The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 04/24/2021 | Report No: ESRSAFA168 Apr 24, 2021 Page 1 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Kyrgyz Republic EUROPE AND CENTRAL ASIA The Kyrgyz Republic Ministry of Health, Ministry of Health and Social Development Project ID Project Name P176054 Kyrgyz Republic Emergency COVID-19 Project - Additional Financing Parent Project ID (if any) Parent Project Name P173766 Kyrgyz Republic - Emergency COVID-19 Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 4/28/2021 5/26/2021 Population Financing Public Disclosure Proposed Development Objective To prepare and respond to the COVID-19 pandemic in the Kyrgyz Republic. Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] COMPONENT 1: EMERGENCY COVID-19 RESPONSE (US$ 31.48 million): This component supports the capacity of the Kyrgyz health system to detect, contain, manage, and treat COVID-19 disease. This component will also finance the Apr 24, 2021 Page 2 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) deployment of COVID-19 vaccines, including vaccine acquisition, systems for vaccine delivery, and follow-up. Supported activities include: Sub-component 1.1 Case Detection, Containment, Confirmation, Recording, and Contact Tracing. The Project supports public health functions related to COVID-19: disease surveillance systems, public health laboratories, and epidemiological capacity for detection and confirmation of cases; active contact tracing; epidemiological investigation; risk assessment; and collection of on-time data and information for guiding decision-making and response and mitigation activities. The Project supports Rapid Response Teams (RRTs) in Bishkek and seven regions by procuring vehicles, equipment, and supplies. The Project also contributes to strengthening testing capacities in designated laboratories through centralized procurement of equipment and supplies. The Project also supports the strengthening of medical points in border points-of-entry with training, personal protective equipment (PPE), and updates to handwashing facilities, restrooms to a basic level. Sub-component 1.2. Health System Strengthening. The Project aims to contribute to strengthening of health system preparedness, improving the quality of medical care provided to COVID-19 patients, and minimizing the risks for health personnel and patients. These objectives will be achieved through the procurement of essential medical goods such as PPE, Intensity Care Unit (ICU) and non-ICU equipment and supplies for hospitals, medicines, and waste management equipment. The Project will also finance repairs and minor modifications in eleven designated hospitals. Eleven designated hospitals will undergo repairs and minor modifications, including the provision and/or repair of handwashing and hygiene facilities, upgrading electrical and plumbing work to safely connect and operate medical equipment, carrying out other emergency repairs to ensure patient and staff safety and infection prevention and Public Disclosure control, and installation of additional doors and partitions to ensure proper isolation of COVID-19 patients. These funds will be advanced to hospitals through the Mandatory Health Insurance Fund (MHIF). Sub-component 1.3. Purchasing and deployment of COVID-19 vaccines. The AF will finance upfront technical assistance to support the Kyrgyz Republic to establish institutional frameworks for the safe and effective vaccine deployment. The AF will also support investments to bring immunization systems and service delivery capacity to the level required to deploy COVID-19 vaccines at scale successfully. The investments are geared towards overcoming bottlenecks identified in the COVID-19 vaccine readiness assessment. The AF will finance goods, consulting services, and non-consulting services needed for: (a) vaccine importing, such as vaccines, customs fees and customs handling services; (b) cold storage of vaccines; (c) transportation of vaccines and vaccination teams; (d) vaccination supplies; (e) training of health workers; (f) vaccine administration services; (g) security of the vaccine deployment chain; (h) infection control in vaccination sites; (i) safe disposal of medical waste generated by vaccination; (j) information systems needed to deploy and monitor vaccines; (k) call center operation; (l) communication services; (m) third-party monitoring of the vaccination effort. COMPONENT 2: IMPLEMENTATION MANAGEMENT AND MONITORING AND EVALUATION (M&E) (US$ 0.67 million). This component supports the capacity of the PIU, located at the Ministry of Emergency Situations (MoES), to coordinate activities with Ministry of Health and Social Development (MoHSD), MHIF, and other entities and manage the financial management and procurement functions of the Project. The PIU was strengthened by the recruitment of additional staff/consultants responsible for the overall administration, procurement, environmental and social safeguards, and financial management. This component also supports the M&E of Project implementation. Apr 24, 2021 Page 3 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) The AF finances activities under sub-component 1.3 (vaccination) for US$ 19.5 million as well as under component 2 (US$ 0.5 million). The AF will not finance new activities under sub-component 1.1 or subcomponent 1.2. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The Parent Project, with a total funding envelope of US$12.15 million, was prepared as part of the emergency response under the COVID-19 Strategic Preparedness and Response Program using the Multiphase Programmatic Approach. It was approved in April 2020. In early 2021, plans were made to provide Additional Financing to enable affordable and equitable access to COVID-19 vaccines, ensure effective vaccine deployment in the Kyrgyz Republic through vaccination system strengthening, and further strengthen preparedness and response activities under the parent project. The original Project includes two components: Component 1: Emergency COVID-19 Response (US$ 11.98 million) and Component 2: Implementation Management and Monitoring and Evaluation (US$ 0.17 million). The AF, with total funding of US$ 20.00 million, will finance vaccination against COVID-19, including vaccine acquisition, systems for vaccine delivery, and follow-up. There are no substantial changes in the activities under subcomponents 1.1 and 1.2. The only significant change is the addition of vaccination-related activities under subcomponent 1.3. (US$ 19.50 million). The AF will also increase the amount of funding available under Component 2 (US$ 0.50 million) to ensure proper implementation management and M&E of AF activities. Public Disclosure The AF seeks to enable the acquisition of vaccines from a range of sources to support the Kyrgyz Republic's objective to have a portfolio of options to access vaccines under the right conditions (of value-for-money, regulatory standards, and delivery time, among other key features). The COVAX facility has developed a framework that will anchor the Kyrgyz Republic's strategy and access to vaccines: on December 7, 2020, the Government of the Kyrgyz Republic entered into an agreement with COVAX to provide vaccines for 20 percent of its population. The proposed IDA financing will build on this to expand the Kyrgyz Republic's access to vaccines. The availability and terms of vaccines remain fluid and prevent the planning of a firm sequence of vaccine deployment, especially as the actual delivery of vaccines is unlikely to be immediate. Instead, the proposed financing enables a portfolio approach that will adjust during implementation in response to developments in the country's pandemic situation and the global market for vaccines. The Bank will support the Kyrgyz Republic in considering the options to access vaccines, but the country will ultimately decide which options to use based on its specific context and needs within the options that satisfy the Bank's VAC. The National Vaccine Deployment Plan approved by the Kyrgyz Government in February 2021 is geared towards planning for the first 20 percent of the population, in line with the expected provision of vaccines through the COVAX AMC mechanism. The initial target groups are health workers, social and education workers, special groups (Ministry of Emergencies, airport, Ministry of Internal Affairs, Customs Service, Border Service, Etc.), population over 60 years of age, population with chronic conditions (cancer, cardiovascular diseases, diabetes, chronic lung diseases, kidney diseases, and obesity). The plan will be updated to include additional groups of the population to the extent that the country secures sources of vaccines and the required financing. Apr 24, 2021 Page 4 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) The AF represents an extension of Project coverage due to the nation-wide introduction of vaccination activities at primary, secondary, and tertiary healthcare organizations and in temporary vaccination points. The measures to address social and environmental risks in the parent project remain relevant, including infection prevention and control improvements in health facilities, such as assessment and mitigation measures for medical waste risk management. To help build the Client's capacity under ESF, the ESF team proposed that the project enhance medical waste management (MWM) at primary health organizations (HO) by potentially equipping selected priority primary HOs with medical waste disinfection and processing equipments. The original project has developed a good foundation for infectious control and medical waste management by operationalizing ICMWM plans for targeted hospitals and for Oblast-level HO (applicable to all levels of HO). D. 2. Borrower’s Institutional Capacity The Ministry of Health and Social Development (MoHSD) is responsible for the coordination and implementation of COVID-19 activities. The implementing agency for this Project is the MoHSD, which will coordinate the implementation of Project activities as well as coordinate them with other agencies. The Deputy Minister of Health assigned to the COVID-19 response is responsible for the oversight of project activities. In addition, other technical divisions at the MoHSD, research institutes, national medical services, regional and local health authorities, village health communities, and other key agencies are involved in project activities based on their functional capacities and institutional mandates. Public Disclosure The Project will continue to rely on the PIU under the Ministry of Emergency Situations (MoES). It will provide implementation and project management support, including procurement, E&S risk management and fiduciary support to the MoHSD. The PIU will directly implement certain technical activities, including procurement of goods, consulting and non-consulting services, and small works (repairs and minor renovation). At present, the PIU is adequately staffed to ensure the effective implementation of social and environmental mitigation measures at all levels of the Project. It employs two specialists, an Environmental Specialist and a Social Development/ Communications (SDC) Specialist to secure compliance with the WB E&S standards. The original project is in the process of hiring an infection control and medical waste management (ICMWM) consultant to develop training modules and conduct offline and online training aimed at all levels of HO. This training will be expanded to cover vaccination-related issues and to cover HOs included in AF activities. Applicable environmental and social standard measures are under implementation and have been rated Satisfactory (January 2021 ISR). The ESMF was developed, reviewed/ approved by the Bank, and disclosed. Delays in recruiting the Environmental and Social Specialists slowed down operationalizing the ESMF in the initial stages. The PIU has prepared and is currently supervising the implementation of the site-specific ESMPs and ICWMPs of 9 participating hospitals. Similar site-specific plans are being prepared for the targeted border points-of-entry sites. Oblast-level ICMWM Plans were developed for HOs that may receive PPEs under the project, and distributed among the HOs. Each target HO has a dedicated ICMWM focal person to ensure compliance with the ICMWM Plan. In general, coordination and roles of key staff responsible for the implementation, including those in the ESF compliance, have been defined and implemented in a satisfactory manner, although with some delay at the beginning of the Project. The lessons learnt from the parent project include: a) A qualified ICMWM consultant played a crucial role by helping to adjust ICMWM plans to local needs to ensure that they can be smoothly monitored by HO focal points. b) It is Apr 24, 2021 Page 5 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) important to conduct refresher training on ICMWM to HO, including through non-traditional means (online, video). c) Given its substantial risk related to ICMWM and wide geographic coverage, the Project would have benefitted from having at least two Environmental and/or ICMWM specialists; and d) The Kyrgyz Republic has an adequate foundation in terms of regulations and processes related to ICMWM, except for deficiencies on MWM at the primary HO level. The format of the ICMWM plan and ESMP prepared under the original Project contributed to capacity building of the Client. The AF represents an extension of Project coverage in the sense that it will include nation-wide vaccination activities at primary, secondary, and tertiary HOs and in temporary vaccination points. Primary HOs are less prepared in terms of medical waste management (disinfection) compared to secondary and tertiary levels HOs. Therefore the Project is considering supplying waste disinfection and management equipment and capacity building to primary HOs. As a result, there will be a need - in addition to PIU Environmental Specialist - to hire additional ICMWM and OHS specialists and consultants for the PIU, who will also help extend training on this subject, including in primary HOs. The Kyrgyz Republic has conducted a vaccine readiness assessment to identify gaps and options to address them and estimate vaccine deployment cost. The country will require additional investment to ensure its readiness for large- scale deployment of COVID-19 vaccination. The country's strengths include the existence of a well-functioning vaccination system through vaccination rooms in PHC centers; expedited regulatory pathways for approval of new vaccines; recent nationwide investments in updated cold-chain equipment (in family medicine centers), and medical waste management equipment (in hospitals); existing surveillance and Grievance Redress Mechanisms; existing financing mechanisms through the Mandatory Health Insurance Fund. The main weaknesses include the low level of Public Disclosure digitalization of health records and lack of adequate electronic registry system for vaccinations; insufficient capacity (both in number and training of staff) in existing vaccination locations in urban areas and rural areas to handle the additional load of COVID-19 vaccination work. The routine vaccination system is also coping with catch-up vaccinations as the national vaccination program was paused twice in 2020 due to the COVID-19 pandemic. While secondary and tertiary healthcare organizations have adequate medical waste management systems in place, mainly using autoclaving and microwave technology, there is a significant gap in PHC organizations. Only 125 feldsher- midwife points (FAP) have waste disinfection equipment, while about 1,000 FAPs rely on chemical disinfection and local incineration. Improvement in medical waste management at PHC organizations will be an integral part of safe vaccine deployment in the short-term. It will have a positive long-term spillover effect on immunization programs in the country. The COVID-19 vaccines will be handled through the existing logistics chain for childhood vaccines. The MOH Department for Disease Prevention and State Sanitary Epidemiological Surveillance (national level) will be responsible for vaccination planning and management. The point of entry will be Manas airport in Bishkek. The Republican Center for Immuno-prophylaxis (RCI) existing fleet of vehicles, complemented with additional refrigerated trucks (recently purchased through UNICEF) will be utilized to ensure the transportation of vaccines from the airport to the national warehouse and from the national warehouse to oblast-level warehouses. From there, the vaccines will be distributed by the MoH to existing rayon-level warehouses. Rayon-level warehouses will retrieve vaccines from the oblast-level warehouses using regular vehicles or ambulances with thermal containers. This exercise will benefit from the recent purchase of vehicles for rayon-level State Sanitary and Epidemiological Surveillance (SSES) departments, financed under the Emergency COVID-19 Project, and from strengthening of capacity that was financed by GAVI in the last two years. Apr 24, 2021 Page 6 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) 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 is rated Substantial mainly because of the issue of infectious control and medical waste. The main environmental risks related to the AF project are: (i) the occupational health and safety issues related to minor repair works at HOs, if required for installation of medical disinfection equipment; (ii) ICMWM and community health and safety issues related to the handling, transportation and disposal of healthcare waste. This includes waste resulting from vaccine delivery such as sharps and the disposal of used and expired vaccine vials financed by the AF. Waste materials generated from vaccination facilities require special handling and awareness, as they may pose an infection risk to healthcare workers or other workers handling the waste. Ensuring contagion vectors are controlled through strict adherence to standard procedures and personal protective equipment (PPE) for all health care workers is critical. In addition to the healthcare waste management information included in the original ESMF and ICWMP guidelines, the Project will revise the ESMF to address specific waste management issues related to the COVID-19 vaccination campaign in accordance with available WHO guidelines. Social Risk Rating Substantial Public Disclosure The proposed AF is anticipated to have positive social impacts both at the individual and community levels as it addresses the health sector responses to the COVID-19 emergency. However, the social risk rating is being upgraded from Moderate to Substantial as the Project will need to address several challenges, mainly related to inclusion and equity: i) the general public may find several difficulties in accessing immunization facilities and services, given the pandemic situation; ii) marginalized and vulnerable social groups, especially in the rural and remote mountainous areas, may find it challenging to access vaccines, facilities, and services as the project activities could be urban- centric; iii) social unrest and conflicts due to limited availability of vaccines and tensions related to the overall difficulties of a pandemic situation; iv) inappropriate data protection measures and insufficient/ in- effective stakeholder communication on the vaccine roll-out strategy; and v) risks associated with Adverse Events Following Immunization (AEFI). The immunization protocols set clear procedures with regard to planning, deployment, storage, and vaccination processes by health professionals. No forced vaccination is permitted and the updated ESMF will define steps to be followed, including getting consent form from each person. An important social risk of vaccination is that marginalized and vulnerable social groups, including women, rural, and disabled populations, may have more barriers to access to COVID-19 information, services, and vaccines. There is a risk that vaccine deployment plans could leave women behind, considering the larger male mortality of COVID-19 and the tendency in many countries to overlook the importance of gender inequalities in social and economic activity. Among health care workers, there is a risk that vaccination may be prioritized among health workers with higher status, disregarding low-paid and volunteer workers, most of them women. Finally, the COVID-19 vaccination campaign may be affected by the distribution of false information. This false information is more likely to negatively influence marginalized and vulnerable social groups who do not have the means of ascertaining the veracity of the received information. The AF will reduce these social risks through a combination of strategies: (i) proactively reaching out to women's group's through a new community engagement platform to both distribute information about COVID-19 Apr 24, 2021 Page 7 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) vaccines and receive feedback from communities; (ii) ensuring all health care workers, independently of their status, are included in the initial phase of vaccination; and (iii) ensuring that verified information on vaccination is made available through formal and informal channels. Overall, most of these impacts and the risks can be contained by an effective and inclusive outreach program encompassing stakeholder engagement throughout the project cycle. In addition, the grievance mechanisms will be in place and equipped to address community, health workers, and/or individual grievances related to such issues. Based on the success of the current national COVID-19 campaign, the AF will expand its scope and information and messages related to the COVID-19 vaccine. The MoH has developed a vaccination campaign communications plan that includes objectives, key messages, proposed communications tools, training plans, and contingency actions. The activities include the preparation and diffusion of audiovisual materials through radio and television, the preparation and publishing of written materials for health workers, posters, and roadside billboards. The MoH will also gather and monitor information through weekly media monitoring reports, engagement of rural health committees through the surveys, and community engagement. The risk of Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) is low to moderate, but the project includes measures to address these risks. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: Public Disclosure The AF will finance activities related to vaccine deployment and improvement of the medical waste management system. Investments in vaccines will prevent new infections and produce economic benefits through saving lives, averting morbidity, and avoiding treatment costs. The measures to address social and environmental risks in the original Project remain relevant, including environmental and social risk related to very minor repair works that could be necessary for primary HOs if medical waste disinfection equipment is supplied under the project, infection prevention and control improvements in HOs, such as assessment and mitigation measures for medical waste risk management that will be expanded as inoculation sites expand. However, the AF-funded procurement, distribution, and administration of vaccines equally can lead to occupational and community health and safety risks, as well as the risks associated with vaccine allocation coverage. To manage these risks, the MoHSD has prepared two major instruments for the Parent Project that will be updated to reflect AF activities. The ESMF updating will include the structure, organizational capacity, and reporting protocols of the Adverse Effect After Vaccination (AEFI) evaluation (M&E) system to be financed by the project. Moreover, the AF will finance upfront technical assistance to support the Kyrgyz Republic to establish institutional frameworks for the safe and effective vaccine deployment. The AF may finance technical assistance, including legal assistance and support in: (i) the establishment of policies related to ensuring that there is no forced vaccination; (ii) the development and approval of an acceptable policy for prioritizing vaccine allocation within the country; (iii) the development of improved pharmacovigilance standards; (iv) updating of standards for vaccine management including cold chain infrastructure; (v) strengthening of accountability, grievances, and citizen and community engagement mechanisms; (vi) the development of a policy/roadmap for management of medical waste at the primary care level; (vi) developing a strategy to manage the final disposal of medical waste from hospitals and PHC facilities. Apr 24, 2021 Page 8 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) The two instruments to be applied under the AF project are: 1. The ESMF, to be updated and disclosed by the AF effectiveness, will include guidelines on safe transportation and storage, and delivery of vaccines, and allocation of vaccines based on WHO guidance including the Values Framework for the allocation and prioritization of COVID-19 vaccination, the Roadmap for Prioritizing Population Groups for Vaccines against COVID-19, and the Fair Allocation Framework. The ESMF updating will also include the structure, organizational capacity, and reporting protocols of the AEFI evaluation (M&E) system to be financed by the project A Vaccine Delivery and Distribution Manual (VDDM) for effective vaccine delivery and vaccination implementation will be included as an annex to the updated ESMF. Measures to ensure the quality of vaccines is maintained throughout the supply chain in accordance with WHO guidance for storage and transportation of vaccines will also be incorporated. Where necessary, existing measures and tools in the ESMF (ESMPs & ICWMPs) will be revised to ensure they fully cover the additional risks associated with the AF-funded activities. 2. The Stakeholder Engagement Plan (SEP) for effective outreach and citizen participation which was prepared under the Parent Project, will be updated to cover AF activities. It will be disclosed by the AF Effectiveness. Additional communication measures financed by the proposed AF will cover information on COVID-19 vaccines and help address potential risks of unfair vaccine access and vaccine hesitancy. The main risks mentioned above must be addressed and mitigated as follow: Medical Waste Management and Disposal. The ESMF under the original Project will be updated to reflect vaccine deployment. As of now, it adequately covers environmental and social infections control measures and procedures Public Disclosure for safe handling, storage, and processing of COVID-19 materials, including the techniques for preventing, minimizing, and controlling environmental and social impacts during the operation of Project-supported medical facilities. It also clearly outlines the implementation arrangements put in place by the MoHSD for environmental and social risk management, compliance monitoring, and reporting requirements, including waste management based on the existing two formats of ICWMP prepared as part of the ESMF. Each targeted healthcare facility will continue to apply infection control and waste management planning following the requirements of the updated ESMF and relevant EHS Guidelines, GIIP, WHO, etc., satisfactory to the Association. To cover the existing gap in medical waste management in terms of waste disinfection in primary HOs, the Project is considering financing medical waste disinfection equipment at priority HOs. This investment will have a positive long-term spillover effect on immunization programs in the country. The updated ESMF will also include recommendations on improving disinfected waste transportation and disposal systems through targeted technical assistance. Worker Health and Safety. Workers in healthcare facilities are particularly vulnerable to contagious diseases like COVID-19. Healthcare-associated infections due to inadequate adherence to occupational health and safety standards can lead to illness and death among health workers and facilitate disease spreading within communities. The ICWMP contains detailed procedures based on WHO guidance, protocols necessary for handling medical waste, and environmental health and safety guidelines for staff and laborers, including the necessary PPE and working conditions. Community Health and Safety. The SEP will continue to serve as a key instrument for outreach to the community at large on issues related to social distancing, higher risk demographics, self-quarantine, and quarantine measures. It is critical that these messages be widely disseminated, repeated often, and clearly understood. Apr 24, 2021 Page 9 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) Vaccine Safety and Efficacy. In the interest of population safety, the AF proceeds can only be used for the procurement of thoroughly tested and approved vaccines. The Project will finance the further development of the new monitoring and evaluation (M&E) system to record the vaccine recipients as well as AEFI. This system will be designed and implemented in line with the WHO Global Manual on Surveillance of Adverse Events. The M&S system will also devote specific attention to data protection concerns and risk of exclusion/elite capture. Vaccine Safe Transportation and Storage. Vaccines are prone to rapid deterioration and ineffectiveness when not stored at the proper temperature, which could lead to high wastage. Administering deteriorated vaccines may be ineffective to outright hazardous. The MOH will implement the National Vaccine Deployment Plan approved in February 2021. The AF will fund necessary investments in cold storage equipment and logistics to enable the safe delivery of vaccines throughout the country, if needed. Vaccine Delivery and Distribution Manual will be developed for the project and will outline vaccine cold chain temperature monitoring, covering the whole chain transport, storage and handling. Vaccine Manual will also include a cold chain monitoring temperature plan. Vaccine Equitable Distribution and Access. Data Privacy. The project recognizes the need for the collection, use, sharing and further processing of data for managing the spread of the virus and aid in accelerating the recovery, especially through digital contact tracing. Several channels could be of help in this-- mobile phones, emails, banking, social media, postal services, for instance. The digital contact tracing may include the collection of vast amounts of personal and non-personal sensitive data which could have significant effects beyond the initial crisis response phase, including, if such measures are applied for purposes not directly or specifically related to the COVID-19 response, Public Disclosure potentially leading to the infringement of fundamental human rights and freedoms. Hence, the project will ensure that any data collection, use and processing shall be rooted in human rights and implemented with due regard to applicable international law, data protection and privacy principles. The protocols to this effect shall be developed drawing upon, among other practices, the UN Personal Data Protection and Privacy Principles and a joint statement issued to this effect by the United Nations, IOM, ITU, OCHA, OHCHR, UNDP, UNEP, UNESCO, UNHCR, UNICEF, UNOPS, UPU, UN Volunteers, UN Women, WFP and WHO, in November 2020. The protocol shall rest on the following key principles: https://www.who.int/news/item/19-11-2020-joint-statement-on-data-protection-and-privacy-in-the- covid-19-response • Law abiding, limited in scope and time, and necessary and proportionate to specified and legitimate purposes; • Ensure appropriate confidentiality, security, time-bound retention and proper destruction or deletion of data in accordance with the aforementioned purposes; • Ensure that any data exchange adheres to applicable international law, data protection and privacy principles, and is evaluated based on proper due diligence and risks assessments; • Be subject to any applicable mechanisms and procedures to ensure that measures taken with regard to data use are justified by and in accordance with the aforementioned principles and purposes, and cease as soon as the need for such measures is no longer present; and • Be transparent in order to build trust in the deployment of current and future efforts alike. ESS10 Stakeholder Engagement and Information Disclosure Apr 24, 2021 Page 10 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) Based on the lessons learned of the national COVID-19 campaign implemented by the Ministry of Health and Social Development (MoHSD) and implementation of the Stakeholder Engagement Plan prepared for the OP, the AF will expand its scope and information and messages related to COVID-19 vaccine. The plan also provide for information about the vaccines themselves, information about the Government vaccine delivery strategies and plans, with a special emphasis on the prevention and mitigation of vaccine hesitancy. The MoHSD has developed a vaccination campaign communications plan, which includes the preparation and diffusion of audiovisual materials through radio and television, the preparation and publishing of written materials for health workers, posters, and roadside billboards. The plan also provide for discussions with the public through an online platform and joint work with volunteers and employees of public organizations. It includes media engagement activities such as briefings, press tours of vaccination sites, roundtables, workshops, and press clubs. The communications plan comprises contingency actions in case of adverse events such as errors in the immunization process, adverse events after vaccination, vaccine rumors, sharp negative voices, and suspension of vaccines either nationally or internationally. Under the AF, communication channels will be expanded by establishing a community engagement platform which is being created at the Republican Center for Health Promotion and Communication. The MoHSD will also gather and monitor information through weekly media monitoring reports, engagement of rural health committees through the RCHPC community engagement platform, and surveys. Third-party monitoring of the vaccination program is also planned. The original Project will continue communication and sensitization activities with the stakeholders identified in the original SEP the Stakeholder Engagement Plan (SEP) prepared under the Original Project. The updated SEP implementation (covering AF project activities) will contribute to the national vaccination campaign communications Public Disclosure plan being implemented by the MoHSD. The SEP will be updated and disclosed by the AF Effectiveness Date. The Grievance Mechanism Unit at the PIU will deal with all the project project-specific grievances received, including the ones received via targeted health organizations. HOs and POEs. The GM will be strengthened through establishing an additional feedback mechanism at the online platform for community engagement. In addition, the grievance mechanisms will also accommodate complaints related to labor and working conditions and SEA/SH. 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 Like the Parent Project, the AF will be implemented in accordance with the applicable requirements of ESS 2, in a manner acceptable to the Association, including through, inter alia, implementing adequate occupational health and safety measures (such as emergency preparedness and response measures), setting out grievance arrangements for project workers, and incorporating labor requirements into the Occupational Health and Safety (OHS) specifications of the procurement documents and contracts with contractors and supervising firms. The Labor Management Procedures (LMP) developed for the original Project will also apply to the AF. The LMP will be updated to reflect the AF activities to respond to the specific health and safety issues, and protect workers' rights as set out in ESS2. Apr 24, 2021 Page 11 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) Healthcare workers play a critical role in the outbreak response and are the backbone of a country's defenses to limit or contain the spread of disease. They face higher risks of potential COVID-19 infection in their efforts to protect the greater community and are exposed to hazards such as psychological distress, fatigue, and stigma. They will be prioritized for early vaccination. Hospital staff, nurses and other frontline workers in this project may be required to work long hours without rest due to the emergency nature of COVID. There is a certain risk that, in accordance with established practice, some of the hours worked will not be counted and workers will not be compensated for overtime. Appropriate mitigation measures are incorporated in the updated LMP. The estimated number of health workers to be covered by the project is 600. The estimated number of volunteers could be around the same number. Worker safety: Healthcare-associated infections due to inadequate adherence to occupational health and safety standards can lead to illness and death among health and laboratory workers. The laboratories to be supported by the Project will process COVID-19 samples, which may expose workers and the community to the virus. and will therefore have the potential to cause serious illness or potentially lethal harm to the laboratory staff and to the community. Therefore, effective administrative and containment controls will be put in place to minimize these risks. Environmentally and socially sound health facilities management will require adequate provisions for minimization of minimize occupational health and safety risks, proper management of hazardous waste and sharps, use of appropriate disinfectants, proper quarantine procedures for COVID-19, appropriate chemical and infectious substance handling and transportation procedures, etc. These measures are covered in the site-specific ICWMPs being prepared based on the template contained in the ESMF and are based on the national healthcare delivery standards and norms set by the MoOHSD in addition to WHO guidance. The current LMP includes this risk and its mitigation measures, the same will be reflected in the ESRS under ESS2. Public Disclosure Under the ongoing Project, the MOH has been implementing the Environmental and Social Management Framework (ESMF), which includes specific instruments on OHS prepared either by the client and/ or the contractor prior to commencement of works (OHS checklists, codes of conduct; safety training, etc.). The PIU has hired dedicated Social and Environmental Specialists who closely monitor compliance to with OHS requirements. These specialists also have been ensuring ensure that , and will make sure that the civil works contractors implement the ESMPs’ social and environmental mitigation measures based as specified in the WBG EHS Guidelines; they continue to do so, per the requirements of and the updated ESMF, and the SEP. All contracts, including civil works and vaccine transportation contracts, will comprise include industry industry-standard Codes of Conduct that incorporate measures to prevent Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH). A locally- based GRM specifically for direct and contracted workers has been in place in each facility/site. The PIU staff regularly collects and analyze the GRM data, is collected and analyzed by the PIU staff on regular basis, although there are some challenges with segregating project Project-specific grievances. The estimated number of health workers is 600. The estimated number of volunteers could be around the same number. ESS3 Resource Efficiency and Pollution Prevention and Management Medical wastes (including water, reagents, infected materials, sharps, etc.) from healthcare facilities can have significant impact on the environment and human health. Each target healthcare facility, following the requirements of the ESMF to be updated for the AF Project, WHO COVID-19 guidance documents, and other best international Apr 24, 2021 Page 12 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) practices, each target HO will updated, if necessary, and follow an Infection Control and Medical Waste Management Plan (ICMWP plan) to prevent or minimize such adverse impacts. Currently, the Project is considering equipping primary HOs with autoclaving technology equipment that does not require a water supply, as compared to micro-wave oven technology that was used under ERIK CERC component in target hospitals. Thus, the risk of wastewater pollution is reduced. Installation of autoclaves will help to prevent local incineration of medical waste at primary PHOs, which is the current practice that is currently often the case. This will avoid us, the emissions from incineration of medical waste. ESS4 Community Health and Safety Medical wastes and general waste from the health care facilities (HOs) have a high potential of carrying micro- organisms that can infect the community at large if they are not properly correctly disposed of. The two formats of Infection Control and Waste Management Plans (ICWMPs) plans prepared under the Parent Project describe: a) how project activities are carried out in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (WHO guideline); b) measures in place to prevent or minimize the spread of infectious diseases; , and c) emergency preparedness measures. These two formats of ICWMPs will be reviewed and revised to ensure they include additional appropriate community health and safety measures to safeguard the public from adverse impacts related to the AF project activities, including monitoring of adverse impacts and side effects of vaccines on recipients of the vaccinations, and handling of Public Disclosure medical waste. The Vaccine Delivery and Distribution Manual (VDDM) to be developed will address the project- related impacts of disproportionate exclusion, prejudice, or discrimination toward individuals or groups in providing access to vaccines and project benefits, particularly in the case of those who may be disadvantaged or vulnerable, as well as not forced vaccination, by defining steps on getting consent from each person. The AF will also invest in safe vaccine transportation and logistics and ancillary supplies (syringes, safety boxes, PPE) for vaccination and strengthening of vaccine delivery systems and management capacity. Only healthcare facilities will be used as vaccination sites, however in rural areas some community centers that conform to the WHO safety requirements might be used for vaccination purposes as well. The VDDM will include the specific selection criteria and safety measures for community centers use and requirement for segregation of activities or temporary suspension of community-based activities while the vaccination activities are ongoing. Procurement and delivery of the vaccine will be managed as detailed in the National Vaccine Deployment Plan. It is envisioned that the proposed Additional Financing will cover the cost of transportation and logistics to delivery to the country via airways. The point of entry will be Manas airport in Bishkek. The Republican Center for Immunoprophylaxis (RCI) will ensure the transportation of vaccines from the airport to the national warehouse and from the national warehouse to oblast-level warehouses. It owns a fleet of vehicles, which will be expanded by refrigerated trucks to be purchased by UNICEF. Only internal RCI truck drivers with signed labor agreements and Code of Conducts will be engaged in transportation of vaccines to regional centers’ centers' warehouses. The Code of Conduct will include strict clauses to follow Road Safety measures. Further vaccines will be distributed by districts, and transportation arrangements, including road safety compliance, will be handled by respective HOs. Thus, the SEA/SH risks are expected to be low. Apr 24, 2021 Page 13 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) To date, there are no plans to use security personnel in any part of the vaccination program. While use of security forces is not anticipated, in the event that they do need to be deployed, the MoHSD and PIU will take relevant mitigation measures to ensure that the engagement of security personnel in the implementation of Project activities for the provision of security to Project workers, sites and/or assets, is consistent with ESS4 and associated WB guidance. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement The Project will not involve resettlement or land acquisition. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources All works will be conducted within the existing footprint of healthcare facilities; hence, this standard is not relevant to the proposed AF interventions. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard is not relevant as there are no indigenous peoples in Kyrgyzstan. ESS8 Cultural Heritage Public Disclosure All works will be conducted within the existing footprint of facilities; hence, this standard is not relevant to the proposed AF interventions. ESS9 Financial Intermediaries This standard is not relevant to the proposed project interventions. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: Apr 24, 2021 Page 14 of 15 The World Bank Kyrgyz Republic Emergency COVID-19 Project - Additional Financing (P176054) Borrower Framework will not be used IV. CONTACT POINTS World Bank Contact: Christel M. J. Vermeersch Title: Senior Economist Telephone No: +1-202-458-9554 Email: cvermeersch@worldbank.org Contact: Asel Sargaldakova Title: Senior Health Specialist Telephone No: 5763+268 / 996-312-625268 Email: asargaldakova@worldbank.org Borrower/Client/Recipient Borrower: The Kyrgyz Republic Implementing Agency(ies) Implementing Agency: Ministry of Health Implementing Agency: Ministry of Health and Social Development Public Disclosure 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): Asel Sargaldakova, Christel M. J. Vermeersch Practice Manager (ENR/Social) Varalakshmi Vemuru Cleared on 20-Apr-2021 at 09:40:49 GMT-04:00 Safeguards Advisor ESSA Agnes I. Kiss (SAESSA) Concurred on 24-Apr-2021 at 17:00:22 GMT-04:00 Apr 24, 2021 Page 15 of 15