The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 06/03/2021 | Report No: ESRSAFA211 Jun 03, 2021 Page 1 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Togo AFRICA WEST Republic of Togo Ministère de la Santé, de l’hygiène Publique et de l’accès universel aux soins Project ID Project Name P176335 Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project Parent Project ID (if any) Parent Project Name P173880 Togo COVID-19 Emergency Response and Systems Preparedness Strengthening Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 5/21/2021 6/11/2021 Population Financing Public Disclosure Proposed Development Objective To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Togo. Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No Jun 03, 2021 Page 2 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The proposed Additional Financing will support the implementation of Togo COVID-19 National Vaccine and Deployment Plan (NDVP). The parent project structure will be maintained with complementary sub-components and additional funds under Component 1, Component 2 and Component 3. This will allow to continue to support mitigation measures and contain the spread of the pandemic in the country under Component 1 which provides immediate support to Togo to prevent COVID-19 from expanding or to limit local transmission through containment strategies; Component 2 which provides assistance to all levels of the health care system for preparedness planning, maintaining essential community services and optimal medical care, and minimizing risks for patients and health personnel, as well as developing intra-hospital infection control measures and strengthening the national laboratory system; and Component 3 which consists of Project Implementation Management and Monitoring and Evaluation, including support for procurement, financial management (FM), environmental and social safeguards, M&E, and reporting as well as the training of the project management unit and technical consultants; and operating costs. These components were designed to support the Government in implementing activities presented in their 2020 COVID-19 National Action Plan and to complement activities that were already being financed by the REDISSE (P154807) Project., to continue support to mitigation measures and contain the spread of the pandemic in the country. In fact, out of the US$25 million of proposed IDA project financing for vaccination, an estimated amount of US$14 million will be for vaccine purchase and US$11 million for selected vaccine deployment activities, in addition to US$4.5 million from Health Emergency Preparedness and Response Trust Fund. The AF will support investments to bring immunization systems and service delivery capacity to the level required to successfully deliver COVID-19 vaccines at scale. The component 1 will increase in scope and cost to complement the activities that are being implemented through Regional Disease Surveillance Systems Enhancement II (REDISSE). The original activities under parent Public Disclosure Component 1 will be maintained and merged into a new “Sub-Component 1.1: Strengthening capacities for COVID-19 case detection and clinical management which will continue to provide support to (i) strengthen disease surveillance systems, public health laboratories, and epidemiological capacity for early detection and confirmation of cases; (ii) combine detection of new cases with active contact tracing; (iii) support epidemiological investigation; (iv) strengthen risk assessment; and (v) provide on-time data and information for guiding decision-making and response and mitigation activities. Furthermore, it will finance the (vi) purchase and installation of a fuel-efficient mobile P2/P3 laboratory; and (vii) acquiring prefabricated isolation and treatment centers in Lomé and equipping them with medical supplies and furniture and network installation.. Complementary interventions will be added as “Sub- Component 1.2: COVID-19 Vaccine Planning, Procurement and Distribution” to support the purchase and delivery of vaccine according to the Togo NVDP operational plan including: (i) upgrading regulatory standards at the national level to ensure there is no forced vaccination, including pharmacovigilance, and authorization mechanisms; (ii) preparation of appropriate minimum standards for vaccine management, including cold chain infrastructure (with financing for the investment to meet the standards); and (iii) operational costs during the vaccine campaign (per diem, travel, fuel etc.); (iv) creation of accountability, grievances, and citizen and community engagement mechanisms. “Sub-component 1.3: COVID-19 vaccines service delivery” to support the enhancement of preparation and operationalization of COVID-19 vaccines deployment in the country including : (i) procurement of needed monitoring and evaluation (M&E) softwares to allow interoperability with existing system DHIS2, IT equipment and capacity building for vaccine campaign roll-out; (ii) Training and Supervision of health workers at all level of the health system, training materials development and distribution, jobs aids adaptation, internet connection and training equipment for efficient virtual capacity building; (iii) demand generation and risk communication campaign through in country renowned communication agency; (iv) Assessment of the vaccine supply chain at all levels of the health Jun 03, 2021 Page 3 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) pyramid according to the Effective Vaccine Management (EVM) procedure; (v) procurement of fuel-efficient vehicles for the supervision and distribution of vaccines from the central, regional, district and to vaccine sites level; and (vi) vaccine safety and management of adverse events following immunization (AEFI) through technical assistance for the development of protocol for vaccination safety, health workers training in detecting, reporting, data analysis, and investigation. Component 2: Supporting National and Sub-national, Prevention and Preparedness. The component 2 will also increase in scope and cost. The original activities under the parent Component 2 will be maintained and merged into a new “Sub-Component 2.1: Strengthening capacities for COVID-19 prevention, coordination and management” will finance : (i) provision of more emergency medical and non-medical supplies including PPEs such as gloves, surgical mask, respirator, eye protection and isolation gowns to health workers for their safety; (ii) provision of drugs, medical equipment and supplies to public health facilities and for intensive care facilities within hospitals; (iii) provision of two more fuel-efficient medical ambulances; (iv) provision of additional laboratory equipment, containers for specimen handling and transportation, diagnostic reagents and commodities, including kits for regional hospitals; (v) the training of health facilities staff and front-line workers on risk mitigation measures and providing them with the appropriate hygiene materials (such as detergents and disinfectants, and safety/sharp boxes); (vi) elaboration of Standard Operating Procedures (SOPs), guidelines and Terms of Reference on sample collection, packaging, transportation and testing of samples at the WHO recommended laboratories for COVID-19; (vii) operation of the Health Emergency Coordination Center (HECC) (including sub-national coordination and support for preparedness that include training, and supervision); and (viii) operating costs and other administrative-related costs for supportive supervision and monitoring; and (ix) procurement and instalment of a medical fluid system with conduits and accessories (oxygen production generator, vacuum unit and medical air unit) for the CHR Lomé-commune. Complementary interventions will be added as “Sub-Component 2.2: Communication, social mobilization and Public Disclosure community engagement to enhance demand for the COVID-19 vaccine” including (i) social mobilization; and (ii) demand creation communication. Component 3: Project Management and Monitoring and Evaluation (M&E). The component 3 will increase in scope and cost as well. The original activities under Component 3 will be maintained. The AF will support capacity building of local immunization stakeholders on new tools and strengthening of existing data and monitoring systems (immunization and public health) to enable monitoring of deployment of COVID-19 vaccines and continued monitoring of routine vaccination. COVID-19 Vaccination campaign has started on March 11, 2021 with priority groups as planned in the NDVP, including 82 percent of health workers vaccinated throughout the country (33,090 vaccinated out of 40,520), and people over 50 years of age (56,334 vaccinated) in the Grand-Lomé. One month later, vaccination was extended to people over 30 years old (51,578 vaccinated) nationwide. 244,815 people (5.1 percent of the targeted population) have received their first dose of AstraZeneca or SINOVAC vaccine, as of May 9, 2021, since the roll-out of the vaccine started. The second dose of COVID-19 vaccine has started on May 10, 2021. Although Togo is considered as one of the leading countries in the region in terms of response to the pandemic, the perception about the safety of the vaccine is negative. An Afrobarometer survey conducted between October and January 2021 revealed vaccine reluctance among the population: about 51 percent were “somewhat likely” to take the vaccine and 62 percent did not trust the government to ensure the safety of the vaccine. The communication on COVID-19 vaccination has successfully addressed these negative perception as evidenced by the high proportion of priority targeted population vaccinated for the Phase 1 of the campaign. Togo communication strategy has also encouraged vaccinated people to promptly report all adverse events to health agents. The enrollment process, follow-up of vaccinated people for the second dose and for the Adverse Event Following Immunization (AEFI) are digitalized. A software has been set up with GAVI support, and health workers have been trained to collect and follow up on AEFI. Individual vaccination data is hosted Jun 03, 2021 Page 4 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) within the information system of the Ministry for Digital Economy and Transformation and interoperable with the MHPHUAC health information system. Legislation for data protection existed since 2019 (Law n°2019-014 dated October 29, 2019 on Protection of Personal Data), but the decree of application is yet to be adopted. Oral consent is requested from all people before their vaccine roll-up. Infectious medical waste generated by health care facilities in general and COVID-19 Treatment Centers in particular, are classified as highly hazardous. These infectious medical wastes are managed in accordance with the Medical Waste Management Plans, under guidelines that adhere to international standards. To address the limitations in the local healthcare waste management system, the waste generated during the AF will be directed towards a site equipped with pyrolytic combustion incinerators with two chambers. There were conventional incinerators in at least eighteen (18) health facilities in 2020, distributed as follows: two (02) in the Savannah region, two (02) in the Kara region, one (01) in the Center region, two (02) in the Plateaux region, two (02) in the Maritime region, four (04) in Greater Lomé public health establishments. In the private sector, there are three (03) conventional incinerators at the hospital of the Order of Malta (Est-Mono), at the Saint Jean de Dieu hospital in Afagnan (Bas-Mono) and at the health center of Regina Pacis (Adidogomé / Grand Lomé). All aspects related to these incinerators are being managed in an environmentally-sound manner. This includes the collection of waste in specific containers (specialized dustbins and bags and safety boxes), temporary storage followed by the transport of waste in specialized vehicles, and finally disposal. These operations will be carried out according to the waste management plan for routine vaccination, including supplementary vaccination activities developed by the Ministry of Health in October 2019. This waste management plan is consistent with the WHO draft 'Laboratory Biosafety Guidelines for New Coronavirus (SARS- CoV2)' and other guidelines (February 12, 2020). The updated ESMF ensures the application of international best Public Disclosure practices with regard to all environmental and social matters. The Parent Project has prepared, consulted upon, and disclosed the ESMF containing the HCWMP. The HCWMP includes (i) training and sensitization of staff and users so that they are aware of all the dangers involved; (ii) provision of PPE and waste collection materials/equipment; (iii) maintenance and operation of existing incinerators; and (iv) organization of waste collection and transport to disposal sites. The progress towards achievement of the PDO and overall implementation progress of the Parent Project was rated Satisfactory in the last Implementation Status and Results Report (ISR) of March 18, 2021, and the project continues to make good progress. As of April 17, 2021, disbursements amount to US$7,338,467 or 98.8 percent of commitments. The remaining amount of US$761,533 is expected to be fully disbursed by end of March 2022. This undisbursed amount is still needed for the original scope and activities in the Parent Project. The targets of all four PDO level indicators have already been surpassed. All components are rated satisfactory. Further, performances in Financial Management, Project Management, Monitoring and Evaluation are all rated satisfactory. The emergency context of the project implementation, along with several layers of approval, and the lack of state budget allocation for the expenses of emergency operations, has been slowing down the execution of the procurement plan as it was the case on the parent project. However, efforts were deployed to make up for the delay, and procurement management was maintained as moderately satisfactory in the last ISR (March 18, 2021). As a result, the disbursement ratio has increased from 15 percent in August 2020 to 99 percent in February 2021. The project complies with key loan covenants, including audit and financial management reporting requirements. In compliance with the Environmental and Social Framework directives, the Parent Project prepared and disclosed Environmental and Social Safeguards instruments, which were cleared by the WB and disclosed. They include the Environmental and Social Commitment Plan (ESCP), Environment and Social Management Framework (ESMF), and Stakeholder Jun 03, 2021 Page 5 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) Engagement Plan (SEP), Labor management procedures (LMP), and the healthcare waste management plan (HCWMP). Implementation of these plans is ongoing. The Grievance Redress Mechanism is being set up, to be accessible to all project-affected people; a manual has been prepared and consultations have taken place. The next step will be to set up committees at community, district, and regional levels. The ESCP was disclosed in the country on April 16, 2020, and by the World Bank on April 17, 2020. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Following the COVID-19 outbreak with its adverse effects on the GDP growth which falled to 1% in 2020 as well as its fatal threats on togolese population, Government of Togo prepared the parent project, COVID-19 Emergency Response and System Preparedness Stregthening project (P173880) using the Multiphase Programmatic Approach (MPA). The project was approved by the Board on April 17, 2020. The project is being implemented at the national, regional, and local levels with the aim of contributing to COVID-19 preparedness, monitoring, surveillance and response. The parent project covers, through the COVID-19 dedicated treatment facilities, six (6) health regions (Savane, Kara, Centrale, Plateaux, Maritime and Grand Lome) which include thirty-nine (39) health prefectures. The Additional Financing (AF) will be implemented in 59 vaccination centers where the inoculations of the COVID-19 vaccines will take place so that all eligible people can have their two doses. The populations of the localities situated beyond 5 km from those fixed vaccination centers will be covered as usual by the advanced strategy according to an Public Disclosure itinerary and a precise timetable, negotiated with the communities concerned in order to vaccinate as many people as possible, including those located in mountain and remote areas not easily accessible during rainy season because of the bad road. An intense focus on expanding immunization capacity is necessary to ensure that the country’s health systems can effectively implement a comprehensive, and unprecedented, COVID-19 vaccine deployment strategy. This includes a critical assessment of and actions to ensure functional, end-to-end supply chain and logistics management systems for effective vaccine storage, handling and stock management; rigorous cold chain expansion and control; robust service and coverage tracking systems; well-trained, motivated and supervised vaccinators; large-scale communication and outreach campaigns tailored to at household, community and national levels; people-centered service delivery models that can reach different target populations effectively; and effective political leadership. Togo may also need to consider and enhance relevant additional institutional frameworks for the safe and effective deployment of vaccines, including voluntary vaccination practices; regulatory standards for vaccine quality; guidelines for acceptable minimum standards for vaccine management, the safe management and disposal of sharp waste; and policies to ensure robust governance, accountability and citizen engagement mechanisms. However, vaccine deployment will be guided by the National Deployment and Vaccination Plan (NDVP) and WHO’s Fair Allocation Framework with considerations for vulnerable and marginalized populations. As the COVID vaccine is new, past vaccination behaviors in the health prefectures as well as the social, economic and geographical characteristics of the areas may facilitate vaccine acceptability or underpin skepticism and undermine participation. In the region, low adult literacy especially so for women, high poverty rates, and inadequate access to healthcare services remain constraints. Difficult geographical areas because of poor access roads and bad weather could disrupt cold-chain requirements of vaccines and affect the overall efficiency and effectiveness of the proposed vaccination Jun 03, 2021 Page 6 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) program especially in rural remote locations. Disease surveillance, vaccination activities and health risks communication may also confront cultural protocols of local communities, and depending on vaccine availability, could further marginalize access to quality healthcare services for vulnerable groups. As per the government’s NDVP, the vaccination program is free and voluntary, and provides opportunities for individuals to participate on their own volition without coercion. Also, the project is not expected to impact natural habitats and cultural sites. Civil works (rehabilitation/renovation and upgrade existing health structures, rehabilitation and construction of incinerators) will be brown filed activities. D. 2. Borrower’s Institutional Capacity The Ministry of Health, Public Hygiene and Universal Access to Care (MHPHUAC) is the implementing agency for the parent project and this AF will be managed through the same arrangement. The Ministry of Numeric Economy is involved in project implementation, particularly with regards to vaccine registration and monitoring digitalization. The parent project is coordinated by the Project Coordination Unit (PCU) of REDISSE project, guided by the REDISSE Project Implementation Manual (PIM), including standard project safeguard requirements. The Project implementation has been carried out under the Direction of Disease Control, complemented by other MHPHUAC ’s technical departments and national programs, as well as the Regional and district hospitals, and Health Centers. the Project Coordination Unit (PCU) of REDISSE project has considerable experience with World Bank financed projects. However, its staff have limited familiarity with the requirements of the Environmental and Social Framework (ESF) having worked only on one project (the parent project) under this framework. To date, the E&S unit of the PCU has been managing and supervising overall E&S aspects of the Parent Project and the implementation of the ESCP. Recently, the Environmental Specialist of the E&S Unit was appointed elsewhere and the PCU is currently processing the recruitment of a new specialist who will be in place not later than four (04) months after Effective Date. During Public Disclosure this period, the Environment specialist of the Essential Quality Health Services For Universal Health Coverage Project, under the same Ministry of health shall assist the PCU on environmental safeguards provisions’ compliance, as mentioned in the ESCP. The environmental and social performance rating for the Parent Project is considered moderately satisfactory. Under the Parent Project, the project achieved with slight delays ESCP material measures and actions, such as the preparation, consultation, and disclosure of ESF instruments (ESCP, SEP, LMP and ESMF including HCWMP). However, the Parent Project has also faced delays on the implementation of some E&S measures and actions, including the timely delivery of quarterly monitoring reports on environmental, social, health and safety (ESHS) performance. Enhanced oversight from the Bank E&S team has been provided during the early stages of the Parent Project's implementation and will continue to be needed during the implementation of the AF. In general, the environmental and social risk management capacity in Togo is low, including at MHPHUAC. The borrower’s capacity to manage E&S risks and impacts should be improved, by supporting the PIU to build their capacity through trainings, support from third party entities to deliver on the objectives of the COVID-19 response operation. Moreover, given the need for a comprehensive stakeholder engagement and communications strategy in the context of COVID-19 management, specialists in the field of public health awareness and communication drawing from other Bank-financed projects and/or appointed by the borrower, should be included in the project team immediately at the beginning of project implementation. As mentioned in the ESCP, the project must hire an environment specialist not later than four (04) months after Effectiveness (as the previous has resigned) and include communication specialist to carry out efficiently the project communication strategy. Thus, trainings related to infection control and waste management, Covid19 exposure and prevention measures, occupational and community health and safety measures, etc., will be needed specifically at the local level. This is corroborated by the findings of the Vaccine Introduction Readiness Assessment Tool (VIRAT) and the Vaccine Readiness Assessment Jun 03, 2021 Page 7 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) Framework (VRAF) which identified the need for further technical assistance to MHPHUAC to finalize the training packages including Effective Vaccine Management Assessment (EVMAs) as well as to ensure the adequate cascade training. However, the E&S Unit of the PCU is dedicated to ensuring compliance with the environmental and social commitment plan (ESCP) and supervising the implementation of the recommended environmental and social risk mitigation measures through the screening of proposed activities and preparation of site-specific ESMPs and Health Care Waste Management Plans (HCWMPs) and any other requirements that may arise from the present AF. Other entities and sponsors (third parties) such as UN Agencies, NGOs, WHO, UNICEF and GAVI are also involved in the project implementation in supporting the PIU through various activities including: risk communications and safety surveillance; and establishing (or engaging an existing committee) a National Coordinating Committee (NCC) for COVID-19 vaccine introduction with terms of reference, roles and responsibilities and regular meetings, updating vaccine stock management tools and operating procedures to reflect COVID-19 characteristics, establishing/strengthening the national logistics working group with terms of reference and standard operating procedures, providing technical assistance, supporting improvement of the climate-sensitive cold chain and of the waste management. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial Combined with the parent project, the AF will enhance Togolese’s systems for disease surveillance, containment and Public Disclosure control of infectious diseases; and specifically finance the procurement and deployment COVID-19 vaccines. An estimated 1 595 352 people - averagely 20 percent of the country’s population- will receive the first set of vaccines that will be procured by the country; starting with health workers - largely women, other essential workers, elderly people (50+ years) and persons with co-morbidities that are highly susceptible to COVID-19. Over time, the rest of the population will be vaccinated as more vaccines are procured. Additional funds will be dedicated towards training more health care workers on the vaccination program and the risks communication issues. Overall, the AF project is expected to provide positive environmental and social impacts. Along with the positive impacts, the AF activities are expected to increase the scale of adverse environmental and social risks and impacts of the project. The environmental risks rating of the AF and the parent project remain Substantial due to concerns about occupational health and safety (OHS) for workers and the potential for improper handling and disposal of medical waste and bio- hazards which could injure human health. In addition, there are several short-term risks which are expected to be mostly temporary, predictable and reversible. The main environmental risks of the project include: (i) environmental and community health related risks from the inadequate storage, transportation and disposal of medical waste, because the COVID vaccine, unlike other vaccines are targeted at the whole population and expected to produce significant quantities of medical hazardous waste, generated from labs, quarantine and isolation centers, screening posts, treatment and vaccination facilities to be supported by the AF and constituted of contaminated fluids (e.g. blood), infected materials such as reagents, sharps, syringes, empty vials and laboratory solutions which require special handling and awareness as they may pose a risk of infection for healthcare workers; (ii) occupational health and safety (OHS) issues related to the availability and supply of personal protective equipment (PPE) for healthcare workers and the logistical challenges in transporting PPE across the Togo in a timely manner; (iii) community health and safety risks, given close social contact and limited sanitary and hygiene services (clean water, soap and Jun 03, 2021 Page 8 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) disinfectants) and isolation capabilities at healthcare facilities across the country; and (iv) OHS risks related to the rehabilitation of existing facilities. As noted above, the support from the World Bank task team and development partners like GIZ, WHO, and UNICEF, will also enable the MHPHUAC to improve capacity in managing these notable risks and impacts overtime. The ESMF which was developed under the parent project is updated, has been submitted for review and will be consulted upon, redisclosed and implemented to address existing and emerging E&S risks and impacts. The review process will be guided by the World Bank Group’s Environmental, Health and Safety Guidelines and all relevant WHO Protocols on epidemics such as COVID-19, relevant national laws and regulations. Social Risk Rating Substantial The social risk rating of the project is Substantial, as possible social impacts are reversible but, given the highly infectious nature of the COVID-19 virus, some risks could persist. The main social risks are related to: (i) difficulties in access to health services and facilities by vulnerable social groups such as people with chronic conditions/disabled, poor people, migrants, the elderly and disadvantaged sub-groups of women, and pastoral communities from border countries living seasonally in the country, especially in the northern part; (ii) lack of access to vaccine supplies, facilities and services designed to control the disease by marginalized and vulnerable social groups; (iii) the accelerated pace of vaccine development and the information conveyed by media on associated risks that could increase public anxiety and compromise public acceptance. This risk could be exacerbated by a lack of transparency in the dissemination of information by the government, which may create public mistrust of vaccines; (iv) social conflicts and risks to human safety resulting from diagnostic testing; (v) the limited availability of vaccines and social tensions related to the challenges of a pandemic situation; (vi) the risks of sexual exploitation and abuse/sexual harassment (SEA/SH) among patients and health care providers, particularly with regard to vaccine distribution; (vii) Public Disclosure labor influx and the issue of migrant workers; (viii) inadequate data protection measures and insufficient or ineffective communication by stakeholders on vaccine deployment strategy; (x) risks related to adverse events following immunizations (AEFIs), which may lead to the stigmatization of vaccine-friendly populations in certain communities and contribute to refusal of vaccines or second dose. These risks will be mitigated through effective risk communication and community engagement to raise awareness among the general population. Continuous awareness raising and education campaigns that will help rebuild community and citizen trust will be done through engagement with religious leaders, political and local traditional leaders, and women's and young people's associative movements, which are generally very dynamic and representative. This Additional Financing will invest in small civil works to rehabilitate existing health facilities, but no new land will be acquired or accessed. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: The AF will extend positive environmental and social impacts as it focuses on improving the overall capacity of Togo to carry out surveillance and control of infectious epidemic diseases (including COVID 19); and enabling the procurement and safe deployment of COVID vaccines. At the same time, it will extend some substantial environmental, health and safety (EHS) risks to direct workers, contracted workers and local communities. The risky nature of the pathogen which are being used in the project-supported laboratories and quarantine facilities present Jun 03, 2021 Page 9 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) safety concerns to health workers and volunteers. Healthcare-related infections due to poor adherence to OHS standards can lead to illness and mortality among health and laboratory workers. The hospitals and laboratories particularly in Lome, Baguida, Kara, Dapaong, etc… that provide diagnostic testing and patient isolation generate biological and chemical waste, and other hazardous byproducts. With support from the AF, these laboratories and facilities will continue to process COVID-19 specimen with the potential to cause COVID infections, serious illness and lethal harm to the laboratory staff and to the community. The air pollution risks related to continuation to operate old medical waste incinerators or open burners has been observed in some health facilities and site specific ESIAs/ESMPs will assess risks of pollution and recommend adequate measures consistent with the EHSGs or other GIIP. Thus, administrative and containment controls as noted in the parent ESMF will be enhanced to minimize these risks and impacts. In general, the hospitals, health facilities and vaccine delivery facilities to be supported by this project require adequate operating procedures to help minimize and control occupational health and safety risks, manage hazardous waste and sharps, maintain proper quarantine procedure for COVID-19, ensure safe operation of cold chain infrastructure and equipment, appropriate chemical and infectious substance handling and transportation procedures. Without adequate planning and service delivery, disadvantaged or vulnerable groups could be further marginalized from accessing the services that are provided by this project. Under the parent project, the PCU prepared an ESMF which was disclosed in country on 19th April 2021 and in World Bank on 23rd April 2021 to mitigate these risks. The main activity deployed on ground under the parent project and prior to the adoption and disclosure of relevant E&S instruments is a mobile testing P2 level lab next to the Lomé’s airport. During this period the disclosed ESCP and SEP prior to the project appraisal were used to guide the implementation of project activities. A due diligence is conducted by the E&S specialists of the WB in the framework of the AF. The findings of this due Public Disclosure diligence are: (i) the security measures in place are acceptable and should be improved with capacity building and awareness raising on the risks associated with laboratory activities (ii) the waste management must be improved with the finalization of the temporary storage room for waste and acceleration of the process of acquiring the conventional MP100 type incinerator for INH in the elimination of waste (iii) the necessity to develop a risk management plan and regular monitoring of the implementation of its measures (iv) the need for rigorous follow-up with the supplier so that defective laboratory equipment is repaired and / or replaced during the warranty period. A detailed action plan is prepared and should be implemented by the PCU. The ESMF being updated shall be disclosed, consulted upon and adopted by the Effective date to include additional administrative and engineering controls for environmental et social risks that may be induced by the AF. This revised ESMF follows good international practices in COVID-19 diagnostic testing and handling the medical supplies, disposing of waste, procurement and deployment of vaccines, and articulate strict compliance with road safety measures. An exclusion list was included in the ESMF for the parent project, outlining project activities that will not be supported by the project. The WBG’s EHS Guidelines for Health Care facilities, WHO’s “Operational Planning Guidelines to Support Country Preparedness and Response”, existing relevant national regulations like Public health Service Regulations, National Health Care Waste Management standards, WHO Framework for Allocation and Prioritization of COVID-19 Vaccination and operations informs the review of the ESMF and other relevant environment and social management plans to be implemented in this AF project. Major social risks that are anticipated in this project include concerns related to the use of security personnel to secure vaccine transport and personnel; the potential for inequitable access to COVID vaccines and other project financed medical services for local communities and other vulnerable groups community health and safety issues which may arise from improper disposal of medical waste; and social tensions which may arise from surveillance and disease control measures and inequitable vaccine distribution. In line with the NDVP (2021) the activities to be financed by the AF are inherently Jun 03, 2021 Page 10 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) designed to prioritize people with health vulnerabilities and the larger eligible population. The revised ESMF includes enhanced procedures for waste segregation, transport and disposal so as to avoid or minimize risks of injury and illness to local populations and the potential for contamination of land and surface water. It also offers procedures for screening for environmental and social risks in any proposed works on cold-chain infrastructures, incinerators and where potential risks are identified, mandates the need for an Environmental and Social Management Plan (ESMP) to mitigate potential impacts of the proposed works. Where relevant project suppliers and executing agencies will prepare and implement the ESMPs. As an additional control measure, activities that are screened as high E&S risk, are not eligible for project support. The AF includes technical assistance to upgrade regulatory standards at the national level and ensure there is no forced vaccination, including pharmacovigilance, and authorization mechanisms. The NDVP provides sufficient guidance on the entire COVID vaccination program and outlines key measures for appropriate targeting, vaccine transportation and storage, vaccine deployment and security, as well as training of vaccination and support teams. Significantly the plan articulates broader plans for managing waste and anticipates the potential for occurrence of Adverse Events Following Immunization (AEFIs) including contraindications which may cause serious illness vaccine recipients; and has outlined measures to address such situations. In addition to managing health and environmental concerns, the MHPHUAC commits in the ESCP to continued stakeholder engagement, maintaining timely dissemination of information to: (i) better inform and counter misinformation and rumors; (ii) ensure equitable access to all project-financed medical services; and (iii) address tension resulting from people being detained in mandatory quarantine. ESS10 Stakeholder Engagement and Information Disclosure Public Disclosure Experience in the parent project and in similar emergency epidemic operations suggests that the risks of misinformation is always apparent. A significant risk in the proposed AF relates to the potential for vaccine skeptism and misconceptions about the benefits and risks of the COVID vaccine. There is also the risk that information needs of local communities could be sidestepped if not carefully assessed and incorporated in the mainstream information dissemination of the MHPHUAC. As part of the parent project, and in line with the standard, the MHPHUAC developed a SEP streamlining its procedures and strategies for public disclosure of relevant project-related information, public consultations, and risks communication. The SEP is being implemented as an integral part of the activities under component 2 of the project. Activities under Component 2 will be scaled up and deepened with a focus on cultural contextualization of targeting and vaccine deployment plans; social and behavior change communication for preventive and promotive health, and citizen engagement for feedback and grievance redressal mechanisms. The SEP includes strategies for meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with combating COVID-19. Under this AF, the SEP for the parent project has been updated to include specific consultation and engagement activities with strategies and plan that will help create awareness about COVID vaccines, generate vaccine acceptability by reversing rumors and addressing fears and the government establish its vaccine deployment plans. The updated SEP reflects new AF activities and aim to (i) facilitate appropriate stakeholder engagement and outreach towards a differentiated audience (concerned citizens, suspected cases and patients of covid 19, relatives, health care workers, etc.) and (ii) prevention of Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH). The ESCP and the updated SEP will be approved and disclosed both in the country and on the Bank’s web site prior to Appraisal. The SEP conveys messages that discourages attacks against health workers and clarifies that no forced vaccination is supported by the project. As part of the updated SEP, consultation and engagement activities will deploy key messages on priority population (inclusion and exclusion criteria), vaccination centers and procedures, and other COVID-related information. Jun 03, 2021 Page 11 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) Communications materials will be translated into local languages. Before end of appraisal of the AF, the updated SEP will be consulted upon and disclosed to relevant stakeholders. The SEP acknowledges the need for engaging marginalized and vulnerable social groups such as persons with disabilities, especially those living in remote or inaccessible areas, while keeping a clear focus on those who are most susceptible to the transmission of the coronavirus, such as the elderly and those with compromised immune systems due to pre-existing conditions. Different engagement methods will be used for different stakeholder groups particularly vulnerable groups. The SEP also includes a grievance mechanism to address project-related concerns. For SEA/SH-related grievances, the project will prepare a SEA/SH Prevention and Response Plan, which outlines steps for addressing SEA/SH grievances. Activities to enhance the SEA/SH prevention plan includes: appointing an SEA/SH focal person for SEA/SH incidences; training of GRM helpline operators on GBV issues; developing an abridged operational guidelines for handling SEA/SH cases; and developing SEA/SH-related training materials and organizing a short virtual training/orientation on SEA/SH for project implementation units and grievance operators. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions Through some of the parent and proposed AF project activities, direct and contracted workers, especially public health workers, could be exposed to OHS risks mainly due to the project being implemented during an ongoing COVID-19 pandemic. Most of the proposed activities will be conducted by public health staff and laboratory technicians, civil servants, and specialized consultants. The procurement and installation of laboratory and cold-chain Public Disclosure equipment will be carried out by staff of suppliers. The most significant risks confronting health workers is related to OHS and include exposure to infectious diseases (including COVID-19) and hazardous materials. Transport of vaccines and operation of light and refrigerated vehicles can also present the risks of accidents to drivers and community members; albeit marginal and insignificant risk. Given the scope of labor-related risks, the stand-alone labor management plan of the Parent Project will be updated. However, the updated ESMF of the parent project includes OHS measures which are outlined in the WHO and World Bank ESH guidelines. The existing ESMF of the Parent Project includes (i) procedures for entry into health care and quarantine facilities, including minimizing visitors and undergoing strict checks before entering; (ii) procedures for protecting workers against infections and hazardous waste; (iii) training and toolbox meetings on OHS procedures to all categories of workers including direct and contracted workers; (iv) post signage to isolate and moderate risks exposure; and (v) mandatory use of Personal Protective Equipment (PPE), both direct and contracted workers. The ESMF and all other guidelines developed under this project will be flexible to allow review and update as new guidelines are provided by WHO over time. In line with ESS2, the use of child labor and forced work is prohibited in both the parent and the AF project. Persons under the age of 18 are not allowed to work on any facility or site that is being financed by the project. Age verification (using certified birth certificates and citizen identification cards) will be carried out as precondition for employment. The project will provide accessible grievance mechanism to allow workers to raise workplace concerns to be addressed by the MHPHUAC, hospital administrators, and facility managers. A separate grievance mechanism will be maintained for SEA/SH related grievances, as provided in the parent project’s SEA/SH Prevention and Response Plan. ESS3 Resource Efficiency and Pollution Prevention and Management Jun 03, 2021 Page 12 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) Medical and chemical wastes (including water, reagents, infected materials, etc.) from the laboratories, quarantine, vaccination centers and screening posts to be supported (drugs, supplies and medical equipment) can have substantial environmental impacts and with human consequences. Solid wastes generated from medical facilities, discharge of contaminated water and fluids, chemicals and hazardous materials, and other material waste from laboratories and quarantine and isolation centers such as sharps used in diagnosis and treatment can endanger health and safety of local communities. With the proposed vaccination program, the quantity of medical waste in the form of used vials and syringes will increase and overwhelm the prevailing limited capacity for management of health care waste. With support from other partners such as WHO, GIZ, World Bank, etc., the MHPHUAC is improving its capacity to manage waste from medical facilities. As noted above, a national healthcare waste management standard and procedures has been developed. Yet, these procedures are only being implemented at selected hub facilities located at the central and regional capitals, leaving out other facilities doted across the country due to budget and resource constraints. Project supported hospitals and health facilities will follow the procedures outlined in the ESMF, WHO COVID-19 Guidelines. Otherwise, the parent projet used the HCWMP prepared under REDISSE and a similar plan was integrated in the PP ESMF. Therefore, a dangerous waste management plan (DWMP), including management of medical waste and Infection Control, was developed by the MHPHUAC in the framework of “Essential Quality Health Services for Universal Health Coverage Project”. ESMF includes annexed documents among which the Infection Control and Waste Management Plan (ICWMP) templates that all health facilities providing vaccines must use in the fight against infections and sanitary waste management during all phases of the project. The hospitals will apply the National Health Care Waste Management standards in disposing off used vials, syringes, and other vaccine-related waste. In line with the NDVP, the project will provide funds and logistics (under component Public Disclosure 1 and 2) that will allow health facilities to implement health care management procedures and adhere to the procedures outlined in the NDVP – mainly using incinerators to dispose off waste. In the framework of improving its capacity to manage waste from medical facilities, partners such as WHO, UNICEF, GIZ, and World Bank support the government in acquisition and installation of 210 functional “Montfort” type incinerators, 18 conventional incinerators spread over the six (6) sanitary regions. Among the conventional incinerators, ten (10) AddField MP100 type incinerators were financed by the WB, three (03) by UNICEF, three (03) by the Order of Malta’s hospital and two (02) by Catholic Church. Indeed, for an efficient destruction of the waste produced by the vaccines used to vaccinate 60% of the population, the country must rehabilitate 88 “Montfort” type incinerators and build 25 additional incinerators. Meanwhile, provision of resources for the proper functioning of these incinerators is necessary: fuel, generator in case of load shedding, sufficient personal protective equipment, hand washing devices and colored plastic bags, etc. The air pollution risks relate to continuation to operate old incinerators or open burners has been observed in some health facilities. The site specific ESIAs/ESMPs will assess risks of pollution and recommend adequate measures consistent with the EHSGs or other GIIP. The updated ESMF also includes guidance related to: (i) transportation and management of samples, medical goods (including vaccines and PPEs) and expired chemical products; (ii) measures for ensuring energy and resource efficiency during refurbishment and operation of health facilities; and (iii) collection, transport and disposal of medical waste at designated sites. Considerations for energy efficiency will guide the procurement, operation and monitoring of climate-sensitive equipment and low-carbon cold-chain facilities such as off-grid solar refrigerators/freezers and waste management equipment that would need to be procured to ensure a reduced impact on the climate and environment. Wastewater, used chemicals and solid waste generated from quarantine facilities and laboratories will be treated and discharged as per the standards and measures by WHO. Jun 03, 2021 Page 13 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) ESS4 Community Health and Safety Apart from injury from sharps and syringes on landfills and open dumps, medical and general wastes from the laboratories, hospitals, and quarantine and isolation centers have a high potential of carrying micro-organisms that can transmit diseases to the local populations if they are not properly disposed of. There is a possibility for the infectious microorganism to be introduced into the environment if such organisms are not well contained within the laboratories or escape from source due to accidents e.g. a fire incidents or natural disasters (e.g., tornados). The project design includes investments to strengthen bio-safety measures. The OHS procedures in the parent ESMF outlines measures to prevent and minimize the spread of infectious diseases as well as Emergency preparedness and response measures. Another community health concern in the project include the potential for individuals to experience adverse events (including serious contraindications and illnesses) following vaccinations, although these events rarely occur. The MHPHUAC will closely monitor, track and respond to adverse events including provisions for compensation. This would be done with reference to the guidelines in the WHO Global Manual on Surveillance of Adverse Events Following Immunization (2014). Laboratories, quarantine and isolation centers, and screening posts will follow respective procedures for managing contaminated materials as well as protocols on the transport of samples. Vaccine deployment, cold-chain and distribution capacity are currently inadequate in Togo, 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 and UNICEF and coordinating with other partners in their provision of systems strengthening support. Workers will be mandated to clean before leaving the workplace. The operation of the quarantine and isolation facility at the Lome Hospitals and other facilities in the regions will be implemented in a way that both the wider public, as well as the quarantined patients, are treated in line with international best practice as Public Disclosure outlined in WHO guidelines referenced under ESS1. Operators of project-financed equipment and vehicles will be trained/oriented on safe operation of equipment and vehicles and the national road safety regulations. The likelihood that project activities will generate or exacerbate the risks of Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) is low. Nonetheless, all facilities that will receive funds and support from the project will adopt basic work site ethics and protocols to prevent and deter workers from engaging in SEA/SH. The MHPHUAC has committed to working with the Bank to develop and implement an SEA/SH Action Plan. The plan will promote gender-sensitive messaging and implement a mandatory Code of Conduct (CoC) for workers and staff. The above activities for preventing and minimizing risks to community health and safety will be an integral part of the SEP with focus on creating awareness and promoting safe community conduct. Activities proposed in the SEP will include also messages aimed at reducing the potential for social tension. Based on the NDVP, security personnel - mainly the police and/or military – may be used to provide security for vaccine transport, storage and to protect vaccination crews throughout the vaccination program. As such the risks related to human rights abuses through the proposed vaccination programs is considered moderate and manageable. As indicated in the NDVP, the deployment of security, where relevant, will be governed by the procedures set out in the plan, allowing the MHPHUAC and the Ministry of Interior and Security to ensure that only personnel trained on Code of Conduct and respect for human rights are deployed for project purposes. The security agents mobilized in the project will have to sign the codes of good conduct in accordance with the requirements of the ESF. Consistent with the NDVP, the MHPHUAC commits to specific requirements of the ESCP including ensuring that security deployments are done in accordance with the relevant requirements of the World Bank’s Environmental and Social Standards (ESSs) and the ESCP. The MHPHUAC and the Interior and Security ministry will monitor, document, and resolve potential concerns regarding the lapses in the conduct of security personnel whilst enforcing compliance with the code of conduct. The project will prepare a Jun 03, 2021 Page 14 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) SEA/SH Prevention and Response Plan, for responding to SEA/SH incidences comprised of a health sector One-Stop Crisis Management Center (OCMC) and a GRM helpline. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This standard is not relevant. The project will not require any land acquisition leading to physical or economic displacement. All rehabilitation/renovation and construction will take place within existing health facilities. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The AF will not finance new construction or expansion of existing ones. As well, it will not purchase new mobile laboratory which will generate hazardous medical waste and risks on biodiversity related to improper management of waste. . Hence, no impacts on natural habitats and biodiversity are expected. Accordingly, this standard is not considered relevant. The ESCP requires prior screening of activities for project support and will determine activities that will be implemented making sure that activities that present risks to sensitive biodiversity will be excluded. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is not relevant to the AF as there are no IP/SSAHUTLCs in Togo. ESS8 Cultural Heritage Public Disclosure This standard is not currently relevant. It is not anticipated that the AF will impact cultural heritage and any physical works planned in the context of the project will be limited to rehabilitation or upgrading of existing facilities and some new constructions in existing sites. However, the planned works will include excavation during construction phase and demolition during the rehabilitation of some infrastructures. The ESMF will include a “chance finds” procedure which will require contractors to stop construction/rehabilitation if cultural heritage sites are encountered during civil works and to contact the Ministry of Culture. ESS9 Financial Intermediaries No financial intermediary is involved in the AF. B.3 Other Relevant Project Risks This AF project may be affected by the security situation in neighboring countries like Burkina Faso and North of Benin. It should be noted that these contextual risks could affect the project implementation, especially the adequate supervision of activities. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No Jun 03, 2021 Page 15 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: N/A IV. CONTACT POINTS World Bank Contact: Voahirana Hanitriniala Rajoela Title: Senior Health Specialist Telephone No: 5220+6033 Email: vrajoela@worldbank.org Contact: Andy Chi Tembon Title: Senior Health Specialist Public Disclosure Telephone No: +1-202-458-4879 Email: atembon@worldbank.org Borrower/Client/Recipient Borrower: Republic of Togo Implementing Agency(ies) Implementing Agency: Ministère de la Santé, de l’hygiène Publique et de l’accès universel aux soins V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Voahirana Hanitriniala Rajoela, Andy Chi Tembon Jun 03, 2021 Page 16 of 17 The World Bank Additional Financing to the Togo COVID-19 Emergency Response and System Preparedness Strengthening Project (P176335) Practice Manager (ENR/Social) Maria Sarraf Cleared on 03-Jun-2021 at 14:04:46 GMT-04:00 Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Concurred on 03-Jun-2021 at 15:18:0 GMT-04:00 Public Disclosure Jun 03, 2021 Page 17 of 17