BHIS will allow for case reporting in a real- time basis and reduce data reporting gaps in remote areas, consequently strengthening emergency planning systems and the capacity for early warning and response to events, including climate change-induced ones. Climate considerations intended to mitigate climate change will be adopted throughout, including through the use of procurement measures to ensure the acquisition of the most energy and resource efficient options (e.g., in the case of the purchase of IT and medical equipment) and through the provision of training, specifically aiming to minimize the carbon footprint of the health sector, as well as to promote green and climate friendly practices among health care staff. Overall, 36 percent of the loan (US$2.2 million) will finance activities that will directly contribute to increasing the mitigation and adaptation capacity of the MOHW in the context of the climate vulnerabilities previously identified. This includes activities under Subcomponent 1.2 and Component 2, which will support the adequate implementation of the Project overall. C. Project Beneficiaries 52. The proposed Project will benefit the entire population of Belize. The direct project beneficiaries will be the 237,222 Belize inhabitants whose primary vaccination against COVID-19 will be financed by the IBRD loan, namely 169,722 Page 20 of 46 The World Bank Belize COVID-19 Response Project (P177987) persons aged 12 years and over, and 67,500 children aged 5-11 (Table 3). However, it is expected that the entire population of Belize will benefit from the Project as COVID-19 vaccination is needed to achieve herd immunity in Belize and beyond, thus contributing to the country’s economic recovery. In addition, investments in health system strengthening such as strengthening the outreach program are expected to benefit the younger children who are not yet eligible to be vaccinated. Addressing gender gaps 53. The pandemic has aggravated gender inequalities in Belize which, in turn, have amplified the negative impacts of the pandemic in the country. There are widespread gender inequalities in Belize, which pose important obstacles for social and economic development, for example, through different labor market participation rates among men (81 percent) and women (50 percent).39 Women have almost universal access to essential delivery services (about 97 percent of women who gave birth in the previous two years received antenatal care from a skilled provider, and the same percentage of births were delivered by a skilled provider). Moreover, the percentage of children fully immunized is similar between girls (80.1 percent) and boys (82.7 percent),40 and on average, women have equal access to COVID-19 vaccines as men. There is, however, a clear sex disparity in noncommunicable disease risk factors in Belize: men on average consume more alcohol and have increased rates of high blood pressure while women have higher rates of blood glucose and higher prevalence of obesity. Older, low-income, indigenous women may have more limited access to information on vaccination deployment and overall information on vaccines (e.g., misconceptions, fears of vaccines causing fertility problems - sterilization, miscarriages/abortions). It is also expected that females bear a disproportionate share of the mental and social burden from the COVID-19 pandemic because: (i) the majority of health workers in Belize are women (an estimated 75 percent),41 especially amongst nurses (95 percent),42 who are the ones are at the forefront of the COVID- 19 immunization efforts which exposes them to an increased level of risk working in rural or insecure neighborhoods, generating a significant emotional and mental toll. Many nurses are also at risk of further discrimination linked to their status as migrant workers (Belize has a large number of health workers from the Philippines, United States, Nicaragua and other countries); (ii) Women are more likely to be the primary care givers for sick family members and children, which can lead to additional mental stress or difficulties attending work; and (iii) COVID-19 has led to an increase in the incidence of GBV in many countries, including Belize. For example, the Stann Creek District in central Belize saw a 57 percent increase in domestic violence from January to June 2021 when compared to January to June 2020.43 Currently, the majority of frontline workers lack sufficient knowledge and training on GBV, which increases the risk of instances of GBV taking place in health care settings and represents a missed opportunity to detect women at risk when they get vaccinated and increase access to available services. 54. This Project will support specific measures to address identified gender gaps and promote a COVID-19 response that adequately meets the particular needs/priorities of women and men including sex-disaggregated monitoring systems, where possible. To address the disproportionate impact of the pandemic on women, the Project will apply a gender lens to project interventions. These include: (a) training for frontline workers (approximately 2,400 frontline workers, of which 40 percent are clinical staff) on GBV to increase their awareness and knowledge to detect GBV and to prevent instances of GBV in health care settings, (b) training for health care workers on self-care, skills and resources to better cope with the stress and emotional toll caused by the pandemic; (c) support to communication campaigns that include messages to minimize psychological impact of the pandemic, such as: (i) promotion of the role of health workers 39 With a value of 0.415, the 2020 UNDP Gender Inequality Index (GII) ranks Belize in the 97 position among 197 countries. This value indicates that 41.5 percent loss in potential human development due to gender inequality; United National Development Programme, Human Development Reports, 2020 Gender Inequality Index (GII). Retrieved under: http://hdr.undp.org/en/content/gender-inequality-index-gii on 10/20/2021. 40 2015-16 MICS. 41 Estimates from the MOHW, 2021 and The Revised National Gender Policy. 2013. The National’s Women Commission. 42 Interview with Ann Matute, Acting Deputy Director of Health Services. 2020. News 5 43 Gender-Based Violence: Incidents By District, January to June 2021, 2021, Belize Crime Observatory Page 21 of 46 The World Bank Belize COVID-19 Response Project (P177987) to prevent stigmatization during vaccination, (ii) appropriate care for sick family members, (iii) resources available to women, and coping strategies; (iv) targeted community messages on sexual exploitation (SEA) and abuse and sexual harassment (SH) as well as other vaccines related misinformation (e.g., misconceptions about vaccines causing fertility problems, stigmatization of workers administering vaccines, immunization information for pregnant women, messaging to prevent adolescent fertility); (v) recognizing the status of community volunteers to enhance support of family and communities; and (d) collecting and reporting sex disaggregated data on core indicators wherever possible including on the share of females vaccinated. An indicator was added to the Results Framework to track progress on frontline workers’ knowledge. By supporting the procurement and deployment of safe and effective COVID-19 vaccines, the Project has the potential to reduce these additional burdens placed on women. Citizen engagement (CE) 55. Ongoing implementation of the Government’s communication strategy will require tailored outreach and engagement mechanisms when dealing with the full range of citizens eligible to be vaccinated, including the elderly, children, people with underlying conditions, those in poverty, men, women, minority groups (i.e., indigenous peoples, Afro-Belizeans), migrants, and those with disabilities. The approaches taken will ensure that information is accessible via indigenous-speaking outreach teams (covering indigenous tongues and English) while also accounting for illiteracy or disabilities. The draft Stakeholder Engagement Plan (SEP) developed for the Project outlines a systematic approach to stakeholder engagement that builds heavily on the CE dimensions in the VIP and its related communication plans. The communication activities will include distribution of information and aim to capture feedback from beneficiaries that can inform the Government’s VIP. 56. To track levels of engagement by those who stand to benefit directly from the Project and improve project financed interventions, a citizen feedback survey will be conducted, and findings reported as part of the Results Framework. An indicator will record the feedback provided by beneficiaries, people who provided feedback on COVID-19 vaccination service (Number), which the Government will use to adjust the deployment of the VIP. In addition, the Project will also track the number of grievances received and addressed on time through the Project’s Grievance Redress Mechanism. D. Project Cost and Financing 57. The overall budget of the Project will be US$6.2 million. Component 1, “COVID-19 Response” has a budget of US$5.8 million (94 percent of the project financing) to cover vaccine acquisition (US$3.9 million, 64 percent of total project financing) and vaccines deployment (US$1.9 million, 30 percent of total project financing). Component 2, “Project Management and Monitoring”, will ensure adequate project management and monitoring of activities (US$0.4 million, 6 percent of total project financing) (Table 4). Table 5 provides a summary of vaccine sourcing and Bank financing. Page 22 of 46 The World Bank Belize COVID-19 Response Project (P177987) Table 4. Project Cost and Financing Project Components Project Cost IBRD or IDA Trust Funds Co-financed with (US$ million) Component 1: COVID-19 Response 5.8 IBRD NA NA Subcomponent 1.1: Vaccine purchase 3.9 IBRD NA NA Subcomponent 1.2: Vaccine deployment 1.9 IBRD NA NA Component 2: Project Management and 0.4 IBRD NA NA Monitoring Total Costs 6.2 Table 5. Summary of vaccine sourcing and Bank Financing Source of vaccine financing and population coverage Specific No. of National plan Bank-financed (US$ million) vaccines Doses Estimated target COVAX Through and purchased allocation of (population Through Through GoB Donations Grant direct sourcing with Bank Bank financing %) COVAX AVAT purchase plans financing Purchase: Phases 1A-5B J&J, AZ, US$3.9 0 1.0 1.1 0 0.5 0.0 (ages 12+) Pfizer, 228,360 Deployment: Sinopharm US$1.9 71.5% 0.0% 8.3% 31.1% 0.0% 10.5% 71.3% Other: US$0.4 (project management) Phase 5C Pfizer 0.0 0.0 0.0 1.8 0.0 0.0 (ages 5-11) (child 150,000 formula) 17.0% 0.0% 0.0% 0.0% 15.7% 0.0% 0.0% Total 0 1.0 1.4 1.8 0.5 0.0 NA 378,360 88.5% 0.0% 8.3% 31.1% 15.7% 10.5% 71.3% 58. Retroactive Financing: An option of retroactive financing will be made available to the Project covering up to 70 percent of the IBRD loan allocation for expenditures incurred within 12 months before the financing agreement is signed. This provision for retroactive financing provides the GoB with the flexibility to pay for the procurement of eligible vaccines before the Project becomes effective and allows the GoB to finance priority activities to continue the deployment of the COVID-19 vaccines. Retroactive financing will cover procurement of the 148,800 doses of the J&J vaccine from the AVAT facility and the 79,560 doses of the currently deferred Pfizer vaccine from COVAX if payment for the latter is made before the signing of the project financing agreement. Moreover, retroactive financing will be used for the procurement of vehicles for vaccines deployment. Vaccines procured through retroactive financing will have to meet the Bank’s Vaccine Approval Criteria (VAC), and contracts will need to be in line with Bank policies and requirements. IV. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 59. The key departments at the MOHW will lead project implementation. Specifically, the PPPMU will be responsible for project implementation with technical support from the MCH and the EPI team. The MCH unit will be Page 23 of 46 The World Bank Belize COVID-19 Response Project (P177987) responsible for vaccine deployment. The MOHW is Belize’s primary sector ministry responsible for the national health care system. The MOHW has considerable experience implementing donor-financed projects, such as the IDB and the European Union. Despite this existing experience, this Project will be the first Bank-financed investment project implemented by the MOHW. An implementation capacity assessment carried out during project preparation revealed that implementation of project activities will require complementary staffing in the PPPMU to ensure adequate monitoring, supervision and reporting throughout the Project. The Project activities will be carried out in accordance with the Operational and Vaccine Delivery and Distribution Manual which will be prepared and adopted by the GoB within 60 days from project effectiveness. A well-developed VIP and the District Vaccine Deployment Plans currently guide the transport, storage, and deployment of COVID-19 vaccine. In addition, the Project activities will be coordinated with support from other partners to avoid duplication of efforts and maximize synergies. Box 2 provides a summary of partners support to the COVID-19 response and immunization program. Project implementation will also be coordinated with other line ministries and agencies where necessary. 60. PPPMU staffing. The PPPMU will be strengthened with the following technical staff: (a) Project Officer; (b) M&E Officer; (c) Environmental and Social Officer; and (d) Senior Accounts Officer. 61. Project Duration: The proposed Project would be implemented until April 30, 2024, to allow the GoB sufficient time to implement its VIP adequately. B. Results M&E Arrangements 62. To measure overall project progress, the PDO-level indicator will monitor the percentage of “Eligible population fully vaccinated”. Two sub-indicators will also be monitored to track progress by sex: “Eligible male population fully vaccinated (Percentage)” and “Eligible female population fully vaccinated (Percentage)”. In addition, the Results Framework includes intermediate results indicators (IRIs) which will help monitor progress across the various areas supported by the Project. The Results Framework includes a full list of these indicators. 63. The Project includes indicators designed to measure its impact on addressing gender and CE gaps. While vaccination rate is the same at present, the sex-disaggregated data on immunization will allow to continue monitoring and act to prevent a potential gender gap in the future. An IRI will also track the increased knowledge gained through training sessions carried out to increase the awareness and knowledge of frontline workers to detect GBV and reduce the mental and emotional stress brought on by the pandemic, which currently is not part of the training curriculum and has been identified as a gap. As per Bank’s corporate commitments on closing the feedback loop, a CE and social accountability IRI is also included: people who provided feedback on COVID-19 vaccination service (Number). The MOHW will use the findings obtained through this feedback to adjust its vaccination strategy. This will be monitored in addition to the indicator on monitoring grievances addressed in a timely manner. Further information, including a description of each indicator and plans to measure each, can be found in the Results Framework. 64. The PPPMU will be responsible for M&E activities. The MOHW has a good HIS system in place which allows near real time data on vaccination status and has good capacity to report on the Project M&E activities; however, it lacks manpower. To strengthen the PPPMU capacity to report data in a timely manner, a dedicated M&E specialist will be recruited. As and when necessary, the PPPMU will coordinate with different units of the MOHW to: (i) compile and collect data on the PDO and intermediate indicators; and (ii) report results to the Bank during each semiannual supervision mission. The Project will mainly rely on the country’s existing BHIS and on MOHW administrative data. The only additional data collection effort is through a phone survey to collect data on clients’ feedback after having been immunized. 65. The PPPMU will prepare project reports and share data and information on: (i) compliance with the planned project activities; (ii) the updated Procurement Plan; (iii) progress on the achievement of indicators as defined in the Page 24 of 46 The World Bank Belize COVID-19 Response Project (P177987) Results Framework; and (iv) the application of the Environmental and Social Management Framework (ESMF), SEP and Project Grievance Redress Service (GRS). The PPPMU will submit these reports to the Bank semi-annually. 66. The Bank will support the GoB to incorporate best international practices for data security in the Project. Large volumes of personal data, personally identifiable information, and sensitive data are likely to be collected and used in connection with the management of the COVID-19 outbreak under circumstances where measures to ensure the legitimate, appropriate and proportionate use and processing of that data may not feature in national law or data governance regulations or be routinely collected and managed in the BHIS. To guard against abuse of that data, the Project will incorporate best international practices for dealing with such data in such circumstances. Such measures may include, for example, data minimization (collecting only data that is necessary for the purpose), data accuracy (correct or erase data that are not necessary or are inaccurate), use limitations (data are only used for legitimate and related purposes), data retention (retain data only for as long as they are necessary), information to data subjects of use and processing of data, and opportunity for data subjects to correct information about them. In practical terms, data operations will ensure that these principles apply through assessments of existing or development of new data governance mechanisms and data standards for emergency and routine healthcare, data sharing protocols, rules or regulations, revision of relevant regulations, training, sharing of global experience, unique identifiers for health system clients, strengthening of health information systems, etc. C. Sustainability 67. There is strong political commitment in Belize to mobilize financial resources for COVID-19 response, including for vaccine purchase and deployment. This is evidenced by the high immunization rate already achieved in the country just a few months after having initiated the deployment of COVID-19 vaccines and the fact that the country has already secured sufficient vaccines to immunize the eligible population. Having the funds through the proposed Project for vaccine purchase and deployment will allow the GoB to further scale up efforts to increase immunization coverage and achieve the desired immunization target. As the economy reopens and recovers, the GoB can dedicate additional domestic resources to the COVID-19 immunization program. Finally, investments under the Project are expected to strengthen the health system in the country, ensuring institutional sustainability to deal with infectious diseases in the future. V. PROJECT APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis 68. The economic rationale for investment in a COVID-19 vaccine is strong, considering the massive and continuing health and economic losses due to the pandemic. As of February 15, 2022, more than 413 million people have been infected by the virus, and over 5.8 million have died. Following a 3.5 percent contraction caused by the COVID-19 pandemic in 2020, by 2022, global output will remain about 2 percent below pre-pandemic projections. The pandemic has had a devastating effect on per capita income growth, poverty, and inequality, which will linger for a protracted period. Per capita income growth in emerging markets and developing economies is expected to weaken from an estimated 5.1 percent in 2021 to 3.4 percent on average in 2022-23, according to the January 2022 World Economic Prospects. 69. While the uncertainty around the costs and effectiveness of a COVID-19 vaccine make it difficult to calculate its cost-effectiveness, the successful deployment of a vaccine has the best potential to reverse these trends, generating benefits that will far exceed vaccine-related costs. Global experience with immunization shows that vaccines are one of the best buys in public health. Estimated COVID-19 treatment costs from low- and middle-income countries are US$50 for a non-severe case and US$300 for a severe case. The estimated cost of vaccinating 80 percent of the population eligible in Belize is US$6.2 million; even if the vaccine averts 100,000 non-severe cases and no other benefits are considered, the investment will break even. Further, investments to strengthen the vaccine delivery systems generate health and Page 25 of 46 The World Bank Belize COVID-19 Response Project (P177987) economic benefits beyond solely delivering the COVID-19 vaccine. First, investments in last-mile delivery systems to administer the COVID-19 vaccine to remote communities will require strengthening community health systems, which can spillover to the effective delivery of other services, helping close the significant urban-rural gap. Second, as the COVID-19 vaccine is introduced and lockdowns and movement restrictions are eased, patients can continue to access care for other conditions. Third, the economic benefits of slowing down the economic downturn are likely to significantly exceed the US$6.2 million needed to vaccinate 80 percent of the eligible population, leaving aside the immediate health benefits. Fourth, income losses, disruptions in health services, and school closures are likely to generate long-term negative impacts resulting in loss of human capital. Recent simulations suggest that school closures caused by COVID-19 translated into a loss of five percent of the human capital of the current school-age children cohort. This loss is of the same order of magnitude as the average global improvement in human capital of the past decade. Although projections vary and entail significant uncertainty, a vaccine’s economic and health system benefits would be large, and its full social value is likely not reflected in vaccine market prices. 70. Although there are significant gaps in knowledge of the scope and features of the COVID-19 pandemic, it is apparent that one main set of economic effects will derive from increased sickness and death among humans and the impact this will have on the potential output of the global economy. In the Spanish Influenza pandemic (1918-19), 50 million people died -about 2.5 percent of the then global population of 1.8 billion. The most direct impact would be increased illness and mortality on the size and productivity of the world labor force. The loss of productivity caused by illness which, even in regular influenza episodes, is estimated to be ten times as large as all other costs combined, will be quite significant. 71. Another significant set of economic impacts will result from the uncoordinated efforts of private individuals to avoid becoming infected or to survive the results of infection. The SARS outbreak of 2003 provides a good example. The number of deaths due to SARS was estimated at “only” 800 deaths, resulting in economic losses of about 0.5 percent of annual GDP for the entire East Asia region, concentrated in the second quarter. People took measures that resulted in a severe demand shock for service sectors such as tourism, mass transportation, retail sales, and increased business costs due to workplace absenteeism, disruption of production processes and shifts to more costly procedures. Prompt and transparent public information policy can reduce economic losses. 72. A last set of economic impacts are those associated with Governments’ policy efforts to prevent th e epidemic, contain it, and mitigate its harmful effects on the population. These policy actions can be oriented to the short, medium, or long-term or in spatial terms at the national, regional or global levels. 73. A key risk that could potentially increase the economic impacts of COVID-19 is an intensification of the pandemic domestically and abroad. Further spread of the pandemic in the United States and Europe could delay tourism recovery, while further spread in Belize could lead to more stringent social distancing and hurt activity in contact-intensive sectors. There could also be delays in reaching widespread inoculation, further delaying the tourism recovery. Protests by public sector workers against the reduction in wages could disrupt activity. Belize also remains highly vulnerable to natural disasters. Materialization of some of these downside risks would further tighten financial conditions, weaken economic activity, delay the recovery of revenues, postpone the unwinding of pandemic-related expenditures, and accelerate the fall in international reserves. On the upside, rapid vaccine distribution could revive economic activity earlier than expected. B. Fiduciary 74. Fiduciary risks for this Project are rated Substantial. The procurement and financial management (FM) risks initially assessed for the project cover risks associated with the procurement and distribution of vaccines, including fraud and corruption risks. Page 26 of 46 The World Bank Belize COVID-19 Response Project (P177987) (i) Financial Management (FM) 75. A FM assessment44 was conducted by the Bank in December 2021 to evaluate the adequacy of the FM arrangements for the implementation of this Project. The Project will be implemented by the MOHW PPPMU, including FM aspects. Accordingly, the MOHW PPPMU will be responsible for the following FM aspects: budget, accounting, financial reporting, funds flow and disbursement arrangements, and audit. The PPPMU is staffed with a qualified project accountant and procurement manager assisted by two project officers. The PPPMU will be strengthened as indicated in (a) below. 76. Belize’s public FM system has been strengthened over the past decade but still suffers from gaps often found in small states. Belize has a robust budget preparation system and strong budget execution controls facilitated by SmartStream (the IT-based budget execution, reporting and accounting system). Belize has a strong commitment control function (Funds Control module) through SmartStream and has achieved significant progress in using electronic banking channels for disbursements. However, accountability over public funds is weak due to the delays in submitting audited financial statements. The Project will benefit from using the country system in budget preparation and execution controls but will rely on independent private audit firms to conduct an external audit of the Project’s financial statements. 77. Key Project FM risks and mitigation measures are: (i) lack of institutional fiduciary experience of the implementing agency in Bank-funded projects; (ii) deficiencies in controls over the reception, storage, and deployment of vaccines; and (iii) due diligence and documentation to determine the scope of activities which will be eligible for retroactive financing. Mitigating measures include: a. Leveraging and strengthening the capacity established in the MOHW PPPMU. The PPPMU has considerable experience implementing donor-financed projects. Despite this existing experience, this Project will be the first Bank-financed investment project implemented by the MOHW. The PPPMU will be strengthened with recruiting a senior accounts officer to complement staffing and ensure adequate fiduciary capacity throughout the Project implementation. The PPPMU will be provided with training on the Bank’s FM and disbursement procedures and guidelines as well as close FM implementation support. b. Internal Controls over vaccines deployment are maintained at several distribution levels and will be documented in the POM. The GoB has adapted its health information system to accommodate the electronic entry of vaccination data, which allows for near real-time tracking of vaccination progress. In addition, and to enhance internal controls, an expanded term of reference of the Project’s external audit will be required to ensure adequacy of internal controls to receive, store, record, and deploy vaccines. c. The team reviewed the proposed activities supported by the retroactive financing and confirmed that they are aligned with the Project’s development objective (procurement of vaccines and vehicles for immunization). All contracts proposed for retroactive financing under this Project will be subject to the Bank’s procurement review to determine if they meet the Bank’s eligibility criteria for retroactive financing. The GoB has agreed to provide the Bank with the complete list of contracts to be considered for retroactive financing, with corresponding procurement methods and payment amounts and records, enabling the Bank to determine the eligibility of such contracts for retroactive financing as well as to assess the financial management arrangements in place. The Bank’s due diligence would include, among others, that payments conform to the contract and made according to the conditions of the contract and within the time eligible for retroactive financing, that suppliers, consultants, and contractors sign the Letter of Acceptance of the Bank’s Anticorruption Guidelines and Sanctions Framework and comply with the Bank’s right to inspect and audit as deemed necessary. Documentation and reimbursement of retroactive expenditures will be based on a Statement of Expenditure (SOE). In addition, and to enhance ex-post oversight and assurance, an expanded 44 Following FM Manual for Bank-Financed Investment Operations, issued February 10, 2017. Page 27 of 46 The World Bank Belize COVID-19 Response Project (P177987) term of reference of the Project’s external audit will be required to ensure that the eligibility criteria of retroactive expenditures have been satisfied. 78. The FM assessment concluded that the MOHW has adequate capacity to implement the project funds. With the mitigating measures described, it is expected that the Project will have adequate FM arrangements that should provide, with reasonable assurance, accurate and timely information on the status of the funds as required by the Bank. With the implementation of the mitigating measures, the residual FM risk is Substantial. Summary of FM & Disbursement Arrangements 79. Planning and Budgeting. The preparation of the annual work plan and budget will be under the procedures established by the MOHW PPPMU in consultation with the Director of MCH, who is responsible for the vaccination program, and the Chief Executive Officer responsible for the MOHW. The PPPMU will be responsible for: (i) budget formulation and allocation in accordance with the annual plan, (ii) proper recording of the approved budget in the government’s system, and (iii) timely recording of commitments and payments to allow adequate budget monitoring. Analysis of significant variations of actual expenditures to budget will be conducted by the PPPMU and reported to the Bank along with the quarterly financial reports. 80. Accounting and Financial Reporting. The project funds, expenditures, and resources will be accounted for using the government’s computerized accounting software (SmartStream), and the basis of accounting will be cash basis. The PPPMU will also use another computerized accounting software (QuickBooks) to record and report on project activities. The chart of accounts for this Project will be integrated into both QuickBooks and Smart Stream based on Project components and eligible expenditures. Controls over preparation and approval of transactions will be included in the FM chapter of the Project’s Operations Manual. Invoices are entered in the SmartStream system with reference numbers, approved, stamped, paid, and filed along with the supporting documentation for payment. Contract payments require a payment certificate verified by the personnel supervising the activity, verified by the PPPMU Director, and authorized for payment by the Chief Executive Officer. Payment in SmartStream will be approved by Director and Project Accountant or Accountant General Office with direct approval by the Accounting Officer. The Project Accountant will prepare bank reconciliations, and the Ministry of Finance reviews them. 81. The PPPMU will be responsible for producing and submitting the quarterly interim financial reports (IFRs) to the Bank within 45 days from the end of each quarter. In addition to the quarterly financial reporting, the PPPMU will prepare annual project financial statements, which will include the Project’s sources and uses of funds; a detailed analysis of project expenditures; a schedule of withdrawal applications presented during the year; a reconciliation of the Designated Account (DA), and notes to the financial information. The annual financial statements will be audited by private audit firms and submitted to the Bank within six months from the end of each fiscal year. 82. Internal Controls. MOHW PPPMU must comply with local requirements related to FM, including internal controls and internal procedures. In addition, the Project’s FM tasks and activities will be guided by the FM chapter of the POM, which will include project-specific FM procedures and processes including: (i) roles and responsibilities of the FM staff; (ii) internal controls including procedures to manage and control vaccines, assets and supplies acquired with loan proceeds; (iii) content and format of the IFRs and financial statements; and (iv) auditing arrangements. The FM procedures will be an integral part of the POM which will be reviewed and cleared by the Bank. 83. Internal controls over deployment of COVID-19 vaccines. The GoB has adequate internal controls and adapted its health information system to accommodate the electronic entry of vaccination data, which allows for near real-time tracking of vaccination progress. Vaccines are initially stored at the NVSF in the capital Belmopan. When vaccines are received, vaccines technicians secure all relevant accompanying documentation (e.g., invoice, certificate of analysis) within the supply chain management system. COVID-19 vaccines are distributed by MOHW vehicles (or by air or sea transport where land transportation is not an option (e.g., Cayes) to the six districts according to available quantities, the Page 28 of 46 The World Bank Belize COVID-19 Response Project (P177987) regional distribution of target populations, and the orders districts place with the NVSF via hard copy or the BHIS electronic supply chain management module. Once the vaccines are picked up, the person receiving the vaccines, signs a hard copy form, documenting the name of the vaccines, manufacturing company, batch number, lot number and quantity of vaccines issued. These signed forms are filled in chronological order. The receiving districts would then need to accept the quantity dispensed by the vaccine technician and are responsible for accounting, maintaining, and keeping documentation for vaccines according to store orders. When the dose administered to a person is documented in the BHIS, the dose is deducted from the actual vaccine stock in the immunization module of the BHIS. The MOHW produces a report daily, by the vaccination site (facility or mobile vaccination team), which allows for checks and balances of the doses administered. The vaccines are stored in walk-in coolers at required temperatures, monitored through an electronic temperature monitoring system managed by PAHO through beyond wireless technology, and there is a paper trail of temperature monitoring twice a day for each equipment. In addition, alerts of temperature issues are sent for verification to select phone numbers 24/7. The reconciliation of vaccines is done via physical count of stock vs. BHIS stock. The reporting procedures are done in real-time and shared with relevant parties. The actual stock count is always readily available. Finally, vaccine shipments to the districts accommodate an estimated 10 percent wastage. Wastage due to expiration or any other form requires the destruction of the vials following public health regulations. A document detailing wastage is produced, and public health inspectors oversee the process. The PPPMU files and shares a copy of destroyed vials with the Ministry of Finance and maintains a copy for the Project records. 84. In addition to the above, and to further enhance accountability, an expanded Terms of Reference (ToR) of the Project’s external audit will be required to verify and report on the adequacy of internal controls to receive, store, record and deploy vaccines. 85. External Audit. Annual audit reports (or other period agreed with the Bank) on project financial statements, including management letters, should be submitted to the Bank within six months after the end of the Borrower’s fiscal year (March 31). The audit should be conducted by an independent audit firm acceptable to the Bank, following international auditing standards, and under terms of reference approved by the Bank. The selection of the audit firm should be performed following Bank’s procurement procedures. The cost of the external audit may be financed out of loan proceeds. Audit report and audited financial statements will be disclosed to the public in accordance with the Bank’s policy on access to information. The PPPMU will prepare the auditors’ terms of reference, which will be reviewed by the Bank and will include an expanded term of reference to provide an opinion on the eligibility of retroactive expenditures verify the adequacy of internal controls to receive, store, record and deploy vaccines financed under the loan. The Project’s first audit will cover retroactive and regular expenditures incurred as of March 31, 2022 and will be due to the Bank within six months from the end of such period. 86. Flow of funds and Disbursement Arrangements. Bank’s loan proceeds will follow the Bank’s disbursement policies and procedures as described in the Disbursement and Financial Information Letter (DFIL) and Disbursement Guidelines for Investment Project Financing. All withdrawal applications will need to be signed off by the Government's authorized representatives via the Bank’s Client Connection. The Project will use advances, direct payment and reimbursement methods for disbursements. For advances, disbursement would be channeled through a segregated DA denominated in U.S. dollars, which the MOHW will maintain at the Central Bank of Belize. Advances to the DA would be made based on the forecast of eligible expenditures for a six-month period, up to a fixed ceiling as defined in the DFIL. As eligible expenditures are incurred, the PPPMU would withdraw the amount to be financed by the Bank from the DA in accordance with the Financing Agreement. The PPPMU would operate a local currency account at a financial institution acceptable to the Bank to finance project expenditures in local currency, where funds from the U.S. dollar DA would be periodically transferred. The Disbursement deadline is four months after project Closing Date specified in the Loan Agreement. The MOHW PPPMU will prepare a SOE when payments are processed to report to the Bank. Expenditures financed by the loan will be documented using SOEs. The loan will retroactively finance up to 70 percent of the loan Page 29 of 46 The World Bank Belize COVID-19 Response Project (P177987) proceeds for reimbursement of eligible expenditures consistent with the PDO, incurred prior to the loan signature specified in the Loan Agreement. 87. FM implementation support will include on-site and off-site supervisions. At project inception, training sessions will be provided to project FM staff on the Bank’s FM and disbursements procedures. If circumstances permit, on site missions will be carried out twice a year and calibrated based on assessed risks and project performance. In case of lack of physical access to project facilities once implementation begins, virtual FM implementation support monitoring will be conducted using information technology (IT) tools. Off-site implementation support will comprise review of progress reports, supporting documentation, bank reconciliations, FM system, IFRs, audit reports, and management letters. (ii) Procurement 88. Procurement under the Project will be carried out in accordance with the Bank’s Procurement Regulations for Investment Project Financing Instrument (IPF) Borrowers for Goods, Works, Non-Consulting and Consulting Services, dated November 2020. The Project will be subject to the Bank’s Anticorruption Guidelines, dated October 15, 2006, revised in January 2011, and as of July 1, 2016. The Project will use the Systematic Tracking of Exchanges in Procurement (STEP) to plan, record and track procurement transactions. 89. The major planned procurement under the Project will include: (i) purchase of vaccines and medical supplies/kits; (ii) vehicles and related operating costs; (iii) demand creation – including mass media and communication campaigns; (iv) training; (v) HIS; (vi) IT equipment; and (vii) medical equipment. Retroactive financing will cover the procurement of vaccines and vehicles. 90. The key procurement risk associated with vaccines relates to: (i) the complexity of the vaccines market given the significant market power enjoyed by vaccine manufacturers; (ii) inability of the market to supply adequate quantities of vaccines to meet the demand; (iii) the limited market access due to advance orders by developed countries; (iv) weak bargaining; and (v) delays in triggering emergency procurement procedures at the country level, which could delay procurement and contract implementation, including payments. However, these risks are substantially mitigated since the MOHW has set up agreements with COVAX and AVAT facilities for vaccine purchases. A significant number of doses have already been delivered or are on the way. The Bank requested to review the contracts signed between the GoB and UNICEF/PAHO, following the Agreement signed with COVAX and AVAT facilities to ensure the eligibility for retroactive financing and necessary future acquisition. If the GoB confirms the purchase of any additional doses of the vaccine with other manufacturers, those contracts will also be reviewed. 91. Other main risks are related to the vaccine deployment and acquisition of PPE, tests for COVID-19 diagnosis, syringes, and other medical supplies, vehicles, and any related procurement need related to support COVID-19 immunization campaign and the development and distribution of risk communication products for COVID-19 vaccination, including communication on the risks and climate shocks and ensuring adequate medical waste management. 92. A simplified procurement capacity assessment was prepared by the Bank in December 2021 and found the proposed procurement arrangements satisfactory subject to implementation of the proposed mitigation measures. A short form of the Project Procurement Strategy for Development (PPSD) and the Procurement Plan were also prepared. All remaining risks were addressed in the PPSD and will be mitigated by providing options to support the country’s needs. 93. The procurement risk is Substantial. The Bank’s oversight of procurement will be done through increased implementation support. The Bank’s standard prior and post review arrangements apply as specified in the procurement plan. Page 30 of 46 The World Bank Belize COVID-19 Response Project (P177987) C. . Legal . Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . 94. By supporting the Project, the Bank does not intend to make any judgment on the legal or other status of the territories concerned or to prejudice the final determination of the parties’ claims. D. Environmental and Social Standards 95. The combined Environmental and Social Risk Classification is Substantial given the emergency context of the pandemic, inherent occupational and community health and safety risks, issues associated with biomedical waste management and limited capacity of the implementing agency with the Bank’s Environmental and Social Framework. 96. The environmental risk is considered to be substantial. The potential environmental and human health risk associated with the Project are: (i) community health and safety risks from inadequate handling, storage, transportation, and disposal of infected medical waste and expired and used vaccine vials; (ii) occupational health and safety impacts related to the availability, supply, and appropriate use of PPEs; and (iii) health care waste management and disposal. 97. The social risk is considered substantial. The potential social risks are related to: (i) challenges in ensuring distribution of the vaccines inclusively and equitably so that socially vulnerable and disadvantaged people can adequately share in the benefits of the Project. These include Indigenous Peoples, people living in extreme poverty, the elderly, people living with disabilities, people in the LGBTQ community, people living with HIV/AIDS and those with underlying medical conditions and migrants; (ii) challenges in service and supply delivery to rural and remote areas of the country (iii) inadequate public engagement and consultation regarding the vaccine delivery rollout, including lack of reliable, pertinent, well-timed, and culturally appropriate information in terms of its safety or effectiveness; (iv) lack of enforcement of measures at vaccination sites to avoid crowding and contagion; and (v) inadequate management of needles, sharps, PPEs, and other materials left over from the vaccinations that could put community members at risk if not properly disposed of. 98. Seven Environmental and Social Standards (ESSs) are considered relevant. These are: ESS1, ESS2, ESS3, ESS4, ESS7, ESS8 and ESS10. To manage the environmental and social risks and impacts the MOHW will prepare an ESMF as early as possible, but no later than 60 days after project effectiveness, which will include actions keeping in line national and WHO standards as well as the Bank’s Environmental Health and Safety General and Specific Guidelines. The ESMF will include Labor Management Procedures (LMP) detailing the rights and protections for project workers, as well as a labor grievance mechanism. A draft SEP has been prepared to outline MOHW’s outreach efforts to a wide range of stakeholders (including the most vulnerable). The SEP includes a GRM for addressing any concerns and grievances raised that are related to the Project and elements of an Indigenous Peoples Planning Framework (IPPF) to outline principles and practices that ensure full uptake of Project benefits by Indigenous Peoples. The draft ESCP and SEP were disclosed on the MOHWs website prior to consultations in December 2021 and on the Government of Belize Press Office45 on February 10, 2022 and on the Bank’s website on January 10, 202246. The SEP will be finalized and disclosed within one month of Project effectiveness. As the Project includes retroactive financing for vaccines already deployed, a rapid Environmental and Social Due Diligence Review will be carried out before retroactive financing can be disbursed. 45https://www.pressoffice.gov.bz/belize-covid-19-emergency-response-project-bcerp/ 46https://documents.worldbank.org/en/publication/documents- reports/documentdetail/099900001102241830/stakeholder0en0e0project000p177987 Page 31 of 46 The World Bank Belize COVID-19 Response Project (P177987) 99. Although project activities will be carried out against a backdrop of vaccine hesitancy in certain pockets of Belize, stakeholder engagement has been a central feature of the country’s vaccination campaign to date. The current VIP is backed up by the implementation of communication strategies. The MOHW has consistently promoted vaccines using multiple media (e.g. phone, text, billboards, radio and television), and is expected to continue playing a central role in consultations going forward. Concrete actions taken to engage and consult with indigenous peoples and other vulnerable groups, as a subset of all those eligible for vaccination, have included dialoguing with both national indigenous people organizations and traditional authorities on the ground, to review and agree on strategies to mitigate the lack of information (or circulation of misinformation) within those communities. The draft SEP developed for the Project and adopted by MOHW takes account of these and related efforts in outlining a systematic approach to stakeholder engagement during Project implementation. Consultations on the Project with several stakeholders took place December 10-13, 2021. Key stakeholders that participated included: frontline health care workers; members of other interested parties (e.g. PAHO/WHO, Belize Chamber of Commerce and Industry, United Nations Development Programme Belize), and members of vulnerable groups such as National AIDS Commission, Autism Belize, Toledo Alcaldes Association and Belize National Indigenous Council. During the sessions, personnel from the MOHW presented an overview of the objectives, components and activities of the Project, the stakeholder engagement plan and the GRM. Feedback received during the consultations was positive and constructive. 100. Note on the risks from the use of government security personnel: The use of security forces in the vaccination efforts under the Project is not envisioned in Belize. Security forces (Belize Police Department) may be deployed on an ad- hoc basis, for example, to coordinate if large crowds gather in front of vaccinations centers. For such cases, the measures outlined in the Environmental and Social Commitment Plan (ESCP) will be followed and in a manner consistent with applicable national law. 101. Note on vaccines donations: all Bank’s vaccine requirements under the Project (e.g., VAC, data protection, no forced vaccination) as well as general requirements for Bank-financed projects (Anti-corruption Guidelines, Environmental and Social Framework, ESF) apply for donations, with the exception of procurement regulations if no financing is provided for that. VI. GRIEVANCE REDRESS SERVICES 102. Communities and individuals who believe that they are adversely affected by a Bank supported project may submit complaints to existing project-level GRMs or the Bank’s GRS. The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the Bank’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of Bank non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the Bank’s corporate GRS, please visit: http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the Bank’s Inspection Panel, please visit www.inspectionpanel.org. VII. KEY RISKS 103. The Project’s overall risk rating is Substantial as Belize has already achieved over 50 percent immunization rate and has secured most of the vaccines to achieve the immunization target in their VIP (with the exception of vaccines for people aged 5-11). Moreover, achieving high immunization rate is critical for the GoB to achieve economic recovery; hence it will be prioritized. The GoB is also benefiting from the support from multiple partners and governments to scale up COVID-19 immunization efforts, with increasing donations, grants and technical assistance availed to countries. Finally, while this is Page 32 of 46 The World Bank Belize COVID-19 Response Project (P177987) the first Bank-financed project with MOHW, they have worked with other partners such as the IDB and are thus familiar with similar requirements and procedures. Specific risks are discussed below. 104. The macroeconomic risk is Substantial. Belize entered the COVID-19 pandemic with high public debt, external vulnerabilities, and low economic growth. The pandemic brought additional pressures on multiple fronts; led to a sharp drop in tourism and manufacturing and has led to an increase in poverty and unemployment. While the macroeconomic situation is expected to improve, key risks remain related to the increasing public debt, lower overall revenue, and higher expenses to continue fighting the COVID-19 pandemic, including the immunization program. The emergence of new COVID-19 variants, potential future outbreaks, and the need to potentially institute additional lock down periods may further impact on the country’s economy. Coupled with higher oil prices and exposure to extreme climate-related shocks which may delay COVID-19 vaccines deployment, Belize has a substantial overall macroeconomic risk. Improving the business climate and protecting the most vulnerable remains a policy priority. The risk is mitigated taking into consideration the GoB’s commitment to prioritize immunization as a way to stabilize the economy. 105. Fiduciary risks are Substantial. The Procurement and FM risks result from risks associated with the procurement and deployment of the vaccines, including fraud and corruption risks. For procurement, many of the risks (such as the complexity of markets, demand over the availability, limited access, weak bargaining, etc.) are already mitigated, since the MOHW has set up agreements with COVAX and AVAT facilities for vaccine purchases and a large number of doses have already been delivered or are on the way. The Bank requested to review the contracts signed between the GoB and UNICEF/PAHO, following the Agreement signed with COVAX and AVAT to ensure the eligibility for retroactive financing and necessary future acquisition. If the GoB confirms the purchase of any additional doses of the vaccine with other manufacturers, those contracts will also be reviewed. The key FM risks are: (i) lack of institutional fiduciary experience of the implementing agency in Bank-funded projects; (ii) deficiencies in controls over reception, storage, and deployment of vaccines; and (iii) due diligence and documentation to determine the scope of activities which will be eligible for retroactive financing. The Project activities will be carried out in accordance with the OVDDM which will be prepared and adopted by the GoB within 60 days from project effectiveness. The risks of not having the OVDDM by Project effectiveness are not deemed significant, as a well-developed VIP and the District Vaccine Deployment Plans currently guide the transport, storage, and deployment of COVID-19 vaccine and the largest share of expenditure is for vaccine procurement. 106. The overall Environmental and Social risks are Substantial. Key environmental and social risks include: (i) environmental and community health related risks from inadequate handling, storage, transportation, and disposal of infected medical waste and expired and used vaccine vials; (ii) occupational health and safety impacts related to the availability, supply, and appropriate use of PPEs; (iii) community health and safety exposure risks in the immediate vicinity of health care facilities and vaccination centers; (iv) pollution and human health and safety risks stemming from cleaning and disinfection products, chlorine, and other hazardous byproducts; and (v) exclusion of marginalized and vulnerable social groups from access to vaccines, facilities, and services designed to fight against the disease, among others. To manage the risks under the retroactive financing, due diligence/audit will be conducted to confirm: (i) biomedical waste management practices; (ii) presence and effectiveness of a GRM; (iii) inclusion; and (iv) occupational health and safety. If the findings identify gaps, the Borrower will prepare and implement an Action Plan. In addition, if security forces (Belize Police Department) are deployed, the measures outlined in the ESCP will be followed and in a manner consistent with applicable national law. An ESMF will be prepared for the Project, containing provisions for storing, transporting, and disposing of contaminated medical waste, and outlining guidance in line with international good practice and WHO’s standards on COVID-19 response on limiting viral contagion in health care facilities. 107. Other risks – vaccine hesitancy and risks from natural disasters are rated Substantial. Vaccine hesitancy risks may hamper the ability to reach the immunization target tracked by the Project. This risk will be mitigated through outreach delivery efforts and communication campaigns to inform the population that the Project will support. Belize is also very vulnerable to natural disasters; these would lead to significant negative impacts on the economy and society as a whole, Page 33 of 46 The World Bank Belize COVID-19 Response Project (P177987) potentially slowing down deployment activities for COVID-19 vaccines due to disruptions to the logistics system, inability to reach certain areas, disruptions to health facilities and critical inputs such as human resources and medical supplies. . Page 34 of 46 The World Bank Belize COVID-19 Response Project (P177987) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Belize Belize COVID-19 Response Project Project Development Objective(s) To support the Government of Belize in the acquisition and deployment of Project COVID-19 vaccines. Project Development Objective Indicators RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target To support the Government of Belize in the acquisition and deployment of COVID-19 vaccines. Eligible population fully vaccinated (Percentage) 19.00 75.00 Eligible male population fully vaccinated (Percentage) 19.00 75.00 Eligible female population fully vaccinated (Percentage) 19.00 75.00 PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target COVID-19 Response COVID-19 vaccines that meet the VAC procured (Number) 0.00 375,000.00 Page 35 of 46 The World Bank Belize COVID-19 Response Project (P177987) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Mobile visits to the rural areas to strenghten COVID-19 0.00 1,600.00 immunization (Number) Increase in frontline workers knowledge about gender based 0.00 75.00 violence (GBV) (Percentage) User satisfaction survey conducted and findings used to adjust the Belize vaccination strategy (Yes/No) No Yes IO Table SPACE UL Table SPACE Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: Number of people aged 5 and above Routine health who are fully vaccinated Quarterly BHIS MOHW Eligible population fully vaccinated information system (excluding boosters). Denominator: Belize’s total population. Numerator: Number of male people aged 5 and Routine health Eligible male population fully above who are fully Quarterly BHIS MOHW information system vaccinated vaccinated (excluding boosters). Denominator: Belize’s male population. Numerator: Number of Routine health Eligible female population fully Quarterly BHIS MOHW female people aged 5 and information system vaccinated above who are fully Page 36 of 46 The World Bank Belize COVID-19 Response Project (P177987) vaccinated (excluding boosters). Denominator: Belize’s female population. ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Number of COVID-19 Administrative COVID-19 vaccines that meet the VAC vaccines that meet the VAC Quarterly Financial reports MOHW data procured criteria financed through the Project. Number of visits through mobile clinics (equipped with a vehicle, health staff, IT equipment for data Administrative Mobile visits to the rural areas to Quarterly MOHW Registry MOHW entry, and operational data strenghten COVID-19 immunization costs to cover for outreach) to strenghten COVID-19 immunization service delivery. Numerator: number of frontline workers (including clinical staff, porters, drivers, etc.) trained of GBV Administrative Increase in frontline workers knowledge related issues as per PAD, Bi-annually MOHW data about gender based violence (GBV) who are able to answer correctly a higher number of questions related to the training after completing it, compared to their answers Page 37 of 46 The World Bank Belize COVID-19 Response Project (P177987) before the training. The number and composition of these questions will be determined during the design of the training. Denominator: number of frontline workers (including clinical staff, porters, drivers, etc.) trained on GBV related issues as per PAD. User satisfaction survey to collect beneficiary feedback conducted and findings reported to User satisfaction survey conducted and relevant MOHW agencies Annually Survey Phone survey MOHW findings used to adjust the Belize (MCH). The MOHW will use vaccination strategy the findings obtained through this feedback to adjust their vaccination deployment strategy. ME IO Table SPACE . Page 38 of 46 The World Bank Belize COVID-19 Response Project (P177987) ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS (as of January 11, 2022) Manufacturer / Name of Vaccine SRA approval WHO EUL 47 WHO Emergency use received Platform NRA of Record Status of assessment listing (EUL) holder for WHO EUL 1. BNT162b2/COMIRNATY United Kingdom: Nucleoside EMA ▪ Finalized: December 31, Tozinameran (INN) December 2, modified mNRA 2020 BioNTech Manufacturing 2020 ▪ Additional sites: GmbH − Baxter Oncology GmbH Canada: December 9, Germany (DP). 30/06/2021 2020 − Novartis Switzerland. United States of 08/07/2021 America: − Mibe (Dermapharm) December 11, Germany (DP). 16/07/2021 2020 − Delpharm, Saint-Remy European Union: FRANCE (DP). 17/09/2021 December 21, − Siegfried Hameln GmbH, 2020 Germany (DP). 11/11/2021 Switzerland: − Patheon Italia S.p.A, Italy December 19, (DP). 07/12/2021 2020 ▪ Shelf-life extension: 09 Australia: January months at -70 to - 90°C. 25, 2021 20/09/2021 − Sanofi-Aventis Deutschland GmbH Germany 06/10/2021 47 https://extranet.who.int/pqweb/sites/default/files/documents/Status_COVID_VAX_23Dec2021.pdf Page 39 of 46 The World Bank Belize COVID-19 Response Project (P177987) ▪ Diluent suppliers: − Pfizer Perth, AustraliaFresenius Kabi, USA 18/06/2021 − Fresenius Kabi, USA 20/09/2021 − Pfizer Manufacturing Belgium 30/11/2021 ▪ Booster dose approved for adults 18 years of age and older 12/17/2021 USFDA ▪ Additional sites: − Pharmacia & Upjohn, Kalamazoo (DP)PGS McPherson (DP) 16/07/2021 − Exelead, Inc. Indianapolis USA 30/09/2021 2. AZD1222 Vaxzevria UK: December 30, EMA ▪ Core data finalized. April 2020 Recombinant 16, 2021 European Union: ChAdOx1 ▪ Additional sites: AstraZeneca, AB January 29, 2021 adenoviral − SK-Catalent Australia: February vector − Wuxi (DS). April 16, 2021 16, 2021 (overseas encoding the − Chemo Spain. April 30, manufacturing); Spike protein 2021 March 21, 2021 antigen of the − Amylin Ohio US (DP). July (for local SARS-CoV-2. 23, 2021 manufacturing by MFDS KOREA ▪ Finalized. Feb 15, 2021 CSL – Seqirus) Canada: February Page 40 of 46 The World Bank Belize COVID-19 Response Project (P177987) 26, 2021 Japan ▪ Finalized. July 9, 2021 MHLW/PMDA ▪ Additional site: − Nipro Pharma Corporation Ise, Japan. 11 October 2021 Australia TGA ▪ Finalized. July 9, 2021 ▪ Additional site: − Siam Bioscience Co., Ltd Thailand. 11 October 2021 COFEPRIS ▪ Finalized. December 23, (Mexico) 2021 ANMAT (Argentina) 3. Covishield Recombinant DCGI ▪ Finalized. Feb 15, 2021 (ChAdOx1_nCoV- ChAdOx1 − DS and DP Manjari Bk Serum Institute of 19) adenoviralvector Pune. 11/12/2021 India Pvt.Ltd encoding the Spike protein antigen of the SARS-CoV-2. 4. COVOVAX™ Recombinant DCGI ▪ Finalized. December 17, COVID-19 vaccine nanoparticle 2021 (SARS-CoV-2 rS prefusion spike Protein protein Nanoparticle formulated with [Recombinant]) Matrix-M™ adjuvant 5. mRNA-1273 USA: December 18, mNRA-based EMA ▪ Finalized. April 30, 2021 2020 vaccine Canada: December encapsulated 23, 2020 Page 41 of 46 The World Bank Belize COVID-19 Response Project (P177987) European Union: in lipid USFDA ▪ Additional Sites. August 6, January 6, 2021 nanoparticle 2021 Switzerland: (LNP) − ModernaTx. Norwood (DS) January 12th, 2021 − Catalent Indiana, LLC (DP) UK: January 8, − Lonza Biologics, Inc. 2021 Portsmouth, USA (DS) − Baxter, Bloomington, USA (DP) MFDS ▪ Finalized. December 23, 2021 6. 1 SARS-CoV-2 Inactivated, NMPA ▪ Finalized. May 7, 2021 Sinopharm / BIBP Vaccine (Vero Cell), produced in Vero ▪ 2 and 5 dose presentation Beijing Institute of (new manufacturing site) -- Inactivated(lnCoV) cells BiologicalProducts Co., Ltd. TBC after ongoing (BIBP) inspection 7. COVID-19 Vaccine Inactivated, ▪ Finalized. June 1, 2021 Sinovac Life Sciences Co., (Vero Cell), produced in Vero ▪ 2-dose presentation. Ltd.Sinovac Life Sciences Inactivated/ cells September 30, 2021 Co., Ltd. CoronavacTM 8. Ad26.COV2.S USA: February 27, Recombinant, EMA ▪ Core data finalized (US 2021 replication- +NL sites). March 12, 2021 Canada: March 5, incompetent ▪ Additional sites: 2021 adenovirus type − Aspen RSA (DP). 25 June European Union: 26 (Ad26) 2021 Janssen–Cilag International March 11, 2021 vectored vaccine − Catalent Agnani Italy (DP). NV Switzerland: encoding the 02 July 2021 March 22, 2021 (SARS-CoV-2) − Grand River Aseptic UK: May 28, 2021 Spike (S) protein Manufacturing Inc., USA. Australia: June 05 Nov 2021 25, 2021 − MSD (Merck, West Point/PA, USA (DP)). 05 Nov 2021 Page 42 of 46 The World Bank Belize COVID-19 Response Project (P177987) 9. SARS-CoV-2 Vaccine, Whole-Virion DCGI ▪ Finalized. Nov 3, 2021 Inactivated (Vero Cell)/ Inactivated Vero COVAXIN Cell Bharat Biotech, India 10. NVX-CoV2373/Nuvaxovid Recombinant EMA ▪ Finalized. December 20, nanoparticle 2021 prefusion spike protein formulated with Matrix-M™ adjuvant Page 43 of 46 The World Bank Belize COVID-19 Response Project (P177987) ANNEX 2: PROJECT COST COUNTRY: Belize Belize COVID-19 Response Project COSTS AND FINANCING OF THE COUNTRY PROJECT Project IBRD or IDA Trust Counterpart Program Components Cost in US$ Financing in US$ Funds Funding million million Component 1: COVID-19 Response US$ 5.8 US$ 5.8 -- -- Component 2: Project Management and Monitoring US$0.4 US$0.4 -- -- Total Costs US$ 6.2 US$ 6.2 -- Total Costs US$ 6.2 US$ 6.2 -- Page 44 of 46 The World Bank Belize COVID-19 Response Project (P177987) ANNEX 3: IMPLEMENTATION SUPPORT PLAN COUNTRY: Belize Belize COVID-19 Response Project I. Institutional Arrangements 1. The MOHW will lead Project implementation. The PPPMU will be responsible for Project implementation with technical support from the MCH and the EPI team. The MCH unit will be responsible for vaccine deployment. The MOHW is Belize’s primary sector ministry responsible for the national health care system (See Figure 3.1 below with the organizational structure of the MOHW). Implementation of project activities are expected to require complementary staffing to ensure adequate monitoring, supervision and reporting throughout the Project. In addition, project activities will be coordinated with support from other partners to avoid duplication of efforts and maximize synergies. Project implementation will also be coordinated with other line ministries and agencies where necessary. The PPMU will be complemented with the following staff that will be financed by the Project: (a) Project Officer; (b) M&E Officer; (c) Environmental and Social Officer; and (d) Senior Accounts Officer. Figure 3.1. MOHW Organizational Structure II. Implementation Support Plan 2. The following implementation support plan reflects the preliminary estimates of skill requirements, timing, and resource requirements over the life of the Project. Keeping in mind the need to maintain flexibility over project activities from year to year, the implementation support plan will be reviewed periodically to ensure that it continues to meet the needs of the Project. Table 3.1 indicates the Bank team’s implementation support plan and the required skill mix. Page 45 of 46 The World Bank Belize COVID-19 Response Project (P177987) Table 3.1. Implementation Support Plan and Skill Mix Time Needed Focus Skills 0–24 months • Setting up additional expertise on • Core team, particularly FM, fiduciary, safeguards, and M&E and procurement, environmental and project management systems. social, M&E specialists. • Staff capacity building of the Project Management Team 3. Skill mix. The skill mix and team composition for supporting project implementation is as proposed in Table 3.2. Table 3.2. Skill Mix and Team Composition No. of Staff Skills Needed Number of Missions48 Comments Weeks Task team leader 12 Three per year Staff in Washington, DC Health Economist 4 Two per year Staff in Washington, DC Operations Analyst 4 Two per year Staff in Washington, DC Health Specialist 4 Two per year Staff in Washington, DC Procurement specialist 3 Two per year, including field travel Staff in Brasilia, Brazil FM specialist 3 Two per year, including field travel Staff in Washington, DC Social and environmental 6 Two per year, including field travel Staff in Washington, DC safeguards specialists 48 Virtual missions will be implemented while restriction to travel be in place. Page 46 of 46