The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 28-Apr-2021 | Report No: PIDA31667 Apr 29, 2021 Page 1 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Sierra Leone P176441 Sierra Leone COVID-19 P173803 Emergency Preparedness and Response Project Additional Financing Parent Project Name Region Estimated Appraisal Date Estimated Board Date Sierra Leone COVID-19 AFRICA WEST 28-Apr-2021 05-May-2021 Emergency Preparedness and Response Project Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Ministry of Finance Ministry of Health and Financing Sanitation Proposed Development Objective(s) Parent To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Sierra Leone. Components Supporting National and Sub-national Public Health Institutions for Prevention and Preparedness Strengthening Multi-sector, National Institutions and Platforms for Policy Development and Coordination of Prevention and Preparedness using One Health approach Emergency COVID-19 Response Implementation Management and Monitoring and Evaluation PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 8.50 Total Financing 8.50 of which IBRD/IDA 5.00 Financing Gap 0.00 Apr 29, 2021 Page 2 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 5.00 IDA Grant 5.00 Non-World Bank Group Financing Trust Funds 3.50 Health Emergency Preparedness and Response Multi-Donor Trust 3.50 Environmental and Social Risk Classification Substantial Other Decision (as needed) B. Introduction and Context 1. This Project Paper seeks the approval of the World Bank’s Regional Vice President to provide a grant in the amount of US$5.00 million equivalent from IDA and US$3.50 million equivalent from the Health Emergency Preparedness and Response Trust Fund (HEPRTF) for an Additional Financing (AF). The AF would support the costs of expanding activities of the Sierra Leone COVID-19 Emergency Preparedness and Response Project (P173803) under the COVID-19 Strategic Preparedness and Response Program (SPRP), using the Multiphase Programmatic Approach (MPA), approved by the Board on April 2, 2020, and the vaccines AF to the SPRP approved on October 13, 2020.1 The primary objectives of the AF are to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccines deployment in Sierra Leone through vaccination system strengthening, and to further strengthen preparedness and response activities under the parent project. A Sierra Leone COVID-19 Emergency Preparedness and Response Project (P173803) in an amount of US$7.50 million IDA, prepared under the SPRP, was approved on April 2, 2020 and became effective on April 3, 2020. 2. The purpose of the proposed AF is to provide upfront financing to help the government purchase and deploy COVID-19 vaccines that meet the World Bank’s vaccine approval criteria (VAC) and strengthen relevant health systems that are necessary for a successful deployment and to prepare for the future. The 1 The Bank approved a US$12 billion WBG Fast Track COVID-19 Facility (FTCF or “the Facility�) to assist IBRD and IDA countries in addressing the global pandemic and its impacts. Of this amount, US$6 billion came from IBRD/IDA (“the Bank�) and US$6 billion from the International Finance Corporation (IFC). The IFC subsequently increased its contribution to US$8 billion, bringing the FTCF total to US$14 billion. The Additional Financing of US$12 billion (IBRD/IDA) was approved on October 13, 2020 to support the purchase and deployment of vaccines as well as strengthening the related immunization and health care delivery system. Apr 29, 2021 Page 3 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) proposed additional financing will help the government vaccinate an additional 3.5 percent of the country’s population while the COVID-19 Vaccines Global Access Facility (COVAX) Advance Market Commitment (AMC) Facility will cover 20 percent of the population by the end of calendar year (CY) 2021. The World Bank financing for the COVID-19 vaccines and deployment will follow the World Bank’s VAC. As of April 16, 2021, The World Bank will accept as threshold for eligibility of IBRD/IDA resources in COVID-19 vaccine acquisition and/or deployment under all Bank-financed projects: (i) the vaccine has received regular or emergency licensure or authorization from at least one of the SRAs identified by WHO for vaccines procured and/or supplied under the COVAX Facility, as may be amended from time to time by WHO; or (ii) the vaccine has received WHO Prequalification (PQ) or WHO Emergency Use Listing (EUL). COVID-19 vaccination in Sierra Lone is free for the entire population. 3. The need for additional resources to expand the COVID-19 response was formally conveyed by the Government of Sierra Leone in the letter dated March 15, 2021 for COVID-19 vaccines purchase and deployment in the amount of US$5.0 million from IDA financing. The proposed AF will form part of an expanded health response to the pandemic, which is being supported by development partners under the coordination of the Government of Sierra Leone (GoSL). Additional World Bank financing will provide essential resources to enable the expansion of a sustained and comprehensive pandemic response that will appropriately include vaccination in Sierra Leone. Sierra Leone has been allocated a HEPRTF grant to the value of US$3.5 million under the response window to support COVID-19 response, under the condition that HEPRTF resources are not used for purchase of COVID-19 vaccines. 4. Critically, the additional financing seeks to enable the acquisition of vaccines from a range of sources to support Sierra Leone’s objective to have a portfolio of options to access vaccines under the right conditions of value-for-money, regulatory approvals, and delivery time among other key features. The COVAX Facility has put in place a framework that will anchor Sierra Leone’s strategy and access to vaccines. Since October 30, 2020, the Government of Sierra Leone has entered into an agreement with COVAX to undertake necessary actions so that Sierra Leone could receive COVAX-supported vaccines. The COVAX Facility has agreed to provide vaccines for up to 20 percent of the total population. Access to vaccines, however, depended on the country’s signing of the COVAX vaccine request and indemnity forms, which was eventually signed on February 25, 2021 by the GoSL. On March 8, 2021, the first batch of 96,000 doses of Covishield (AstraZeneca) arrived in the country. Together with 200,000 doses of SinoPharm donated from the Government of China and an additional 42,000 doses of AstraZeneca vaccines donated by MTN through the Africa Union, the COVID-19 vaccination has commenced since March 15, 2021. The World Bank’s support in expanding access to COVID-19 vaccines beyond the COVAX’s AMC allocation shall be prioritized to source through the COVAX Facility, the African Vaccine Acquisition Task Team (AVATT) or the Bank-Facilitated Procurement (BFP) individually or jointly with other countries. The availability and terms of vaccines remain fluid and prevent the planning of a firm sequence of vaccine deployment, especially as the actual delivery of additional vaccines is unlikely to be immediate. Rather, the proposed financing enables a portfolio approach that will be adjusted during implementation in response to developments in the country’s pandemic situation and the global market of COVID-19 vaccines. 5. In addition to vaccines acquired through COVAX, the AVATT convened by the African Union, is in the process of negotiating, through United Nations Children’s Fund (UNICEF), additional access to vaccines that would contribute to taking the total population covered up to 23.5 percent with the current World Bank’s financial envelop if the country opts for AVATT for additional vaccine acquisition. When firm contracts are in place between UNICEF, as the appointed procurement agent, and the manufacturers, Apr 29, 2021 Page 4 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) UNICEF will conclude contracts with the participating AVATT countries for the supply of COVID-19 vaccines. These contracts will be reviewed by the World Bank, if the country chooses to use the IDA financing for its procurement, to ensure that they comply with all the operational policies and provide value for money in terms of both price and delivery times before the financing from this Grant can be disbursed toward the member country upon its request. 6. Even prior to the detection of the first COVID-19 case in the country, the government has promptly taken preparedness and response measures to contain the virus. As of April 7, 2021, Sierra Leone had reported 3,993 cumulative COVID-19 cases. A total of 143,561 tests were conducted, bringing the test positive rate to 18.73 per 1,000 population. There are currently 79 deaths bringing the case fatality rate (CFR) to 2.0 percent (excluding community deaths). More men are more infected than women (59 percent of the total tested positive was men). While the median age of all positive cases is 34 years old, those above 45 years of age are disproportionately affected, consisting of 71 percent of all the cases. The average age of COVID-19 deaths is 61.5 years old and the CFR among those above 60 years old is significantly higher (12.6 percent) than other age groups. Health workers account for 6.2 percent of the confirmed COVID-19 cases (249 cases), making it the single most profession affected by the pandemic in the country.2 Among health workers who tested positive, more female health workers (153) were infected than male health workers (96).3 From December 2020 to February 2021, Sierra Leone experienced an exponential rise in confirmed COVID-19 cases wherein positive cases from routine testing and outbound passengers account for more than 95 percent of the confirmed positive cases, which indicated the active community transmission and the second wave. From mid-February 2021, the incidence of COVID-19 was significantly decreased and steady. To date, there are no COVID-19 variants reported in Sierra Leone. 7. The government launched its COVID-19 vaccination program on March 15, 2021. Prior to the launch of the COVID-19 vaccination program, the KAP survey was conducted in February 2021 to assess the COVID-19 vaccines acceptance and hesitancy among the population. Three-fourths of the survey respondents showed acceptance to COVID-19 vaccines. The vaccine acceptancy is higher in rural districts than urban districts. However, even those who showed COVID-19 vaccines acceptance had concerns about the vaccine safety. The majority of key informant interview participants revealed that they were aware of COVID-19 vaccines, yet, had little knowledge about them and their potential side effects. Health workers were by far the most trusted information source of COVID-19 vaccines (76 percent), followed by religious leaders (9 percent) and politicians (6 percent). As of April 15, 2021, a total of 42,566 people was vaccinated their first dose and 124 people received their second dose. Among those vaccinated, 57 percent are males and 43 percent are females. The COVID-19 vaccine intake has been slow due to the limited accessibility to vaccination sites (two static sites and one mobile team per district) only in district headquarters. To overcome this challenge with the limited government funds for COVID-19 vaccination, the MoHS has expanded the target population groups to health workers at all ages, those above 60 and essential workers at age 40 and above from Day 5. Daily briefings of COVID-19 vaccination were held in the first 10 days to closely monitor progress, facilitate timely discussion for immediate adjustments. With the proposed AF, the COVID-19 vaccination coverage is expected to be significantly expanded, reaching hard-to-reach areas, informal settlements and the vulnerable population. 2 Ministry of Health and Sanitation, Sierra Leone. Corona Virus Disease (COVID-19) Situational Report. Report No. 373. Issued on April 7, 2021. 3 WHO Sierra Leone data on COVID-19. Apr 29, 2021 Page 5 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) C. Proposed Development Objective(s) Original PDO 8. To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Sierra Leone. Current PDO 9. As the proposed activities to be funded under the AF for the Sierra Leone COVID-19 Emergency Preparedness and Response Project (P173803) are aligned with the original Project Development Objective (PDO), the PDO will remain unchanged. Key Results 10. The project’s progress towards achievement of the PDO and overall implementation progress were rated Satisfactory in the last Implementation Status Report (ISR) of December 18, 2020 and the project continues to make good progress. As of April 20, 2021, the parent project has disbursed US$6.44 million or 81.6 percent of its commitments. The country’s surveillance system has been strengthened with 150 ports of entry (POE) staff, district surveillance officers and DHMT staff. The 117 Toll-Free Emergency Call Center enables proactive collection of data and feedback from the general public, helps case finding of suspected and confirmed COVID-19 cases, and operates as a triage for the public. Risk communication was intensified through community engagement in nine out of 16 districts where the number of COVID- 19 cases were relatively high. The trained community workers engaged farmers, traders, youth, women, men to discuss and advocate preventive measures from COVID-19 and its impact for human and animal health. In the capital alone, the epicenter of COVID-19, 7,681 residents were reached through daily focus group discussions. The Freetown City Council (FCC) proactively engages Councilors, the Tribal Heads, religious leaders, Mammy Queens, Community Health Workers (CHWs), youth leaders, Ward Development Committee (WDC) members and community influencers to promote preventive measures against COVID-19 infection. Coupled with the Regional Disease Surveillance Systems Enhancement Project (REDISSE: P154807)’s support for the One Health coordination mechanism, the project extensively supports EOC and FCC for coordination at the national and district levels, convening multisectoral collaboration with social welfare, local government, water and sanitation, education, food and agriculture, and security. Furthermore, building on the World Bank-supported Ebola Emergency Response Project (EERP: P152359), Rapid Response Teams (RRTs) in all the districts received refresher training in early detection, effective and timely response to COVID-19 cases, IPC, risk communication and community engagement. A total of 700 POE staff, auxiliary and support staff were trained to enhance skills in providing culturally appropriate, basic mental health and psychosocial support to persons and communities affected by COVID-19, especially for those in quarantine homes, treatment centers and community care centers, covering 130 out of 190 chiefdoms across the country. Personal Protective Equipment (PPEs) were delivered to the vulnerable women and girls in the above facilities in isolation. The project contributed to reducing the case fatality rate from 6.0 percent in May 2020 to 2.1 percent in February 2021 by strengthening health systems through the procurement of essential laboratory supplies, reverse transcription polymerase chain reaction (RT-PCR) test kits, one PCR analyzer, essential medicines, equipment, PPEs and consumables. D. Project Description Apr 29, 2021 Page 6 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) 11. The changes proposed for the AF entail expanding the scope of activities in the parent project: Sierra Leone COVID-19 Emergency Preparedness and Response (P173803), adjusting its overall design. In summary, the proposed AF will include the following changes: (a) Revision of the total project cost from US$7.5 million to US$16.0 million to account for commitments of US$8.5 million, US$5.0 million of which is from IDA grant and US$3.5 million is from the HEPRTF grant; (b) Scaling up of risk communication and community engagement for COVID-19 vaccination under sub- component 1.2; (c) Expansion of support for national and district coordination for COVID-19 vaccination under Component 2; (d) Replace the sub-component 3.3, whose activities for social and financial support to households were dropped at the first restructuring, with a sub-component for the operationalization of the COVID-19 vaccine deployment (See details below); (e) Addition of sub-component 3.5 to scale up COVID-19 vaccines acquisition beyond 20 percent of the total population; (f) Revision of the results framework to include new indicators for the COVID-19 vaccine deployment under the proposed AF and modify indicators in response to the evolving pandemic situations; and (g) Extension of the closing date of the project from March 31, 2022 to June 30, 2023. 12. The additional activities will be incorporated into the existing components of the parent project as described below. Component 1: Supporting national and sub-national public health institutions for prevention and preparedness (total US$3.10 million, of which AF US$0.80 million from IDA grant) Sub-component 1.2: Community Engagement and Risk Communication (total US$1.30 million, of which AF US$0.80 million from IDA grant) 13. This sub-component is proposed to be scaled up. The parent project’s activities that support risk communication and community engagement will continue and expand to include communication and social mobilization on COVID-19 vaccination. With the lessons learned from the first 10 days of COVID-19 vaccination in the country, the GoSL needs to intensify risk communication and community engagement to improve COVID-19 vaccine literacy and acceptance, which includes building confidence and trust, and reducing stigma around the vaccine. The current uptake of COVID-19 vaccination is slower than expected, especially in the Western Urban and Rural Areas where the high density of populations, particularly in informal settlements, is observed and record the highest number of COVID-19 cases (see details in Annex 3). This activity is critical for the COVID-19 vaccination, building on the ongoing efforts for strengthening community-based disease surveillance and the 117 Toll-Free Emergency Call Center under the REDISSE, the active CHW Program under the HSDSSP, and community engagement with Councilors, the Tribal Heads, religious leaders, Mammy Queens, youth leaders, WDC members and volunteers under the parent project. The AF will actively facilitate the MoHS for the engagement of CSOs and community-based organizations (CBOs) to monitor the vaccine deployment processes and to ensure no forced vaccination and their feedback to be incorporated into the improved COVID-19 vaccination. Communication activities will also have a focus on climate-related diseases to ensure greater awareness of the risks among key population groups about the climate-related health risks linked to the COVID-19 crisis. Apr 29, 2021 Page 7 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) Component 2: Strengthening multi-sector, national institutions and platforms for policy development and coordination of prevention and preparedness using One Health approach (total US$1.20 million, of which AF US$0.20 million from IDA grant) 14. This sub-component is proposed to be scaled up. The scope of the parent project’s support for national and district coordination will be expanded to include the National and District COVID-19 Vaccine Technical Working Groups and the NITAG. These coordination mechanisms operate under the umbrella of the ICC and the EOC. Strengthening the existing coordination mechanism by disbursing directly from the IHPAU to the DHMTs is expected to solve the current constraints in delayed fund disbursement for social mobilization and COVID-19 vaccination at the designated vaccine centers in the district headquarters. Component 3: Emergency COVID-19 Response4 Sub-component 3.3: COVID-19 vaccines service delivery (AF US$3.50 million from the HEPR TF) 15. This sub-component is proposed to be restructured to include new activities. New activities will be added to support the enhancement of preparation and operationalization of COVID-19 vaccines deployment in the country. The project will support service delivery at the national and sub-national levels, including: (i) the development of necessary COVID-19 deployment micro plans, based on the COVID-19 vaccine readiness assessment results presented in Table 1 above; (ii) support the MoHS and the PBSL for monitoring and supervision of the safety of COVID-19 vaccines and deployment in the country; (iii) procurement of essential consumables and equipment for the COVID-19 vaccination nationwide, including syringes, graves and face masks to ensure the safety of vaccinators and vaccinees; (iv) training of vaccinators and volunteers for scale-up of the COVID-19 vaccination, including the integrated training for CHWs in their routine refresher training; (v) strengthening M&E system, especially stock management of COVID-19 vaccines, using the existing SMT, and the vaccine coverage as per the set target population groups. The support includes training of district vaccination teams in data entries to effectively utilize the developed vaccine surveillance system, which is linked to the DHIS2; (vi) enhancing cold chain and logistics to scale up COVID-19 vaccination, including medical waste management; and (vii) strengthening vaccine safety surveillance to effectively monitor and promptly respond to and investigate AEFI, which could contribute to health systems strengthening in the context of Sierra Leone. The above is an indicative list of activities and that technical assistance for prioritization will be provided, whenever needed, to ensure that the prioritized activities are financed. It is also expected to scale up mobile vaccination teams to further reach the population, especially health workers, outside of the district headquarters. 16. The proposed AF will pay special attention to: (i) the enforcement of policies related to ensuring that there is no forced vaccination and that any mandatory vaccination program (such as for entry to schools) is well designed, following due process for those who choose to opt out; (ii) acceptable approved policy for prioritized intra-country vaccine allocation; (iii) regulatory standards at the national level, including pharmacovigilance; and (iv) appropriate minimum standards for vaccine management, including cold chain infrastructure. The policies for prioritizing intra-country vaccine allocations follow principles established in the WHO Allocation Framework, including targeting an initial coverage of 20 percent of the 4The Component 3 of the parent project is about COVID-19 Emergency Response, which corresponds to Component 1 of the SPRP. Apr 29, 2021 Page 8 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) country’s population by focusing first on health workers and frontline officers and then focusing on the elderly and those with underlying conditions that places them at higher risk. Sub-component 3.5: COVID-19 vaccines acquisition (AF US$4.00 million from IDA grant) 17. This sub-component is proposed to be added as a new sub-component. Vaccine purchasing will be done through Component 1 of the Global COVID-19 MPA (SPRP). The support for vaccines, which was anticipated in the initial Global COVID-19 MPA, will be added as part of the containment and mitigation measures to prevent the spread of COVID-19 and deaths under Component 3: Emergency COVID-19 Response of the parent project. Up to US$4.00 million out of the US$5.00 million from IDA grant will be used to expand the coverage of additional COVID-19 vaccines to the COVAX Facility by 3.5 percent to make it a total of 24.98 percent of the population vaccinated. Sierra Leone will use the COVAX Facility, the AVATT or bilateral agreements for vaccine purchase either individually or jointly with neighboring countries. . Legal Operational Policies Triggered? No Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 Summary of Assessment of Environmental and Social Risks and Impacts . A. Environmental and Social 18. Activities under the AF should have positive impacts as it will improve capacity for surveillance, monitoring and containment of COVID-19. However, it could also cause environment, health and safety risks due to the dangerous nature of the pathogen (COVID-19) and reagents and equipment used in the project-supported activities. Facilities treating patients may also generate biological, chemical waste, and other hazardous by-products that could be injurious to human health. These risks will be mitigated with occupational health and safety standards and specific infectious-control strategies, guidelines and requirements as recommended by WHO and CDC. Effective administrative and infectious-controlling and engineering controls would be put in place to minimize these risks. Climate change can affect the trajectory of the COVID-19 pandemic and impact groups that are most susceptible to the virus including healthcare workers, the elderly, those with pre-existing conditions, people with disabilities and other disadvantaged groups. These vulnerabilities will be addressed through targeting and improving health care interventions described above as well as the surveillance monitoring. If engagement of security or military personnel is being considered for project activities, including deployment of vaccines, this section should describe the risks and impacts of engaging such personnel, including any mitigation measures to manage such risks and impacts. Apr 29, 2021 Page 9 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) 19. In line with WHO Interim Guidance (February 12, 2020) on “Laboratory Biosafety Guidance related to the novel coronavirus (2019-nCoV)�, and other guidelines, the parent project developed a Hospitals’ Waste Management Plan and prepared an ESMF for the Project by adding to it WHO standards on COVID-19 response. The plan includes training of staff to be aware of all hazards they might encounter. This provides for the application of international best practices in COVID-19 diagnostic testing and handling the medical supplies, disposing of the generated waste, and road safety. 20. Gender inequalities and norms are critical considerations when designing policies and interventions in emergency situations and pandemics. They play an important role in who gets access and how fast, to critical health services. Gender norms also influence risk of exposure to disease, as well as of spreading it. At the same time, biological sex can influence how susceptible a person is to disease and how well they respond to treatment and/or vaccines. In a pandemic, this has multiple implications. On the one hand, pandemic response has to be cognizant of the gender-based differences in access to and use of services due to limited mobility and financial capacity, and on the other hand, support needs to be provided to at-risk groups such as family caregivers (the majority of whom are women) to reduce their risk of getting ill and/or passing it on to others. Moreover, pandemics can create or exacerbate the conditions that especially put women and girls at greater risk of gender-based violence. 21. As part of the ESF requirements, the World Bank projects can also take steps to mitigate the risks of sexual exploitation, abuse (SEA), and sexual harassment (SH). In pandemics, access to services may be reduced due to lockdowns and reduced mobility, and the rule of law becomes fragile, increasing the risks of gender-based violence (GBV). For instance, women and girls may be forced into exchanging sexual favors for access to testing, treatment, vaccines or even supplies. Another social risk is that marginalized and vulnerable social groups, including women and disabled populations, may have more barriers to access to COVID-19 services and information. There is also a risk that vaccine deployment plans could leave women behind, considering the larger male mortality of COVID-19 and the tendency in many countries to overlook the importance of gender inequalities in social and economic activity. This risk will be reduced as teams are encouraged to carefully assess this aspect of deployment. 22. In addition to the ESMF, the client will implement the activities set out in the ESCP. The Environmental and Social Review Summary (ESRS), ESCP, ESMF, SEP, and Labor Management Procedure (LMP) (where required) of the parent project have been updated. The project implementation will ensure appropriate stakeholder engagement, proper awareness raising and timely information dissemination. This will help: (i) avoid conflicts resulting from false rumors; (ii) ensure equitable access to services for all who need it; and (iii) address issues resulting from people being kept in quarantine. These will be guided by standards set out by WHO as well as other international good practices including social inclusion and prevention of SEA and SH. No security and/or military forces will be involved in COVID-19 vaccination in the country. 23. Gender gap analysis. The Systemic Country Diagnostic 2018 (SCD)5 highlights the priority areas for gender equity: improving health and education outcomes and strengthening women’s legal rights. However, the acceptance and prevalence of domestic violence remain high in the country while domestic violence, including GBV, is criminalized. Over half of women accept that men can beat their partners, 5 World Bank. 2018. Sierra Leone Systematic Country Diagnostic (SCD). Washington, DC: World Bank. Apr 29, 2021 Page 10 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) compared to only 30 percent of men. Years of conflict have normalized violence against women and eroded the self-esteem of girls and women over time. Women are largely ignored in the debate about their own sexual and reproductive health. Moreover, about 62 percent of the total health workforce of Sierra Leone are women, mainly nurses and physical assistants, the majority of who require more direct contacts with patients for longer time than medical doctors. In fact, more female health workers were infected to COVID-19 than male health workers.6 Furthermore, women are less educated than men. Three in four girls complete their primary education, only one in two completes lower secondary education, and fewer than one in five completes upper secondary. Thus, there are likely gaps in accessibility to information sources and absorption level of correct information about COVID-19 among women as compared with men. 24. Measures to take to reduce the above gender gaps. The proposed AF will address the above gender gaps and ensures the implementation of equitable COVID-19 vaccine distribution and information dissemination through intensive RCCE prior to and during the national COVID-19 vaccine campaign. IEC materials in promotion of COVID-19 vaccination and COVID-19 prevention will be developed with pictures for the less educated to understand and easily comply with the recommended public health measures. The World Bank has supported the development of the Information Brief on COVID-19 vaccination for CHWs under the Programmatic Advisory Services and Analytics (PASA: P163519). The proposed AF will support intensification of social mobilization where CHWs will play a critical role in outreaching population, especially women in communities. The developed Information Brief on COVID-19 vaccination will help CHWs disseminate correct information and reduce information gaps by sex or socio-economic status. The project will also further support for strengthening IPC measures at the healthcare settings and vaccination centers to prevent the infection. Three key indicators are proposed to add to measure disproportionate effects of COVID-19 among women. These are: (i) the proportion of females among those vaccinated; (ii) Infected female health workers to COVID-19 treated; and (iii) females having adequate knowledge on IPC measures and vaccine efficacy. 25. Mechanisms to engage citizens, and target beneficiaries more specifically, in providing ideas and feedback on program delivery are helpful in identifying gaps at the point of service delivery (information availability, access to testing and vaccination, access to relevant care, equal treatment etc.), build community knowledge and confidence, establish trust, ensure governments respond to community needs (including vulnerable groups), and thus to optimize the impact of the COVID-19 emergency response. The parent project will continue to support the 117 Toll-Free Emergency Call Center and the ACC to ensure feedback mechanism with citizens and to resolve their complaints in a timely manner. B. Climate Co-Benefits 26. Climate change is expected to aggravate the impact of adverse natural events in the future and emerging epidemics. Sierra Leone’s exposure to climate change and its associated disaster risks can undermine the country’s growth prospects and slow down poverty reduction efforts. Future climate scenarios indicate: (a) increases in temperature; (b) more extreme weather, including more intense precipitation; and (c) sea level rise. This extreme climate leads to risks specific to Sierra Leone’s society. 6Ministry of Health and Sanitation, Sierra Leone. Corona Virus Disease (COVID-19) Situational Report. Report No. 349. Issued on March 14, 2021. Apr 29, 2021 Page 11 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) On one hand, the combination of such higher average temperatures and humidity leads to high heat index values, which can have a detrimental impact on some areas of the economy such as the energy sector7 and has the potential to bring additional health risks. Among them are a higher prevalence of diarrheal diseases; an increase in toxic algae blooms, leading to seafood poisoning; and an expansion in breeding locations and seasons for mosquitoes, which are carriers of malaria and dengue, among other diseases. On the other hand, extreme rainfall events can lead to flash floods in urban areas, riverine flooding, and landslides. If poorly managed, the effects of climate change could be significant, particularly given the high dependence on agriculture and natural resources, combined with high poverty levels, unemployment, and environmental degradation. 27. Greenhouse gas (GHG) emissions are also expected to rise in Sierra Leone due to continued urban population growth. Between 2000 and 2015, total annual GHG emissions were estimated to have grown from 0.57 to 4.8 million tons of carbon dioxide equivalent (CO2e) and projected to reach about 6.6 million tons in 2030. By 2030, under a business-as-usual scenario, total GHG emissions are expected to be 6.6 million tons of CO2e. This increase is driven by waste and agriculture sectors, with combined projected emissions between 95 to 98 percent of the projected national emissions from 2015 to 2030. The expected largest emitting category is waste management and will be responsible for about 56 percent in 2030. Poor waste management system, coupled with poor environmental and sanitation conditions in urban informal settlements, also lead to increased risks of vector-borne diseases, water contamination, injuries and infrastructure damage. For instance, each day in Freetown, more than 350 tons of municipal waste are buried in uncontrolled dumpsites, burned, or dumped in waterways or drains, contributing to the release of contaminants into the natural environment and residential areas. Improving the performance of waste collection and disposal is therefore essential to reduce emissions, while vegetation enhancement can both protect existing carbon stocks and promote the sequestration of carbon dioxide. Therefore, it is critical to put sustainable and climate-resilient measures in place to reduce the impact of climate change on the population. However, the risk on project activities and outcomes is categorized as low due to several adaptation measures to ensure climate resilience in the future. Some mitigation measures will also be put in place to reduce the impact of the project's activities on the environment and reduce the country’s greenhouse gases. 28. The AF intends to address the above described climate vulnerabilities and assist the government to adapt to climate change through several activities. The Climate co-benefits (CCB) methodology assesses the proportion of IDA/IBRD funding that is contributing to either adaptation or mitigation benefits to either the outcomes of a project or the beneficiary population. Other sources of funding such as trust funds (TFs) are therefore not included in the CCB calculations. This AF is receiving financing from the HEPRTF, which is financing most climate adaptation and mitigation activities in this project, and therefore, low CCBs are expected. Under Component 3: Emergency COVID-19 Response (AF: US$7.5 million), the purchase of COVID-19 vaccines will consume US$4.0 million. This includes the costs of the vaccines, international freight, procurement fees to UNICEF or private suppliers. While no direct climate financing is expected to be assigned at this time to any of these investments, it is expected that some suppliers are taking active steps to ensure climate resilient considerations are taken into account 7 High temperatures can affect solar panel efficiency, although some cell types do better than others in tropical regions (Osarumen et al., 2017; Peters et al., 2018) an aspect to consider as there exists a push for Sierra Leone to rely largely on mini solar grids and standalone solar panel for electrification of some communities. Further temperature increases likely under climate change could lead to load shedding and impact the country’s energy policy. Apr 29, 2021 Page 12 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) during the manufacturing, shipment and distribution stages of the vaccines. The World Bank team, together with UNICEF, WHO and GAVI will continue to explore these areas in order to provide latest information on any specific climate adaptation and mitigation actions taken with regard to the vaccines. Under sub-component 3.3: COVID-19 vaccines service delivery (AF HEPRTF: US$3.5 million), the National COVID-19 Vaccine Deployment Plan and its micro-plans include measures to deal with any unexpected disruptions to the vaccine supply chain, distribution and storage from climate change impacts and other unexpected disasters (i.e., power outages from flooding and extreme heat). The AF will also finance solar and off-the-grid refrigerators and freezers that will provide reliable 24/7 power and efficient cooling in an environment with unstable electrical power as well as energy-efficient refrigerated trucks and low-carbon, energy efficient waste management equipment, if gaps remain. These items as well as the installation of temperature controls and monitoring system on the refrigerators and freezers will monitor any fluctuations and cut down on excessive use of energy, thus, reducing the project’s impact on the country’s greenhouse gas emissions. 29. The MoHS is implementing a digital vaccine registry to manage COVID-19 vaccination process, which links to the District Health Information Software (DHIS2) platform. The proposed AF will support this initiative as part of health systems strengthening under sub-component 3.3. This will help the national COVID-19 vaccine campaign reducing the use of paper and the incidence of record loss, enabling timely recording and ensuring the vaccine safety. Under sub-component 1.2: Community Engagement and Risk Communication (AF IDA: US$0.80 million), sensitization activities at the community level to promote adaptive behavior in vulnerable populations to COVID-19 and the impacts of climate change will be financed. The vaccine communication campaign will also enable dissemination of important health information on climate change-related health risks linked to the COVID-19 crisis such as the increased risks associated with social isolation and quarantine in extreme heat events. This would include sensitization of the population on the risks of co-morbidities such as being infected with COVID-19 and climate-related diseases such as malaria, EVD or other communicable diseases and non-communicable diseases as these can lead to more severe complications or deaths. E. Implementation Institutional and Implementation Arrangements 30. There is no change in implementation arrangements for project implementation and oversight. As described above, the MoHS will continue to be responsible for the overall project implementation, prompt and efficient coordination, oversight, and monitoring of the project. The MoHS, especially the EPI, will closely coordinate with the ICC and the national and district EOCs as well as the National and District COVID-19 Vaccine Technical Working Group and the NITAG. The Social Mobilization Pillar of the National COVID-19 Response Working Group will remain in close collaboration with FCC. The uptake of COVID-19 vaccination in the Western Urban district in the first 10 days was slower than expected despite its high population density and the highest number of COVID-19 cases. The ACC will continue to play an important role to oversee the appropriate fund utilization and mitigate risks of corruption. . Apr 29, 2021 Page 13 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) CONTACT POINT World Bank Kofi Amponsah Senior Economist, Health Kazumi Inden Senior Health Specialist Borrower/Client/Recipient Ministry of Finance Jacob Jusu Saffa Minister of Finance jsaffa@mof.gov.sl Implementing Agencies Ministry of Health and Sanitation Austin Demby Minister of Health and Sanitation austin.demby@gmail.com 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 APPROVAL Kofi Amponsah Task Team Leader(s): Kazumi Inden Approved By Practice Manager/Manager: Apr 29, 2021 Page 14 of 15 The World Bank Sierra Leone COVID-19 Emergency Preparedness and Response Project Additional Financing (P176441) Country Director: Gayle Martin 28-Apr-2021 Apr 29, 2021 Page 15 of 15