The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 04/29/2021 | Report No: ESRSAFA131 May 04, 2021 Page 1 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Malawi AFRICA EAST Republic of Malawi Ministry of Health Project ID Project Name P176402 Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project Parent Project ID (if any) Parent Project Name P173806 Malawi COVID-19 Emergency Response and Health Systems Preparedness Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 5/13/2021 6/18/2021 Population Financing Public Disclosure Proposed Development Objective To prevent, detect and respond to the threat posed by COVID-19 in Malawi and strengthen national systems for public health preparedness. Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] May 04, 2021 Page 2 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) The proposed additional financing would support the costs of expanding activities of the Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P173806) under the COVID-19 Strategic Preparedness and Response Program (SPRP) using the Multiphase Programmatic Approach (MPA), approved by the Board on April 2, 2020, and the vaccines AF to the SPRP approved on October 13, 2020. The primary objectives of the proposed AF is to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccine deployment in Malawi through vaccination system strengthening and to further strengthen preparedness and response activities under the parent project. The scope and the components of this project are fully aligned with the COVID-19 Fast Track Facility. The changes proposed for the AF entail expanding the scope of activities in the parent project Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402), and the procurement and deployment of vaccines, adjusting its overall design. The proposed AF will also provide an opportunity to address health system and case management gaps such as oxygen therapy with broader potential health system benefits. The project components will remain unchanged with new or scaled up activities incorporated into existing components. It will address critical activities and fill financing gaps that have been identified and are not financed by other partners. Component 1: Emergency COVID-19 Response This component would provide immediate support to Malawi to prevent COVID-19 from arriving or limiting local transmission through surveillance and containment strategies. It would support enhancement of disease detection capacities through provision of technical expertise, laboratory equipment and systems to ensure prompt case finding and contact tracing, consistent with WHO guidelines; strengthening of case management capabilities; and provision Public Disclosure of care for respiratory illnesses including essential medical supplies, oxygen therapy and assisted ventilation. Vaccine procurement and deployment is added as a new subcomponent. (i) Subcomponent 1.1: case detection, confirmation, contact tracing, recording, and reporting (ii) Subcomponent 1.2: health system strengthening (iii) Subcomponent 1.3: vaccination procurement and deployment (new) Component 2: Supporting National and Sub-national, Prevention and Preparedness This component will support strengthening the capacity of the public health system for preparedness and respond to COVID-19 pandemic and to future pandemics and other threats to health security. The financing of this component will target existing institutions such as the EOC within the PHIM as well as new institutions through support for growth of health worker cadres with capacity to respond to EIDs. Component 3: Implementation Management and Monitoring and Evaluation Project Management and Monitoring and Evaluation (M&E). The existing Project Implementation Unit (PIU) of the ongoing Southern African Tuberculosis and Health System Strengthening Project (SATHSSP) will lead coordination of Project activities, as well as fiduciary tasks of procurement and financial management, M&E and environmental and social safeguards. If needed, the PIU will be strengthened by the appointment of additional staff/consultants responsible for specific responsibilities under the Project. To this end, this component will support costs associated May 04, 2021 Page 3 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) with Project management and coordination, monitoring and evaluation, operational reviews to assess implementation progress and logistical support. The component will also support the grievance redress mechanism, including a WhatsApp number to provide feedback and register complaints and other activities in the Environmental and Social Commitment Plan. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] This Additional Financing (AF) has been prepared to scale up the parent project activities to better respond to the COVID-19 threat in Malawi and to prepare the immunization systems for the deployment of the COVID-19 vaccine. The AF will strengthen the national immunization and related health delivery system in a way that will promote an effective COVID-19 response and generate, as far as feasible, long-lasting resilience. The proposed AF to the COVID-19 Emergency Response and Health System Preparedness Project will scale-up selected activities that are included in the Government of Malawi's (GoM) revised COVID-19 Response and Preparedness Plan as well as introduce new activities that are included in the National Vaccine Deployment Plan. The project components will remain unchanged with new or scaled up activities incorporated into existing components: (i) Emergency COVID-19 Response; (ii) Supporting National and Sub-national Prevention and Preparedness; and (iii) Implementation Management and Monitoring and Evaluation. The changes are mainly in Component 1: (i) scale up and add new activities under Subcomponent 1.1 (case detection, confirmation, contact tracing, recording, and reporting); (ii) add new activities under Subcomponent 1.2 (health system strengthening); and (iii) add a new Subcomponent 1.3 focusing on vaccination including (i) Public Disclosure procurement of COVID-19 vaccines to complement financing under the COVAX Facility; and (ii) deployment and related system strengthening. Unlike the Parent Project, the proposed AF will support: (i) well targeted communication campaigns through mass media, social media and community outreach to improve knowledge and correct myths and misconceptions that cause vaccine hesitancy; (ii) track and monitor correct knowledge of COVID-19 vaccination, and identify views, perceptions, norms and attitudes in order to design correct messaging and effective community outreach strategies; and (iii) facilitate civil society and citizen engagement mechanisms for feedback, accountability and grievance redressal. As with the Parent Project, the AF is being implemented nationwide in existing health facilities in urban as well as rural areas across the country. Although no civil works are expected in the AF, the upgrading of existing isolation units and medical facilities is included in Parent Project and have not yet been implemented. These minor works will take place in existing facilities within existing physical footprints. The project is not expected to impact natural habitats or cultural sites and there will be no taking of land. All environment and social risks—such as medical waste, worker safety, SEA/SH, etc.—will be addressed through the updated Environmental and Social Management Framework (ESMF), which sets out environmental and social (E&S) risk assessment requirements of each sub-component/activity (including the management of vaccine transport and distribution and all refurbishments and/or construction). It also provides guidance on the preparation of site-specific Environmental and Social Management Plans (ESMPs) as well as Medical Waste Management Plans (MWMPs). The May 04, 2021 Page 4 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) ESMF includes a section on Occupational Health and Safety (OHS) of workers and relevant aspects of Labor Management Procedures (LMP). It considers national and international protocols for infectious disease control and will include updated provisions on medical waste management. Malawi has identified the management of medical wastes as a challenge through previous World Bank-funded projects such as Southern Africa Tuberculosis and Health Systems Support Project and the Infection Control and Medical Waste Management Plan prepared for that project. The Malawi Standard (MS) 615: 2005: Waste Within Health Care Facilities, Handling and Disposal outlines criteria for segregation, collection, movement, storage and on- site disposal of waste within healthcare units and biological research facilities. Within medical facilities wastes are not fully graded/segregated and Personal Protective Equipment (PPE) for waste handling staff not fully adequate. As municipal waste sites are largely simple dumps without appropriate land-fill techniques most medical waste is dealt with on site. While some of the larger medical facilities have diesel-fired high temperature incinerators, the smaller facilities are using simple chimney incinerators or practicing open burning. Additionally, the lack of diesel often means the high temperature incinerators are not used and open burning is practiced. Ash/sharps pits are usually available but not always used which is particularly problematic with open burning. An additional challenge is the lack of security around medical waste facilities allowing staff, patients and the public free access to open and chimney incinerator sites. D. 2. Borrower’s Institutional Capacity The Borrower is the Ministry of Health and Population (MoHP), which is currently hosting the PIU of the Southern Public Disclosure Africa Tuberculosis and Health Systems Support Project (SATBHSSP – P161791) and the Parent Project COVID-19 Emergency Response and Health Systems Preparedness Project (P173806). The same PIU will manage the AF. The PIU has a full time Environment and Social Safeguard Specialist, a Medical Waste Management Specialist and is in the process of recruiting a Health and Safety Specialist. Health sector delivery constraints. Malawi faces a number of substantial challenges related to quality health service delivery: (i) there are not enough health care workers to cope with the demand for services; (ii) physical infrastructure is overburdened; (iii) outages of essential commodities are not uncommon; and, (iv) implementation of safe management of medical wastes is largely absent. To address the capacity gaps and minimize or avoid environmental and social risks associated with the project activities focusing on technical assistance including works, goods and services to plan, prevent and respond to COVID 19, all related laboratory operations and quarantine facilities and/or emergency operation centers’ activities will need to have and follow an appropriate medical waste management system as well as communication and awareness process during the implementation of the Project. The World Bank has prior experience working with the Ministry of Health and Population (MoHP) through the Malawi Nutrition and HIV/AIDS Project (MNHAP – P156129) and the Southern Africa Tuberculosis and Health Systems Support Project (SATBHSSP – P161791). The Parent Project COVID-19 Emergency Response and Health System Preparedness Project (P173806) is the first World Bank project that the MoHP is implementing under the World Bank Environmental and Social Framework (ESF). As such, the capacity of MoHP to deliver trainings, other capacity building activities as well as environment and social risk management and oversight is still not clear at this stage and there are no lessons yet gleaned from the Parent Project given that it had only commenced its activities. However, the MoHP has already commenced the WHO COVAX program in Malawi and with it is a national vaccine social mobilization and risk communication strategy to conduct communication campaigns for vaccine distribution and provision. May 04, 2021 Page 5 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) In addition, the current Environment and Social Safeguard Specialist has good experience with Environment and Social risk management and has been trained on the ESF. The project also has in place a Medical Waste Management Specialist and are in the process of recruiting an Occupational Health and Safety Specialist. Nevertheless, environment and social capacity gaps will continuously be assessed during implementation and gaps filled as and when needed. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The environmental risk rating for the this project is considered Substantial. The project will have long term positive environmental impacts, as it should improve COVID-19 detection, surveillance, monitoring, treatment and containment prioritized in the Malawi COVID-19 Preparedness and Response Plan. Nevertheless, there is a number of substantial short-term environmental risks that need to be taken into account. The main environmental risks identified are: (i) the Occupational Health and Safety issues related to testing and handling of supplies during treatment as well as due to civil works renovations inside functional health care facilities. The OHS issues are also related to the availability and supply of personal protective equipment (PPE) for healthcare workers; (ii) generation and management of medical healthcare waste; and (iii) community health and safety issues related to the handling, transportation and disposal of hazardous and infectious healthcare waste. As small civil works will only be conducted within existing health facility grounds or other government owned sites, environmental risks associated with these works are expected to be minor and readily mitigated. The civil works under the parent project include Public Disclosure upgrading of existing isolation units and renovations of the Emergency Operations Center office building. These works are anticipated to be minor in terms of works and scale and will take place in within existing facilities, hence individual subproject footprints are expected to be modest, with the risks associated with the operation being moderate. Risks include well understood construction-generated occupational and community health and safety impacts, waste management (from construction, laboratory, disposal of used chemical and material waste), and resource use efficiency. The project will support the procurement of medical supplies including vaccines and deployment of the vaccines, and environmental risks are associated with handling, storage and use of clinical supplies as well as risks linked to operation of the labs or healthcare facilities. Health care waste and chemical wastes (including water, reagents, infected materials, etc.) generated from disease detection capacities to be supported can have substantial impact on the environment and human health. Wastes that may be generated from health facilities/ labs could include liquid contaminated waste, chemicals and other hazardous materials, and other waste from labs/quarantine/isolation centers including sharps used in diagnosis and treatment. All of this requires special handling and awareness as it may pose a risk to health care workers from occupational infections and to the communities if not disposed properly. The project will finance improvements (goods and services) in the collection and disposal of medical waste, including biological, chemical, and material waste (e.g., sharps) in healthcare facilities, labs, field locations, and isolation units where COVID-19 patients are treated. Environmental risks remain substantial during transportation and disposal of such waste if not achieved in line with international good practices and guidelines for healthcare waste acceptance and packaging which will be documented in the ESMF and cascaded into each site’s ESMP. Social Risk Rating Substantial May 04, 2021 Page 6 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) The proposed AF will involve the procurement and deployment of vaccines. Possible social risks may include construction generated occupational and community health and safety impacts, the risk of contagion to local communities, elite capture leading to the exclusion of marginalized and vulnerable social groups, some of whom are already at a greater risk of fatality from COVID-19, such as the elderly and persons with HIV/compromised immune systems, subsequently causing them to be unable to access facilities and services, exclusion of populations based on gender, race, ethnicity, citizenship and refugee status, religion, etc., and inadequate consultations, engagement and communication with diverse stakeholder groups. These risks will be mitigated through measures to ensure vaccine delivery targeting for the most vulnerable populations, particularly women, elderly, people living with disabilities, poor, refugees and noncitizens, and minorities in accordance with ESS 1 and criteria specified in this proposed AF as well as broadened stakeholder consultation, engagement and communications in accordance with ESS10 and in line with GoM’s Social Mobilization and Risk Communication Strategy. The MoHP, in the ESCP, has committed to ensure that ESMPs are prepared and implemented for each construction of isolation/quarantine centres and to the provision of services and supplies based on the urgency of the need, in line with the latest data related to the prevalence of COVID-19 cases. MoHP will use the SEP for consultations and disclosure, ensuring engagement with local communities to provide access to information for all populations, accounting for age, disability, education, gender, sexual orientation, and the existence of pre-existing health conditions, taking cognizance of the fact that no group is homogenous. Part of the government’s plan being financed by multiple partners, comprising communication preparedness activities including developing and testing messages and materials to be used in the event of a pandemic, will ensure that messages are packaged and disseminated in a manner that reaches marginalized and vulnerable social groups. International guidance for COVID-19 identification, prevention and control contains several social risk management measures designed to inform the community of impacts and risks of Public Disclosure the virus, include marginalized people and communities in efforts to manage the spread of the disease and emphasize inclusion of marginalized people and communities, culturally appropriate and two-way engagement. Social norms that expect women and girls to be responsible for domestic work including nursing sick family members are likely to exacerbate the risk of females catching COVID-19 in addition to the psychological, physical and socioeconomic harm likely to be caused by the pandemic. While GBV risk for the AF remains moderate as in the Parent Project, crises do exacerbate social risks including a surge in SEA/SH incidents if restrictions on movement or quarantine measures are in place. Children face additional risks as when schools are closed, girls are less able to access health, hygiene, and protection messaging and their caregiving burdens may increase. The economic impact of public health emergencies may force families to take children, particularly girls, out of school to work, potentially exposing them to risks associated with transactional sex or early/forced marriages. Prevention and response measures, as provided in the Good Practice Note, will include assessment and mitigation of SEA/SH risks and impacts and subproject ESMPs will cascade mitigation measures outlined in the Project’s ESMF including GBV response actions such as mapping of GBV prevention and response actors, outlining a referral pathway, stakeholder consultations, contractor requirements, and redesigning of the GRM to be responsive to SEA/SH. The AF does include the use of security forces. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts May 04, 2021 Page 7 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) Overview of the relevance of the Standard for the Project: The AF will have positive impacts as it will improve COVID-19 surveillance, monitoring and containment as well provision of COVID-19 inoculation. However, the project could also cause substantial environment, social, health and safety risks due to the dangerous nature of the pathogen (COVID-19) and reagents and equipment to be used in the project-supported activities. These include risks associated with transportation and delivery of clinical supplies including vaccine deployment as well as laboratory- or health care facilities associated infections if occupational health and safety standards and specific infectious-control strategies, guidelines and requirements as suggested by WHO are not in place and implemented, leading to illness and death among laboratory workers and communities. Health care facilities which will treat COVID 19 exposed patients and laboratories which will use COVID-19 diagnostic testing will generate biological waste, chemical waste, and other hazardous biproducts and represent pathways for exposure to the virus. Hence, laboratories or clinical facilities supported by the project will increase exposure to COVID-19 that can have the potential to cause serious illness or potentially lethal harm to patients, suppliers, laboratory staff and to the community that may be in contact with the virus. Therefore, effective administrative and infectious-controlling and engineering controls should be put in place to minimize these risks. Procurement and installation of liquid oxygen plants could lead to risks of explosion and that may endanger the neighboring community, hospital workers, and patients in the hospitals. These risks may result from (i) oxygen enrichment of the atmosphere from leaking equipment; (ii) use of materials not compatible with oxygen; (iii) use of oxygen in equipment not designed for oxygen service; (iv) incorrect or incautious operation of oxygen equipment; (v) improper disposal of pressurized containers. The design of these plants, choice of location within the medical facilities, selection of materials used in their maintenance, and training of the medical personnel on use and maintenance will be cognizant of necessary risk management. Social risks may include possible elite capture leading to exclusion of Public Disclosure marginalized and vulnerable social groups, some of whom are already at a greater risk of fatality from COVID-19, such as the elderly and persons with HIV/compromised immune systems and exclusion of population groups outlined in the WHO Framework for Allocation and Prioritization of COVID-19 Vaccination as disadvantaged or vulnerable groups including people living in poverty, especially extreme poverty. homeless people and those living in informal settlements or urban slums, disadvantaged ethnic, racial, gender, and religious groups, and sexual minorities and people living with disabilities, low-income migrant workers, refugees, internally displaced persons, asylum seekers, vulnerable migrants in irregular situations, hard to reach population groups, older adults defined by age-based risk, older adults in high risk living situations (examples: long term care facility, those unable to physically distance), groups with comorbidities or health states (e.g. pregnancy/lactation) determined to be at significantly higher risk of severe disease or death, sociodemographic groups at disproportionately higher risk of severe disease or death, social groups unable to physically distance (examples: geographically remote clustered populations, detention facilities, dormitories, military personnel living in tight quarters, refugee camps), groups living in dense urban neighborhoods and groups living in multigenerational households. There is risk of inadequate consultations, engagement, communication with and information provision to diverse stakeholder groups. There are also risks of exacerbated GBV due to restrictions on movement or quarantine measures in place and which may surge due to the socio- economic pressures caused by the pandemic. Renovation works within existing healthcare facilities are anticipated to have moderate risks as the works are expected to be relatively minor and within existing buildings or campuses. Construction-related risks are well known and are expected to be fully addressed through the ESMF and the site- specific ESMPs. No impacts on land or habitats of conservation value are expected. The AF does not include the use of security forces and as in the Parent Project there is existing health facility based and stores security services from private guards. Risks of exclusion and inadequate consultations and communication are addressed in the project’s May 04, 2021 Page 8 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) design whereby vaccinations will be availed in an inclusive and equitable manner as per the WHO SAGE Roadmap for Prioritizing Uses of COVID-19 Vaccines in the Context of Limited Supply and will be voluntary and free of charge as outlined in the national COVID-19 Vaccine and Deployment Plan with training materials on communication and demand generation being developed to help districts provide targeted information. The messaging will address gender-sensitive issues, emphasize that the vaccine is voluntary and free of charge, and highlight the benefits of the vaccine to increase confidence and uptake. With support from UNICEF, a data collection system was established which includes social media listening and rumor management and assessing behavioral and social data. As misinformation and conspiracy theories remain a concern, there are plans to engage religious leaders and CSOs as well as the media for further outreach. Risks associated with GBV and construction works including occupational health and safety risks associated with construction works are addressed in the updated ESMF and LMP. Infectious medical wastes generated by the health facilities is being managed in accordance with the project’s Infection Control and Health Waste Management Plans (ICHWMP). Regional hospitals have incinerators for the treatment of hospital waste, and rural health facilities take the waste to be treated in the nearest central hospitals or other designated medical waste management facility with functioning incinerator. The increase in medical waste will be taken into account and addressed in the updated ESMF and MWMPs. To manage the risks, the MoHP will update the ESMF and ICWMP to reflect the proposed new activities under the AF, identify additional potential risks and E&S impacts, and outline appropriate mitigation measures based largely on adopting WHO guidance, World Bank Group EHS Guidelines and other good international industry practices (GIIP): - An updated ESMF - The ESMF includes an ESMP template for minor works associated with the rehabilitation of the health facilities; cold chain needs assessment for vaccine transport, storage and distribution and associated mitigation measures, MWMP template; updated LMPs for contracted workers to ensure proper working conditions Public Disclosure and management of worker relationships, OHS, and to prevent potential sexual harassment; and updated GBV/SEA/H Prevention and Response Action Plan as part of the ESMF to propose mitigation measures to address SEA/SH risks related to the AF activities. - An updated ICHWMP. Wastes generated from labs, screening posts and treatment facilities could include liquid contaminated waste, and infected materials require special handling and awareness. Informal disposal may lead to spreading of the virus to nearby communities, as well as contamination of soil and groundwater. ESS10 Stakeholder Engagement and Information Disclosure The parent project had already established a structured approach to stakeholder engagement and public outreach that is based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with combating COVID-19. The client will apply the Stakeholder Engagement Plan (SEP) prepared for the parent project, to engage citizens as needed and for public information disclosure purposes. The SEP has been updated to include more information on the environmental and social risks of AF project activities and new modalities that take into account the need for improved hygiene and social distancing . The updated SEP acknowledges the particular challenges with engaging marginalized and vulnerable social groups such as children and women, persons with disabilities, refugees and noncitizens, minorities and especially those living in remote or inaccessible areas and groups outlined in the WHO Framework for Allocation and Prioritization of COVID-19 Vaccination as disadvantaged or vulnerable groups, while keeping a clear focus on those who are most susceptible to the transmission of the novel coronavirus, such as the elderly and people living with HIV or those with compromised May 04, 2021 Page 9 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) immune systems due to pre-existing conditions. Stakeholder engagement strategies will point out ways to minimize close contact and follow the recommended good hygiene procedures as outlined in WHO guidance. People affected by or otherwise involved in project-supported activities, including different types of health care workers, will be provided with accessible and inclusive means to raise concerns or lodge complaints, via the Health Facility based Grievance Redress Mechanism (GRM) included in the SEP and already set up in the Parent Project. Beyond this, project implementation has been underlined by a strong and well-articulated broader project communication strategy in the project design and as outlined in the national vaccine social mobilization and risk communication strategy, which will not only help with the implementation of the community awareness and behavioral change objectives of the project, but also help in a broader sense to address false rumors about COVID-19, the vaccine and to ensure equitable access to services, and to counteract the isolation and uncertainty that comes from people being kept in quarantine. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This standard is relevant. Most activities of the AF will be conducted by health workers and the rehabilitation work by construction contractors. The Project will involve the use of a range of workers including: Public Disclosure • Direct workers including volunteers and support staff who will be engaged directly by the MoHP to undertake technical assistance, training and capacity building of health workers, testing for COVID-19 as well as procurement and deployment of vaccines. • Contracted workers who may be hired to support implementation including training and capacity building, communications, testing procedures, etc., and undertake the Project-supported minor works. The envisaged works will be of minor scale and thus pose limited risks, but workers will have access to necessary PPE and handwashing stations. Labor influx is not expected. The key risks for project workers (primarily direct and contracted healthcare workers and labor engaged in works within hospitals) is contamination with COVID-19 or other contagious illnesses, which can lead to illness and death of workers. Risky environments include laboratories, hospitals and health care centers, isolation centers and the broader community where project workers may be exposed to the virus. The Project will ensure the application of OHS measures as outlined in WHO guidelines, which will be captured in the ESMF. At this stage the number of workers required in each group is unclear. It is expected that most of the direct workers will be civil servants and therefore subject to their existing contracts but also covered by the OHS provisions of ESS2. Due to the hazardous nature of the work, no children under the age of 18 will be employed on any aspect of the Project. The use of forced labor to carry out any activities is also prohibited. Contracted workers are likely to be a mix of highly skilled individuals and low-skilled construction workers and their contracts should be in line with the requirements of ESS2 including access to OHS, details of hours of work, rest periods and compensation. It is anticipated that existing contract requirements of the MOHP will be aligned with the requirements of ESS2 and this will be confirmed within the first 4 months of project implementation. All of these measures and prohibitions will be documented in labor management procedures (LMP). The MoHP has updated the current parent project Labor May 04, 2021 Page 10 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) Management Procedures (LMP) to make sure it reflects the AF activities and to respond to the specific health and safety issues, and protect workers’ rights as set out in ESS2. Health and safety issues associated with project financed activities will be managed through the ESMF. A grievance mechanism has been made available to all workers to report any issues associated with OHS and / or labor and working conditions. The mechanism includes contact details for submission of grievances, timelines for responses and escalation procedures. ESS3 Resource Efficiency and Pollution Prevention and Management Medical wastes and chemical wastes from the COVID 19 supported activities (drugs, vaccines, clinical supplies and medical equipment) can have substantial impact on the environment or human health. Pollution prevention and management will be an important activity under the Project. Medical waste, including chemicals, contaminated PPE and equipment, and lab testing kits from healthcare facilities will need to be safely stored, transported and disposed. Wastes generated from labs, screening posts and treatment facilities to be supported by the COVID-19 emergency response project could include contaminated waste (e.g. blood, other body fluids and contaminated fluid) and infected materials (water used; lab solutions and reagents, syringes, bed sheets, majority of waste from labs and isolation centers, etc.) require special handling and awareness, as they may pose an infectious risk to healthcare workers in contact with the waste. Each beneficiary medical facility/lab, following the requirements of the ESMF to be prepared for the Project, WHO COVID-19 guidance documents and other good international practices, will prepare an updated ICHWMP to prevent or minimize such adverse impacts as part of the ESMF. This ICHWMP describes in detail the entire process and responsibilities between the generation of the infectious medical waste and its disposal. Public Disclosure The Plan takes account of the specific features of each facility and the available waste management services and systems. Regional hospitals (Kamuzu Central Hospital in the central region and Queen Elizabeth Central Hospital in the south) have incinerators for the treatment of hospital waste, and rural health facilities take the waste to be treated in the nearest central hospitals or other designated medical waste management facility with functioning incinerator. The increase in medical waste will be taken into account and addressed in the updated ESMF and MWMPs. The project has engaged a Medical Waste Management Specialist to support the implementation of the ICWMPs, WMPs, and other relevant protocols for management of hazardous and medical waste, as well as build capacity on good/best practice at the local and national level. The project will mitigate against greenhouse gas (GHG) emissions. Under Subcomponent 1.2, the proposed AF will procure and deploy climate smart oxygen therapy equipment such as energy efficient equipment to reduce net GHG emissions. In addition to procurement of vaccines and cold chain equipment, the project will invest in energy efficient cold storage, solar and other renewable energy technologies to power mobile cold chains for the delivery and distribution. The ESMF and site-specific instruments (ESMPs) for building works on existing facilities will include guidance related to transportation and management or expired chemical products as well as sustainable ways to use environmental resources (water, air, other relevant solutions/reagents). ESS4 Community Health and Safety May 04, 2021 Page 11 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) In line with safety provisions in ESS2, it is equally important to ensure the safety of communities from infection with COVID-19 including increased risk of COVID-19 transmission and adverse events following immunization. As noted above, medical wastes and general waste from the labs, health centers, and quarantine and isolation centers have a high potential of carrying micro-organisms that can infect the community at large if they are is not properly disposed of. There is a possibility for the infectious microorganism to be introduced into the environment if not well contained within the laboratory or due to accidents/ emergencies, e.g., a fire response or natural phenomena event (e.g., seismic). The Infection Control and Medical Waste Management Plan in the ESMF and site-specific ESMPS therefore describes: • how Project activities will be carried out in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (WHO guideline) • measures in place to prevent or minimize the spread of infectious diseases. • emergency preparedness measures, including measures to address and plan for cold chain storage during power outages and natural disasters. Malawi has adequate cold chain storage capacity to accommodate and support roll out of COVID-19 vaccine without interrupting the supply chain for other vaccines. The country has a total vaccine cold chain storage capacity of about 150,000 liters of which 55 percent (~82,500 liters) are used for routine vaccines. It is estimated that the COVID-19 vaccine doses will require at most 36,725 liters of storage space including a buffer of 5 percent. Malawi is further adding 19,048 liters of storage space (with support from UNICEF). Each vaccine transport vehicle as well as vaccine container will have a temperature tag. Vaccines will be stored at +2 to +8 degrees in WHO prequalified refrigerators and cold rooms. Public Disclosure Laboratories, quarantine and isolation centers, and screening posts, will thereby have to follow respective procedures with a focus on appropriate waste management of contaminated materials as well as protocols on the transport of samples and workers cleaning before leaving the work place back into their communities. The project will thereby follow the provisions outlined in the ESMF, noted in ESS1. Secondly, the operation of quarantine and isolation centers needs to be implemented in a way that both the wider public, as well as the quarantined patients, are treated in line with international good practice as outlined in WHO guidelines referenced under ESS1. This includes the following requirements: • Infrastructure: there is no universal guidance regarding the infrastructure for a quarantine facility, but space should be respected not to further enhance potential transmission and the living placement of those quarantined should be recorded for potential follow up in case of illness • Accommodation and supplies: quarantined persons should be provided with adequate food and water, appropriate accommodation including sleeping arrangements and clothing, protection for baggage and other possessions, appropriate medical treatment, means of necessary communication if possible, in a language that they can understand and other appropriate assistance. Further information is also included in the Africa CDC Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in Healthcare Settings. • Communication: establish appropriate communication channels to avoid panic, reduce stigma and to provide appropriate health messaging so those quarantined can timely seek appropriate care when developing symptoms in accordance with national vaccine social mobilization and risk communication strategy . May 04, 2021 Page 12 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) • Respect and Dignity: quarantined persons should be treated, with respect for their dignity, and fundamental freedoms and minimize any discomfort or distress associated with such measures, including by treating all quarantined persons with courtesy and respect; taking into consideration the gender, sociocultural, ethnic or religious concerns of quarantined persons. The project will ensure that there is no forced vaccination in accordance with the national COVID-19 Vaccine and Deployment Plan and that there is prevention and response to any form of Sexual Exploitation Abuse and Harassment by relying on the WHO Code of Ethics and Professional conduct for all workers in the quarantine facilities as well as the provision of gender-sensitive infrastructure such as segregated toilets and enough light in quarantine and isolation centers. GBV risk has been assessed, rated moderate and prevention and response measures outlined in the ESMF. During implementation, the risks of Sexual Exploitation Abuse and Harassment will be re-assessed, ensuring that prevention and response measures are outlined in site specific ESMPs. The project will also ensure via the above noted provisions, including stakeholder engagement, that quarantine and isolation centers and screening posts are operated effectively throughout the country, including in remote and border areas, without aggravating potential conflicts between different groups, including host communities and refugees/IDPs. The AF will not include the use of security forces and as in the parent project and as in the Parent Project there are existing health facility based and national stores security services from private guards. In case project assets are secured by security forces personnel, it will be ensured that the security personnel follow a strict code of conduct and avoid any escalation of situation, taking into consideration the protocols included in the ESMF and SEP, and the guidance provided in the World Bank technical note, “USE OF MILITARY FORCES TO ASSIST IN COVID-19 OPERATIONS Public Disclosure SUGGESTIONS ON HOW TO MITIGATE RISKS”. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Economic or physical displacement resulting from land acquisition is not expected under this AF project. Constructions in the parent project will take place within existing structures and facilities. Any restrictions on land use undertaken or imposed in connection with project implementation will be undertaken through voluntary negotiations between the parties, to the extent possible. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources No construction or rehabilitation activities are expected in this project that could affect protected areas or flora or fauna. Hence, likely impacts of the project on natural resources and biodiversity are low. However, if supplies transportation or medical and chemical wastes generated are not properly disposed of, they can have impact on living natural resources. The procedures to be established in the ESMF will describe how these impacts will be minimized. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities May 04, 2021 Page 13 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) This ESS is not applicable in Malawi as there are no groups that meet the criteria for ESS7 in Malawi. ESS8 Cultural Heritage The AF does not include any activities that entail construction or the the movement of earth. The construction activities in the parent project related to the upgrade of isolation units anticipated in the project are within existing structures and facilities hence the potential for risks to and impacts on cultural heritage are very low. A chance finds procedure will be included in the ESMF and for site-specific ESMPs for the isolation units at Kamuzu International Airport in Lilongwe and Chileka Airport in Blantyre. ESS9 Financial Intermediaries This ESS is not relevant as no financial intermediaries will be used. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No Public Disclosure B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: None IV. CONTACT POINTS World Bank Contact: Toni Lee Kuguru Title: Health Specialist Telephone No: 5327+6806 / 254-20-2936806 Email: tkuguru@worldbank.org Contact: John Bosco Makumba Title: Senior Operations Officer Telephone No: 5338+3243 / 260-21-125-2811 Email: jmakumba@worldbank.org Borrower/Client/Recipient May 04, 2021 Page 14 of 15 The World Bank Additional Financing for Malawi COVID-19 Emergency Response and Health Systems Preparedness Project (P176402) Borrower: Republic of Malawi Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Toni Lee Kuguru, John Bosco Makumba Practice Manager (ENR/Social) Helene Monika Carlsson Rex Cleared on 29-Apr-2021 at 03:53:23 GMT-04:00 Public Disclosure May 04, 2021 Page 15 of 15