The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 04/13/2021 | Report No: ESRSAFA164 Apr 20, 2021 Page 1 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Sierra Leone AFRICA WEST Ministry of Finance Ministry of Health and Sanitation Project ID Project Name P176441 Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing Parent Project ID (if any) Parent Project Name P173803 Sierra Leone COVID-19 Emergency Preparedness and Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 4/23/2021 5/5/2021 Population Financing Public Disclosure Proposed Development Objective To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Sierra Leone. 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 Apr 20, 2021 Page 2 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The proposed Project will be part of the COVID-19 Strategic Preparedness and Response Program using the Multiphase Programmatic Approach (MPA). The proposed AF builds on the gains made from the parent project, the Regional Disease Surveillance System Enhancement (REDISSE) Project, the Ebola Emergency Response Project (EERP) and the Health Service Delivery and Systems Support Project (HSDSSP). The proposed AF will fill critical financing gaps for the national COVID-19 vaccine deployment. The content of the components and the Results Framework of the parent project are adjusted to reflect the expanded scope and new activities proposed under the AF, while keeping the following four components of the parent project: Component 1: Supporting National and Sub-national Public Health Institutions for Prevention and Preparedness; Component 2: Strengthening Multi-sector, National Institutions and Platforms for Policy Development and Coordination of Prevention and Preparedness using One Health Approach; Component 3: Supporting National and Sub-national Public Health Institutions for Prevention and Preparedness; and Component 4: Implementation Management and Monitoring and Evaluation. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The Parent Project, the COVID-19 Emergency Preparedness and Response Project, was prepared under the COVID-19 Strategic Preparedness and Response Plan (SPRP) (P173803) using the Multiphase Programmatic Approach (MPA), approved by the Board on April 2, 2020. The project will have positive impacts as it will improve COVID-19 surveillance, monitoring and containment. The Additional Financing (AF) is proposed to support the costs of Public Disclosure expanding activities of the Parent Project. The primary objectives of the AF are to further strengthen preparedness and response activities under the parent project and to help ensure equitable and effective vaccine deployment in Sierra Leone through enhanced vaccination system strengthening. The PDO of the parent project will remain the same, as will the parent project component structure. An increase in scope and cost will be required to support: (i) vaccine and drug purchase; (ii) systems strengthening and service delivery efforts to ensure effective vaccine deployment; and (iii) monitoring, tracking of vaccine use and recording of any adverse reactions to vaccination. The project is being implemented throughout Sierra Leone and covers the capital Freetown and all 16 districts and 196 chiefdoms (sub-district level). The 2021 projected census population of Sierra Leone is 8.2 million people, with a population annual growth rate of 2.1, of which 40% reside in urban areas. Governance in all these areas involves layers of authority within the MOHS and administrative jurisdiction over local governance (in accordance with the 2004 Local Government Act). In the event of a public health emergency, national authority takes precedence through the MOHS, and its regional, district and peripheral units. Sierra Leone has weak health systems which are still recovering from major shocks (Ebola, mudslides, ongoing Lassa fever and measles outbreaks with inadequate health workforce). For the surveillance and community-based sensitization activities of the project, it is noteworthy that rural settlements and villages are largely difficult to access, with accessibility decreasing towards the border sections with Guinea and Liberia. Due to the large and porous borderline, there are numerous illegal entry points into Sierra Leone from these countries, making disease surveillance and restrictions a major challenge. The terrain along the border is characterized by mountainous and densely forested, often pristine ecosystems interspersed by rivers and streams, alongside small villages and hamlets. There is a long-standing communal system of trade and movement of persons and goods across these borders. Hence, not all persons entering or leaving the country can be accounted for or tracked. With these porous borders, confirmed COVID-19 cases in neighboring Guinea, Liberia, Ghana, Nigeria and Apr 20, 2021 Page 3 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) Senegal pose a threat that can further cloud an already fragile outlook and set back the fight against poverty. The Lungi International Airport is in Port Loko District. It is the main port of entry (POE) into the country by air and is only a few hundred meters from the fairly remote quarantine site at the government owned Lungi International Hotel, en route to the sea taxi jetty that conveys visitors across the estuary to Freetown. The primary objectives of the AF are to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccines deployment in Sierra Leone through vaccination system strengthening, and to further strengthen preparedness and response activities under the parent project. The parent project is also supporting construction of key public health infrastructure (Isolation Center, Treatment Center and ICU) at Freetown International Airport at Lungi, the country’s main point of entry. Hence, some of the key environmental and social risks associated with the AF activities are related to worker and community health and safety, pollution and public health from inappropriate management of liquid and solid waste materials arising from immunization and other clinical care operations, and social risks associated with exclusion of people such as vulnerable and disadvantaged people (including ethnic minority communities). The project is not expected to impact natural habitats or cultural heritage sites if properly managed. No proposed activities have the potential to lead to involuntary resettlement issues. An intense focus on expanding immunization capacity is necessary to ensure that the health systems can effectively implement a comprehensive COVID-19 vaccine deployment strategy. This includes a critical assessment of and actions to ensure functional, end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management; rigorous cold chain expansion and control; robust service and coverage tracking systems; welltrained, motivated and supervised vaccinators; tailored large-scale communication and outreach Public Disclosure campaigns at the household, community and national level; people-centered service delivery models that can reach different target populations effectively; and effective political leadership. Sierra Leone may also need to consider and enhance relevant institutional frameworks for the safe and effective deployment of vaccines, including voluntary vaccination practices; regulatory standards for vaccine quality; guidelines for acceptable minimum standards for vaccine management, including cold chain infrastructure; safe management and disposal of sharps; and policies to ensure robust governance, accountability, and citizen engagement mechanisms. D. 2. Borrower’s Institutional Capacity This section assesses the project implementation arrangements and the capacity of various actors to implement a comprehensive COVID-19 vaccine deployment strategy effectively and safely. Project management arrangements under the parent project are currently functioning satisfactorily. The Bank’s engagement with the health sector also includes the implementation of the Regional Disease Surveillance Systems Enhancement in West Africa (P154807), the Health Service Delivery & Systems Support Project (HSDSSP, 153064) and the Ebola Emergency Response Project (EERP, P152359). The AF will utilize existing capacity in EOC of MOHS to coordinate the project activities with all stakeholders. EOC will leverage existing immunization governance mechanisms of the Expanded Programme for Immunization (EPI) through its central and districts and provincial offices. the Integrated Health Project Administration Unit (IHPAU) provides fiduciary support. IHPAU has however been expanded with an environmental and social safeguards unit staffed with an environmental specialist, a social specialist and a technical environmental and social advisor to support the preparation and implementation of the project’s ESMF, Stakeholder Engagement Plan (SEP), Labor Management Procedure (LMP) and ESCP, and safeguards instruments prepared and implemented for Bank funded projects in general. The SEP for the parent project has since been finalized and disclosed. The ESMF however received conditional clearance from the Bank and is yet to be disclosed. For the purposes of the AF, the Apr 20, 2021 Page 4 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) ESMF and SEP are being updated to reflect the additional engagement requirements associated with the AF funded activities. While the E&S recruitment suffered some delays, the full team is in place now and are experts in their fields and have ample experience with implementing environmental and social risk management strategies. The team has gained ample experience in implementing other health projects including the parent project of this AF. As such, the capacity of the team to manage ongoing and emerging E&S risks is deemed to be adequate. Currently a new COVID-19 Vaccine Technical Working Group (COVID-19 Vac TWG) has been created chaired by CH/EPI program manager of the MoHS. The working group has a multisectoral representation composed of senior-level officials from relevant ministries. It also includes external partners, representatives from private sector providers and civil society organizations, with decision-making authority. The COVID-19 Vac TWG performs its functions through six sub-groups, including Leadership, Planning, Coordination, and Finance; Communication and Social Mobilization; Logistics and Supply Chain and Waste Management; Vaccine Safety; Monitoring, Evaluation, and Surveillance; and Training and Capacity Building. Membership of the working group include WHO, UNICEF, CDC, CHAI, ICAP, CDC and other ministry of health programs and directorates. The working group is also responsible for ensuring synergies between the project activities and the State emergency preparedness plan. Deployment of COVID-19 vaccines and rapid vaccination of the target population will require a great number of personnel with the correct skillset who are trained, motivated, and supported to carry out the implementation. There are competent and dedicated vaccination logistics teams at the national, district, and facility levels, to support vaccine management. However, gaps remain for more Zonal supervisors, vaccinators, recorders, social mobilizers, independent monitors and IPC and waste management officers to make the team adequate. The COVID-19 task force Public Disclosure (including Directorate of HRH) will develop a human resource deployment plan based on district micro plans that will ensure that adequate personnel for routine services are in place. In terms of human capacity development, some 150 ports of entry (POE) staff in 13 out of 16 districts (118 men and 32 women), district surveillance officers and DHMT have been trained under the parent project to strengthen the country’s surveillance system. Rapid Response Teams (RRTs) in all the districts (seven per district: more than 110 officers in total) received refresher training in early detection, effective and timely response to COVID-19 cases, IPC, and RCCE. 700 POE staff, auxiliary and support staff (500 in Lungi, 100 in Gbalamuya and 100 in Jendema) were trained in IPC to ensure their safety during the course of performing their duties. Seventy Psychosocial Support Service (PSS) Chiefdom Field Officers (50 men and 20 women) were trained to enhance skills in providing culturally appropriate, basic mental health and psychosocial support to persons and communities affected by COVID-19, especially for those in quarantine homes, treatment centers and community care centers. Although there is adequate positive and negative storage capacity at central and district levels for routine vaccines, the COVID-19 vaccination programme will need an additional 200 Solar Direct-Drive (SDD) cold chain freezers. For vaccines requiring UCC equipment, a dedicated system will be established through the provision of 17 additional UCC equipment for the national and district levels to complement the existing 2 and 196 Arktek vaccine carriers will be needed at chiefdom vaccination centers. There is adequate capacity with the Expanded Programme on Immunization (EPI) to transport vaccines from central stores to district stores, apart from that requiring UCC equipment for which an Arktek vaccine carrier will be provided. Apr 20, 2021 Page 5 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) High Environmental Risk Rating Substantial The AF environmental risk rating is assessed as substantial because of the scale and nature of the vaccine roll-out operations, the sensitivity of the receptors (threat to human health and risk of transmission of the infection) and the environmental and community health related risks from inadequate medical waste management, but also the relatively weak capacity of the borrower to manage these risks. The project does stand to benefit from the experience of the government and MOHS in dealing with infectious diseases in the past, with reference to ebola in 2014/2015, but the comcomitant deployment of Ebola, polio and the sheer scale of the COVID-19 vaccine programs could further strain and overwhelm an already overstretched limited capacity, facility and resources. The environmental risks and mitigation measures akin to the parent project, in relation to infection prevention and control (IPC), and medical wastes risk management remain relevant. The risk is expected to increase as the vaccine rollout is ramped up and expanded across the country to increase coverage when resources are available. In Sierra Leone, there is a lack of medical wastes disposal facilities/equipment and limited capacity to manage environmental risks. As things stand, only a few, mostly regional, health centers have attempted to establish an MWM facility as part of their operations, and these are fraught with numerous sustainability issues. Lack of trained personnel and equipment, and failure to mainstream MWM into the operations of these centers, are the main challenges. Currently, there is no functioning MWM facility in the country; most incinerators, autoclaves, placenta pits and Public Disclosure metal crushers have broken down and are being replaced by open burning and ash burial, with major air and groundwater pollution risks. There are plans under the new Health Project (Quality Essential Health Services and Systems Response- P172102) to rehabilitate some of the incinerators and pilot a centralized medical waste management system to develop a practical and sustainable approach that can be replicated across the regions and districts. But it is unlikely that the pilot system will be operational within the timeframe of the AF. Alternatives should therefore be explored to manage the wastes produced by the vaccination, such as the large quantum of empty vials, used syringes, needles, etc. To manage this a health care waste management plan (IHCWMP) developed for the parent project (P154807) will be updated, and the program to develop the capacity of the client will be enhanced through trainings and the provision of resources. Of course, the AF activities could benefit from other systems put in place in the parent project and other Bank funded projects implemented by MOHS, including utilization of trained and equipped staff, such as waste handlers and incinerator operators, POE, auxiliary and support staff. The Environmental Health Directorate of the MOHS and the Safeguards unit of IHPAU are developing a medical wastes strategy and action plan in line with the IHCWMP and SOPs prepared under the parent project. Risks related to the construction of key public health infrastructure (Isolation Center, Treatment Center and ICU) at Freetown International Airport at Lungi or renovation of hospitals, medical facilities and laboratories can be mitigated through general or activity specific mitigation measures to be described in E&S safeguards instruments (see ESS1). These include occupational health and safety risks involving construction workers, labor management issues, air, soil, and water pollution and threat to biodiversity and sensitive ecosystems from construction wastes, community health and safety. As works will be done on existing facilities, cultural heritage is unlikely to be affected. Social Risk Rating High The social risk for the AF is rated High. No proposed activities of the AF have the potential to lead to involuntary resettlement issues. Nonetheless, the social risks are considered High. Key social risks include exclusion of Apr 20, 2021 Page 6 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) vulnerable and disadvantaged groups especially for the poorest, those living far from health facilities, the elderly or those living with disability who may not have access to the vaccination centers. Experience from ongoing vaccination by the government is showing low uptake among those 70+ years, remote areas and among women. The ongoing deployment is challenged by limited funding for social mobilization and establishing centers at the chiefdom levels and limited logistics for increased mobile team deployment. As a result, the target beneficiaries have now been expanded to include all persons over the age of 60 years as well as people between 40 and 60 years with comorbidities. The country vaccine deployment plan commits to adopt differentiated strategies to reach each group's peculiar characteristics. This project will need to ensure these are funded and in place for the Bank supported Vaccine roll-out. Another particular risk is the potential for COVID-19 infection among project workers and communities due to mass mobilization of the public for vaccination and inadequate adherence to occupational health and safety standards. Infectious waste materials generation are also potential sources of COVID-19 transmission without effective administrative and containment controls. The AF will procure additional IPC materials for vaccination. Adherence to all COVID-19 prevention measures will be observed at vaccination locations. Health workers are prioritized for early vaccination and the project’s grievance is available to allow workers quickly inform management of issues such as lack of PPE. Risks of corruption could lead to diversion of vaccine from the most marginalized and SEA/SH risks for women and girls. Vaccines that the Bank finances will be provided free of charge to the population and no user fees will be levied. The communication campaign will build public knowledge on this through the Anti-Corruption Commission. This will be complemented with the engagement of Civil Society Organizations (CSO) and community-based organizations (CBOs) to monitor the vaccine deployment process. The risk of forced vaccination is low, and the project is not likely to employ security forces in any aspects of the vaccine deployment. Notwithstanding, the project has developed consent forms for COVID-19 vaccination and will form part Public Disclosure of the vaccine leaflet to manage the risk of forced vaccination. Risk Communication and Community Engagement component will need to be robust to manage disinformation and conspiracy theories about vaccine efficacy, build trust, promote public willingness to participate in vaccination campaign and ensure vaccine services reach those in greatest need in a timely fashion. 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: Both the COVID-19 Emergency Response and Preparedness parent project and Additional Financing (AF) activities will have positive environmental and social impacts as they should improve COVID-19 surveillance, monitoring, containment and response in accordance with WHO guidelines and GIIP, as well as prepare the country for future health emergencies. The project will also provide a benchmark for the collection, storage, handling, transport and disposal of infectious and non-infectious wastes from hospitals and health centers in emergency situations. Notwithstanding, High environmental and social risks could potentially occur in the procurement, distribution and administration of vaccines under the AF. There is the risk of direct negative health impact on the community and personnel involved in the campaign, and indirect health effects in the community and impact on the environment from the inadequate management of the large quantum of wastes, such as sharps and infectious non-sharp wastes generated by immunization activities. An infectious health care waste management plan (IHCWMP) is in place for the handling of COVID-19 generated wastes, and will be adapted to manage wastes generated from the vaccine roll out. Apr 20, 2021 Page 7 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) In the absence of a comprehensive and proper medical waste management system, the MOHS E&S safeguards personnel and Environment Directorate are developing a Medical Waste Management strategy and action plan in line with WB and WHO guidelines. Risks related to the construction or renovation of hospitals, medical facilities and laboratories can be mitigated through a general or activity specific ESMPs. The ESMPs will inform construction designs and vice versa. All project activities should be included in the recently updated ESMF for the COVID-19 vaccine roll out project. An ESCP on government’s commitment to managing E&S risks is under review by the Bank. From the social side, there is risk of inequity in access to vaccines. People living in remote or isolated communities, persons with disabilities, the elderly, homeless, slum communities, women, low-income workers, prisoners and other hard-to-reach population could potentially miss out on vaccination due to elite capture, distance and poor road network to health facilities, and barriers in communication. Inclusion is not only fundamental to improved social development outcomes, but given the nature of COVID, if parts of the population are excluded, the overall efficacy of vaccine deployment will be compromised. In terms of prioritization of population groups that will receive vaccination first, the country’s vaccine deployment plan followed the WHO Strategic Advisory Group of Experts on Immunization (SAGE) values framework as well as the national context and local epidemiological data. The population prioritized for the initial phase includes health workers, older people, and those with underlying health conditions. Delivery of the vaccines will be brought as close to the population as possible to prevent possible access challenges. Mobile teams will be used to access beneficiaries unable to reach the vaccination sites. Vaccine safety and efficacy: Potentially adverse health effects from procuring unsafe vaccines and inadequate vaccine storage, handling and transportation practices may lead to vaccine quality deterioration. Ultra-cold storage and transportation is a challenge in global supply chains, and particularly so in Low and Middle Income Countries. The Public Disclosure country’s December 2020 national cold chain inventory updates show that an additional 30 cubic meter Walk-in Cold Rooms, 17 additional Ultra-Cold Chain and 200 SDD cold chain equipment to store the COVID-19 vaccine will be required for the first 3% of the target population. Project funds can only be used to procure thoroughly tested and approved vaccines. The Bank will accept as the threshold either (i) approval by 3 Stringent Regulatory Authorities (SRAs) in three regions or (ii) WHO prequalification and approval by 1 SRA. With support from GAVI, the Ministry of Health and Sanitation will expand the cold chain expansion to fill the capacity gaps at central and district levels. In addition, the AF includes a program for monitoring issues of Adverse Events Following Immunizations (AEFI). About 62 percent of the total health workforce of Sierra Leone are women, the majority of who require more direct contact with patients for longer time. In fact, more female health workers were infected with COVID-19 than male health workers. There are also likely gaps in access to information sources and absorption level of correct information about COVID-19 among women as compared with men as low education and illiteracy rates are higher among women. Some women need to gain authorization from their husbands to get vaccinated. Moreover, pandemics can create or exacerbate the conditions that especially put women and girls at greater risk of SEA/SH. For instance, the measures put in place to address the pandemic such as confinement and physical distancing that affect livelihoods and access to services are likely to increase the risks of women and girls experiencing violence. The proposed AF will address the above gender issues by implementing equitable COVID-19 vaccine distribution and information dissemination during the national COVID-19 vaccine campaign. There will be clear messaging to prohibit SEA/SH during provision of health care whether healthcare providers are perpetrators or survivors. The project will make information available to health service providers on where GBV psychosocial support and emergency medical services can be accessed (within the health system). Additional rapid guidance on how to deal with SEA/SH Apr 20, 2021 Page 8 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) complaints within existing GRMs will be communicated. The project will also further support strengthening IPC measures at the healthcare settings and vaccination centers to prevent infection. The parent project prepared an ESMF and a SEP. The SEP has since been finalized and disclosed. The ESMF received conditional clearance from the Bank and is yet to be disclosed. The ESMF contains Infection Prevention and Control & Waste Management measures (IPC&WMP) to safeguard health care workers, patients and the larger community from transmission and infection by the COVID-19 virus and managing the safe disposal of the resulting medical waste. The EMSF provides for the application of WHO guidance, World Bank EHS Guidelines and other GIIP in COVID-19 diagnostic testing and handling the medical supplies, disposing of the generated waste, and treating confirmed cases. The ESMF for the parent project will be updated and disclosed by the effectiveness date of AF and will account for the AF related activities, which focus on the procurement, distribution and administration of safe vaccines, in addition to expanding existing activities under the parent project, including vaccination awareness and risk communication campaigns, training of vaccinators and other workers. Specific guidance on the selection of priority population groups to be vaccinated and monitoring of adverse health effects from vaccination will be included in accordance with emerging WHO guidance. 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. The updated ESMF will also identify risks related to the transport, storage, handling and disposal of vaccines. The ESMF will be prepared, consulted, disclosed and implemented by AF effectiveness. The parent project SEP is being updated to reflect the additional engagement requirements associated with the AF funded roll out of a broad scale vaccination program. It will also identify risks related to the transport, storage, handling and disposal of vaccines. Public Disclosure ESS10 Stakeholder Engagement and Information Disclosure This standard is relevant. Integrating effective stakeholder engagement approaches in design and implementation is critical if the project is to succeed. Among the many risks that the project can face as it rolls out the COVID-19 vaccination campaign, are risks of vaccine hesitancy, misinformation, mistrust surrounding the vaccine trial etc. Project therefore need to ensure (i) there is public willingness to participate in the vaccination campaign (ii) those in greatest need of health services and vaccinations receive it first and in a timely fashion; (iii) health services and vaccinations are performed effectively; and (iv) the results of vaccine support services, including beneficiary feedback, are thoroughly captured and used to inform the project. To address these the project will need to operationalize ESS10 to build public trust, to target and reach those in greatest need (especially those who are often left out of the public health system), to identify weaknesses and improve the quality of services, and to learn from experience and beneficiary feedback to strengthen the response. The Risk Communication and Community Engagement component of the project will be fundamental. The component will include activities to inform the public of the rationale for vaccinating selected target populations; vaccine safety; the process for vaccine deployment; and possible side-effects to foster confidence in a new vaccine. Effective communication and outreach will be imperative to increase awareness and vaccine literacy, build trust, and reduce stigma around the COVID-19 vaccine. Several surveys on citizen perceptions and obstacles to vaccine uptake such as the Sierra Poll, and the Knowledge, Attitudes, and Practices survey will be drawn on to help prepare an appropriate risk communication strategy. The Communication and Social Mobilization technical working group (TWG) Apr 20, 2021 Page 9 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) has been established under the EPI COVID-19 Vaccine Deployment Task Force to respond to COVID-19 vaccine’s unique communication challenges. The pillar is co-chaired by Health Education Division (HED) and UNICEF and composed of representatives of MoHS (CH/EPI, HED), UN agencies, development partners, NGOs and CSOs. The project will ensure communications are adapted to varied urban / rural contexts and population groups (e.g., people living in remote or isolated communities, persons with disabilities, the elderly, homeless, slums communities, and women), distributed across high-penetration platforms, and foster support and endorsement through trusted community representatives and national leaders. Verifying that such stakeholder representatives are legitimate and genuine advocates of the community they represent remains an important task. The project will update the existing SEP to include stakeholder engagement requirements under AF activities as well as relevant WHO guidance. According to WHO guidance, the overall purpose of the stakeholder engagement and consultation process is to build trust in the prevention and response of misinformation that may interfere with decision-making among citizen with regards to COVID-19 and to adhere to public health advice. The project will draw on standards set out by WHO (as well as local and international good practice) to facilitate appropriate stakeholder engagement and outreach towards specific segments of the population, such as concerned citizens, suspected cases and patients, relatives, and health care workers. Key priorities in the SEP will include the following: (i) developing communication materials in a way that can reach all groups of people, particularly the most vulnerable, and in a format and manner that is applicable to them; (ii) using various approaches to improve vaccine literacy among the general population, especially disadvantaged or vulnerable groups; (iii) conducting consultations regarding beneficiary perceptions and obstacles to vaccine uptake; (iv) Public Disclosure sensitization activities to counter misconceptions about COVID-19, vaccine introduction, and any negative perceptions; (v) timely dissemination of vaccination-related information (e.g., overview of the COVID-19 vaccine program, priority risk groups, commodity availability, and tracking of those who need to receive a second dose); (vi) paying particular attention to engagement strategies with disadvantaged and vulnerable groups including elderly and people with pre-conditions during the life of the project, especially where adverse impacts may arise; (vii) leveraging trusted local interlocuters to facilitate aspects of the communication campaign, behavior change messaging, and community mobilization where appropriate; and (viii) offering mechanisms for people to raise concerns, provide feedback, or make complaints about the project and monitoring these to ensure they inform project implementation and any needed adjustments to vaccine support services. The updated SEP will be shared with relevant stakeholders via culturally appropriate means and giving due consideration to logistical and technological constraints. It will be disclosed on the website of MOHS and printed copies will be placed in health facilities. The grievance redress mechanism (GRM) will respond to complaints throughout the project lifecycle and has been devised to promptly respond to any project grievances. The 117 Toll Free emergency call center at the existing Emergency Operations Center (EOC) is used to respond to any adverse events observed after vaccination. All other project related complaints will be channeled to the Anti-Corruption Commission Toll Free line with linkages to the Integrated Health Project Administration Unit (IHPAU) which include the E&S unit. The SEP will define: (i) the ways in which users can submit their grievances (e.g., in person, by phone, text message, mail, email, website); (ii) how grievances will be logged and maintained as a database; (iii) procedures for popularizing the GRM; (iv) the length of time users can expect to wait for acknowledgement, response and resolution of their grievances, (v) transparency aspects of the grievance procedure, governing structure, and decision makers; (vi) the appeals process to which unsatisfied grievances may be referred when resolution of grievance has not been achieved; and (vii) SEA/SH Apr 20, 2021 Page 10 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) sensitive measures such as confidential and/or anonymous reporting with safe and ethical documenting of SEA/SH cases. In addition, the GRM may be enhanced by allocating a specific channel to register and respond to complaints/feedback linked with the deployment of the COVID-19 vaccination since the primary objective of the AF is to enable affordable and equitable access to COVID vaccines in the country. 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. Deployment of COVID-19 vaccine and rapid vaccination of the target population will require a great number of personnel with the correct skill-set who are trained, motivated and supported to carry out the implementation. This will involve various types of workers (direct, contracted workers, community workers and primary supply workers) to administer the vaccines, infection control, pharmacovigilance and environmental safety measures as well as interpersonal communication tools to counter any resistance to the vaccine. The exact number of direct workers and contracted workers engaged in the project over the whole cycle of the project is not yet known, but, a reasonable estimation from the vaccine deployment plan provides that it could reach up to 13,542. The COVID- 19 task force (including Directorate of HRH) will develop a human resource deployment plan based on district micro plans that will ensure that adequate personnel for routine services are in place. Most of the project personnel will however be full-time civil servants of the Ministry of Health and Sanitation (project management personnel, medical Public Disclosure staff, etc.) and other relevant line ministries, departments and agencies and will be subject to their existing contracts and terms of employment. The EPI program will prepare job descriptions for every function. Each description will define the tasks and responsibilities a staff member will be given as well as the skills required to perform their job. Step-by-step instructions on how staff will perform specific tasks and improve performance will also be developed. Elements of the project activities (including community engagement work under Component 1.1) may also include use of Community Workers and CSO groups. Through the AF, direct contracting of WHO and UNICEF for the roll out of vaccine awareness campaigns, vaccine procurement, distribution and administration will also occur. Workers under the project play a critical role in outbreak response and are the backbone of a country's defenses to limit or contain the spread of disease. However, they could be exposed to OHS risks, including risk of COVID-19 infection due to inadequate IPC systems in place at vaccination sites and adherence to all COVID-19 prevention measures. Health facilities treating patients administering vaccines may also generate biological, chemical waste, and other hazardous by-products that could be injurious to human health. Poor working conditions (long working hours, delayed salaries, inadequate compensation etc) may lead to strikes as evidenced in the parent project. Transportation of COVID-19 vaccines from one location to the other and operation of light and refrigerated vehicles, to supplement rapid delivery of COVID-19 vaccines to hard-to-reach communities also present the risks of accidents to drivers, albeit marginal and insignificant risk. Environmentally and socially sound health facilities management will require adequate provisions for minimization of occupational health and safety risks, proper management of hazardous waste and sharps, use of appropriate disinfectants, appropriate chemical and infectious substance handling and transportation procedures, etc These measures are covered in the IPC&WMP contained in the updated parent project ESMF. The measures are based on national healthcare delivery standards and norms set by MOHS in Apr 20, 2021 Page 11 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) addition to specific infectious-control strategies, guidelines and requirements recommended by WHO and CDC and other recommended OHS measures based on the World Bank EHS guidelines. Construction of a medical treatment center at Lungi is envisaged for the parent project. This will be carried out in existing health facilities. The contractor will largely hire local labor and no large-scale labor influx is expected. An ESMP for this works has been prepared and includes Labor Management Procedures including OHS measures to protect workers from injuries, accidents and COVID-19 infections. The contractor will have a workers GRM to allow workers to quickly inform management of any labour related complaints. This will be linked to the project GRM for tracking of resolution. ESS3 Resource Efficiency and Pollution Prevention and Management Vaccination rollout will increase medical waste, including used vials, sharps, needles, and other infected materials. This will overwhelm the prevailing limited capacity for the management of health care waste. Used cotton swabs (which may carry COVID-19 inactivated vaccine ingredients), needles and syringes could be a source of transmission of the infection if not contained and disinfected. Depending on handling practices, vials may be categorized as non- infectious, but wastes nonetheless. Management of COVID-19 vaccination waste demands special attention, due to the highly infectious nature of the virus, and the emergence of more virulent strains. Also, as the vaccines are delivered as part of a mass vaccination campaign, a much higher quantity of health care waste will be generated from use of disposable or reusable PPE worn by the vaccination teams. In the absence of a proper medical waste Public Disclosure management system, vaccination wastes may end up in informal channels, such as backyards, drains, dumps and landfill sites, where they may pose even greater health risks to the community and the environment. The borrower will therefore have to develop a mechanism to prevent these sharps, plastics and bottles from being released into rivers, dumpsites or the marine ecosystems. A general and hazardous waste management will be included in the ESMPs for site-specific operations. The Health care Waste Plan (HCWMP) prepared for the parent project shall be updated as a separate document and implemented in accordance with WHO Guidelines on COVID-19 deployment . To minimize risk of contamination and pollution, each vaccination team should practice on-site waste segregation. The updated HCWMP will include adequate budget for training and employment of additional waste handlers (covering both infectious and non-infectious wastes), provision of waste containers and treatment technologies, and possible outsourcing to private sector services with proven track-record of waste treatment and disposal. The waste management system should recognize and comply with the use of best available technologies in accordance with the Stockholm Convention when possible. WHO, UNICEF and UNEP have all provided guidance documents for management of COVID-19 related wastes . For construction activities, liquid and solid wastes will mainly include scraps from buildings, construction wastes, excavated soil, oils from construction machinery, concrete blocks, metal and glass pieces and domestic wastes. Waste will be segregated, stored and disposed of at approved sites to be agreed with the local councils and authority. Air emissions and water pollution: The highest air pollution risks relate to continuation to operate defunct incinerators or open burners, which has been observed in some health centers, as toxic fumes of soot, and possibly, persistent organic pollutants (POPs) and biphenyls, such as dioxins and furans, etc., are spewed into the atmosphere. Toxic trace metals, such as cadmium, chromium, lead, mercury, etc., could also be contained in these emissions, as well as in the residual ash from the combustion chamber due to improper waste sorting that precedes burning. If not Apr 20, 2021 Page 12 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) properly disposed of, these could be dumped or washed out into waterways and groundwater with chronic carcinogenic impacts especially, in locations around large vaccination centers. The risks of emissions and disposal could be addressed by WHO Guidelines on COVID-19 deployment, the updated HCWMP and other GIIPs. Other sources of air emissions include exhaust from heavy vehicles and machinery, and fugitive dust generated by compaction and construction activities, but their impacts are much lower than those from incinerators. Individuals prone to respiratory infection, such as children and the elderly are more susceptible to these risks. Dust and noxious substance emissions should be minimized through dust suppression and regular vehicle maintenance. The design of buildings and laboratories and construction works will be supervised to ensure that E&S considerations have been included. Water Pollution: COVID-19 vaccination wastes, if improperly managed, could contaminate and pollute surface and groundwater exposing sections of the community using the water for domestic purposes to infection and possibly, cancer. Plastics from syringes, and persistent organic pollutants from combustion ash could accumulate in wetlands and aquatic ecosystems resulting in irreversible physiological and anatomical damage to biota, and degradation of these ecosystems. Burial of partially treated or poorly incinerated medical wastes could contaminate the receiving soil and water. The updated HCWMP that covers an appropriate handling and disposal method will help mitigate this risk. COVID-19 Transmission risks: Risks of transmission of COVID-19 identified with the parent project continue to apply. For all works conducted at hospitals and other sensitive areas, care must be taken to prevent transmission of COVID Public Disclosure among construction workers and the community at large. All works must follow WHO guidelines on COVID-19 preparedness and prevention, and COVID-19 vaccine deployment. Noise: Noise levels will vary with the project environment. Remote areas are more likely to experience higher impact due to difference between ambient levels and the elevated noise from contractor mobilization. People may tend to congregate around vaccination centers as they queue up to get vaccinated, both increase risks of transmission and noise levels. The ambience of hospital vaccination centers may be impacted. Contractor workers involved in the construction of hospitals and laboratories, and vaccination teams will observe the decorum of the immediate environment by conducting themselves in accordance with good civic behavior and the CoC. They must be respectful of local events by suspending all noise generating activities during religious or cultural/traditional occasions to prevent conflict with the community. Inefficient resource use from sourcing and utilization of raw materials: This aspect may only apply to construction works. Projects under the ESF are designed to demonstrate environmental stewardship and sustainability. Materials used in construction of health centers, laboratories, etc., shall be selected to reflect the prevailing climatic conditions, while taking into cognizance the convenience of the occupants or users of the facilities. Energy-efficient equipment will be used in labs, health centers and waste treatment facilities. The coolants to be used in the SDD and UCC equipment should not contain ozone-depleting substances. The project will identify opportunities for incorporating efficient, sustainable cooling technologies. Cement, sand, timber, aggregates and sticks will be obtained from certified or licensed suppliers, or approved local sources, in close proximity to the project site to reduce transportation related impacts. Water for construction works will not be obtained from community potable water Apr 20, 2021 Page 13 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) sources. Materials will not be obtained from sources that could exacerbate deforestation, coastal erosion or global warming. Due diligence will be conducted to ascertain the environmental compliance of suppliers and third parties. ESS4 Community Health and Safety This standard remains relevant to ensure project activities will be carried out in a safe manner with low incidences of accidents to protect communities from infection with COVID-19. The country targets to cover 20% (1,639,622/ 8,200,000) of its population, which has been segmented as the deployment will be done in a phased approach. While the vaccine deployment is expected to slow the devastating impact of the pandemic and restore livelihoods and economic progress, some community health and safety risks may be associated with the COVID-19 Vaccine Deployment and include: (i) risk of COVID-19 spread. Medical 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. (ii) unsafe vaccines and inadequate vaccine storage, handling and transportation practices may lead to vaccine quality deterioration with potential for increased AEFI cases. (iii) Sharps and, more specifically, needles are considered the most hazardous category of health care waste for health workers and the community at large if they are not properly handled and disposed of. Injuries from needle prick can easily occur and carry a high potential for infection, including hepatitis B and C, HIV and sepsis. To prevent risk of infection, the safe disposal of used needles and syringes and the provision of safety boxes should form an important aspect of immunization programs. (iv) There is the possibility of using community infrastructures such as community centers, churches, etc. for administration of vaccination at the chiefdom levels which will require proper risk communication Public Disclosure and disinfection. (v) Feedback on various vaccine surveys and experience from the government’s ongoing vaccination exercise across the country indicates low risk of stigma and vaccine refusal with about 85% percent of caregivers declaring being positive about vaccine. Notwithstanding this, WHO guidelines to help manage this risk will be applied https://www.who.int/docs/default-source/coronaviruse/covid19-stigma-guide.pdf (vi) Vaccination will be voluntary. Effective communication and outreach will be used to minimize vaccine hesitance and public willingness to participate in the vaccination campaign. A written consent form will be filled by the person who will take the vaccine against COVID-19. (vii) There are possible sociopolitical risks related to residency requirements and demands for proof of citizenship for vaccination; (viii) Disinformation and conspiracy theories about vaccine efficacy coupled with low trust in the government which could lead to the rejection of public health intervention/information (ix) Pandemic related measures such as confinement and physical distancing that affect livelihoods and access to services are likely to increase the risks of women and girls experiencing SEA/SH risks. These identified risks will be managed in several ways through the ESMF, a robust risk communication strategy, and SEP. The ESMF will be expanded following WHO and CDC guidelines for assuring quality control of the vaccines during storage, transportation, handling, and disposal throughout the country. The MOHS will closely monitor the potential side effects of vaccines. Emergency preparedness measures and monitoring of adverse impacts and side effects of vaccines on recipients of the vaccinations are detailed in the Vaccine deployment plan. There are already existing AEFI committees in every district and a national committee at central level. The 117 Toll Free emergency call center at existing Emergency Operations Center (EOC) is used to receive complaints of any adverse events. Following receipt of complaints, the case is referred and investigated by Apr 20, 2021 Page 14 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) the AEFI focal person at the primary, secondary, and tertiary levels. In addition, Capacity building sessions for health workers on AEFI will be conducted. Emergency drugs for AEFI management will be available at each post. Health and vaccination centers (including community spaces/ infrastructures) and screening posts, will have to follow respective procedures with a focus on appropriate waste management of contaminated materials as well as protocols on the transport of samples and workers cleaning before leaving the workplace back into their communities. The MOHS will address community concerns and maintain community confidence by creating and sharing a COVID-19 vaccine safety communication plan and access to project GRM. The various stakeholders and the appropriate communication channel and format will be outlined in the Stakeholder Engagement Plan (SEP) and in the Risk Communication Strategy. Residency requirements – Whereas the Vaccine Deployment Plan does not clearly outline need for residency requirements for vaccination, the project will ensure that neither such requirements nor forced vaccination are included in the Bank financed vaccination project. Such requirement will lead to social exclusion and compromise the overall efficacy of vaccine deployment. The project is not likely to employ security forces to ensure law and order around the Vaccination Centers or to force vaccination; but if the situation changes, the project will undertake a Security Risk Assessment (SRA) to review the security force’s rules of engagement with the community and identify the specific risks related to providing increased security at the various health and vaccination centers. The project would then propose adequate mitigation measures, and strengthen existing measures, where necessary, to ensure that the use of the security forces will not Public Disclosure result in adverse consequences to community health and safety, including in matters relating to GBV and SEA/SH. The project will ensure that the security personnel follow a strict code of conduct and avoid any escalation of situation, taking into consideration the protocols included in the ESMF and SEP, and the guidance provided in the World Bank technical note, “USE OF MILITARY FORCES TO ASSIST IN COVID-19 OPERATIONS SUGGESTIONS ON HOW TO MITIGATE RISKS”. The project will continue to promote the avoidance of SEA/SH by relying on the WHO Code of Ethics and Professional Conduct for all workers in the quarantine facilities. There will be clear messaging to prohibit SEA/SH during provision of health care whether healthcare providers are perpetrators or survivors. The project will make information available to health service providers on where GBV psychosocial support and emergency medical services can be accessed (within the health system). Additional rapid guidance on how to deal with SEA/SH complaints within existing GRMs will be communicated. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This AF will not involve resettlement or land acquisition ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources All works will be carried out within the existing footprints of healthcare facilities; hence, this standard is not relevant to the proposed AF interventions. The ESCP and ESMF require a prior screening of the proposed project activities and any project activities that present risks to sensitive biodiversity will be excluded from the project scope. Apr 20, 2021 Page 15 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard is not relevant in the context of Sierra Leone. ESS8 Cultural Heritage This standard is currently considered Not Relevant as the project is not expected to support interventions with potential to impact on tangible cultural heritage. ESS9 Financial Intermediaries This standard is Not Relevant to the proposed project interventions, as no financial intermediaries will be used. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No 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: Kofi Amponsah Title: Senior Economist, Health Telephone No: 5342+3302 Email: kamponsah@worldbank.org Contact: Kazumi Inden Title: Senior Health Specialist Telephone No: 5220+82530 Email: kinden@worldbank.org Borrower/Client/Recipient Apr 20, 2021 Page 16 of 17 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) Borrower: Ministry of Finance Implementing Agency(ies) Implementing Agency: Ministry of Health and Sanitation 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): Kazumi Inden, Kofi Amponsah Practice Manager (ENR/Social) Senait Nigiru Assefa Cleared on 13-Apr-2021 at 17:26:17 GMT-04:00 Public Disclosure Apr 20, 2021 Page 17 of 17