Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD4576 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT PROJECT PAPER ON A PROPOSED ADDITIONAL LOAN IN THE AMOUNT OF EURO 10.2 MILLION (US$12.0 MILLION EQUIVALENT) TO THE GABONESE REPUBLIC FOR THE GABON COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROJECT October 15, 2021 UNDER THE COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROGRAM (SPRP) USING THE MULTIPHASE PROGRAMMATIC APPROACH (MPA) WITH A FINANCING ENVELOPE OF UP TO US$6 BILLION APPROVED BY THE BOARD ON APRIL 2, 2020 AND UP TO US$12 BILLION ADDITIONAL FINANCNG APPROVED BY THE BOARD ON OCTOBER 13, 2020 Health, Nutrition and Population Global Practice Western and Central Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective August 31, 2021) Currency Unit = Central African FCFA franc EUR 0.8450 = US$1 FISCAL YEAR January 1 - December 31 Regional Vice President: Ousmane Diagana Country Director: Abdoulaye Seck Regional Director: Dena Ringold Practice Manager: Magnus Lindelow Task Team Leaders: Agnès Couffinhal André L. Carletto ABBREVIATIONS AND ACRONYMS AEFI Adverse Events Following Immunization AF Additional Financing AU Africa Union AVAT African Vaccine Acquisition Trust BFP World Bank Facilitated Procurement CERC Contingent Emergency Response Component CDC Centres for Disease Control and Prevention COVAX Facility COVID-19 Vaccines Global Access Facility COVID-19 Coronavirus Disease 2019 CN-TIPPEE National Commission of Entrepreneurship and Employment (Commission Nationale des Travaux d’Intérêt Public pour la Promotion de l’Entrepreneuriat et de l’Emploi) E&S Environmental and Social EPI Expanded Program on Immunization ESCP Environmental and Social Commitment Plan ESMF Environmental and Social Management Framework EUL World Health Organization Emergency Use Listing FM Financial Management FTCF Fast Track COVID-19 Facility FY Fiscal Year Gavi Global Alliance for Vaccines and Immunizations GDP Gross Domestic Product GoG Government of Gabon GRM Grievance Redress Mechanism HEIS Hands-on Expanded Implementation Support HNP Health, Nutrition, and Population IBRD International Bank for Reconstruction and Development ICU Intensive Care Unit ICWMP Infection Control and Waste Management Plan IDA International Development Association IFC International Finance Corporation IP Indigenous People IPF Investment Project Financing ISR Implementation Status and Results Report J&J Johnson and Johnson LMP Labor Management Procedures M&E Monitoring and Evaluation MOH Ministry of Health MPA Multiphase Programmatic Approach NCC National Coordination Committee NGO Non-governmental Organization NITAG National Immunization Technical Advisory Group NTWG National Technical Working Group NVDP National Vaccination and Deployment Plan PAD Project Appraisal Document PDO Project Development Objective PHC Primary Health Care PIU Project Implementation Unit PIM Project Implementation Manual PPE Personal Protective Equipment PQ World Health Organization Prequalification PrDO Program Development Objective of SPRP (Global COVID-19 Response MPA) SAGE Strategic Advisory Group of Experts on Immunization SEA/SH Sexual Exploitation Abuse/Sexual Harassment SEP Stakeholder Engagement Plan SOP Standard Operating Procedures SPRP Strategic Preparedness and Response Program, also known as Global COVID-19 MPA SRA Stringent Regulatory Authority STEP Systematic Tracking of Exchanges in Procurement TA Technical Assistance UN United Nations UNICEF United Nations Children’s Fund USA United States of America VAC Vaccine Approval Criteria (of the World Bank) VDDM Vaccine Delivery and Distribution Manual VIRAT Vaccine Introduction Readiness Assessment Tool VRAF Vaccine Readiness Assessment Framework WB/WBG World Bank/World Bank Group WHO World Health Organization GABONESE REPUBLIC ADDITIONAL FINANCING FOR COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROJECT TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ........................................ 9 A. Introduction ................................................................................................................. 9 B. Consistency with the Country Partnership Framework (CPF) .................................. 11 C. Project Design and Scope .......................................................................................... 11 D. Project Performance .................................................................................................. 12 E. Rationale for Additional Financing ............................................................................ 13 F. National Capacity and COVID-19 Vaccination Plan .................................................. 15 II. DESCRIPTION OF ADDITIONAL FINANCING .................................................................... 23 A. Proposed Changes ...................................................................................................... 23 B. Sustainability .............................................................................................................. 30 III. KEY RISKS ..................................................................................................................... 31 IV. APPRAISAL SUMMARY .................................................................................................. 33 V. WORLD BANK GRIEVANCE REDRESS .............................................................................. 44 VI SUMMARY TABLE OF CHANGES ..................................................................................... 45 VII DETAILED CHANGE(S) .................................................................................................... 45 VIII. RESULTS FRAMEWORK AND MONITORING ................................................................... 49 ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS .............. 57 ANNEX 2: LATEST COVID-19 SITUATION IN THE COUNTRY .................................................... 58 ANNEX 3: SUMMARY OF THE PARENT PROJECT COMPONENTS ............................................ 61 LIST OF TABLES Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment .............. 15 Table 2: National Vaccine Coverage and Acquisition Plan1 as of October 2021 ................................... 21 Table 3: Priority Groups for Vaccination in Gabon ............................................................................. 28 Table 4: Project Cost and Financing .................................................................................................. 28 Table 5: Summary of COVID-19 Vaccine Sourcing and World Bank Financing ..................................... 29 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) BASIC INFORMATION – PARENT (GABON COVID-19 Strategic Preparedness and Response Project (SPRP) - P173927) Country Product Line Team Leader(s) Gabon IBRD/IDA Agnes Couffinhal Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P173927 Investment Project HAWH2 (9322) AWCC1 (6544) Health, Nutrition & Financing Population Implementing Agency: Commission nationale des travaux d'intérêt public pour la promotion de l'entrepreneuriat et de l'emp ADD_FIN_TBL1 Is this a regionally tagged project? No Bank/IFC Collaboration No Expected Approval Date Closing Date Guarantee Environmental and Social Risk Classification Expiration Date 15-May-2020 30-Jun-2022 Substantial Financing & Implementation Modalities Parent [✓] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [✓] Hands-on Expanded Implementation Support (HEIS) Page 1 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Development Objective(s) MPA Program Development Objective (PrDO) The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Project Development Objectives (Phase 044) The Project Development Objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Gabon. Ratings (from Parent ISR) RATING_DRAFT_NO Implementation Latest ISR 20-Aug-2020 02-May-2021 Progress towards achievement of PDO S S Overall Implementation Progress (IP) S S Overall ESS Performance U MS Overall Risk S M Financial Management S MS Project Management S MS Procurement S S Monitoring and Evaluation S S BASIC INFORMATION – ADDITIONAL FINANCING (Gabonese Republic Additional Financing for COVID-19 Strategic Preparedness and Response - P176464) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P176464 Gabonese Republic Restructuring, Scale Up No Additional Financing for COVID-19 Strategic Preparedness and Response Financing instrument Product line Approval Date Page 2 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Investment Project IBRD/IDA 14-Oct-2021 Financing Projected Date of Full Bank/IFC Collaboration Disbursement 31-Dec-2024 No Is this a regionally tagged project? No Financing & Implementation Modalities Child [✓] Multiphase Programmatic Approach [MPA] [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [✓] Hands-on, Enhanced Implementation Support (HEIS) [ ] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments IBRD 9.00 8.92 0.50 95 % IDA % Grants % MPA Financing Data (US$, Millions) Financing MPA Program Financing Envelope 18,000,000,000.00 MPA FINANCING DETAILS (US$, Millions) MPA FINA NCI NG DET AILS (US$, Millions) Approve d Board Approved MPA Financing Envelope: 18,000,000,000.00 MPA Program Financing Envelope: 18,000,000,000.00 Page 3 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) of which Bank Financing (IBRD): 9,900,000,000.00 of which Bank Financing (IDA): 8,100,000,000.00 of which other financing sources: 0.00 PROJECT FINANCING DATA – ADDITIONAL FINANCING (Gabonese Republic Additional Financing for COVID-19 Strategic Preparedness and Response - P176464) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFi n1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 9.00 12.00 21.00 Total Financing 9.00 12.00 21.00 of which IBRD/IDA 9.00 12.00 21.00 Financing Gap 0.00 0.00 0.00 DETAILS - Additional Financing NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 12.00 COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ✔ ] Yes [ ] No Page 4 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Explanation The project applies the waiver granted in October 2020 to enable management approval of individual projects under SPRP rated Substantial for Environmental and Social risk classification. [Given uncertainties related to the timing of vaccine availability, and to provide adequate flexibility to borrowers, the standard IBRD commitment fees for projects under the Additional Financing will be waived for the first 18 months, starting from the approval date of financing for each project.] Has the waiver(s) been endorsed or approved by Bank Management? Approved by Management [ ] Endorsed by Management for Board Approval [✔] No [ ] Explanation The MPA-specific waivers have been endorsed by management as part of the Global SPRP MPA approval. Page 5 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) ESStandards Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance Assessment and Management of Environmental and Social Risks and Impacts Relevant Stakeholder Engagement and Information Disclosure Relevant Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and Management Relevant Community Health and Safety Relevant Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Relevant Local Communities Cultural Heritage Not Currently Relevant Financial Intermediaries Not Currently Relevant ESStandardsNote NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Page 6 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) PROJECT TEAM Bank Staff Name Role Specialization Unit Team Leader (ADM Agnes Couffinhal Health economist HAWH2 Responsible) Rose Caline Desruisseaux- Procurement Specialist (ADM Procurement EAWRU Cadet Responsible) Lanssina Traore Procurement Specialist Procurement EAWRU Financial Management Celestin Adjalou Niamien Financial Management ELCG1 Specialist (ADM Responsible) Henie Dahlia Takodjou Financial Management FM EAWG2 Meku Specialist Environmental Specialist (ADM Albert Francis Atangana Ze Env Safeguards SAWE4 Responsible) Social Specialist (ADM FNU Owono Owono Social AFWDE Responsible) Amba Denise Sangara Team Member Operations Support HAWH2 Amparo Elena Gordillo- Team Member Gender HAEH2 Tobar Amy Champion Team Member Operations Support HAWH2 Andre L. Carletto Team Member Emergency Operations HAWH2 Antoinette Pongui Team Member Operations Support AWMGA Charlie Foyet Sonkeng Environmental Specialist Environment SAWE4 David Oliveira De Souza Team Member Health specialist HAWH2 Elisa Ilibagiza Mugiraneza Counsel Legal Advisory LEGAM Faly Diallo Team Member Disbursement Officer WFACS Joao Verissimo Figueiredo Team Member Health specialist HAEH2 Rodrigues E Pires Nicole Nguema Metogo Social Specialist Social specialist SAWS1 Nikolai Alexei Sviedrys Procurement Team Procurement EAWRU Wittich Saba Nabeel M Gheshan Counsel Legal Advisor LEGAS Sameera Maziad Al Team Member Gender Focal Point HHNDR Tuwaijri Sonia Barbara Ondo Ndong Team Member Economist EAWM2 Page 7 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Sonia Uwera Team Member Operations Support AWMGA Sylvie Munchep Ndze Team Member Operations Support AWMGA Extended Team Name Title Organization Location Page 8 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING A. Introduction 1. This Project Paper seeks the approval of the Regional Vice President to provide an IBRD loan in the amount of US$12 million equivalent for an Additional Financing (AF). The AF will support expanding activities of the Gabon COVID-19 Strategic Preparedness and Response Project (P173927), under the COVID-19 Strategic Preparedness and Response Program (SPRP) (P173789) using the Multiphase Programmatic Approach (MPA) approved by the Board on April 2, 2020, and the vaccines AF to the SPRP approved on October 13, 2020.1 The primary objectives of the AF are to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccine deployment in Gabon through vaccination system strengthening, and to further strengthen preparedness and response activities under the parent project. The Gabon COVID-19 Strategic Preparedness and Response Project in the amount of US$9 million equivalent was approved on May 15, 2020 prepared under the SPRP. 2. The purpose of the proposed AF is to help the Government of Gabon (GoG) purchase and deploy COVID-19 vaccines that meet the World Bank’s vaccine approval criteria (VAC) and strengthen relevant health systems that are necessary for a successful deployment. The proposed AF will help vaccinate 43.5 percent of the country’s population, by availing 945,255 doses to cover the population through the African Vaccine Acquisition Trust (AVAT) chaired by the African Union (AU)2 by the end of calendar year (CY)2021. Additional project support for immunization campaign will also support the deployment of the vaccines donated by bilateral donors such as the People’s Republic of China (400,000 doses of Sinopharm3 received in May 2021) and the United States of America (USA) (164,000 doses of Johnson and Johnson – J&J – received in September 2021. World Bank financing for the COVID-19 vaccines and deployment will follow World Bank’s VAC. As of April 16, 2021, the World Bank accepts as threshold for eligibility of IBRD/IDA resources in COVID-19 vaccine acquisition and/or deployment under all World Bank financed projects: (i) the vaccine has received regular or emergency licensure or authorization from at least one of the Stringent Regulatory Authorities (SRAs) identified by WHO for vaccines procured and/or supplied under the COVAX Facility,4 as may be amended from time to time by WHO; or (ii) the vaccine has received WHO Prequalification (PQ) or WHO Emergency Use Listing (EUL) (see Annex 1). The GoG will provide free of cost vaccination to the population. 1 The World Bank approved a US$12 billion World Bank Group (WBG) Fast Track COVID-19 Facility (FTCF or “the Facility”) to assist IBRD and IDA countries in addressing the global pandemic and its impacts. Of this amount, US$6 billion came from IBRD/IDA (“t he World Bank”) and US$6 billion from the International Finance Corporation (IDA). The IFC subsequently increased its contribution to US$8 billion, bringing the FTCF total to US$14 billion. The AF of US$12 billion (IBRD/IDA) was approved on October 13, 2020 to support the purchase and deployment of vaccines as well as strengthening the related immunization and health care delivery system. 2 The AVAT is a COVID-19 vaccine procurement agreement signed by all African Union Member States on March 28, 2021. AVAT is complementary to COVAX and available to participating countries to use World Bank financing to purchase vaccines. 3 Based on MOH projections it is expected that inventory of Sinopharm vaccines to be exhausted by September 2021. 4 The COVAX AMC is an initiative (co-led by WHO, Global Alliance for Vaccines and Immunizations (Gavi) which aggregates vaccine supply and demand, with the objective of providing access for 92 low and middle-income countries. COVAX aims to procure enough vaccines to cover 20 percent of the population of its member countries by the end of 2021: https://extranet.who.int/pqweb/sites/default/files/documents/Status_COVID_VAX_16Feb2021.pdf . Page 9 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 3. The need for additional resources to expand the COVID-19 response was formally conveyed by the GoG on February 4, 2021 in a letter requesting financing for vaccine purchase and delivery to cover 20 percent of the country’s population. The proposed AF aims to purchase vaccines to cover 43.5 percent of the population through the AU/AVAT. The initial request from the GoG of roughly US$20 million overestimated the price of the vaccines at US$10/dose for a two-dose regimen. The proposed AF, due to the recently established agreement with the AU/AVAT, will allow the country to access COVID-19 J&J vaccines at a lower cost and therefore purchase vaccines to cover 43.5 percent of the population with this US$12 million additional funding. This AF will form part of an expanded health response to the pandemic, which is being supported by development partners under the coordination of the GoG. Additional World Bank financing will provide essential resources to enable the expansion of a sustained and comprehensive pandemic response that will appropriately include vaccination in Gabon. 4. Critically, the AF seeks to enable the acquisition of vaccines from a range of sources to support GoG’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 World Bank will support the country to source vaccines through AVAT as a priority, and beyond AVAT as necessary. The proposed IBRD financing will build on this to expand Gabon’s access. The availability and terms of vaccines remain fluid and prevent the planning of a firm sequence of vaccine deployment especially as the actual delivery of vaccines is unlikely to be immediate. Rather, the proposed financing enables a portfolio approach that will adjust during implementation in response to developments in the country pandemic situation and the global market for vaccines. 5. Latest COVID-19 situation in Gabon. A total of 30,648 COVID-19 confirmed cases as of October 3, 2021 shows one of the highest infection rates in the region. Gabon is relatively small, both in area and population, with an area of 270,000 km2 and an estimated population of 2,276,650. It is one of the few countries in sub-Saharan Africa (SSA) with upper middle-income status and its prosperity is due to its rich and diverse endowment of natural resources. It boasts the second largest economy in the Central African Economic and Monetary Union (Communauté économique et monétaire de l'Afrique centrale - CEMAC). Notwithstanding the above, Gabon was not sufficiently prepared to prevent, detect, and respond to an epidemic on the scale of COVID-19. Gabon’s score on the Global Health Security Index is 20.0, ranking 186 out of 195 countries. Its capacity for detection and reporting (which encompasses laboratory systems, real-time surveillance and reporting, the epidemiological workforce, and data integration across human/animal/environmental health sectors) is considered among the least prepared, with a score of 6.1 (versus an average of 41.9), and a ranking of 188.5 6. With funding from the parent project, via a large contract with the World Health Organization (WHO), Gabon has been able to procure planned goods (ambulances, laboratory kits and other health related commodities) and therefore improve the country’s capacity to respond to the COVID-19 pandemic. Up to December 2020, Gabon had experienced a very low number of confirmed positive COVID-19 cases. This could be partly explained by the efforts made by the GoG to limit people’s movements, encourage the use of masks and to close the airport for an extended period of time. However, Gabon has faced a significant increase in transmission during September 2021 (see Annex 2), which, 5 Could add that WHO’s Epidemic Risk Index assigns Gabon a score of 6.5, classified as ‘very high epidemic risk’ (page 12 in: https://reliefweb.int/sites/reliefweb.int/files/resources/01%20Inform%202020%20ONLINE.pdf ) Page 10 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) coupled with the country’s still limited capacity to respond, is proof that much more still needs to be done to bring community transmission under control. B. Consistency with the Country Partnership Framework (CPF) 7. The project is aligned with the broader engagement of the World Bank in Gabon, which in turn takes into consideration the priorities of the GoG. Like the parent project, this operation was not envisaged in the 2012-2016 Country Partnership Strategy (CPS)6 nor in the Program Learning Review. However, given the global pandemic and the state of pandemic preparedness in Gabon, the World Bank’s forthcoming Country Partnership Framework (CPF) in fiscal year (FY)22 will include this operation and will propose to pursue the objectives of human capital and pandemic preparedness. It should also be noted that the current CPS is closely linked to the national economic recovery plan (Plan d’Acceleration de la Transformation - PAT) which aims at strengthening resilience and reduce vulnerability, among other objectives. The proposed operation clearly supports these objectives and is aligned with both global health priorities and IBRD/IDA priorities on improving pandemic preparedness. C. Project Design and Scope 8. The Project Development Objective (PDO) remains the same: to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Gabon. The parent project7 includes three components: C1. Emergency COVID-19 Response, to provide immediate support to limit local transmission through containment strategies in line with GoG’s COVID- 19 Preparedness and Response Plan (PRP); C2. Supporting National and Sub-national, Prevention and Preparedness, to strengthen laboratory capacity to manage large-scale testing for COVID-19; and C3. Implementation Management and Monitoring and Evaluation (M&E), to support the administrative and human resources needed to implement the project and monitor and evaluate progress. The proposed AF activities will be housed primarily under C1, which will expand project activities for vaccines purchasing and deployment (investments in cold chain upgrading, logistics, surveillance and training among others). Additional activities will also be added to the other two components, in terms of public information vaccination campaigns and monitoring of immunization. 9. The National Commission of Entrepreneurship and Employment (Commission Nationale des Travaux d’Intérêt Public pour la Promotion de l’Entrepreneuriat et de l’Emploi, CN-TIPPEE) is the implementing agency for the project. Under the National COVID-19 Response Steering Committee oversight, the CN-TIPPEE has been acting as the project implementation unit (PIU). A steering committee under the supervision of the Prime Minister has also been set up, as well as a national response committee coordinated by the Ministry of Health (MOH) and the Military Health Services. CN-TIPPEE was set up specifically to manage and provide central support functions for externally financed projects, including those of the World Bank. It is the main implementing agency for World Bank-financed projects in Gabon, responsible for project management, fiduciary and safeguards functions. The CN-TIPPEE performance 6 World Bank. 2019. Country Partnership Strategy 2012-2016 for the Republic of Gabon (Report No. 67343-GA, dated February 23, 2012). Washington, D.C.: World Bank. 7 Project Appraisal Document (PAD) is available at: https://documents.worldbank.org/en/publication/documents- reports/documentdetail/904221590529578314/gabon-covid-19-strategic-preparedness-and-response-project Page 11 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) managing the parent project has been satisfactory, in spite of some delays in complying with the preparation and updating of safeguards documents during the first year of implementation. D. Project Performance 10. The project’s progress towards achievement of the PDO and overall implementation progress were rated Satisfactory in the last Implementation Status and Results Report (ISR) of May 2, 2021 and the project continues to make good progress. As of September 27, 2021, disbursements amount to 94.73 percent of commitments. By October 30, 2021, expenditures amounting to about US$0.65 million are estimated to be disbursed. As the main contracts have been delivered, implementation management and M&E need to be completed. Furthermore, an estimated US$0.3 million will be accounted in savings due to market prices and exchange rates fluctuations, which can bridge operational costs and anticipate consulting services related to vaccines deployment until the proposed AF becomes effective. Overall implementation has been successful, evidenced by the fact that most results indicators have been met or surpassed. To this extent, all PDO indicators have shown remarkable performance, for instance 23 laboratories are currently with equipped for COVID-19 testing (five original targeted) and 100 percent of the diagnosed cases are treated following the approved protocol (70 percent original targeted). In terms of intermediary indicators, 95 percent of health staff is equipped with personal protection (80 percent original target) and 26 medical ambulances have been provided to transport patients (10 original target). 11. Key concerns highlighted by the May 2021 ISR have been fully addressed. The ISR downgraded Project Management and Financial Management (FM) from Satisfactory to Moderately Satisfactory due to delays in recruiting the internal auditor and finalizing the operations manual, but both tasks have since been completed. In order to address the shortcomings on the Environmental and Social (E&S) Standards performance rated Moderately Satisfactory, an E&S audit was carried out in June 2021. Its recommendations were used to finalize the E&S documents of the parent project (Environmental and Social Management Framework - ESMF, Labor Management Procedures - LMP, and Infection Control and Waste Management Plan - ICWMP) and those of the AF (Environmental and Social Commitment Plan - ESCP, Stakeholder Engagement Plan (SEP) and Environmental and Social Review Summary - ESRS). The updated versions documents of the parent project address the non-conformities observed and include the new activities proposed by the AF. All E&S documents of the parent project and AF8 were disclosed before appraisal on September 1, 2021. In terms of staffing, since the PIU is responsible for implementing several World Bank projects,9 key personnel were shared among projects, including the social specialist. The project did not carry out specific communications activities that required having a full-time staff as originally planned, thus funding for this position was used to support MOH’s community outreach activities instead. Finally, an environmental specialist at the PIU was recruited in May 2021 bringing the project to compliance with E&S requirements. 12. The E&S audit findings will continue to guide implementation. The E&S audit pointed out as major issues: (i) the lack of coordination between the PIU and the WHO which prevented the proper development and validation of safeguards instruments and their consideration for contracts/purchase 8 All documents for the parent project (ESMF, LMP and ICWMP) and additional financing (ESCP, SEP and ESRS) were published at the National Gazette on September 1st, 2021 and are available at https://cntippee-gabon.org/publications/ 9 World Bank projects managed by the PIU include: eGabon (P132824), Access to Basic Services in Rural Areas and Capacity Building Project (P144135), and Gabon Statistical Development Project (P157473). Page 12 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) agreements; and (ii) ineffective communication between the different stakeholders necessary for the dissemination of project information. The E&S audit proposed a certain number of remedial measures, some of which are now completed (i.e., preparation of safeguards documents), others are in progress and expected to be concluded during AF implementation (i.e., improving coordination and communication among stakeholders and sensibilization of project beneficiaries). 13. The PIU has been coordinating effectively and satisfactorily project planning and procurement. It is supported by a team composed by a technical coordinator and technical experts (procurement, FM, environment and social safeguards and M&E), fulfilling their duties satisfactorily. As informed at the Procurement Post Review Report filed on November 11, 2020, no major issues have been found with contract management, only minor findings reported in the specific contract review. E. Rationale for Additional Financing 14. The proposed AF will play a critical role in providing upfront financing for safe and effective vaccine acquisition and deployment in Gabon. This AF is being proposed at a crucial stage in the GoG’s response to COVID-19, as it has been taking vigorous measures against the spread of COVID-19 since the beginning of 2020. To guard against the risk of a local outbreak, and to accelerate economic and social recovery in the country, further preventive measures, supporting health system improvements and providing access to COVID-19 vaccines will be critical. This AF presents an opportunity to increase the development effectiveness of the operation and response to COVID-19 in Gabon by expanding the scale and scope of the parent project. 15. The AF will enable affordable and equitable access to vaccines, and it will form part of an expanded health response to the pandemic thus playing a critical role in further strengthening the health system in Gabon. The GoG is in a particularly difficult position when it comes to accessing COVID- 19 vaccines as it was not included in the COVAX-AMC due to its middle-income status. Further, due to a constrained national economy together with the limited supply of COVID-19 vaccines and small negotiation power, Gabon has not been able to purchase COVID-19 vaccines and has thus far only received vaccines through donations from the People’s Republic of China (400,000 Sinopharm vaccines) and Russia (10,000 doses of Sputnik V). The latter doses were used to vaccinate security forces and therefore does not benefit from support of this AF. By procuring COVID-19 vaccines and strengthening the health care delivery system, this AF will provide the only source of financing to allow the country to achieve 43.5 percent coverage of their population and therefore protect the most at risk and vulnerable groups. As the largest external financier of the health sector in Gabon, the World Bank is conveniently placed to support the distribution of vaccines while ensuring that these activities are conducted in synergy with existing government programs and in close collaboration with other development partners. 16. The GoG has put in place a National Immunization Technical Advisory Group (NITAG) for the preparation of the introduction of the COVID-19 vaccine in Gabon, which is composed by the heads of the Steering Committee for the Monitoring and Response Plan against the Coronavirus Epidemic (COPIL- coronavirus) Technical and Scientific Committees and the Director of the Expanded Program on Immunization (EPI). This committee, with assistance from WHO and the United Nations Children’s Fund (UNICEF), among other development partners, has been supporting the preparation of the National Page 13 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Vaccination and Deployment Plan (NVDP) and associated budget. This AF will finance the scale-up of selected activities that are part of the NVDP. 17. While the World Bank is currently the only confirmed source of external financial support for vaccine deployment, WHO and UNICEF have been instrumental in preparing Gabon’s vaccination deployment plan. The COVAX VIRAT and the World Bank’s VRAF were used by the GoG to assess its readiness to deliver COVID-19 vaccines and optimize vaccine delivery and use within the ambit of the existing project. The WHO and UNICEF will continue to play an integral role in supporting implementation and building capacity, especially in the areas of health system development and health service delivery. Through the parent project, the GoG has established a memorandum of understanding (MoU) with WHO for technical assistance (TA) to support the response to COVID-19. This MoU will be expanded to enable the country to receive TA from WHO for the preparation, planning and implementation phase of the COVID-19 vaccine roll-out, thus ensuring successful COVID-19 immunization roll-out. Potential supportive roles for partner agencies during implementation are provided in Box 1. Box 1: Potential Supportive Roles for Partner Agencies in Implementation Financing WHO Role amount Providing technical leadership for vaccine introduction; providing technical support to National Immunization Technical Advisory Group to define COVID-19 vaccination policy objectives, strategy, targets and vaccine safety issue; developing guidelines and N/A conduct training on adverse events following immunization (AEFI); surveillance for COVID-19 vaccine related issues and other issues of vaccine pharmacovigilance, etc. Financing UNICEF Role amount Supporting the development of a roadmap for improved integration of COVID-19 vaccine deployment with EPI and other primary health care (PHC) services, N/A supporting the quantification and forecasting of supply needs, support to procure and install quality cold chain rooms at national level, etc. • Financing Gavi Role amount Providing technical support for vaccine introduction and preparation of the National N/A Vaccination and Deployment Plan. • Financing Africa Union/AVAT role amount • (financed Providing vaccines to cover 43.5 percent of the population and beyond. through the project) 18. This AF is being proposed at a critical juncture in the GoG’s response to COVID-19. A critically important change in the state of science since the early stages of the pandemic has been the emergence of the new therapies and also the successful development and expanding production of COVID-19 vaccines (see Annex 1 for status). A key rationale for the proposed AF is to provide upfront financing for safe and effective vaccine acquisition and deployment in Gabon, thus enabling the country to procure safe and effective vaccine at the earliest, recognizing that there is currently excess demand for vaccines from both high-income and lower-income countries. The success of the vaccine deployment will depend on strong PHC systems, supported by centrally managed M&E processes. The readiness assessment Page 14 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) (VIRAT/VRAF) has exposed some weaknesses in the PHC system for service delivery and thus a successful COVID-19 vaccines deployment, including training of healthcare workers, cold chain infrastructure and supply chain systems strengthening as envisioned by this project will boost the EPI’s capacity and contribute to overall health system strengthening. 19. The proposed AF will form part of an expanded health response to the pandemic. The activities will build on Gabon COVID-19 Strategic Preparedness and Response Project, as well as on the support of other developing partners in the context of the overall Government’s COVID-19 response. F. National Capacity and COVID-19 Vaccination Plan (i) Vaccine Readiness Assessment 20. Gabon has conducted a vaccine readiness assessment to identify gaps and options to address them, as well as to estimate the cost of vaccine deployment, with the support of international organizations including WHO and Gavi (see Table 1 below). This assessment considers the GoG’s vaccine deployment strategy, described below. Considering the uncertainties related to the COVID-19 vaccine market, including testing, approval, availability and pricing, which require flexibility and close monitoring and strong World Bank support during implementation, the assessment will continue to be an evolving process and will be dynamically revised and updated as necessary to continue to improve project implementation. Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment10 Readiness Readiness of GoG Key gaps to address before deployment domain • A National Coordinating Committee (NCC) and the National Technical Working Group (NTWG) along with its sub-committees for • All planning and coordination COVID-19 vaccination were established and activities in the country have been are operational. going very well and no gaps have • Regular COVID-19 briefings to key been found at the roll-out of the first Planning and ministries, NITAG, stakeholders and 400,000 Sinopharm doses. The coordination partners have been carried out. country institutions seem well • An NVDP, in line with WHO guidance and organized and coordinated to deploy Strategic Advisory Group of Experts on the vaccines as soon as they arrive in Immunization (SAGE) recommendations, the country and before they expire. has been developed and validated at central and subnational levels in February 2021. 10 A multi-partner effort led by WHO and UNICEF developed the Vaccine Introduction Readiness Assessment Tool (VIRAT) to support countries in developing a roadmap to prepare for vaccine introduction and identify gaps to inform areas for potential support. Building upon the VIRAT, the World Bank developed the Vaccine Readiness Assessment Framework (VRAF) to help countries obtain granular information on gaps and associated costs and program financial resources for deployment of vaccines. To minimize burden and duplication, in November 2020, the VIRAT and VRAF tools were consolidated into one comprehensive framework, called VIRAT-VRAF 2.0. Page 15 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Readiness Readiness of GoG Key gaps to address before deployment domain • A plan for procurement of waste management supplies (Waste Management Plan) was developed and is under implementation. • Budget was prepared with WHO guidance. • The National budget has included funding for the COVID-19 vaccination program. • Bilateral partners have been mobilized to • Mapping of resources to address address financing gaps, particularly on financial gaps is under preparation Budgeting vaccines donations (People’s Republic of and is expected to be completed by China 400,000 doses already received and November 2021. USA 164,000 J&J doses were delivered in September); and Russia Sputnik V, 10,000 doses administered to armed forces. • Country has an expedited regulatory pathway for approval of COVID-19 vaccines. Currently, in addition to WHO EUL • Gabon does not currently have approved vaccines, Gabon has also legislation in place to provide approved the use of Sputnik V in country. statutory immunity for • All documents for processing authorization manufacturers. for emergency use including importation Regulatory • Country does not have a national no are up to date. fault compensation scheme. • Protocol to release imported vaccines • Gabon will use AVAT no fault under two days based on summary review compensation until a national scheme is approved and operational. is available • The procedural for importation of vaccines for emergency use under five days has been updated and approved. • Prioritization has been done based on the SAGE (WHO) guidance. Under the leadership of the National Immunization Technical Advisory and the Scientific Council for Public Health Emergencies, the process of prioritization, identification of Prioritization, priority population and coordination for targeting, surveillance has been completed. • No gaps observed surveillance • Coordination with COVID-19 disease surveillance group was established to ensure data collection for vaccination planning and outbreak response. • A monitoring system to ensure vaccination of population based on established target is available. • Standard Operating Procedures (SOPs) • Need to recruit more healthcare relating to infection prevention and control workers/vaccinators for service Service delivery and personal protective equipment (PPE) delivery, especially in mass- have been updated. vaccination sites as well as in remote Page 16 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Readiness Readiness of GoG Key gaps to address before deployment domain • Existing EPI arrangements will be utilized areas through mobile outreach for COVID-19 vaccination particularly for vaccination campaigns. storage, transport, and distribution. • Vaccine delivery strategies and outreach strategies leveraging both existing vaccination platforms and non-vaccination approaches to best reach identified target groups have been identified. • Strategies, service providers and points of delivery, including fixed and outreach and associated medical supplies that could effectively deliver COVID-19 vaccine to target populations, are well described in the NVDP. • Protocols for vaccination consent or refusal, and measures to protect those that refuse vaccination are in place. • A plan to operationalize service delivery for each district with support from the central level, region, non-governmental organizations (NGOs) and community has been developed. • The GoG has designated a focal point who is responsible for training, and a plan has been developed for COVID-19 vaccine. This plan includes key groups of participants and all topic areas related to vaccination. • Adaptation and translation of WHO training • Even though the training plans have materials has been carried out. been established, the pool of • Development of protocols, training and vaccinators (including existing staff Training and plan for security/safeguard of staff, storage and new staff/vaccinators to be supervision facilities, and transport, including sexual recruited) will require training, harassment and discriminatory practices training refresher courses and have been completed. supervision. • Weekly in person/virtual supervision meetings have been carried out. • In person training sessions for vaccine administration and logistics have been carried out. • A surveillance and monitoring framework with a set of WHO recommended indicators for COVID-19 vaccine was developed • Grievance Redress Mechanism (GRM) M&E • No gaps observed mechanism is in place and operational • Adaptation of paper-based reporting to electronic monitoring is completed, and country uses REDCAP software and a daily Page 17 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Readiness Readiness of GoG Key gaps to address before deployment domain Excel report transmitted with all NVDP indicators. • Protocols for data protection are available. • Monitoring tools for service providers are up to date. • Exhaustive inventory of the cold chain equipment and estimation of the gap has been done. • Storage and distribution strategy developed. • Plan to address infrastructure gaps • The plan to address infrastructure developed. gaps in terms of cold rooms, Vaccine, cold • Assessment of dry storage and cold chain refrigerators and freezers has been chain, logistics, capacity carried out. developed but has not been infrastructure • SOPs for disposal of medical waste implemented due to the lack of funds developed. that will be supported by this project. • Update/implementation of systems and protocols to monitor vaccines stock, distribution and key supplies developed. • SOPs for securing integrity of vaccines and ancillary products through the supply chain developed. • Guidelines for pharmacovigilance in place. • AEFI Committee established, trained and in • Provisions requiring manufacturers to capacity to review cases. implement risk management plans, • AEFI surveillance plan developed. data collection and reporting related • Channels of data sharing mechanisms to to AEFI is under validation and will be Safety share COVID-19 vaccine safety data and completed by November 2021. surveillance findings with relevant regional and • Establishment of compensation international partners have been identified schemes as consequence of an AEFI is and secured. under preparation and will be • Adequate and trained human resources in completed by November 2021. place. • Organization of strategic communication activities including information awareness, community engagement, and media presence carried out. • Broadcast of 24/7 radio and tv messages to • Efforts to address vaccine hesitancy Demand address disinformation messaging and particularly amount vulnerable and generation and vaccine hesitancy. hard to reach groups need to be communication • Data collection system (social media, rumor scaled up and will be supported by management, behavioral/social data) the project. established and operational. • Development of key messages and materials for public communications and advocacy developed and broadcasted Page 18 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Readiness Readiness of GoG Key gaps to address before deployment domain • At GoG’s request, UNICEF has launched a survey to gather evidence on vaccine hesitancy among all groups, with disaggregated data on women (ii) National Vaccination and Deployment Plan (NVDP) 21. The GoG has prepared an NVDP, which draws on the findings of the VRAF/VRAT 2.0 assessment and gap analysis. The NVDP is a multi-partner and multi-sectoral effort led by the EPI at the MOH. The NVDP plan follows the WHO guidance for such COVID-19 immunization plans and has been developed in close collaboration with WHO, Gavi and UNICEF. The plan includes all technical areas described in the readiness assessment table above. Planning will be continuously adjusted throughout the vaccination campaign in a phased approach with lessons learned and in response to rapidly evolving situations. The NVDP was validated with an approved budget in February 2021. The NVDP for Gabon was also submitted to the WHO COVID-19 Partners Platform and validated by the United Nations (UN) partners. 22. The national plan includes two sequential phases with a stated goal of vaccinating up to 50 percent of the population. Phase 1 will take place in 2021 and will cover 20 percent11 of the population (around 445,0000 people), where 9.2 percent (200,000 people) will be immunized with the 400,000 doses of Sinopharm vaccines already available in the country; 7.5 percent (164,000 people) will be immunized with the J&J vaccine donated by the United States and the remaining 3.3 percent (71,000 people) with the AF financed vaccines. The priority groups have been established following the WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccination and as follows: healthcare professionals (including rapid response team, doctors, nurses, laboratory assistants, radiologists, nursing assistants, nursing care facility staff; community health workers and social workers; totaling about 0.6 percent of the population); population aged 60 years old and above (8.4 percent); people with diagnosed underlying medical conditions (11 percent). 23. In terms of service deployment strategy for Phase 1, the healthcare workers will be vaccinated in the main hospitals/health centers in the seven health districts. The other priority groups will be reached through a combination of community health posts and outreach community vaccination activities. As part of the proposed AF, the supply chain logistics systems will be strengthened and modernized to ensure effective distribution of vaccines. In terms of readiness to rollout vaccination, the GoG has put forward a logistical sub-commission that monitors and controls daily the stock of vaccines at the central storage and vaccinations sites to prevent losses and better plan the distribution based on vaccine lot expiration date. The WHO and UNICEF are partnering with the MOH to ensure the successful roll out of the COVID-19 vaccines. 24. Phase 2 is planned preliminarily to take place in calendar year 2022 (CY2022) and is now expected to cover an additional 40.2 percent of the population allowing the country to reach 60.7 percent coverage. As outlined earlier, the 50 percent target currently in national documents reflected 11Sputnik doses do not count for the Phase 1 target as the donation agreement was to be used exclusively on security forces, but is accrued in total population. Page 19 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) anticipated costs at the time of drafting. Given the current vaccine prices, the GoG welcomes the opportunity to reach 60.7 percent coverage allowed by the AF. Priority groups for the second phase of the COVID-19 immunization plan are still under consideration, but are expected to follow the WHO SAGE values framework, focusing on the more vulnerable and older population groups, followed by inclusion of younger and healthier age strata in an effort to increase vaccine coverage and get closer to herd immunity. The roll-out of Phase 2 will be affected by uncertainties around COVID-19 epidemiology post-vaccination, emergence of variants, vaccine availability and global and regional trends. Page 20 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Table 2: National Vaccine Coverage and Acquisition Plan1 as of October 2021 Vaccines already Source of Population targeted2 Vaccine(s) World Number of Estimated cost Contract arrived in the country financing Bank’s VAC doses needed US$ (millions) status – IBRD Loan Price Shipping Status % Number Source Name Name Doses (US$/dose) (US$/dose) Phase 1 Includes healthcare frontline workers, people with diagnosed co-morbidities, and people aged 60 years old and above (20 percent coverage) IBRD loan 3.3 71,000 AU/AVAT J&J 0 0 1 0.7 WHO EUL In process Donations from the 400,000 People’s 9.2 200,000 China Sinopharm 0 0 2 0 WHO EUL Completed Sinopharm (May 2021) Republic of China Donation 7.5 164,000 United States J&J 0 0 1 0 WHO EUL In progress from USA Donation 10,000 0.5 10,000 Russia Sputnik V 0 0 2 0 No Completed Sputnik V from Russia3 (April 2021) Phase 2 Population over 18 years old prioritized from elder to younger in 10-year intervals (40.2 percent coverage) IBRD loan 40.2 874,255 AU/AVAT J&J 0 0 1 7.4 WHO EUL In process National 60.7% 1,319,2554   Multiple       8.1       400,000 Total 1 This plan covers 60.7 percent of the population of the country and reflects the latest information about prices which allows the GoG to go beyond its initially stated 50 percent goal. 2 Country population used for calculation is 2,173,000. 3 Sputnik doses do not count for the Phase 1 target as the donation agreement was to be used exclusively on security forces, but is accrued in total population 4 AF will finance: Phase 1 – 71,000 doses (3.3 percent of population) and Phase 2 – 874,255 doses (40.2 percent of population) for a total of 945,255 doses (43.5 percent of population) Page 21 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 25. The rapid development of vaccines increases manufacturers’ potential liability for adverse effects following immunization. Manufacturers want to protect themselves from this risk by including immunity from suit and liability clauses, indemnification provisions, and other limitation of liability clauses in their supply contracts. Contractual provisions and domestic legal frameworks can all operate to allocate that risk among market participants, but no mechanism will eliminate this risk entirely (See Box 2). Box 2: Liability and Indemnification Issues in Vaccine Acquisition Key Points: • The rapid development of vaccines increases manufacturers’ potential liability for adverse effects following immunization. • Manufacturers want to protect themselves from this risk by including immunity from suit and liability clauses, indemnification provisions, and other limitation of liability clauses in their supply contracts. • Contractual provisions and domestic legal frameworks can all operate to allocate that risk among market participants, but no mechanism will eliminate this risk entirely. For vaccines purchased through AVAT: • The Advance Purchase Agreement (“APA”) signed on March 28, 2021 by AVAT, Janssen Pharmaceutica NV (“Janssen”) and the African Export-Import Bank includes indemnification provisions in favor of Janssen for vaccines purchased and supplied under the APA. Participating countries will assume those indemnification obligations upon execution and delivery of a deed of adherence to the APA. • As a condition for the delivery of vaccine doses under the APA, participating countries shall also participate in or establish and adequately fund an NFCS in accordance with certain minimum requirements. Participating countries shall either: (i) participate in the NFCS to be established by AVAT, or (ii) establish and maintain their own NFCS. For the avoidance of doubt, AMC countries will not be able to rely on their participation in the COVAX NFCS to meet the conditions under the Janssen APA. • For vaccines purchased through AVAT, Gabon will have to consider how to implement the indemnification provisions and NFCS requirements under the APA with Janssen. For vaccines obtained outside of COVAX: • Gabon will need to enter direct indemnification arrangements with manufacturers. • Gabon does not currently have legislation in place to provide statutory immunity for manufacturers. Country does not have national no fault compensation scheme. • Adoption of any such indemnification provisions or compensation scheme would have to be in accordance with national strategy and framework. Possible World Bank support to Gabon, depending on needs, may include: • Information sharing on (i) statutory frameworks in Organization for Economic Cooperation and Development (OECD) countries and other developing countries; and (ii) overall experience in other countries. • Provide training and workshops for government officials to cover familiarize them with the issues. • For World Bank-financed contracts, World Bank can provide Hands on Expanded Implementation Support. The project operational documents Vaccine Delivery and Distribution Manual (VDDM)/Project Implementation Manual (PIM) will clarify that the country’s regulatory authority is responsible for its own assessment of the project COVID-19 vaccines’ safety and efficacy and is solely responsible for the authorization and deployment of the vaccines in the country. Page 22 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 26. This AF will only finance the procurement of vaccines through AVAT that has embedded in its supply contract a percentage for their Indemnification and No-Fault Compensation Fund, should they need to address any undesirable adverse reaction to the vaccine applied to a patient. Further to this, the MOH is currently finalizing the proposal of a decree to establish a National Indemnification and No-Fault Compensation Fund by November 2021, to complement AVAT’s mechanism. (iii) COVID-19 vaccination roll-out: Status update 27. The GoG started the vaccination effort in late April 2021 with 100,000 doses of Sinopharm donated by the Government of the People’s republic of China. In May 2021, a second donation of 300,000 doses from China arrived in the country along with 10,000 doses from Sputnik V donated by the Government of Russia to be used on forces of security exclusively. At the onset, the vaccination program did not deploy clear and strong messaging around the importance and safety of vaccines, and early data showed that women and older people were more hesitant to vaccines. This situation led the GoG to conduct a massive communication campaign on radio and television to address hesitancy and counteract the negative effects of wrong/fake information. Further to it, new vaccinations sites were opened as well as mobile units established to provide access to the most vulnerable groups and in remote areas. Currently, vaccination ratio between gender is balanced and the GoG continues to invest in communications and community engagement to ensure lower level of vaccination hesitancy and better inform the population. 28. The GoG expects that demand for the vaccine will continue to accelerate. About 181,700 doses of Sinopharm have been administered so far, where 103,000 have been the first dose. The MOH is confident that the remaining doses will be consumed in the course of the next months. The pace of vaccine administration is on average 2,200 doses per day and has improved from the early days of May, thanks to (i) the deployment of communication campaigns to reduce vaccines hesitancy; (ii) outreach vaccination efforts; (iii) increasing vaccine literacy; and (iv) the opening of mass-vaccination sites in Libreville. Following the successful example of Libreville, mass vaccination sites will be opened in other large cities such as Franceville and Port Gentil through this AF. Furthermore, this AF will provide access to the J&J vaccine for which the hesitancy in Africa seems to be lower and from a systems roll-out viewpoint will simplify the immunization of the population, as the low human resources systems capacity has been challenged by the Sinopharm 2-dose regimen. II. DESCRIPTION OF ADDITIONAL FINANCING A. Proposed Changes 29. The changes proposed for the AF entail expanding the scope of activities under the parent project and adjusting its overall design (see Annex 3 for details). As the proposed activities to be funded under the AF are aligned with the original PDO, the PDO would remain unchanged but a new PDO indicator and seven intermediary indicators will be added to measure the percentage of the priority population vaccinated, based on the targets defined in the NVDP. 30. The proposed changes include: (a) adjustment to the components content; (b) revision of results framework to reflect the expanded scope and new activities proposed under the AF); (c) modification to Page 23 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) the institutional and implementation arrangements; and (d) extension of the closing date to implement vaccine-related activities. a. Components and cost: i. Component 1: • To reflect vaccine procurement and deployment (including cold chain cost, logistic arrangement), Subcomponent 1.3 was added to support: (i) vaccine purchase and deployment; and (ii) health system strengthening activities such as training of health personnel on vaccination and building capacity to address adverse events following immunization (AEFI). • To reflect community engagement and risk communication for demand creation, Subcomponent 1.4 was added to support communication efforts to better inform the population and reduce vaccine hesitancy. ii. Component 3: revised to reflect the expanded funding. b. Results framework: To reflect the expanded scope of the proposed AF, a PDO level indicator is being added, tracking vaccination rates by gender, as well as nine intermediate results indicators. Among these, three track the gender impact of the project and one monitors citizen engagement though the Grievance Redress Mechanism. The original indicators, their end dates and targets are not being modified. c. Institutional and implementation arrangements: The National COVID-19 Coordination Committee will continue to provide support for defining project implementation strategies and overall leadership, coordination, and strategic planning for the response. The sub- committee on immunization led by the EPI established for the purpose of vaccine purchase and deployment will provide technical and strategic leadership. d. Closing date: The closing date will be extended from June 30, 2022 to June 30, 2024 to allow for sufficient time to implement the activities related to immunization considering global supply-side constraints resulting in longer procurement and delivery timelines and the complexity of rolling out nationwide vaccination. (i) Proposed New Activities 31. Vaccine purchasing will be done through Component 1 of the Global COVID-19 Response MPA (SPRP). The support for vaccines when available, which was anticipated in the initial Global COVID-19 MPA, is added as part of the containment and mitigation measures to prevent the spread of COVID-19 and deaths under Component 1. Emergency COVID-19 Response. Gabon will use World Bank approved options for vaccine purchase, including: (i) direct purchases by countries from vaccine manufacturers, either individually or jointly with other countries; (ii) purchase of excess stocks from other countries that reserve excess doses; and/or (iii) purchase through AU/AVAT. Given the recent emergence of COVID-19, there is no conclusive data available on the duration of immunity that vaccines will provide. While some evidence suggests that an enduring response will occur, this will not be known with certainty until clinical trials follow participants for several years. As such, this AF will allow for re-vaccination efforts if they are warranted by peer-reviewed scientific knowledge at the time. Page 24 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 32. The additional activities will be incorporated into the existing components of the parent project as described below. Component 1. Emergency COVID-19 Response (total of US$15.3 million equivalent, of which AF is US$11.0 million) 33. Subcomponent 1.3 - COVID-19 vaccine acquisition, planning and distribution: To support the GoG’s NVDP, the AF will finance upfront TA to support Gabon to establish institutional frameworks for the safe and effective deployment of vaccines. These will include: a. Strengthening of COVID-19 vaccination planning including, inter alia (i) supporting the implementation of the NVDP and associated budget; (ii) support the GoG to update and roll out/train personnel on the manual of procedures for COVID-19 vaccines (prepared in March 2021) that includes: rules and procedures for prioritizing in-country vaccine allocation following principles established in the WHO Fair Allocation Framework; rules and procedures establishing minimum standards for vaccine management and monitoring, as well as third- party monitoring arrangements; rules and procedures for processing and collecting personal data in accordance with national law on personal data protection (Law No.009/2011 dated September 25, 2011) and good international practice; vaccine distribution microplanning; and criteria for the procurement, importation, storage and deployment of project COVID-19 vaccines; and (iii) implementing contingency measures included in the NVDP to deal with any unexpected disruptions to vaccine supply from climate change and natural disasters (i.e., flooding and extreme heat). b. Supporting the procurement, supply and distribution of inter alia: (i) COVID-19 vaccines meeting the criteria outlined in the present document; (ii) ancillary supply kits that would include needles, syringes, alcohol prep pads, COVID-19 vaccination record cards for each vaccine recipient, and PPEs for vaccinators and other consumables; (iii) equipment required to support low-carbon cold chains (storage, transportation and distribution of COVID-19 vaccines), including certified climate friendly solar powered refrigerators/freezer to reduce GHC emissions; (iv) equipment for remote temperature monitoring; (v) rehabilitation of health facilities and cold rooms to meet global standards; (vi) low-carbon and energy efficient incinerators and waste management equipment. c. Regulatory Systems Strengthening: (i) strengthen and adapt the Pharmacovigilance System to be sensitive to detect AEFI for the COVID-19 vaccines; and (ii) undertake relevant traceability activities to ensure capabilities for the system to track and trace from “production to people.” The project will support country level policy and operational actions to implement lean traceability in coordination with global and regional efforts taking place in this area around COVID-19 vaccinations. These “lean traceability” tools will form basic building blocks for Page 25 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Gabon to enhance visibility related to COVID-19 vaccines and will also support sustainable approaches for traceability post-pandemic.12 d. Service delivery including: (i) improvements will be made to health facilities designated as vaccination centers to ensure proper patient flow, accommodation, and service provision; (ii) identification and training of health facility staff and frontline ancillary staff on vaccine preparedness. Models for efficient two-way mass communication as well as training platforms for frontline workers that allow for more frequent touchpoints for capacity building “on the job” as well as facilitating sharing of information, verification of vaccine delivery, and monitoring the performance of the vaccines will also be explored; and (iii) building a human resources health information system (HRHIS) that can produce an accurate, current and dynamic snapshot of health workers while building planning capacity that informs HRHIS strategies for quantifying health workforce needs, demands and supply under various forward-looking scenarios.13 e. Health information system: Comprehensive and effective immunization programs require robust data infrastructure at different levels of the health system to be able to effectively track and monitor vaccination. Patient tracking is particularly important in the case of COVID- 19 vaccinations which will likely require a two-dose regimen (currently Sinopharm). Activities will include: (i) developing context-appropriate models for innovative tracking schemes such as digitized health records, electronic immunization records, and individual and community coverage mapping methods; and (ii) supply chain digitization which will improve the efficiency of COVID-19 vaccination as well as broader immunization strengthening efforts. In the near- term, support will be provided to assess and identify keyways to strengthen existing health and logistics information systems for improved data collection and reporting. The project will also identify potential entry points for innovative, context-appropriate systems that leverage and integrate with existing platforms (AEFI platform using Open Data Kit). These systems could include predictive data analytic platforms that can inform rapid, remote and dynamic health facility capacity assessments through built-in feedback loops, geospatial information and optimization capabilities for improved performance over time. 34. Subcomponent 1.4 - Community engagement and risk communication for demand creation: Under this subcomponent, a national risk-communication plan, and activities to ensure community participation in COVID-19 vaccination efforts and accountability mechanisms will be ensured. Main activities include: 12 A lean traceability model will help COVAX Facility participating countries to enhance supply chain integrity related to COVID-19 vaccines. Building on strong pre-COVID-19 national strategies and support for medicines traceability, the Global Steering Committee for Quality Assurance of Health Products is working closely with the private sector to rapidly equip systems to prevent theft and diversion of health commodities while also reducing the presence of falsified versions of COVID-19 vaccines in the legitimate supply chain. Traceability will rely on use of GS1 global standards to enhance interoperability. The initial planning is focused on a hub and spokes model similar to the European Union (EU) approach. A “global repository” of uniform master data will provide a single point of data transfer for industry and national approaches will interact with the global repository via web- based secure portals and mobile apps. 13 Data from the snapshot can be leveraged via linkages to human resource information systems, forecasting models, and mobile payment platforms. Additionally, this also provides an opportunity to get a holistic picture of health workers in the private sector and less formal workers (such as those working in the community). Page 26 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) a. Preventing elite bias and increasing community confidence in vaccines are crucial to acceptability and improved participation in the response to COVID-19. This will include accurate information sharing, efforts to create demand, counter measures for addressing mis- or disinformation, and dissemination of educational materials to promote behavior changes that prevent transmission and COVID-19 infection, and climate induced water and vector- borne diseases (e.g., vaccination, hand washing, etc.). This project will capitalize on previous undertakings by the GoG, use existing structures such as the network of community health workers as the mobilization channel recognized by the MOH to support the COVID-19 communications campaign, NGOs/community-based organizations and their relations with established women and youth-led civil society organizations as well as with local and traditional leaders and faith-based organizations. b. Multi-level health promotion interventions will be tailored to the specific needs of vulnerable and hard-to-reach groups. These interventions will be designed to be understood by all, including women, girls, and other disadvantaged populations who are illiterate or lack access to information sources. Building “vaccine literacy” for the COVID-19 vaccine is also an opportunity to boost overall confidence in vaccinations, thereby leading to greater utilization and retention in the EPI program. To monitor perceptions and behavioral change interventions, financing will include beneficiary research on perceptions, obstacles, and levels of vaccine uptake and equity of distribution. c. Gender dimensions of social and behavior change communications. Operational research will be supported to ensure that communication efforts identify and monitor possible misconceptions that may be disproportionately held among women who face greater barriers in accessing and using reliable information, and/or among men who may oppose vaccination for themselves or for female members of their households. Since the inception of the vaccine roll-out, the coverage among men has been significantly higher than women. This may partly be reflecting the higher proportion of men among the target group of chronic patients but early interventions with gender sensitive risk communications that corrected this trend should continue to be delivered using multiple outreach mediums, including messaging through radio, television, and community-based platforms in local languages. Risk communications will also incorporate information related to disease prevention in the event of climate shocks. 35. Component 3: Project Implementation and Monitoring (total of US$1.50 million equivalent, of which AF is US$1.0 million) a. This component will continue to support the administrative and human resources needed to implement the project and monitor and evaluate progress. It will finance staff and consultant costs associated with project management, procurement, FM, E&S, M&E, reporting and stakeholder engagement, as well as operating and administrative costs. It will also support TA to strengthen the NVDP implementation; flexibility in the recruitment of additional short-term consultants who could help to overcome with the workload which will occur during the implementation of the COVID-19 vaccine roll out; and longer-term capacity- Page 27 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) building for pandemic preparedness and response. It will also finance project audits, to be conducted through Gabon’s Supreme Audit Institution (SAI). 36. The AF will support the population groups as summarized in Table 3 below: Table 3: Priority Groups for Vaccination in Gabon % of Phase Population group Number of people population Health care workers 13,038 0.6 Individuals with hypertension 197,743 9.1 First Individuals with diabetes 41,287 1.9 Individuals aged 60 years old and above 182,532 8.4 Population over 18 years old prioritized from elder to Second 874,655 40.2 younger in 10-year intervals Security personnel 10,000 0.5 Total 1,319,255 60.71 1 Country population estimated in 2,173,000 inhabitants. 37. This AF budget has not been retained for re-vaccination, thus if needed, the GoG or other development partners may consider financing such purchase, or a second AF may be required. In the case that re-vaccination is required, limited priority populations (such as health workers and the elderly) will be targeted given currently limited availability of vaccines and equity considerations (i.e., tradeoffs between broader population coverage and re-vaccination). (ii) Financing Arrangements 38. The increase in scope as outlined above will be reflected in an increase in indicative component allocation from US$9.0 million to US$21.0 million, with the largest amount of the AF being added under Component 1 for activities related to vaccine purchase and rollout (see Table 5 below) and to support communications/community engagement. Component 3 will be reinforced with funds for supporting project management and monitoring while Component 2 funding will remain unchanged. The allocations to Components 1 and 3 will increase from US$4.3 million to US$15.3 million and US$0.5 million to US$1.5 million respectively, to reflect the AF made available, as shown in Table 4. Table 4: Project Cost and Financing Original AF IBRD Trust Co-financed Project Components Parent + AF allocation financing funds with C1. Emergency COVID-19 Response 1.1 Case detection, confirmation, contact tracing, recording, reporting 1.2 Health system strengthening 4.3 11.0 - - 15.3 1.3 COVID-19 vaccine acquisition, planning and distribution 1.4 Community engagement and risk communication for demand creation Page 28 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) C2. Supporting National and Sub-national 4.2 0.0 - - 4.2 Prevention and Preparedness C3. Project Implementation and Monitoring 0.5 1.0 - - 1.5 Total 9.0 12.0 - - 21.0 Table 5: Summary of COVID-19 Vaccine Sourcing and World Bank Financing Source of vaccine financing and population coverage Doses National plan World Bank-financed Estimated allocation Specific vaccines purchased target COVAX Through of World Bank Through Other1 and sourcing plans with World (population %) grant direct financing COVAX Bank finance purchase Chinese donation of - - - 9.2% - Purchase: US$8.1 Sinopharm Stage 1: 20% million - - - 7.5% USA donation of J&J - Deployment: US$2.9 AVAT purchase of 71,000 - - 3.3% - million J&J (Single dose) Other: US$1.0 AVAT purchase of 874,255 Stage 2: 40.2% - - 40.2% - million J&J (Single dose) 1 Other: Includes coverage financed by the Government, bilaterally, from other multilateral development banks, etc. 10,000 Sputnik doses do not count for the Stage 1 target as the donation agreement was to be used exclusively on security forces. They add another 0.5 percent of the population for a total proportion of the population covered of 60.7 percent. (ii) Changes in institutional arrangements for NVDP implementation and oversight 39. All institutional arrangements from the parent project will be maintained. Further to it, the PIU will contract procurement of vaccines to UNICEF, relying on its technical expertise with COVID-19 vaccine procurement. 40. The National COVID-19 Coordination Committee and its technical committees will continue to provide support for defining project implementation strategies and overall leadership, coordination, and strategic planning for the response. At the central level, the national coordination will continue to engage all sectors related to the response to COVID-19, manage the Multidisciplinary National Technical Group of Experts, and the Health Partners Coordination Platform. Furthermore, the immunization subcommittee in which the EPI is located will ensure the preparation of the documentation that will be submitted to the National Coordination through the National Technical Group. At the provincial level, the coordination will be led by the Regional Health Directorate which will serve as the secretariat for the provincial COPIL immunization commission. 41. The implementation of activities will be carried out by the CN-TIPPEE, who will remain as the PIU. It will support the vaccination program led by the MOH and supported by the Ministry of National Defense through the General Directorate of the Military Health Service in collaboration with the other ministries: Interior, Communication, Justice, Social Affairs and Budget. These governmental agencies are part of the National Emergency Response Platform responsible to respond the COVID-19 pandemic and served as the project’s steering committee. The military support focuses on providing personnel for security and transportation to remote areas in the country. The Technical and Financial Partners will provide support in the various areas of intervention of immunization. These include WHO, UNICEF, the World Bank and others. Page 29 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) (iv) Changes in the disbursement categories 42. The project disbursement categories will remain the same. Disbursements will be frontloaded as much as possible, however, delays may be experienced due to availability of the vaccines from direct purchase, AVAT, etc. (v) Results Framework 43. To measure overall progress in the coverage and deployment of the COVID-19 vaccine, and the gender gaps the project can address, the following indicators will be added to the project results framework: At PDO level: • One indicator will be added to capture the coverage of COVID-19 vaccines among priority populations by gender: Percentage of population vaccinated, which is included in the priority population targets defined in the national plan (Target 60 percent), with a sub-indicator: Percentage of women vaccinated, which are included in the priority population targets defined in the national plan (target 50 percent). At IRI level: • Nine indicators will be added to assess effective deployment of vaccines: (i) Number of effective Vaccine Management (EVM) assessments completed with composite scores of 80 percent or higher (number); (ii) Number of health districts with health facilities that have adopted COVID-19 related AEFI mechanisms (number); (iii) Number of vaccination centers that have implemented SOPs or guidelines updated for collection and disposal of COVID-19 vaccine related medical waste (number); (iv) Percentage of targeted sites where requested Cold Chain Equipment has been installed and functional (percentage); (v) Radio/TV stations broadcast COVID-19 vaccine communication message communication message in French and local languages (yes/no); (vi) Gender sensitive educational communication materials on COVID-19 vaccines distributed (yes/no); (vii) Share of female community health workers provided with vaccine information (percentage); (viii) Share of vaccinators who are women (percentage) and (iv) Grievances received that were timely addressed through the GRM mechanism (percentage). B. Sustainability 44. There is a strong political commitment in Gabon to mobilize financial resources for COVID-19 response, including for vaccine purchase and deployment. Having the funds through the proposed AF for vaccine purchase and deployment will establish an enabling environment for other donors, multilateral development banks and UN agencies to also support efforts for strengthening the COVID-19 response in the country. Investments under the parent project and this AF are expected to strengthen the health system in the country and ensuring institutional sustainability to deal with future pandemics as well as other infectious diseases. Page 30 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) III. KEY RISKS 45. The overall risk to achieving the PDO is High. The risks and associated mitigation measures to achieving the development objectives have been adjusted to reflect the unprecedented nature of this vaccination effort. The overall project risk rating for the project was High and the underlying causes remain relevant, including: (i) adverse effects on the macroeconomic and fiscal situation of the Government of Gabon stemming from COVID-19; (ii) vaccine hesitancy; (iii) health sector institutional capacity, which can be easily overwhelmed if there is a surge in the number of new cases; and (iv) fiduciary concerns, including procurement related problems, stemming from potential difficulties in procuring critical equipment given the disruptions in global supply chains, and risk of use of funds for non-project related expenditures. The proposed AF entails additional risks associated to the inclusion of activities linked to the procurement and deployment of vaccines. As a result, the overall risk is rated as High. These risks include potential delays in the access to vaccine doses due to uncertainties in the global production and availability of vaccines and due to the unprecedented nature and scale of the crisis. 46. The large-scale acquisition and deployment of COVID-19 vaccines entails certain risks. First, global demand for vaccines continues to exceed supply, and vaccines that meet the World Bank’s VAC may not be available to be acquired in a timely manner. Second, a mass vaccination effort stretches capacity, in particular in low-capacity environments such as Gabon, entailing risks. The proposed World Bank support for Gabon to develop vaccination acquisition strategies and invest in deployment system capacity specifically aim to mitigate these risks. The remaining risk must be considered against the risk of the country having less timely and effective deployment of vaccines, potentially exacerbating development gaps and eroding past development gains. Further risks and mitigation measures related to this AF are identified below, as well as the residual risks. 47. Political and governance risks are Moderate. There may be political risks to the AF related to the commitment and ability of the authorities to ensure appropriate targeting of the AF-supported vaccines to reach the priority populations, based on objective public health criteria, and ability to manage public sentiment should there be a gap between vaccine targets and vaccine delivery. These risks will be mitigated through the assurance mechanisms that this AF will support such as the establishment of an acceptable policy and plan for prioritized intra-country allocation. There are also risks related to governance of vaccine purchase and deployment, such as potential fraud, substandard quality, and fraudulent attempts to gain access to vaccines to be administered not following approved protocols of priority populations or for personal gain, including the risk of elite capture and of corruption in the implementation of the vaccination program. This will be further mitigated through the application of anti- corruption guidelines for vaccine purchase and deployment, and robust FM oversight of the use of funds, as elaborated in the fiduciary risks below. Considering these mitigation measures, the AF is expected to have little impact on the overall political and governance risk to the parent. 48. Macroeconomic risk is High. There is considerable macroeconomic risk at this time due to a combination of factors including the difficult overall macroeconomic situation in the country and compounded by the further recent reductions in oil prices and the economic impact of the social mitigation measures which are considered necessary to stop the spread of the coronavirus. While the country is experiencing severe fiscal pressures and faces the risk of not having sufficient additional fiscal space for the purchase of vaccines at scale and other COVID-related response interventions, the proposed Page 31 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) AF specifically aims to mitigate this risk by providing financing for vaccine purchase and promoting prioritized deployment to vulnerable groups. Residual macroeconomic risk to the AF and parent PDO is limited to risks that cannot be readily mitigated (e.g., other specific macroeconomic risks that may hinder the operation from achieving its intended results). 49. Institutional capacity risk is rated Substantial. The AF is designed to address key institutional capacity risks related to vaccine deployment and distribution, but residual risks remain substantial. Vaccine distribution capacity is currently not adequate in Gabon, especially for the anticipated scale and population group coverage for COVID-19 vaccination. This risk will be mitigated by this AF financing and technical support for immunization system strengthening needs; conducting capacity assessments in coordination with the WHO, Gavi, UNICEF and other partners; and coordinating with other partners in their provision of systems strengthening support. The residual institutional capacity risk is substantial, considering the inherent risk, and the mitigation via the system strengthening supported under the AF and by partners. The AF is therefore expected to have little impact on the institutional capacity risk to the parent. 50. Fiduciary risks associated with the parent project remain Substantial. The procurement and FM risks initially assessed for the parent project cover risks associated with the procurement and distribution of vaccines, including fraud and corruption risks. Risks specific to vaccines include: • Procurement: The key procurement risk associated with vaccines relates to: (i) the complexity of the vaccines market given the significant market power enjoyed by vaccine manufacturers; (ii) inability of the market to supply adequate quantities of vaccines to meet the demand; (iii) the limited market access due to advance orders by developed countries; (iv) weak bargaining; and (v) delays in triggering emergency procurement procedures which could delay procurement and contract implementation including payments. The risks under this AF will be mitigated by providing options to support the country’s needs for direct or advance purchase, including possible TA through World Bank Facilitated Procurement (BFP). • FM: The key FM risks relate to: (i) potential ineligible expenditures; (ii) risk of duplication of expenses – expenses being charged to multiple partners/financing sources; (iii) non-compliance with contractual terms by principal contractors involved in vaccine acquisition and distribution – especially in the event of single sourcing of UN agencies; (iv) untimely funds flow or lack of liquidity; (v) risk of interference by line MOH in project activities; and (vi) lack of adequate controls over the transparent, prioritized distribution and application of vaccines, particularly for the most vulnerable population groups. This AF will use the same options as in the parent project to assess and strengthen control systems, facilitate the timely flow of funds, and ensure adequate liquidity to finance project activities based on quarterly financial reporting, and will allow the use of third- party monitoring to facilitate the endeavor. • The residual fiduciary risk associated with the AF is substantial, which is expected to leave unchanged the current fiduciary risk to the parent’s DO. 51. The anticipated overall environmental and social risks are Substantial. The measures to address social and environmental risks in the parent project remain relevant, including infection prevention and Page 32 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) control improvements in health facilities, such as assessment and mitigation measures for medical waste risk management that will be expanded as inoculation sites expand. While experience indicates that moderate risk ratings can be expected for environment, for example, if medical waste and occupational health and safety risks are well-managed, the social risk is anticipated to be at least substantial in Gabon because there is a broader social risk of inequity in access to vaccines, such as due to political pressures to provide vaccines to groups that are not prioritized due to need or vulnerability, or should target groups be misaligned with available vaccines. This includes possible exclusion of population groups based on gender, race, ethnicity, refugee status, religion or others, as well as vaccine hesitancy and/or elite capture which, in turn, could result from broader misinformation and public distrust. The use of the Military Health Services is limited to support the national response committee and vaccines deployment under the MOH providing personnel for security and transportation to remote areas in the country. Project proceeds shall not be used for security or military purposes, and if security services to safeguard vaccines, personnel involved in vaccine deployment or population are needed, those can only be contracted under the explicit approval of the World Bank. 52. These risks will be mitigated through several measures to ensure vaccine delivery targets the most vulnerable populations, particularly women, elderly, poor, refugees, and minorities in accordance with criteria specified in this AF. First, the World Bank will support Gabon to develop and adapt an explicit, contextually appropriate, and well-communicated targeting criteria and implementation plan (e.g., the national vaccination program and any subsidiary programs) including criteria for access to vaccines. The Borrower should ensure that this plan be subject to timely and meaningful consultations in accordance with ESS 10. There should be consensus to first target heath workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly, people with co-morbidities, and people in high-population density location such as slums and refugee camps. The World Bank will also continue to provide technical and implementation support to mitigate this risk. The AF will support communication activities including demand creation and addressing vaccine hesitancy and will also support platforms that will regularly convene civil society organizations/NGOs to strengthen accountability and transparency of vaccine deployment. 53. All targeting criteria and implementation plans will be reflected in country’s national vaccination program. Another potential risk is the increased incidence of reprisals and retaliation especially against healthcare workers and researchers. This risk will be mitigated through explicit inclusion in robust stakeholder identification and consultation processes. Further, and linked to the social risks stated above, it is important to have clarity on the risks that may arise related to any mandatory aspect of the national program and whether and how this mandatory element relates to cultural, social and traditional community practices and values. Such risks need to be considered in light of the mitigation hierarchy and balanced against the health-related requirements of any mandatory vaccination program. In addition, the grievance mechanisms required under the Environmental and Social Framework (ESF) should be in place and equipped to address community, worker, and/or individual grievances related to such issues. This includes requirements related to being able to have GRMs in place to address labor and working conditions, and sexual exploitation abuse and sexual harassment (SEA/SH). IV. APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis Page 33 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 54. The economic rationale for investment in a COVID-19 vaccine is strong, considering the massive and continuing health and economic losses due to the pandemic. As of October 1, 2021, more than 219 million people have been confirmed to be infected by the virus and over 4.5 million have been confirmed to have died. Global output declined by 4.3 percent in 2020, with cumulative losses across 2020 and 2021 projected to exceed US$12 trillion. 55. The successful development, production, and delivery of a vaccine has the best potential to reverse these trends, generating benefits that will far exceed vaccine-related costs. Indeed, a rapid and well-targeted deployment of a COVID-19 vaccine can help reduce the increases in poverty and accelerate economic recovery. Public health measures, such as distancing, masks, testing and contact tracing, would still need to continue in an effective manner while the supply of vaccines is enough to cover the entire population. Even at levels of imperfect effectiveness, a COVID-19 vaccine that is introduced and deployed effectively to priority populations can assist in significantly reducing mortality and the spread of the coronavirus and accelerating a safe reopening of key sectors that are impacted. It can also reverse human capital losses by ensuring schools are reopened. The effective administration of a COVID-19 vaccine will also help avoid the associated health care costs for potentially millions of additional cases of infection and associated health-related impoverishment. Global experience with immunization against diseases shows that by avoiding these and other health costs, vaccines are one of the best buys in public health. For the most vulnerable population groups, especially in countries without effective universal health coverage, the potential health-related costs of millions of additional cases of COVID-19 infection in the absence of a vaccine represent a significant or even catastrophic financial impact and risk of impoverishment. The pandemic is also having dire effects on other non-COVID health outcomes. Increased morbidity and mortality due to interruption of essential services associated with COVID-19 containment measures hinder access to care for other health needs of the population, including maternal and childcare services, routine immunization services have been affected, threatening polio eradication and potentially leading to new outbreaks of preventable diseases, with their own related deaths, illnesses and long-term costs. Simultaneous epidemics are overwhelming public health systems in different countries that had few resources to begin with, and services needed to address the needs of people with chronic health conditions, and mental and substance use disorders have been also disrupted. 56. While the uncertainty around the costs and effectiveness of a COVID-19 vaccine make it difficult to calculate its cost-effectiveness, the effective launch of a COVID-19 vaccine will have direct benefits in terms of averted costs of treatment and disability, as well as strengthened health systems. Estimated COVID-19 treatment costs from low- and middle-income countries is at US$50 for a non-severe case and US$300 for a severe case. This excludes costs of testing of negative cases, as well as the medical costs associated with delayed or forgone care-seeking, which usually results in higher costs. The estimated costs of vaccinating 20 percent of the population of Gabon are at US$8.7 million (two dose regimen); even if the vaccine averts non-severe cases and no other benefits are taken into account, the investment will break even. Further, investments in vaccine delivery systems generate health and economic benefits beyond just delivering the COVID-19 vaccine. First, investments in last-mile delivery systems to administer the COVID-19 vaccine to remote communities will require strengthening community health systems, which can have spillover effects to effective delivery of other services, helping close the significant urban- rural gap. Second, as the COVID-19 vaccine is introduced and lockdowns and movement restrictions are eased, patients can continue to access care for other conditions. Given both the economic and health system benefits, an effectively deployed COVID-19 vaccine presents significant benefits. Page 34 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) B. Financial Management 57. In line with the guidelines as stated in the FM Practices Manual issued by the FM Sector Board on March 1, 2010 (revised on September 7, 2021), an FM assessment was conducted for the project restructuring. 58. The FM arrangements originally established for the project are satisfactory and will remain unchanged, as they are assessed as adequate. The last FM review of the project performed in June 2021 assessed the FM performance as Moderately Satisfactory. The main weaknesses raised were: (i) the advance paid to WHO not yet documented while the services are complete; and (ii) the recruitment process of the internal and external auditors not yet complete. An action plan was put in place to address these shortcomings and concluded satisfactorily in July 2021. However, a stronger monitoring of contracts with partners should also be necessary to avoid delays in justification of funds paid in advance, thus, the use of third-party monitoring is highly recommendable. 59. The speed of disbursements of the project will be significantly influenced by the availability of vaccines. The World Bank will provide financial and risk assurances to manufacturers under advance purchase mechanisms. The disbursements will be based on Statements of Expenditures, and other disbursement methods such as reimbursement, special commitment and direct payment will apply as well. Additional instructions for disbursement would be provided in the revised Disbursement and Financial Information Letter. 60. The approved project’s FM manual of procedures will be updated to include the specificities of the AF such as vaccines acquisition and deployment procedures. No separate audit report would be required with respect to the vaccines purchase and deployment, which will be added to the financial statements of the parent project with separate disclosures in the notes to the financial statements. To this end, the implementing agency will sign an addendum to the current auditor contract to include these activities in the scope of the audit. The PIU will also request in the Terms of Reference that specific opinion on the adequacy of vaccines acquisition and deployment be expressed. The audits will be conducted based on International Standards on Auditing. Such an audit report will be submitted to the World Bank on a yearly basis, along with the respective management letters within six (6) months of the end of the fiscal year. 61. The overall residual FM risk is Substantial due to the complexity of the vaccine market and lack of transparent distribution systems, mitigated by the FM arrangements in place and the experience of the PIU. As mitigating measures have been implemented for the project to address FM capacity constraints, the FM system satisfies the World Bank’s minimum requirements under World Bank Policy and Directive on Investment Project Financing (IPF) effective in 2017. C. Procurement 62. Procurement under the AF will be carried out in accordance with the World Bank’s Procurement Regulations for IPF Borrowers for Goods, Works, Non-Consulting and Consulting Services, dated November 2020. As with the parent project, the AF will be subject to the World Bank’s Anticorruption Guidelines, dated October 15, 2006, revised in January 2011, and as of July 1, 2016. The project will use Page 35 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) the Systematic Tracking of Exchanges in Procurement (STEP) to plan, record and track procurement transactions. 63. The major planned new procurement in the restructured project will include: (i) vaccines and the logistics required to deliver to the Gabon’s port of entry, (ii) additional capacity or minor upgrades of national, subnational and facility based and mobile cold chain equipment and supplies including cold rooms, ice lined refrigerators and vaccine carriers; (iii) TA for demand creation and reduction of hesitancy – including mass media and communication campaigns; (iv) other TA to support in-country implementation including assessments of effective vaccine management capacity and training of front- line delivery workers; and (v) vaccine logistics and information management systems and information systems to monitor adverse effects from immunization. 64. The AU beginning in late 2020 embarked on an ambitious effort to vaccinate at least 70 percent of Africa’s population as quickly as possible through a continental approach. The effort to acquire more vaccines has been led by the AU Vaccine Acquisition Task Team (AVATT) – the AU Special Envoys for COVID-19, Africa Centres for Disease Control and Prevention, the African Export-Import Bank (Afreximbank) and UNECA. The AU sees this effort as complementary to COVAX and the World Bank has worked alongside AVATT since January 2021 to inform the design of the AVAT mechanism and to ensure that World Bank financing can be used by participating member countries to purchase vaccine doses. 65. On June 21, 2021, the AU and the World Bank held a joint meeting with African Ministers of Finance to officially launch the partnership to accelerate vaccination in Africa. AVAT has already successfully negotiated 220 million doses of J&J/Janssen COVID-19 vaccine for use by African countries, with an option for 180 million more based on demand. AVAT is negotiating with other suppliers and expected to secure more doses. World Bank financing and TA is available to help countries obtain vaccines from eligible suppliers through AVAT and to effectively deploy them. 66. In August 2021, Gabon entered into a commitment undertaking with AVAT to purchase eligible vaccines under the mechanism and will sign an agreement with UNICEF as the procurement agency one the World Bank financing under this project is made available for the purchase. 67. The current demand for COVID-19 vaccines exceeds the supply in the market which makes it more difficult for client countries to negotiate terms and conditions. Procurement of vaccines will therefore follow Direct Selection. The combination selected by the GoG is (i) purchase through AVAT; and (ii) direct purchase from manufacturers. Contracts for vaccines purchase financed by the World Bank will be subject to the World Bank’s prior review irrespective of value and procurement approach. The arrangements for freight for the vaccines including that for AVAT financed vaccines where freight is financed by the World Bank. The PIU will contract procurement of vaccines to UNICEF, relying on its technical expertise with COVID-19 vaccine procurement. Building on the positive experience with capital equipment and PPE under the parent project and at Borrower request, the World Bank will offer BFP as support to Gabon’s own procurement. 68. The procurement approach for the other non-vaccine procurement may include: (i) streamlined competitive procedures with shorter bidding time; (ii) use of framework agreements including existing ones; (iii) procurement from UNICEF enabled and expedited by World Bank procedures and standard Page 36 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) agreements; and (iv) increased thresholds for Requests for Quotations and national procurement, and Direct Selection. The World Bank’s Standard Procurement Documents for Procurement under COVID-19 Emergency Operations shall be used. Recognizing the significant disruptions in the usual supply chains for medical consumables and equipment, the World Bank will provide TA, at the Borrower’s request, BFP to assist them in accessing existing supply chains. 69. Any contracts concluded with UNICEF will follow the standard forms of agreement agreed and applicable to those agencies and contract types. A Standard Agreement shall be signed between the Government and the UNICEF that will clearly indicate the level of involvement and the specific role of the agency under the project. The agreement shall contain specific Annexes on the payment schedule and reporting requirements by the UN. Therefore, the fiduciary arrangements pertaining to contracting of the UNICEF will follow the agreed upon arrangements that will be included as part of the Standard Agreement to be signed between the Government and the UNICEF. 70. The proposed procurement approach prioritizes fast track emergency procurement for the required goods and services. Options may include among others (i) streamlined competitive procedures with shorter bidding time; (ii) use of framework agreements including existing ones; (iii) procurement from UNICEF and expedited by World Bank procedures and standard agreements; and (iv) increased thresholds for Requests for Quotations and national procurement, among others. 71. Procurement capacity and risk assessment. The summary of the procurement assessment is given below: • The MOH will be the technical implementing agency while CNTIPPEE will have the fiduciary responsibility, including procurement. Streamlined procedures for approval of emergency procurement have been agreed for implementation to expedite decision making and approvals by the Borrower. • The major risks to procurement are: (i) limited knowledge of the procurement regulations; (ii) limited capacity in conducting emergency procurement; (iii) capacity of market and supply chain to meet demands as well as risks associated with BFP, where the approach is agreed with the Borrower; (iv) managing fraud and corruption, and noncompliance; and (v) impact of emergency on supply chains and lead times. • The overall procurement risk is “Substantial”. It will be mitigated by (i) intensive hands-on support all through procurement steps, on use of World Bank new procurement framework and on emergency procurement; (ii) mobilization of upstream potential suppliers, put in place measures for supplier preferences like direct payments by the World Bank, advance payments when needed; and (iii) prior review of all vaccines’ contracts. • To minimize unnecessary delays in the acquisition of specialized and urgent goods in needs, Specialized UN agencies will be contracted by the implementing agency using the Standard Form of Agreement, to procuring critical medical equipment, PPE, and laboratory equipment as well as to providing training of health care workers. Page 37 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 72. The World Bank’s prior and post-reviews will be carried out based on thresholds. The standard post-procurement reviews by World Bank staff should cover at least 10 percent of contracts subject to post-review. 73. Training will be subject to quarterly training plans that will be submitted by the PIU for clearance. These plans should include a description of the training, an outline budget and its implementation arrangements, and list of individuals to be trained. Once the plans have been cleared by the World Bank, reasonable costs for each training will be documented through statement of expenditures disbursement purposes. Reasonable costs will include hire of training venues (if not within MOH and its network of facilities) and other eligible expenditures. The ‘per diems’ paid to the participants should be as mandated by local regulations. 74. Advance procurement, if undertaken by MOH, shall follow the provisions for the same under the Procurement Regulations. See Annex 3 (section II) of the parent project PAD for detailed procurement assessment and arrangements. 75. The World Bank’s oversight of procurement will be done through increased implementation support and where requested by the Borrower, procurement HEIS. The World Bank’s standard prior and post review arrangements apply as specified in the procurement plan. D. Legal Operational Policies 76. The applicable Legal Operational Polices to this AF are presented below: . Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . E. Environmental and Social 77. Activities under the AF should have positive impacts as they should improve COVID-19 surveillance, monitoring, containment. However, they could also cause environmental, health and safety risks due to the dangerous nature of the pathogen (COVID-19) and reagents and equipment used in the project supported activities. Facilities treating patients may also generate, biological, chemical waste, and other hazardous by-products that could be injurious to human health. These risks will be mitigated with occupational health and safety standards and specific infectious-control strategies, guidelines and requirements as recommended by WHO and CDC. Multiple disadvantaged or other vulnerable groups stand to benefit, starting with the elderly and those with compromised immune systems due to pre- existing conditions. The overall project activities will seek to ensure inclusion of these groups. The identification of target groups (Phase 1) that will receive vaccination based on the WHO recommendations has been achieved. COVID-19 vaccine, social mobilization, risk and crisis communication strategy and routine surveys to track knowledge and attitudes has been initiated. The SEP, which has been updated and disclosed on September 1st, 2021, based on audit recommendation, identifies the presence of Page 38 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) disadvantaged and vulnerable groups, such as older population segments or hard to reach groups and indigenous people (IP). Beyond the orientations defined in the ESMF for the consideration of IPs in the project, the PIU will conduct a field mission in four provinces where IPs are located. The objective is to evaluate the level of involvement and participation of IPs in this program and at end to better orient their consideration in the project activities. After this mission, a light IP Plan will be prepared no later than 30 days after project effectiveness and prior to carrying out of relevant Project activities to ensure adequate consideration of IP specific cultural needs, to the satisfaction of the World Bank and will define the activities for IPs as well as the practical modalities of implementation. The community engagement activities proposed under Component 1 will seek to ensure the inclusion of disadvantaged and vulnerable groups. In terms of the prioritization of the population groups that will receive vaccination first, the WHO’s Fair Allocation Framework guidance will be followed, as well as the National Risk Communication and Community Engagement Strategy for outreach and consultation. 78. As previously informed in paragraph 11, the ESMF, LMP, SEP, and ICWMP were developed based on recommendations of the E&S Audit Report and publicly disclosed as mentioned in footnote 8. In terms of E&S audit findings, it reports as operational/administration issues the following: (i) lack of involvement of the CN-TIPPEE’s safeguards specialists during preparation and validation of documents WHO procurement contracts to ensure E&S requirements were taken into account, (ii) ineffective communication / information exchange among stakeholders (MOH, COPIL, E&S specialists, WHO, medical and pharmaceutical warehouse - Office Pharmaceutique National and Military Health Service, among others) necessary for the dissemination of project information; (iii) delay in the recruitment of environmental and communication specialists necessary to support E&S requirements; and (iv) lack of clear definition of roles and responsibilities between the CN-TIPPEE and WHO in terms of management of the project’s E&S issues. 79. All E&S documents from the parent project and AF were disclosed on September 1, 2021 and address specific risks of the vaccination campaign, including the: (i) risk that project-related impacts fall disproportionately on individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable; and (ii) risk of prejudice or discrimination toward individuals or groups in providing access to development resources and project benefits, particularly in the case of those who may be disadvantaged or vulnerable, including risks related to SEA/SH. These risks will be mitigated through the following measures: First, the Government has developed explicit, contextually appropriate, and well communicated criteria for access to vaccines. There is consensus to first target heath workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly and people with co-morbidities. All targeting criteria and implementation plans are reflected in the country’s national vaccination program. Second, the Government will actively use the National COVID Risk Communication and Community Engagement Strategy to address misinformation and distrust as a main barrier to vaccination. In addition, risk mitigation measures be outlined in a SEA/SH Prevention and Response Action Plan, which will incorporate an accountability and response framework, including codes of conduct to be signed by all individuals engaged in the project activities (including if possible MOH relevant partners, health staff, and all suppliers linked to the execution of project activities) outlining prohibited conduct and applicable sanctions, procedural adaptations to the project grievance mechanism to ensure safe and confidential management of SEA/SH claims with timely referrals to appropriate survivor care, as well as training and sensitization activities. In addition, SEA/SH risk will be addressed through robust stakeholder identification and consultation processes, which will take into specific account consultation with women Page 39 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) and other vulnerable groups in safe and enabling, sex-segregated environments (including with same-sex facilitators). 80. The updated ESMF includes: (i) 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, in addition to guidance on mitigation measures to address SEA/SH risk in the context of project activities; and (ii) measures to ensure the quality of vaccines is maintained throughout the supply chain in accordance with WHO guidance for storage and transportation of vaccines. The mitigation measures are largely based on the WHO technical guidelines on COVID-19 response and the Environmental, Health, and Safety guidelines of the World Bank Group, with the responsibilities within the MOH, the required trainings, implementation schedule and budget. In addition, an ICWMP to safeguard health care workers, patients and the larger community from transmission and infection by the COVID-19 virus as the result of their daily routines that include testing, quarantining and treating patients and managing the safe disposal of the resulting medical waste has been developed for the original project activities and updated with new AF activities. The updated ESMF adequately covers E&S infection control measures and procedures for the safe handling, storage, and processing of COVID-19 materials including techniques for preventing, minimizing, and controlling E&S impacts during the operation of project supported laboratories and medical facilities. The relevant parts of WHO’s COVID-19 Quarantine Guideline and COVID-19 biosafety guidelines are incorporated into the ESMF and ICWMP. 81. The MOH will also use the existing stakeholder engagement mechanism of the parent project to engage citizens and for public information disclosure while they update it to include more information on the E&S risks of the project activities and new modalities that take into account the need for social distancing. The original project’s SEP has been updated including the GRM for addressing any concerns and grievances raised regarding vaccinations. In addition to the ESMF and SEP, the Client will implement the activities set out in the ESCP and implementing it throughout the project period. The project implementation will ensure appropriate stakeholder engagement through regular consultations, proper awareness raising and timely information dissemination as well as support to MOH routine targeted surveys. This will help: (i) avoid conflicts resulting from rumors; (ii) ensure equitable access to services for all who need it; and (iii) address issues resulting from people being kept in quarantine. These will be guided by standards set out by WHO as well as other international good practices including social inclusion and prevention of SEA/SH. There are some risks related to the potential exclusion of some groups (such as nomadic pastoralists following seasonal transhumance routes in remote areas and small destitute groups living in the outskirts of urban and semi-urban areas). The situation of non-nationals should also be assessed, and the vaccination roll-out should include them. 82. The community engagement approach is detailed in the national COVID-19 NVDP and focuses on demand generation in communities, clarifying target groups and removing misconceptions related to vaccinations while ensuring a community feedback loop. The community engagement plan’s main objectives are: (i) building trust and awareness on COVID-19 vaccines through use of different channels and a social mobilization approach; (ii) using data and evidence to dispel rumors and public misperceptions; (iii) development and provision of context specific information education and communication / behavior change and communication materials to targeted priority groups; (iv) training journalists about COVID-19 vaccine and its importance for safety and wellbeing of the public, and (v) Page 40 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) promoting the COVID-19 vaccine through social media and mass media campaigns. Community engagement in health facility management will be monitored. 83. In line with WHO Interim Guidance (February 12, 2020) on “Laboratory Biosafety Guidance related to the novel coronavirus (2019-nCoV)”, and other guidelines, the parent project developed a ICWMP and an ESMF with the WHO standards on COVID-19 response. The plan includes training of staff to be aware of all hazards they might encounter. This provides for the application of international best practices in COVID-19 diagnostic testing and handling the medical supplies, disposing of the generated waste, and road safety. 84. In terms of modalities for handling personal data, as risk mitigation measures, personal data will be collected and used only for necessary and intended proposes to ensure data accuracy without unnecessary correction or deletion and ensure the confidentiality and anonymity of personal data when stored. When formative research is planned, the Ethics Review Committee reviews and ensures the use of written consent forms to be filled by study participants. The project implementation manual will design a section on modalities for handling personal data based on the Personal Data Protection Law No.009/2011 dated September 25, 2011. For now, personal data are kept in registers designed for COVID- 19 vaccination accessible only to registered data managers, and only aggregate data is transmitted for up- scale reporting. Data managers are required to sign a confidentiality agreement and are supervised by a subcommittee on data management under the National Emergency Response Platform. F. Climate co-benefits 85. In terms of climate change risks and vulnerabilities, Gabon has been screened for short and long- term climate change and disaster risks and the exposure risk is High. This includes exposure to extreme temperatures, extreme precipitation, droughts, geophysical hazards (landslides), sea-level rise and strong winds. This exposure risk is assessed at this level for both the current and future timescales. Given its geographical location, topographical and geological conditions, Gabon is one of the most vulnerable countries in the world that are exposed to the adverse risks of natural disasters, climate change and disease outbreaks. Climate change may have serious implications on the rainforest, which is 85 percent of Gabon’s land coverage.14 Seventy percent of the population also lives along the coast, which increases the risk of exposure to sea level rise and extreme flooding. The increasing temperatures, changes in rainfall pattern in the country may lead to food insecurity and scarcity of resources, which has implications on the nutritional status of the population including the lack of water availability. Approximately 21,000 people are annually affected by drought in Gabon, which could lead to up to US$185 million impacted each year due to drought.15 Extreme rainfall in the region has also produced more flooding, which may increase vector- and water-borne diseases and can impact the structural integrity of health facilities. Strong wind events are becoming commonplace in Gabon, which can contaminate water supplies and cause power outage leading to food storage issues increasing the risk of foodborne and waterborne diseases. 14 World Bank. 2021. Climate risk country profile – Gabon. Retrieved at: https://climateknowledgeportal.worldbank.org/sites/default/files/2021-06/15858-WB_Gabon%20Country%20Profile- WEB_0.pdf 15 UNISDR. 2019. Disaster Risk Profile – Gabon. Retrieved at: https://reliefweb.int/sites/reliefweb.int/files/resources/Report_Gabon_Finalcompressed.pdf Page 41 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 86. The AF intends to address the above-described climate vulnerabilities and assist the Government to adapt to climate change through several activities. In terms of climate adaptation, through Component 1, Emergency COVID-19 Response (AF: US$11 million), the purchase of COVID-19 vaccines will consume US$8.5 million. This includes the costs of the vaccines, supplies, safety boxes for disposal of syringes, syringes, international freight, procurement fees to UNICEF and other deployment-related costs before arriving in-country. While no direct climate financing is expected to be assigned at this time to any of these investments, it is expected that some suppliers are taking active steps to ensure climate resilient considerations are taken into account during the manufacturing, shipment and distribution stages of the vaccines. The World Bank team, together with UNICEF, WHO and Gavi will continue to explore these areas in order to provide latest information on any specific climate adaptation and mitigation actions taken with regard to the vaccines. The widespread loss of power may seriously threaten the COVID-19 vaccine cold chain as vaccine conservation standards will be impacted. Therefore, as an adaptation measure, some of the CCEs purchased will be off-grid solar equipment/supplies such as solar powered fridges and freezers that will provide reliable 24/7 power and efficient cooling. Low-carbon, energy efficient waste management equipment will also be procured to enhance climate resilience to flooding threats faced by the country. Moreover, the NVDP will include measures to deal with any unexpected disruptions to the vaccine supply chain, distribution and storage from climate change impacts and other unexpected disasters (i.e., power outages from flooding and extreme heat). The component will also support contact tracing, recording, reporting, the strengthened case management capabilities and disease surveillance system will enhance the ability of the health services to better respond to future climate-related health impacts from extreme weather events. This will include the integration of weather surveillance to improve the use of information for detecting, investigating, and responding to public health threats. Moreover, the priority groups targeted for the COVID-19 vaccines are the same groups that are vulnerable to climate change, which include those with underlying conditions, people aged 60 years old and above and individuals who are critical to maintaining service delivery in the event of climate-related events. Therefore, as a climate adaptation measure, important health information on climate change-related health risks linked to the COVID crisis such as the increased risks associated with quarantine in extreme heat events and the promotion of healthy behaviors will be provided. 87. In terms of climate mitigation, investments will be made in climate friendly vaccine logistics such as solarization of EPI cold rooms, low carbon cold chain equipment, and environmentally friendly handwashing stations under Component 1: Emergency COVID-19 Response (AF: US$11 million). The current capacity of the cold chain system and warehousing may be adequate to vaccinate part of the prioritized population. However, additional equipment will be needed to strengthen the health system in the short and long term. Therefore, climate friendly cold chain equipment (e.g., solar direct drive refrigerators, WHO PQs certified climate friendly refrigerators, climate-sensitive waste management equipment to reduce greenhouse gas emissions from fossil fuels and high-greenhouse gas emitting refrigerants in the country will be identified and procured. This will improve reliability of vaccine storage, as well as identification of sustainable end-of-life options for old or high-polluting cold chain equipment. Route optimization will be taken into account for vaccine transportation by adjusting routes for vehicles depending on weather and road conditions. This will improve fuel mileage and fuel efficiency of the vehicles. Climate-friendly mobile vaccine delivery units will also be used to enable vaccinations in closer proximity to beneficiaries. This will reduce the use of transportation by beneficiaries, leading to lower greenhouse gas (GHG) emissions from cars, trucks, buses, and other modes of transportation. The project will also finance climate-smart civil works (thermal insulation and solar reflective roofs) that will improve Page 42 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) the insulation of the health facilities and cold rooms against extreme heat for more energy efficiency buildings. G. Gender 88. Despite Gabon’s progress in advancing gender equity, several gaps persist. The country's Gender Development Index (GDI) is 0.703 (United Nations Development Programme Country Profile 2019), indicating inequities in the country’s health development index achievements between women and men. On average women in Gabon half the years of schooling compared to males. The country has a Gender Inequality Index value of 0.525, ranking it 115 out of 162 countries in the 2019 index. In Gabon, 16.2 percent of parliamentary seats are held by women (as of February 2021), while 33.4 percent of the national population lives below the poverty line, this rate rises to 51.5 percent for women, and 97 percent of them are underemployed. Overall, 28.5 of women are employed and the literacy rate among women over 15 years old is 84.7 percent. On average, every Gabonese woman gives birth to 3.97 children with a maternal mortality rate is of 252 per 100,000 live births. The impact of the COVID-19 is likely to exacerbate these inequities. As such, the project will consider specific activities to mitigate the health and socioeconomic impacts of COVID-19 on women in Gabon such as hiring women in vaccination activities. 89. Evidence from previous infectious disease outbreaks indicates that men and women are often differentially affected, with women impacted more negatively than men. The effects of COVID-19 will likely exacerbate pre-existing gender differences. Gender gaps are different depending on the context and specific characteristics of different groups of women. According to Afrobarometer (2016/2018) data, there is virtually no gender gap on phone ownership (94 percent men vs 93 percent women) and in usage, with 86 percent of both women and men saying they use a phone every day. However, there is a larger gender gap in use of internet to access news on a daily basis (41 percent of women vs 49 percent of men in urban areas; and 6.5 percent of women versus 9.4 percent of men in rural areas). Furthermore, the Domestic Household Survey in relation to the use of various forms of media reports that the largest gender gap is in weekly use of radio (39 percent of women vs 61 percent of men), with a smaller gap in weekly newspaper readership (38 percent of women vs 48 percent of men). The combination of these data lead to estimate that some women may not be reached by relevant information on the pandemic. Gender norms that restrict women’s mobility, working outside of the home, or others might be exacerbated due to confinement measures and the increased burden of care. There is also 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. 90. For women in Gabon access to healthcare is granted by the mandatory health insurance, however, COVID-19 restrictions may impose new constraints. This raises legitimate concerns over women’s lack of access to testing and subsequently to vaccinations. For some women, while they have access to healthcare facilities, they can only engage with female health workers. This becomes a problem that is difficult to overcome given the shortage of female health workers in the healthcare system. The project will, therefore, make it mandatory for Service Providers to recruit a minimum of female health care workers (vaccinators) in each of the vaccination centers (covering all vaccination centers) supported through the project, to create conditions that allow women to visit and get vaccinated in the healthcare facilities. Page 43 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) 91. Similarly, women’s access to information is also limited. The project will ensure gender sensitive, contextualized and accurate information about COVID-19, accounting for differences in literacy rates amongst women and men, and different levels of access to mobile phone, social media, radio and helplines. Furthermore, the project will also mobilize community health workers especially female as they can play a critical role in communicating with women providing them information about the vaccine and managing misinformation regrading COVID-19 vaccination and women’s reproductive health and others that may emerge during the roll-out and deployment. 92. By engaging female community health workers and female health workers and considering gender sensitive communication and information sharing approaches, the project will mitigate the risk of sextual exploitation, harassment and abuse as well as addressing social/cultural barriers to women’s access to information and access to vaccine. The project will ensure that all the vaccine centers have measures in place to promote gender friendly environment and enhance women and girls’ safety. These include separate rooms/vaccine area for female, having at least one female staff in place, Code of Conduct for all the staff, and ensuring that GRMs are accessible by female beneficiaries. V. WORLD BANK GRIEVANCE REDRESS 93. Communities and individuals who believe that they are adversely affected by a World Bank (WB) supported project may submit complaints to existing project-level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org 94. The Project incorporates a comprehensive GRM, which will enable a broad range of stakeholders to channel concerns, questions, and complaints to the various implementation agencies and COVID-19 Call centers. The project supports the COVID-19 Call Centers with call-free numbers. These numbers have been publicly disclosed throughout the country in the broadcast and print media. The GRM will be equipped to handle cases of SEA/SH, as rapid guidance on how to respond to these cases will be developed and shared with operators. This will follow a survivor-centered approach The GRM will continue to be publicized by the MOH and other relevant agencies. Page 44 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) VI SUMMARY TABLE OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Implementing Agency ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ VII DETAILED CHANGE(S) MPA PROGRAM DEVELOPMENT OBJECTIVE Current MPA Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Proposed New MPA Program Development Objective Page 45 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) EXPECTED MPA PROGRAM RESULTS Current Expected MPA Results and their Indicators for the MPA Program Progress towards the achievement of the PDO would be measured by outcome indicators. Individual country- specific projects (or phases) under the MPA Program will identify relevant indicators, including among others: • Country has activated their public health Emergency Operations Centre or a coordination mechanism for COVID-19; • Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents; • Number of acute healthcare facilities with isolation capacity; • Number of suspected cases of COVID-19 reported and investigated per approved protocol; • Number of diagnosed cases treated per approved protocol; • Personal and community non-pharmaceutical interventions adopted by the country (e.g., installation of handwashing facilities, provision of supplies and behavior change campaigns, continuity of water and sanitation service provision in public facilities and households, schools closures, telework and remote meetings, reduce/cancel mass gatherings); • Policies, regulations, guidelines, or other relevant government strategic documents incorporating a multi- sectoral health approach developed/or revised and adopted; • Multi-sectoral operationalmechanism for coordinated response to outbreaks by human, animal and wildlife sectors in place; • Coordinated surveillance systemsin place in the animal health and public health sectors for zoonotic diseases/pathogens identified as joint priorities; and • Mechanisms for responding to infectious and potential zoonotic diseases established and functional; and • Outbreak/pandemic emergency risk communication plan and activities developed and tested Proposed Expected MPA Results and their Indicators for the MPA Program COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Component 1: Emergency 4.30 Revised Component 1: 15.30 COVID-19 Response Emergency COVID-19 Page 46 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Response Component 2: Supporting 4.20 No Change Component 2: 4.20 National and Sub-national, Supporting National and Prevention and Sub-national, Preparedness Prevention and Preparedness Component 3: Project 0.50 Revised Component 3: Project 1.50 Implementation and Implementation and Monitoring Monitoring TOTAL 9.00 21.00 LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline Closing(s) Closing for Withdrawal Applications IBRD-91240 Effective 30-Jun-2022 30-Jun-2022 30-Jun-2024 30-Oct-2024 Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2020 6,225,051.02 6,225,051.02 2021 2,285,076.99 8,510,128.01 2022 5,000,000.00 13,510,128.01 2023 5,000,000.00 18,510,128.01 2024 1,500,000.00 20,010,128.01 2025 989,871.99 21,000,000.00 SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance ⚫ Moderate ⚫ Moderate Macroeconomic ⚫ Moderate ⚫ High Sector Strategies and Policies ⚫ Moderate ⚫ Moderate Technical Design of Project or Program ⚫ Moderate ⚫ Moderate Institutional Capacity for Implementation and ⚫ Moderate ⚫ Substantial Page 47 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Sustainability Fiduciary ⚫ Moderate ⚫ Substantial Environment and Social ⚫ Substantial ⚫ Substantial Stakeholders ⚫ Moderate ⚫ Moderate Other ⚫ Moderate Overall ⚫ Moderate ⚫ High LEGAL COVENANTS2 LEGAL COVENANTS – Gabonese Republic Additional Financing for COVID-19 Strategic Preparedness and Response (P176464) Sections and Description Schedule 2, Section I, B, 1: The Borrower shall by no later than one (1) month after the Effective Date, prepare and adopt a Project operations manual (“Project Operations Manual”) containing detailed guidelines and procedures for Project implementation, including: administration and coordination; monitoring and evaluation; financial management, procurement and accounting procedures; social and environmental safeguards; corruption and fraud mitigation measures; a grievance redress mechanism, personal data collection. ESCP: Per ESCP, the project grievance mechanism will be operational and adequately resourced no later than 30 days after the date of effectiveness and will be maintained throughout the life of the project. Conditions Type Financing source Description Disbursement IBRD/IDA Schedule 2, Section III, B, 1:no withdrawal shall be made for payments made prior to the Signature Date, or under Category 1, unless and until the Vaccine Delivery and Distribution Manual has been adopted. Page 48 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Gabon RESULT_NO_PDO Gabonese Republic Additional Financing for COVID-19 Strategic Preparedness and Response Project Development Objective(s) The Project Development Objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Gabon. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target COVID-19 Emergency Response Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents. (Number) 2.00 5.00 Percentage of suspected cases of COVID-19 reported and 0.00 60.00 investigated per approved protocol (Percentage) (Percentage) Percentage of diagnosed cases treated per approved protocol 0.00 70.00 (Percentage) (Percentage) Percentage of population vaccinated, which is included in the priority population targets defined in the national plan 2.00 60.00 (Percentage) Action: This indicator is New Percentage of women vaccinated, which are included in the priority population targets defined in the national plan 0.60 50.00 (Percentage) Page 49 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target Action: This indicator is New PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Emergency COVID-19 Response Percentage of health staff equipped with appropriate PPE for infection prevention and control per MOH-approved protocols 50.00 80.00 (Percentage). (Percentage) (Percentage) Number of WB financed designated ambulances to transport COVID19 patients per MOH-approved protocols (number) 0.00 10.00 (Number) (Number) Number of Effective Vaccine Management (EVM) assessments completed with composite scores of 80% or higher (Number) 0.00 5.00 Action: This indicator is New Number of health departments with health facilities that have 14.00 47.00 adopted COVID-19 related AEFI mechanisms (Number) Action: This indicator is New Number of vaccination centers that have implemented standard operating procedures (SOPs) or guidelines updated for collection 24.00 57.00 and disposal of COVID-19 vaccine related medical waste (Number) Action: This indicator is New Page 50 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Percentage of targeted sites where requested Cold Chain 0.00 100.00 Equipment has been installed and functional (Percentage) Action: This indicator is New Radio/TV Stations broadcast COVID-19 vaccine communication message in French and local languages (Yes/No) No Yes Action: This indicator is New Gender sensitive educational communication materials on No Yes COVID-19 vaccines distributed (Yes/No) Action: This indicator is New Share of female community health workers provided with 0.00 40.00 vaccine information (Percentage) Rationale: Female community health workers can play a critical role in providing women with information about the vaccine and Action: This indicator is New help reduce hesitancy. Share of vaccinators who are female (Percentage) 0.00 30.00 Rationale: Action: This indicator is New Some women can only engage with and thus seek immunization from female health workers. Supporting National and Sub-national, Prevention and Preparedness Number of suspected COVID19 cases tested per MOH-approved protocols at the 5 designated laboratories equipped to conduct 572.00 60,000.00 COVID-19 diagnosis (number). (Number) (Number) Implementation Management and Monitoring and Evaluation Page 51 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target M&E system established to monitor COVID-19 preparedness and No Yes response plan (Yes/No) (Yes/No) Percentage of grievances received that were timely addressed 0.00 70.00 through the GRM mechanism (Percentage) (Percentage) Action: This indicator is New IO Table SPACE Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Total number of designated Number of designated laboratories with Ministry of laboratories with COVID-19 Quarterly Self Assessment Ministry of Health COVID-19 diagnostic equipment, test kits, Health diagnostic equipment, test and reagents. kits, and reagents. Numerator: suspected cases of COVID-19 cases that were reported and Percentage of suspected cases of COVID- investigated per approved Laboratory Quarterly Seif-assessment Ministry of Health 19 reported and investigated per protocol M&E Data approved protocol (Percentage) Denominator: Number of suspected COVID-19 cases detected. Numerator: number of Ministry of Percentage of diagnosed cases treated COVID19 diagnosed cases Quaterly Self-assessment Ministry of Health Health per approved protocol (Percentage) treated per approved protocol. Page 52 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Denominator: total number of COVID19 treated patients. Percentage of population Percentage of population vaccinated, vaccinated, which is National which is included in the priority Quarterly Project Monitoring Ministry of Health included in the priority Report population targets defined in the national population targets defined plan in the national plan Percentage of population Percentage of women vaccinated, vaccinated, which is National which are included in the priority Quarterly Project monitoring Ministry of Health included in the priority report population targets defined in the population targets defined national plan in the national plan ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: number of health staff equipped with appropriate PPE for infection prevention and Designated Percentage of health staff equipped with control per MOH-approved COVID19 appropriate PPE for infection prevention protocols amongst Quarterly Self-assessment Ministry of Health Health and control per MOH-approved protocols COVID19 designated health Facilities (Percentage). (Percentage) facilities. Denominator: total number of of health staff taking care of COVID19 patients at those HFs Page 53 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Total number of Number of Number of WB financed designated designated ambulances to Ministry of ambulances to transport COVID19 Quarterly Self-assessment Ministry of Health transport COVID19 patients Health patients per MOH-approved protocols per MOH-approved (number) (Number) protocols Effective Vaccine Number of Effective Vaccine Management Management (EVM) National Quarterly Project Monitoring Ministry of Health (EVM) assessments completed with assessments completed Report composite scores of 80% or higher with composite scores of 80% or higher Number of health Number of health departments with departments with health Quarterly MOH Report Project monitoring Ministry of Health health facilities that have adopted COVID- facilities that have adopted 19 related AEFI mechanisms COVID-19 related AEFI mechanisms Number of vaccination centers that have Number of vaccination centers that have implemented standard implemented standard operating operating procedures Quarterly MOH Report Project monitoring Ministry of Health procedures (SOPs) or guidelines updated (SOPs) or guidelines for collection and disposal of COVID-19 updated for collection and vaccine related medical waste disposal of COVID-19 vaccine related medical waste Percentage of targeted Percentage of targeted sites where sites where requested Cold Quarterly MOH Report Project monitoring Ministry of Health requested Cold Chain Equipment has Chain Equipment has been been installed and functional installed and functional Radio/TV Stations broadcast COVID-19 Radio/TV Stations Quarterly MoH and Registries for risk Ministry of Health vaccine communication message in broadcast COVID-19 UNICEF communication and Page 54 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) French and local languages vaccine communication community engagement message in French and activities local languages Gender sensitive Registries of risk Gender sensitive educational educational Quarterly MoH communication and Ministry of Health communication materials on COVID-19 communication materials community engagement vaccines distributed on COVID-19 vaccines distributed Numerator: number of female community health workers who have received Share of female community health Ministry of information/training on Quartely Self-Assessment Ministry of Health workers provided with vaccine Health COVID-19 vaccination. information Denominator: number of female community health workers. Numerator: Number of Ministry of vaccinators who are Quaterly Self-reported Ministry of Health Share of vaccinators who are female Health female. Denominator: total number of vaccinators Total number of number of Number of suspected COVID19 cases suspected COVID19 cases tested per MOH-approved protocols at tested per MOH-approved Ministry of Quarterly Self-assessment Ministry of Health the 5 designated laboratories equipped to protocols at the 5 Health conduct COVID-19 diagnosis (number). designated laboratories (Number) equipped to conduct COVID-19 diagnosis Whether an M&E plan have M&E system established to monitor been established in country Ministry of Quarterly Self-assessment Ministry of Health COVID-19 preparedness and response to monitor COVID19 Health plan (Yes/No) preparedness and response plan (Yes/No) Page 55 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) Numerator: Number of grievances received that Percentage of grievances received that Ministry of were timely addressed Quarterly GRM registries Ministry of Health/PIU were timely addressed through the GRM Health/PIU through the GRM process; mechanism (Percentage) Denominator: Number of grievances received ME IO Table SPACE Page 56 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS (UPDATED OCTOBER 1, 2021) Vaccine SRA Emergency Use Approval WHO PQ/EUL BNT162b2/COMIRNATY T United Kingdom: December 2, 2020 WHO Emergency Use Listing (EUL): December ozinameran (INN) - Pfizer Canada: December 9, 2020 31, 2020 BioNTech USA: December 11, 2020 European Union: December 21, 2020 Switzerland: December 19, 2020 Australia: January 25, 2021 mRNA-1273 - Moderna USA: December 18, 2020 WHO EUL: April 20, 2021 Canada: December 23, 2020 EU: January 6, 2021 Switzerland: January 12, 2021 UK: January 8, 2021 AZD1222 (also known UK: December 30, 2020 WHO EUL: February 15, 2021 for vaccines as ChAdOx1_nCoV19/ EU: January 29, 2021 manufactured by SK Bio and Serum commercialized Australia: February 16, 2021 (overseas Institute of India as COVISHIELD in manufacturing); March 21, 2021 (for local India) - AstraZeneca/Oxfo manufacturing by CSL – Seqirus) rd Canada: February 26, 2021  Ad26.COV2.S - Johnson & USA: February 27, 2021 WHO EUL: March 12, 2021 Johnson Canada: March 5, 2021 EU: March 11, 2021 Switzerland: March 22, 2021 UK: May 28, 2021 Australia: June 25, 2021 BBIBP-CorV - Sinopharm WHO EUL: May 7, 2021 for vaccines manufactured by Beijing Institute of Biological Products Co Ltd E-Town Vaccine Industry Base No. 6 &9 Bo’xing 2nd Road Economic-Technological Development Area Beijing, P.R. China CoronaVac - Sinovac WHO EUL: June 1, 2021 for vaccines manufactured by Sinovac Life Sciences Co., Ltd. No. 21, Tianfu Street, Daxing Biomedicine Industrial Base of Zhongguancun Science Park, Daxing District, Beijing, P.R. China Page 57 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) ANNEX 2: LATEST COVID-19 SITUATION IN THE COUNTRY 1. Since the first case of infection in March 2020, 30,648 cases have been reported by the National Coronavirus Plan Steering Committee (COPIL) as of October 3, 2021 with 190 deaths and 26,497 recovered. The epicenter of the health crisis is in Libreville, which accounts for 70 percent of cases, and in Franceville (10 percent of cases). While Libreville has remained the primary hotspot, the coronavirus has now spread to six out of nine regions, with one of them circumscribing Cameroon from where cases were imported with 61 percent of the cases, men are more affected as well as the population aged between 30 and 39 years. 2. Notably, there was a sharp escalation in daily new confirmed cases and deaths in September, similar to the peak registered from February through April 2021, that surpassed the May-July 2020 peaks. Daily new confirmed cases and cumulative deaths, despite having registered a downward trend for a period between late August 2020 to January 2021 and plateauing between 30 August to 23 December 2020, emerging trends now demonstrate a sharp resurgence as of 9 February 2021. To this end, the GoG, aware of the urgency and gravity of the situation, has taken the urgent prevention, preparedness and response measures. However, a resurgence of cases in February-May 2021 and the new peak likely caused by the Delta variant demonstrate that the threat of COVID-19 has not disappeared. In addition to the direct harms to infected individuals, COVID-19 has also created disruptions in key routine health services, as well as dampened economic activity. The pathway to a sustainable recovery is through control of the COVID-19 pandemic. Figure 1: Daily Cases of COVID-19 reported in Gabon as of September 17, 202116 3. In terms of vaccination against COVID-19, 24 centers are open in the provinces of Estuaire, Ogooué-maritime, Haut-Ogooué, Ogooué-Lolo, Nyanga, Ngounié, Moyen-Ogooué, Ogooué-Ivindo and Woleu-Ntem. There is a total of 181,719 people vaccinated in Gabon as of October 3, 2021, of which 78,805 are fully vaccinated. Economic outlook 4. The transmission of the health crisis to Gabon's economic and social spheres is primarily through foreign trade, in particular the oil market resulting from the recession in most OECD countries and the 16 Source: https://www.worldometers.info/coronavirus/country/gabon/ Page 58 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) People’s republic of China. The health crisis has disrupted this market with a dramatic drop in demand that is weighing on the price of oil, which is at its lowest level in 17 years. This situation has prompted Organization of the Petroleum Exporting Countries (OPEC) countries to reduce production by 9.7 million barrels per day. As part of this agreement, Gabon has committed to reducing its production by 23 percent. The transmission of the crisis also passes the containment measures taken by the government to limit the spread of the virus. This containment is forcing many businesses to operate at less than full capacity or to cease operations, resulting in a decline in supply and labor productivity. The health crisis has enormously affected the Gabonese economy with more than 12,000 jobs lost in 2020. The oil sector, which represents more than 80 percent of the country's income, has been hit hard, resulting in a drop in the growth rate from nearly 5 percent in 2019 to 1.5 percent in 2020. 5. The economic growth contracted 2.7 percent in 2020, after growing 3.9 percent in 2019. The recovery would be gradual; however, it would be below the economic trajectory envisaged before the advent of COVID-19. This growth trajectory would be reflected in almost all sectors (mining, forestry, services, etc.). The effects on public finances would be significant because of the decline in oil tax revenues; the overall budget balance would deteriorate to an annual average of -4.4 percent of gross domestic product (GDP) over the period 2020-2025, compared with -0.6 percent of GDP in 2019, a deterioration due to the decline in revenues, which would fall to 15 percent of GDP compared with 18 percent of GDP in 2020. The external accounts would follow the same trajectory as the decline in exports (-5 percentage points of GDP) following the slowdown in world trade (oil, mining). 6. In addition to the effects on employment due to the freeze on oil exploration and drilling expenditures, particularly in Libreville and Port Gentil, the containment (total or partial) significantly slowed down the activities of SMEs and the informal sector, which are characterized by a sometimes- difficult financial situation and job insecurity; as result, the decline in employment affected unskilled workers in particular. Social outlook 7. In terms of social consequences of COVID-19, whose effects on income affects every worker regardless of social status, while workers in the public sector and in large private sector companies have had a stronger guarantee of job protection and salary maintenance, this was not often the case for workers in SMEs or in the informal sector, especially those affected by the containment measures (trade, transport, catering, hotels, etc.). The same would be true for small farmers in rural areas who would see their opportunities in urban areas reduced. Thus, poor households, often unemployed or self-employed, and unskilled workers have suffered relatively the greatest losses in income. This unfavorable context contributed to an increase in poverty, which was estimated to have risen by 3.6 percentage points in 2020. 8. The impact of COVID-19 on human development in Gabon, beyond the loss of revenue, is measured by the consequences of the closure of school structures in the absence of alternative options for the provision of educational services. Indeed, distance learning in Gabon faces enormous feasibility constraints (lack of learning platforms, connectivity, computers, tablets, etc.). Added to this is the lack of teacher training and digital teaching materials. This situation is problematic because lessons learned from Pakistan, following the 2005 earthquake, show that medium/long term learning losses are far greater than short term learning losses due to the temporary closure of schools; children who missed three months of Page 59 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) schooling lost the equivalent of a year and a half of schooling after four years after the earthquake. On this basis and accounting an eight-months of school closing in 2020, a combined loss for the school years of 2019-2020 and 2020-2021, the human development level was estimated to decrease to 0.695 in 2020, a loss of 0.7 percent from 2019 or 0.8 percent from the 2020 baseline, which would return Gabon to the situation in 2016. Page 60 of 61 The World Bank Gabon Additional Financing for COVID-19 Strategic Preparedness and Response Project (P176464) ANNEX 3: SUMMARY OF THE PARENT PROJECT COMPONENTS 1. The content of the components and the results framework of the parent project will be adjusted to reflect the expanded scope and new activities proposed under the AF. An increase in scope and cost will be required to support vaccine purchase and deployment, including cold chain cost, logistic arrangement to deliver the vaccines to up to provincial level, risk communication, mass communication activities for vaccine uptake, capacity development of health professionals involved in vaccine delivery and management, administration of vaccines to the target population, and M&E. The AF is key to secure an efficient vaccine roll-out. The implementation arrangements would remain the same. The closing date would be extended to June 30, 2024 to accommodate the additional activities, particularly with the market uncertainty on when sufficient quantity of vaccines will be available to Gabon. Project Components 2. The AF is structured around the three original complementary components . The scaling up of these components will support the GoG to continue mitigation measures to contain the spread of the pandemic in the country and to implement its National COVID-19 Vaccination Plan. The components are as follows: • C1. Emergency COVID-19 Response (US$4.3 million) This component aims to provide immediate support to prevent the spread of COVID-19 and to limit local transmission through containment strategies. It seeks supporting the enhancement of disease detection capacities through provision of training of technical staff, laboratory equipment and systems to ensure prompt case finding and contact tracing, and to enable Gabon to mobilize surge response capacity through trained and well-equipped frontline health workers. • C2. Supporting National and Sub-national, Prevention and Preparedness (US$2.5 million) This component seeks to support with the required laboratory equipment to strengthen COVID- 19 diagnostic facilities in Gabon, in addition to procure for diagnostic tests, reagents and other related commodities to ensure adequate laboratory case confirmation for COVID-19 and improve the overall national capacity for preparedness and response. • C3. Implementation Management and Monitoring (US$0.5 million) This component’s objective is to support the strengthening of public structures for project coordination and management, including central and regional arrangements for coordination of activities, FM and procurement, as well as training in participatory M&E at all administrative levels and development of an action plan for M&E and replication of successful models. Page 61 of 61