The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 02/19/2021 | Report No: ESRSAFA124 Feb 22, 2021 Page 1 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Sri Lanka SOUTH ASIA Democratic Socialist Ministry of Health, State Republic of Sri Lanka Ministry of Samurdhi, Household Economy, Micro Finance, Self-Employment, Business Development,, Ministry of Finance Project ID Project Name P176422 Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project Parent Project ID (if any) Parent Project Name P173867 Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project Public Disclosure Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 3/11/2021 4/30/2021 Population Financing Proposed Development Objective To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Sri Lanka Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes Feb 22, 2021 Page 2 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] Component 1: Emergency COVID-19 Response: This component will focus on limiting local transmission of COVID-19 through containment strategies and strengthening systems to mitigate future risks. It will (a) support establishment of an Emergency Operation Center atthe Disaster Response and Management unit at the National level to improve coordination and timeliness of national level activities in emergencies of pandemic nature; (b) strengthen systems for contact tracing, case finding, confirmation, reporting and follow up; (c) strengthen the capacity of secondary and tertiary hospitals to respond to surge capacity through trained and well-equipped health workers and medical officers and equipped facilities; (d) set up isolation wards and intensive care units in select tertiary and secondary care hospitals; (e) implement a community engagement and risk communication strategy; (f) train social welfare workers, particularly those supporting elder care homes, centres with special needs people and orphanages to ensure proper isolation, treatment and transportation of suspected cases and avoid spread within homes; (g) support provision of psycho-social support and community-level outreach to women and children who are experiencing domestic violence when confined to their houses. Component 2: Strengthening National and Sub-national Institutions for Prevention and Preparedness: This component will support strengthening the capacity of national and sub-national institutions to respond to the ongoing COVID-19 pandemic and any public health emergencies that may occur in the future. In particular, it will (a) strengthen the National Institute of Infectious Diseases (NIID) by setting up a new isolation center within the premises of the NIID Public Disclosure and expand isolation units within the institute to build capacities for future responsiveness; (b) establish Regional Quarantine and Testing Centers (QTCs) equipped with testing facilities to augment the capacity of the NIIH; (c) establish Bio-Safety Level (BSL) 3 Laboratory Facilities at the National Medical Research Institute (MRI) to improve the capacity to run investigations for highly contagious diseases; and (d) strengthen laboratory facilities, infection control and waste management systems in secondary and tertiary hospitals. Component 3: Strengthening Multi-sectoral, National institutions and Platforms for One Health: This component will support investments in the one-health approach which will strengthen emergency response systems in the long term. This will entail a convergent approach that covers food safety, the control of zoonoses (diseases that can spread between animals and humans) and combatting antibiotic resistance. Specific focus will be placed on (i) conducting a needs assessment of national protocols for detection, surveillance, and response systems for animal and human health infections; (ii) establishing a mechanism for detection of priority existing and emerging zoonoses; and (iii) conducting awareness on anti-microbial resistance among human health, agricultural, and veterinary and enforcement of related legislations. Activities under this component would be implemented in collaboration with the related Ministries and stakeholders Component 4: Implementation Management and Monitoring and Evaluation: This component will support coordination and management of the project, including central and provincial arrangements for coordination of activities, financial management and procurement. This component would also support monitoring and evaluation of Feb 22, 2021 Page 3 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) prevention and preparedness, building capacity for clinical and public health research, and joint-learning on pandemic preparedness across and within countries. Component 5: Contingent Emergency Response Component (CERC): In the event of an Eligible Crisis or Emergency, the project will contribute to providing immediate and effective response to said crisis or emergency. The allocation to this component is to minimize time spent on a reallocation of funds from programmed activities. The unused amount can be reallocated to other components if the CERC component is not triggered a year prior to project closing. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] This AF operation entails expanding the scope of the Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project by financing the acquisition and deployment of COVID-19 vaccines. This AF will cover the procurement of vaccines for 32% of the population, cold chain cost, logistics arrangement to deliver the vaccines up to provincial level, risk communication, mass communication for vaccine uptake, capacity development of health professionals involved in vaccine delivery and management, administration of vaccines to the target populations and monitoring and evaluation. The additonal actvities proposed under the AF remain well-aliged with the original PDO and the project design. Public Disclosure To achieve high coverage in a short period of time, the vaccination campaign will be carried out through a targeted strategy and deployed via a network of estimated 4000 clinics/vaccination centres spread across the country. These centres will be housed in existing health care facilities within Sri Lanka’s extensive network of primary, seocndary and teritiary health institutions. The GoSL is currently in the process of finalising the vaccination centres along with staffing and infastructure requirements to be able to carry out the proposed mass vaccination drive. In terms of phsyical characteristics, Sri Lanka is an island in the Indian Ocean with a land extent of 65,610 Km2. It has a widely varying topography characterized by three distinct zones (peneplains) distinguishable by elevation. South Central part of Sri Lanka, the highest peneplain, is the rugged central highlands, consisting of rolling hills with peaks rising to 2500 m above sea level, steep escarpments and gorges. The land descends from the central highlands to extensive internal plains which makes most of the island’s surface at 30 – 300 m above sea level elevations and the coastal belt that surrounds the island with a 1340 Km long coastline that consists of scenic sandy beaches indented by coastal lagoons, bays, heads and wetlands. Sri Lanka faces critical environmental challenges of which deforestation, land degradation, loss of soil fertility, soil erosion and landslides, water and soil pollution, solid waste management and human-wildlife conflict take significant proportions. Except for areas protected under the country’s conservation laws, most of the island is inhabited with fairly good road access and other basic infrastructure. Sri Lanka has a free and universal public health care system. Its health institutions are organized according to the level of service provided and are managed by central and provincial health administrations. The secondary, tertiary and specialized care health institutions are located in built-up urban and peri-urban areas whilst most of the primary care Feb 22, 2021 Page 4 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) hospitals are typically located in rural areas with generally good accessibility. The AF will not entail construction of new faclities and hence E&S risks related to civil works will not arise. The key environmetal risk of the AF would be health care waste management and occupational health and safety of health workers and community. Specifically, the vaccination program that is targeted to achieve high coverage over a short period of time will generate large volumes of health care wastes such as used sharps, syringes, vaccine vials, cotton swabs and reagents as well as discarded PPEs that need to be properly disinfected and safely disposed. At present, Sri Lanka has limited capacity for the overall solid waste management, however, in the last decade or so, the country has made noteworthy progress in implementing the national framework for safe management of healthcare waste (HCW). A majority of the secondary and tertiary health institutions in the country have equipment such as autoclaves, metamizors and incinerators for the disinfection and disposal of HCW. As the GoSL intends to carry out the vaccination program in parallel to other regular health care programs, existing HCW equipment avalable in hospitals (such as shredders, autoclaves, metamizers, bins, incinerators etc) may not be adequate to handle activties under the AF. As such, project funds will be used to augment the capacity for HCWM in the vaccination centers via procurement of necessary equipment and training. The project is not expected to impact natural habitats or cultural sites. In terms of social characteristics, Sri Lanka is a lower-middle-income country with a total population of 21.8 million. Sinhalese constitute the largest ethnic group in the country, with 74.8% of the total population. Sri Lankan Tamils are the second major ethnic group (11.2%), followed by Moors (9.2%.) and ‘Others’ including Muslims, Burghers and the forest dwellers (Veddahs) constituting the remaining (4.8%). Buddhism (70.2%) is the most prevalent religion followed Public Disclosure by Hinduism (12.6%), Islam (9.7%), Christianity (7.4%) and Other religions (0.05%). Given the diverse nature of the Sri Lankan society, ethnically, linguistically, and religiously, it is essential that development interventions are designed following a fair, equitable, non-discriminatory and inclusive policy, so that no group is marginalized or discriminated against and equity in vaccine distribution and access is ensured. Sri Lanka also has a considerably large population of 60+ year olds (i.e. 14 percent) who fall into the high-risk and priority group eligible to receive the COVID19 vaccination under the National Deployment and Vaccination Plan for COVID-19 (NDVP). In addition, the NDVP prioritizes health workers and frontline staff and younger people with other co-morbidities. However, children under 18 years of age and pregnant/lactating women are not be eligible for the vaccine. The NDVP lays out these priority groups, based on the availability of vaccine supplies. Therefore, a key social risk would be to ensure the distribution of the vaccines is carried out and administered in an inclusive and equitable manner so that socially and medically vulnerable and disadvantaged people will not be left out from receiveing the vaccine in a timely manner. In addition, ensuring communications and adequate stakeholder engagement is essential while simultaneously addressing public misperceptions and vaccine hesitancy to improve the demand for the Covid19 vaccination. The parent project’s Environment and Social Management Framework (ESMF) clearly sets out the guidance on procedures on E&S assessment, preparation of site-specific Environmental and Social Management Plans (ESMPs) as well as Health Care Waste Management Plans taking into consideration national and international protocols for infectious disease control and health waste management (IC &HCWM) along with neccesary guidance to mitigate the social risks. The ESMF will be reviewed and updated by AF project effectiveness to ensure any additional risks from AF activties and the relevant risk mitigation measures, are duly captured. Feb 22, 2021 Page 5 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) D. 2. Borrower’s Institutional Capacity The Government of Sri Lanka (GoSL) has a number of environmental policies, regulations and standards of specific relevance to environmental protection. The National Environmental Act (NEA), administered by the Central Environmental Authority (CEA), is the overarching environmental regulation that provides the legal basis for environmental protection and pollution control in the country which it does through key regulatory instruments such as EIA, Environment Protection License (EPL), Schedule Waste License (hazardous waste including HCW) and environmental quality standards. The CEA is the mandated regulatory agency overseeing environmental management and to some extent social management issues in the development sector. It has demonstrated technical capacity in assessing environment and social risks of development activity and has benefited from many capacity building initiatives in the past. While Sri Lanka has a strong EIA system, a number of weak areas that need improvement are observed, such as post EIA/EPL compliance monitoring and enforcement. Further, Sri Lanka requires EIA/EPL clearance only for development activity that fall within prescribed thresholds stipulated in its EIA regulations, and as such, development activties that are below the stipulated thresholds, are screened out of the process even when the potentially have serious impacts cumulatively. With regard to the health sector, the country has a draft national policy on health care waste management prepared in 2001, national guidelines on health care waste management, a code of hygiene which the Ministry of Health has been incrementally implementing over the last decade or so. The Ministry of Health (MoH), which is responsible for implementing the parent project and the AF, has been implementing Bank-funded projects in the health sector for the Public Disclosure last 15 years or so and has been trained on numerous occasions on the application of safeguard policies. Thus, awareness on the requirements of Bank’s safeguards policies, is noteworthy. However, additional support will be required by the MoH to build capacity on World Bank's new Environment and Social Framework (ESF) and its additional requirements. Further, the MoH has a Directorate of Environmental and Occupational Health (DE&OH) headed by a Deputy Director General with a separate budget line under the MoH. The DE&OH has a staff strength of 39 with capacity for occupational health and safety, food and drug safety, health care waste management, etc. Regarding HCWM, the DE&OH has facilitated 28 EPLs/SWLs for secondary and tertiary level hospitals in all nine provinces as of 2018 through the provision of equipment, training, evaluation and follow up support. Currently, a Deputy Director from the DE&OH s desiganted to the PMU on a part time basis to assit with E&S requirments. In terms of national labor regulations, Sri Lanka lacks a single unified labor law/code; instead, a number of statutes govern employment and industrial relations in the country, which are fairly consistent with the requirements under ESS2. Likewise, Sri Lanka’s Right to Information (RTI) Act 2016 aims to promote open government, citizens’ active participation in governance, and accountability to the people of the country. However, the implementation of these legal provisions has been challenging due to their incomplete application and weak enforcement. The AF activties will be implemented by the on-going Bank-funded Primary Sector Strengthening Project (PSSP) under the MoH, which serves as the PMU to the parent project – the Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project. In terms of parent project implementation, activities have largely been focused on the procurement of essential equipment, PPEs, financing quarantine centers and strengthening of the health care system through training and capacity building for strengthened emergency response. Plans for expanding hospital facilities for treating infectious diseases are underway which involves medium to large scale construction. Feb 22, 2021 Page 6 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) As is the case with the parent project, advocacy and communication, including risk communication, will be carried out by the Health Promotion Bureau (HPB), together with relevant programme stakeholders of the Epidemiology Unit, MoH, other health officers, and other partners. HPB has decades of experience and learnings implmenting communication activities for the ‘National Immunization Programme’ (NIP) which can be put to use to disseminate timely, accurate and transparent information about COVID vaccines, including information about preparedness, and to manage misinformation in order to alleviate apprehension about the vaccine, ensuring its acceptance and encouraging uptake. The ‘Friends of the Facility’ committees formed by the World Bank financed Primary Sector Strengthening Project (PSSP) which are attached to the Primary Health Care Centers will support community outreach activities of the Vaccination program. The already operationalied GRM under the parent project which functions as the National Grievance Management System for Health Services will be utilized for the vaccination program as well. In addition, the Family Health Bureau already has capacities supported by the parent project to take forward the relevant GBV prevention measures during vaccination deployment. The Directorate of EOHS has also commenced a program to implement OHS measures among health workers addressing some of the requirements of the LMP prepaired for the parent project and under implementation. However, the primary challenge under the parent project has been the limited capacity of the PMU to implement the PSSP and the SL-COVID Emergency Project and its AFs. Due to the emergency nature of the operation, the PMU of the existing PSSP was used to deliver the parent project as a fast track measure. While strengthening the capacity of the PSSP PMU, as necessary, with additional staff and resources was part of the parent project implementation plan, many of the key staff positions identified to provide this support remains vacant to date, including the E&S specialists. Public Disclosure This issue has been raised repeatedly to the higher levels of the MoH without much success. Currently, on E&S management, the PMU is supported by designated specialists from the Directorate of Environment, Occupational Health and Food Safety & Health Promotion Bureau on a part-time basis, which is wholly inadequate. As a result the implementation of environment & social (E&S) risk management of the parent project is currenlty ‘Moderately Satisfactory’. Going forward, having dedicated E&S specialists is critical to ensure successful implementation of E&S actions as described in the ESMF, SEP, LMP and ESCP of the parent project and the AF, and it is of utmost importance that this gap is filled prior to the commencemet of the AF for vaccines operation. The requirement on staffing is included as a commitment in the AF’s ESCP. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The AF project will have net positive environmental and social impacts, as it will help contain the disease via procurement and delivery of vaccines island wide, risk communication, mass communication for vaccine uptake, capacity development of health professionals involved in vaccine delivery and management, administration of vaccines to the target populations and monitoring and evaluation. The AF will carry out immunization according to the NDVP, and thus it will specifically benefit high risk groups such as multiple disadvantaged or other vulnerable groups, starting with the elderly and those with compromised immune systems due to pre-existing conditions. Feb 22, 2021 Page 7 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) The environmental risks are considered Substantial. The key risks include: (i) potential enviromental pollution and community health and safety issues from handling, transportation and disposal of HCW. Waste such as sharps, syrynges, vials, swabs, reagents, medical equipments and PPEs, some of which would be contaminated with blood and bodily fluids, will be generated in large quantities with the targeted 18 million doses to cover 32% of the population. All of this requires special handling and awareness as it may pose a huge risk to health care workers from occupational infections and to the communities if not disposed properly. (ii) OHS issues related to potential infection of health care workers as well as communities through handling of patients, supples and the installation of cold chain facilities. The safety of these front line workers would need to be ensures via proper infection control procedures and provision of adequate PPEs. There will be no new civil works funded under the AF. While the project would likely support strengthening the cold chain for vaccine storage and deployment, the specficiatons for such equipment will ensure that these will not have significant environmental issues. Sri Lanka has experience in managing infectious waste. Infection prevention and control procedures in health institutions, especially higher-level facilities, are fairly standardized. Waste separation at source is almost 100% and many of the secondary and tertiary health institutions have already installed treatment capacity such as sterilizers and incinerators. However, the system is not without gaps and shortcomings and the volume of waste generated via the vaccination program can stretch the existing system capacity. As COVID-19 is highly infectious, the project will need to exercise the highest level of due diligence in planning and implementing precautionary measures against the two risks mentioned above. The parent project has a very comprehensive ESMF which incorporates international and national guidelines published specifically for infection control and health care waste management from COVID Public Disclosure diagnotic, isolation and treatment centres. The ESMF will be updated, applying international best practices specifically published on handling COVID-19 vaccination and the related waste generation. The ESMF already includes a generic Health Care Waste Management Plan (HCWMP) which will be updated with specific guidance on vaccination related isses & protocols on developing site-specific HCWMPs for vaccination centres. Social Risk Rating Substantial TThe social risks are considered ‘Substantial.’ The notable social risks include: i) risk of exclusion of priority groups, especially those who are socially and medically vulnerable and disadvantaged, including minority groups due to targeting errors and/or discriminatory practices preventing them from receiving timely access to vaccines, ii) inadequate public engagement, spread of misinformation/rumors (about vaccine safety, based on previous vaccine experiences and religious and cultural norms) creating confusion, anxiety and affecting uptake of the COVID19 vaccination, which could even lead to possible social tensions incase of inequities and/or discriminatory practices, iii) absence of voluntary consent when vaccinating or people feeling pressured to receive vaccination against their will, iv) risk of SEA/SH, especially for female health care workers, v) health & safety risks due to lack of facilities to manage Adverse Effects Following Immunization (AEFI), and vi) health risks due to improper disposal of medical waste on open waste dumps and discharge of contaminated water, causing injury to waste pickers and contaminating land and surface water. The National Deployment and Vaccination Plan for COVID-19 (NDVP) lays out the rationale and criteria for prioritizing high-risk groups for vaccination. This includes health workers and frontline staff, elderly people aged 60 years or Feb 22, 2021 Page 8 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) more, and younger people with other co-morbidities. Vaccination centers need to ensure that everyone will be treated equally and in a dignified manner including paying attention to specific, culturally determined concerns of minority and vulnerable groups. Communication campaigns and stakeholder engagement activities will need to utilize multiple forms of channels of raising awareness including mobilizing community groups to disseminate information especially among disadvantaged or vulnerable groups in hard to reach areas and will seek to dispel any public misperceptions to address issues of vaccine hesitancy. Informed written consent for vaccination will be obtained from all eligible individuals, and consent forms will be developed adhering to a specific legal framework. Vaccination centers will have gender-sensitive facilities such as separate rooms/vaccine areas for women, having at least one female staff in place, segregated toilets etc. The project will promote the avoidance of SEA/SH by adopting the WHO Code of Ethics and Professional Conduct for all health workers including community groups and military personnel that may be involved in supporting logistics. Sri Lanka has a well-established, targeted, time tested AEFI surveillance system which will be utilized following WHO guidelines during COVID10 vaccine deployment. Other mitigation measures are identified & included in the revised ESMF, SEP, LMP and ESCP. 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 project will have net positive environmental and social impacts as it will improve COVID-19 disease Public Disclosure containment as well as strengthen emergency preparedness of the health system for similar future crisis. However, the project could also cause significant environmental, social, health and safety risks due to the highly infectious nature of the disease that can cause health care associated infections to both health workers and community (that could even lead to fatalities) as a result of exposure and inadequate adherence to OHS measures. It can also pose specific risks to multiple disadvantaged or other vulnerable groups who would be receiving treatment parallelly in the same facility as the vaccination centre for other conditions, starting with the elderly and those with compromised immune systems due to pre-existing conditions. As such, effective administrative and infection containment controls will need be put in place to minimize these risks. In addition, health care facilities which will be used as vaccination centres (approximately 4000 centres in Sri Lanka to achive high coverage) will generate relatively large volumes of hazardous and potentially COVID contaminated wastes, such as sharps, syringes, vials, reagents, swabs, PPEs and other essential medical equipments, within a relatively short period of time as 18 million doses are planned to be admisnitered this year. Environmentally and socially sound vaccination centre management will require adequate provisions for minimization of occupational health and safety risks, proper management of hazardous waste and sharps, use of appropriate disinfectants, appropriate chemical and infectious substance handling, transportation, and disposal procedures, etc. Sri Lanka has a long history of successful immunization programme in the country guided by the National Immunization policy, last updated in 2015 and has a section specifically for introduction of new vaccines. However, this is by far, one of the largest vaccination programs to be deployed in the country and as such the risk of the sector’s current capacity to safely manage HCW could be stretched. The AF will support investments to bring immunization systems and service delivery capacity to the level required to deliver the COVID-19 vaccines. As such Feb 22, 2021 Page 9 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) cold storage managemet will be critically important not to lose the potency of the vaccines. While Sri Lanka will go for a portolio approach in procuring vaccines from the market, it has already undertaken an assessment of its cold staorage facilities to suit the range of vaccines in the market and will increase its cold storage capacity as required. To mitigate these environmental and social risks, the Ministry of Health (MoH) will update the Environmental and Social Management Framework (ESMF) prepared for the parent project. The ESMF already includes a comprehensive generic Infection Control & Health Care Waste Management Plan (IC & HCWMP) which includes specific guidance & protocols on developing site-specific IC & HCWMPs, taking into consideration: (i) existing treatment and disposal methods within the facility, (ii) current treatment capacity, (iii) rapid measures needed to augment capacity and/or, (iv) alternative disposal methodologies. The ESMF is in line with WHO recommendations and best practices in COVID- 19 diagnostic testing and handling of the medical supplies, COVID-19 response, disposing of the generated waste, and road safety. This ESMF will be updated as necessary to cover additional risks identified under the AF and to provide specific guidance on IC&HCWM for each vaccination centre or a cluster of centres within a defined geographical area, as appropriate. Likewise, the LMP will be updated providing additional OHS measures to be followed by staff working at vaccination clinics and also measures for military who may be involved in logistical operations of the project. Site specific IC & HCWMPs will be prepared and E&S measures will be incorporated into operational plans for vaccination clinics. Codes of Conducts will also be prepared and adopted by supply workers, healthcare & frontline workers including military (if involved) in the vaccination program. Site specific IC & HCWMPs, vaccination operation plans with E&S measures and Codes of Conducts will be included into bidding documents when procuring vaccinations, medical supplies and equipments. Public Disclosure The social exclusion risks associated with the AF will be managed by ensuring that targeting and provision of access to vaccination services are carried out in a fair, equitable and inclusive manner. The National Deployment and Vaccination Plan for COVID-19 (NDVP), will identify a list of prioritized groups who will be targeted for COVID-19 vaccines following the WHO concept for fair access and equitable allocation of COVID-19 health products, and the WHO Strategic Advisory Group of Experts (SAGE) values framework for the allocation and prioritization of COVID-19 vaccination. The priority identification of target groups will be based on the criteria specified at the time of the COVAX-AMC, COVAX application for COVID-19 vaccines and as per the NVDP prepared in early January 2021. However, based on availability and supply of COVID-19 vaccines and the demand, the priority population groups may have to be adjusted. Identification and referral of eligible target population for vaccination will be done as a collaborative effort between health and non-health agencies. Further, with regards to gender, there is a risk that vaccine deployment plans could leave women behind, considering the larger male mortality of COVID-19. The project will seek to ensure equitable targeting of vaccines among women, especially those also in the high-risks groups, during vaccine deployment by working with PH midwives and civil society organizations that work on women’s issues to ensure equal access to vaccines. The SEP has also been revised to include details of project affected people, interested parties and vulnerable groups to be reached under the AF as well as key communication messages and channels to be utilized in reaching out to all key stakeholders. Requirements to conduct regular consultations, at different levels, with different partners, and in a culturally appropriate manner, is also described in the SEP. The project will use multiple outreach platforms for informaiton sharing on the vaccination program, to dispel myths and improve vaccine uptake, including radio/TV, social media, informaiton hotlines, community-based platforms, etc. The existing GRM will also be made available for public to raise any complaints. Feb 22, 2021 Page 10 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) GoSL does not have mandatory and forced vaccination policies. Sri Lanka Vaccination policy ensures that voluntary consent will be obtained from all eligible individuals. Accordingly, policies and procedures are in place to ensure voluntary consent is obtained before vaccinating any individual and that there will not be any forced vaccination. Informed written consent for vaccination will be obtained from all eligible individuals, and consent forms will be developed adhering to a specific legal framework. A special COVID-19 vaccination card is also being developed. Monitoring and evaluation of the programme will be done to identify vaccine uptake, coverage for each dose, and to identify dropout rates. In order to address risks associated with gender-based violence as well as equal access to information and services, the ESMF will also draw on COVID-19 Outbreak and Gender: Key Advocacy Points from Asia and the Pacific, UN Women, 2020 and the COVID-19 resources to address gender-based violence risks, WBG EHS Guidelines relating to community health and safety, CDC Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in Healthcare Settings’ (19 March 2020), to name a few. Operational guidelines for vaccination centers will ensure that everyone will be treated equally and in a dignified manner including paying attention to specific, culturally determined concerns of minority and vulnerable group. In addition, vaccination centers will have gender-sensitive facilities such as separate rooms/vaccine areas for female, at least one female staff in place, segregated toilets etc. 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 sexual exploitation, harassment and abuse as well as addressing social/cultural barriers to women’s access to information and to the vaccination program. In addition, the ESMF includes measures and codes of conduct to be adopted when utilizing security forces to support with logistics and transporting patients under the Public Disclosure vaccination project. In doing so, the environmental and social assessment will be guided by the principles of proportionality and GIIP, and by applicable law, in relation to engaging security forces, rules of conduct, training, equipping, and monitoring of security forces. ESS10 Stakeholder Engagement and Information Disclosure The parent project has a structured approach to stakeholder engagement and public outreach that is based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with deployment of COVID19 vaccination. The SEP prepared for the parent project, has been updated based on the added project scope and includes relevant measures related to the provision of the COVID-19 vaccine. Among others, the updated SEP acknowledges the particular challenges with engaging marginalized and vulnerable social groups such as people with comorbidities, elderly, persons with disabilities, veddha community, etc., and provides details on the communications, outreach and stakeholder engagement activities that will be carried out to ensure proper awareness raising, and timely and equitable information dissemination of the vaccination program. Stakeholder engagement strategies also point out ways to minimize close contact and follow the recommended good hygiene procedures as outlined in the US-based Centers for Disease Control (CDC) for patients with confirmed COVID-19 or persons under investigation for COVID-19 in health care settings. The updated SEP, thus, will apply to all implementing agencies to engage citizens (affected people, interested parties and vulnerable groups) as needed and for public information disclosure purposes. Feb 22, 2021 Page 11 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) The community engagement (CE) approach, as described in the revised SEP, is based on the national COVID-19 vaccine deployment plan. The CE strategy, focuses on demand generation in communities, clarifying target groups and removing misconceptions related to vaccinations while ensuring a community feedback loop. Thus the objectives of the community engagement strategy includes: (i) disclosure of the criteria and justification for priority populations identified for vaccination programme as well as details on non-eligible groups such as children under 18 years of age and pregnant/lactating women, (ii) building trust and awareness on COVID-19 vaccines, using data and evidence to dispel rumors and public misperceptions and to address vaccine hesitancy to improve demand generation, (iii) development and provision of context specific IEC/BCC materials targeted to priority groups, details on available services at the vaccination centers catering to needs of women and other high-risks groups and measures in place to manage Adverse Effects Following Immunization (AEFI), (iv) training of front line workers, including ‘Field Health Facilitators’ about the COVID-19 vaccine, its importance and measures to promote safety and wellbeing of the public, (v) promoting the COVID-19 vaccine through use of different channels, including mass communication, social media and community & public outreach interventions, (vi) citizen engagement, feedback and grievance redressal mechanisms in place for the vaccine program, and (vii) dissemination of information on available services and helplines, and integrating SEA/SH mitigation measures in the SEP. These advocacy and communication activities, including risk communication, will be carried out by the Health Promotion Bureau (HPB), together with relevant programme stakeholders of the Epidemiology Unit, Ministry of Health, other health officers, and other partners. In addition, community groups such ‘Friends of Facilities Committees (FFCs)’ and Grama Niladari officers will also visit homes sharing information about the COVID19 vaccination program especially in hard to reach areas. The NDVP recognizes gender gaps in healthcare access, vaccine hesitancy and obstacles due to lack of female Public Disclosure vaccinators. In order to ensure proper outreach and vaccination of women, the AF will support targeted communication, as outlined in the NDVP, to disseminate information regarding the COVID-19 vaccination, particularly to dispel misconceptions about vaccines. Furthermore, the project will also mobilize ‘Field Health Facilitators,’ especially females, to play a critical role in communicating with women, providing them information about the vaccine and managing misinformation regrading COVID-19 vaccination during the roll-out and deployment. Awareness sessions will also target male family members who may prevent women from accessing the vaccine. To support female frontline workers, the project will provide a stipend so they can arrange for child/elderly care needs within their families while participating in the roll-out of the vaccine program. To encourage women to get vaccinated, the vaccination centers will include female vaccinators who will also support outreach activities at the community level. The NDVP specifies that the vaccination team will include at least one female staff and out of four staff at the Vaccination centers. Vaccination sessions will be planned considering the privacy of clients. The vaccine program will utilise the existing GRM of the parent project which currently functions as the National Grievance Management System for Health Services. Information about these services will be publicly disclosed throughout the country in the through broadcast and print media . The grievance redress system will be equipped further to handle cases of SEA/SH with a survivor-centered approach. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. Feb 22, 2021 Page 12 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) ESS2 Labor and Working Conditions Most activities supported by the AF project will be conducted by health staff and supportive non-health staff, i.e public servants and temporary workers employed by the MOH or provincial DOHs. Each vaccination centre will be approximately staffed by a minimum seven health and supportive staff following the standard guideline for COVID 19 vaccination centres issues by the MoH. Activities will encompass delivery of vaccines, cold storage management, risk communication, mass communication for vaccine uptake, patient registration, vaccine administration, patient management and emergency treatment, handling and disposal of health care waste generated. The key risk for workers is exposure to COVID-19 (or other contagious illnesses as patients taken seriously ill with COVID-19 are likely to suffer from illnesses which compromise the immunes system, which can lead to illness and death of workers). The project will ensure the application of OHS measures as outlined in WHO guidelines which are captured in the updated ESMF and IC & HCWM plans. This encompasses procedures for entry into vaccination centers, including minimizing visitors and undergoing strict checks before entering; procedures for protection of workers in relation to infection control precautions; provision of immediate and ongoing training on the procedures to all categories of workers, and post signage in all public spaces mandating hand hygiene and PPE; ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General Environmental and Health Safety Guidelines (EHSGs) and industry specific EHSGs and follow evolving international best practice in relation to protection from COVID-19. Also, the latest guidance from WHO IC&HCWM relevant to vaccination will be integrated into the ESMF update. Measures will also be put in place to provide additional psychosocial support and facilities for health workers to Public Disclosure protect from burnout due to the increase in workload. To support female frontline workers the project will provide a stipend so they can arrange for childcare support for their children while participating in the roll out the vaccine. To encourage women to get vaccinated, the vaccination centers will include female vaccinators who will also support outreach activities at the community level. The NDVP specifies that the vaccination team will include at least one female staff and out of four staff at the Vaccination centers. The use of child labor will be forbidden in accordance with ESS2, i.e. due to the hazardous work situation, for any person under the age of 18. It will further be ensured that workers have access to necessary PPE and handwashing stations. Furthermore, there have not been any suspension or reductions in salaries and other benefits for healthcare or for other essential workers due to COVID-19 emergency measures and the project will continue to ensure that workers rights will be respected such as provision of overtime compensation, annual or sick leave, or severance etc. No large-scale labor influx is expected under the project. The project will adopt the WHO Code of Ethics and Professional Conduct for all health workers including community groups and military personal that may be involved in supporting logistics for the vaccination program. The project will also ensure a responsive GRM to allow workers to quickly inform involved agencies of labor issues, such as a lack of PPE, unreasonable overtime, unsatisfactory work conditions etc. Accordingly, the project’s LMP will be updated with these additional measures. ESS3 Resource Efficiency and Pollution Prevention and Management Feb 22, 2021 Page 13 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) The GoSL plans to deploy the vaccination effort through approximately 4000 vaccination centres apread across the country, housed within existing health care facilities. The vaccnine clinics will operate every other day during the campaign to provide vaccinations to around 300-500 people a day per site. The operation will produce hazarous medical wastes such as sharps, syringes, vials, packaging, PPEs and other medical equipment all of which could potentially be contaminated with the infection. All of this waste requires special handling and awareness as it may pose a huge risk to the environment from inadequate disinfection and unsafe disposal, which in turn can pose risks of occupational infections to health workers as well as communities nearby. While Sri Lanka has regular ongoing immunization campaigns and is well accustomed to the needs, this mass effort can stretch its capacity. As stated before, Sri Lanka has made good progress in terms of HCWM with several secondary and tiertiary care hospitals having obtained the Environment Protection Liscence. These larger facilities have been continually upgraded with regard to their capacity to handle health care waste in a safe manner. However, gaps and shortcoming do exist, especially in the primary care sector where resources for safe HCWM and awareness among health workers are not yet up to standard. Given the highly cantgious nature of the infection, a rapid assessment and a plan to procure basic facilities (such as sharp shredders, autoclaves, bins, incinerators of approproate capacity) for disinfection, transport and disposal of HCW must be put in place covering all vaccination centres with particular attention paid on lower level heath care facilities who are not properly equipped as of present. Each vaccination centre or a cluster of centres within a given geographical areas, will need prepare a site-specific IC & HCWMP following guidelines provided in the updated ESMF (refer ESS1 above), in accordance with WHO COVID-19 Public Disclosure vaccination guidance documents, the World Bank Group Environmental Health and Safety Guidelines for Waste Management Facilities and other best international practices in order to prevent or minimize accidental infections resulting from enviornmental contamination. Project financed activities with potential for environmental and social risks will not be carried out until an updated, consulted and disclosed ESMF is in place for the project and necessary site-specific plans are prepared in accordance. The ESMF will also include guidance related to transportation and management of vaccines, samples and medical supplies or expired chemical products at distribution centers and health care facilities. Regular hospital infection control protocols will be strengthened where needed with WHO environmental infection control guidelines for medical facilities and any evolving COVID specific guidance. Nocivil works are planned under the AF and the activities for cold chain are not expected to have any negative implication on GHGs ESS4 Community Health and Safety In line with safety provisions in ESS2, it is equally important to ensure the safety of communities from potential COVID-19 as well as other infectious diseases. As noted above, health care wastes generated at vaccination centers have a high potential of transmitting pathogenic micro-organisms that can infect the community at large through accidental pricks and injuries from unsafely disposed sharps in landfills and open dumps, contamination of land, water, air or through direct contact. There is a possibility for pathogens to be introduced into the environment if Feb 22, 2021 Page 14 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) waste streams are not well contained/managed or due to accidents/emergencies e.g. a fire response or natural phenomena event (ex: Landslides). The IC&HCWMP in the updated ESMF therefore will describe: (i) how vaccination activities will be carried out out with all necessary biosafety measures with low incidences of accidents and incidents in line with Good International Industry Practice (WHO guidelines), (ii) measures in place to prevent or minimize the spread of COVID-19 and other infectious diseases, and (iii) emergency preparedness measures. Based on this, site-specific or cluster speciifc plans will be derived. All vaccination centres supported by the project will therefore have to follow respective procedures on proper handling, trasnport and disposal of HCW and stringent measures for infection control especially those workers cleaning before leaving the work place back into their communities. 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 country’s existing guidelines will be implemented for the Adverse Events Following Immunization (AEFI) detection, reporting and management of such events. Eligibility screening will be done by competent health staff capable of identifying contra indications for vaccination. Readiness for AEFI will be ensured by developing adequate competencies through trainings, and ensuring proper screening for AEFI before vaccination. Emergency readiness will be assured through observation for minimum 20 minutes post vaccination, the availability of emergency trays with essential medicines together with oxygen facilities for proper management and specialized care arrangements at all vaccination centres. Accordinly, The MoH 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 Public Disclosure Surveillance of Adverse Events Following Immunization (2014). Th project will assess Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) risks associated with project activities and take measures to mitigate the potential SEA/SH risks, by integrating SEA/SH components in trainings for healthcare workers, disseminating information on available services and helplines, and integrating SEA/SH mitigation measures in the SEP. 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 sexual 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 areas for female, having at least one female staff in place, Code of Conduct for all the staff, information and notices stating the zero tolerance of SEA/SH with numbers to key GBV service providers eg: Mithuru Piyasas, WIN, and accessible and function GRM ensuring that it is accessible by female beneficiaries. The project will promote the avoidance of SEA by adopting the WHO Code of Ethics and Professional Conduct for all health workers including community groups and military personal that may be involved in supporting logistics and transportation to bring people from remote locations to vaccination centers. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This standard is currently considered Not Relevant. The project is expected to deliver the vaccination program through existing facilities. As such, no land acquisition is envisaged or required. Feb 22, 2021 Page 15 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The vaccination program will take place within existing facilities. Any capacity enhancement HCWM will be done within existing systems given the fast track nature of the support. Hence, impacts of the project on natural resources and biodiversity are likely to be none or low, as such this standard is considered Not Relevant. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities Sri Lanka’s population includes Veddhas-forest-dwellers, whose collective identity and presence is consistent with the characteristics that are specified in paragraphs 8 and 9 of ESS7. The population of Veddhas is estimated to be around 2,500 - 6,600 and while they used to be concentrated in the south-central jungles of Sri Lanka, in the area known as Mahiyangana, they are becoming completely assimilated with most of them speaking Sinhala instead of their indigenous languages—the latter now nearing extinction. The proposed AF activities do not present adverse impacts on indigenous people. However, there is a potential for marginalizing indigenous and vulnerable people in accessing vaccines and vaccine related information. Vaccine deployment and delivery when available, could counter local perceptions as well as cultural protocols and local medicinal practices of IP groups. Accordingly, ESS 7 is considered relevant for this project. To address this risk, vaccinations among the Veddas will be carried out with due respect for the rights, dignity, aspirations, identity, culture and livelihoods of IPs. Training and capacity building for health care workers under the project will emphasize the need to provide care for the priority and eligible population, regardless of ethnicity and Public Disclosure social status, and with due considerations for the cultural protocols of IPs. The relevant aspects of ESS7 will be adopted to ensure full participation and consultation of IPs throughout the project implementation, and to create culturally-sensitive mechanisms by which IPs can raise concerns or seek redress for project-related grievances. Consultations and vaccination campaigns will be conducted through partnership with relevant IP organizations and traditional authorities. Lastly, stakeholder engagement and vaccinations will be conducted with extra precautions to minimize COVID-19 transmission risks, especially for Indigenous Peoples living in more remote areas or in voluntary self-isolation. This may require testing or vaccinating intermediaries conducting consultations who may travel in and out of communities. Based on the information available, the project activities (i) will not undertake forced vaccination; and is (ii) not expected to induce adverse impacts on land belonging to indigenous groups and are not expected to cause relocation of such groups or cause material changes to their ways of life. The principles and parameters to guide project activities among IP groups will be set out in the revised ESMF & SEP. ESS8 Cultural Heritage This standard is currently considered Not Relevant as the project is not expected to support any construction or rehabilitation activities that would involve the movement of earth (thereby potentially having an impact on tangible cultural heritage), or other activities that could have an impact on intangible cultural heritage. Feb 22, 2021 Page 16 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) ESS9 Financial Intermediaries This standard is Not Relevant for the suggested project interventions, as no financial intermediaries will be used. B.3 Other Relevant Project Risks Potential environmental and social impacts would be exacerbated as the result of the natural disaster, for example the flooding, drought or excessive heat, especially for poor and vulnerable population both in urban and rural areas. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways OP 7.60 Projects in Disputed Areas 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 Public Disclosure Areas where “Use of Borrower Framework” is being considered: Note relevant IV. CONTACT POINTS World Bank Contact: Deepika Eranjanie Attygalle Title: Senior Health Specialist Telephone No: 5723+311 / 009-411-5561311 Email: dattygalle@worldbank.org Borrower/Client/Recipient Borrower: Democratic Socialist Republic of Sri Lanka Implementing Agency(ies) Implementing Agency: Ministry of Health State Ministry of Samurdhi, Household Economy, Micro Finance, Self-Employment, Business Implementing Agency: Development, Feb 22, 2021 Page 17 of 18 The World Bank Additional Financing for Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P176422) Implementing Agency: Ministry of Finance 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): Deepika Eranjanie Attygalle Practice Manager (ENR/Social) Robin Mearns Cleared on 19-Feb-2021 at 12:31:18 GMT-05:00 Public Disclosure Feb 22, 2021 Page 18 of 18