The World Bank Eswatini COVID-19 Emergency Response Project (P175875) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 17-Feb-2021 | Report No: PIDA31198 Jan 14, 2021 Page 1 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Eswatini P175875 Eswatini COVID-19 P173883 Emergency Response Project Parent Project Name Region Estimated Appraisal Date Estimated Board Date Eswatini COVID-19 Emergency AFRICA EAST 19-Feb-2021 26-Mar-2021 Response Project Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Kingdom of Eswatini Ministry of Health Financing Proposed Development Objective(s) Parent The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Eswatini. Components Component 1: Emergency COVID-19 Response Component 2: Strengthening Capacity in Preparedness for Health Emergencies Component 3: Implementation Management and Monitoring and Evaluation PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 8.00 Total Financing 8.00 of which IBRD/IDA 5.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 5.00 Non-World Bank Group Financing Jan 14, 2021 Page 2 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) Trust Funds 3.00 Health Emergency Preparedness and Response Multi-Donor Trust 3.00 Environmental and Social Risk Classification Substantial B. Introduction and Context Country Context 1. This Project Information Document outlines an Additional Financing (AF) comprising a loan in the amount of US$5 million IBRD and a grant in the amount of US$3 million from Health Emergency Preparedness and Response Trust Fund (HEPRTF) for the Eswatini COVID-19 Emergency Response Project (P173883). The AF would support the costs of expanding activities of the parent project under the COVID-19 Strategic Preparedness and Response Plan (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 vaccines, help ensure effective vaccine deployment through enhanced vaccination system strengthening, and further strengthen preparedness and response activities in the Kingdom of Eswatini. 2. The need for additional resources to expand the COVID-19 response was formally conveyed by the Minister of Finance on behalf of the Government of the Kingdom of Eswatini (GoKE) on October 29, 2020, with the objective to provide additional financing as well as technical assistance to the Ministry of Health (MOH) to adequately plan and rollout the vaccines for COVID-19, once available. The proposed AF, which includes loan and grant financing with a combined value of US$8 million, will form part of an expanded health response to the pandemic, which is being supported by development partners under the coordination of the GoKE. The additional financing will provide essential resources to enable an expansion of a sustained and comprehensive pandemic response that will appropriately include vaccination in Eswatini. 3. The AF seeks to enable the acquisition of vaccines from a range of sources to support Eswatini’s objective to have a portfolio of options to access vaccines under the right conditions (of value-for-money, regulatory standards and delivery time among other key features). Eswatini's application to the COVID-19 Vaccines Global Access (COVAX 2) Advance Market Commitment (AMC) was approved in July 2020 to reach 16 percent coverage free of charge. The proposed IBRD financing will build on this to expand Eswatini’s access to vaccine through COVAX, African Union, and/or direct acquisition from manufacturers. The availability and terms of vaccines remain fluid and prevent the planning of a 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 AF of US$12 billion 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. 2COVAX is co-led by Gavi, the Coalition for Epidemic Preparedness Innovations and WHO. Its aim is to accelerate the development and manufacture of COVID-19 vaccines, and to guarantee fair and equitable access for every country in the world. Jan 14, 2021 Page 3 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) firm sequence of vaccine deployment: rather the proposed financing enables a portfolio approach that will adjust during implementation in response to developments in the country pandemic situation and the global market for vaccines. 4. Eswatini remains vulnerable to COVID-19. As of February 10, 2021, the country of 1.15 million had recorded 16,341 confirmed cases, and 616 deaths, figures which show a sharp escalation from the previous months, surpassing the July 2020 peak of both daily confirmed cases and deaths. The Eswatini situation mirrors observations made in neighboring South Africa, where a large second wave unfolded at a concerning rate, exacerbated further by the December holidays and the spread of a new variant of concern, the B1.351, which is likely to be highly transmissible, quickly becoming the predominant variant in South Africa.3 It is highly likely that the B1.351 variant has spread to Eswatini, given its close proximity and economic linkages with South Africa. While there are signs the second wave is abating, there is a continuing risk of increased escalation of the epidemic. In addition to the increased transmission, the B1.351 variant is of immense concern due to its potential for vaccine escape. It will be critical for Eswatini to quickly scale up effective and safe vaccines while continuing to strengthen the overall COVID-19 response. Sectoral and Institutional Context 5. Eswatini has developed a National Contingency Plan to address COVID-19 and the MOH has been effectively managing its implementation with support from development partners (DPs). However, the recent surge in daily confirmed COVID-19 cases and deaths indicate that further investments are required. Preparation for rolling out vaccines is in its early phase, with the draft National Deployment and Vaccination Plan prepared in February 2021. Operational planning is ongoing under considerable uncertainty, particularly regarding when and how many doses of vaccines would be made available. The World Bank team has been working closely with key DPs supporting the MOH in health emergency preparedness and response, particularly for the ongoing COVID-19 emergency. 6. This AF is being proposed at a crucial juncture in the GoKE’s response to COVID-19. A critically important change in the state of science since the early stages of the pandemic has been the emergence of new therapies and the production of COVID-19 vaccines. Dexamethasone, an anti-inflammatory, has been shown to reduce mortality in critical cases by one-third, and by one-fifth in severe patients receiving respiratory support.4 5 The WHO recommends the use of dexamethasone for severe and critical cases of COVID-19. In addition to new therapeutics, a number of promising COVID-19 vaccines are being developed. Twenty are already in large-scale Phase-3 clinical trials. Recently published results from the trials of three vaccines show that they are safe and effective at reducing the incidence of symptomatic COVID-19. COVID-19 vaccination commenced in many high-income countries in December 2020. COVID-19 vaccination, along with improved diagnostics and therapeutics, is essential to protecting lives and enabling the world to reopen safely. Given the centrality of limiting the spread of COVID-19 to both health and economic recovery, providing access to COVID-19 vaccines will be critical to accelerate economic and social recovery in Eswatini. This AF will enable affordable and equitable access to vaccines and play a critical role in further strengthening the health system. 7. In addition to COVID-19, Eswatini is also under constant threat from other infectious diseases, droughts, storms, food contamination, antimicrobial resistance, traffic accidents and other emergencies. Despite the country’s 3 Tegally H., Wilkinson E., Giovanetti M., et al. Emergence and rapid spread of a new severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) lineage with multiple spike mutations in South Africa. medRxiv 2020.12.21.20248640; doi: https://doi.org/10.1101/2020.12.21.20248640 4 WHO. 2020. Corticosteroids for COVID-19. https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020. 5 The RECOVERY Collaborative Group. 2020. Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa2021436. Jan 14, 2021 Page 4 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) commitment to strengthening health emergency preparedness and response capacity – a priority area in the country’s National Health Sector Strategic Plan (2019-2023) -, capacity is limited. The country scored low at 38 in its most recent (2018) Joint External Evaluation of the Internal Health Regulations (2005) - with preparedness scoring particularly low (no or little capacity). Global Health Security Index score was also low at 31.1, thus Eswatini was classified as a ‘least prepared’ country. The US$3 million grant from HEPRTF will finance activities that strengthen Eswatini’s health emergency preparedness capacity, through strengthened surveillance, prepared health system and facilities for health emergencies, and strengthened systems for rapid procurement of the necessary consumables and equipment needed in case of a health emergency. The grant will not be used for any procurement of COVID-19 vaccines. 8. The Project Development Objective (PDO) of the parent project and this AF is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Eswatini. The parent project includes two components: (1) Emergency COVID-19 Response (US$5.5 million) and (2) Implementation Management and Monitoring and Evaluation (M&E, US$0.5 million). The components aim to strengthen Eswatini’s health system preparedness to respond to the COVID-19 emergency and potential future emergencies, with a focus on: (a) strengthening COVID-19 case detection, confirmation, contact tracing, recording and reporting; (b) strengthening health systems for COVID-19 preparedness planning and maintaining essential services; and (c) improving implementation of nonpharmaceutical interventions and strengthening communication preparedness. The AF will expand Eswatini’s COVID-19 response through (a) co-financing vaccine procurement to reach 30 percent of the country’s population who are the most vulnerable (US$2.25 million, (b) strengthening the systems required to support effective and efficient vaccine deployment under four core areas: planning and management, supply and distribution, program delivery and supporting systems and infrastructure (US$2.25 million); and (c) strengthening public structures for the coordination and management of the project, including central and local arrangements for coordination of activities, financial management and procurement (US$0.5 million). It will be complemented by a US$3 million grant from the HEPRTF to assist Eswatini in strengthening its preparedness capacity and resilience, ensuring it is able to rapidly and effectively respond to future health emergencies. 9. The MOH is the implementing agency for the project. As the primary response to COVID-19 is by the health sector, the lead technical agency for project implementation will remain the MOH. The Project Implementation Unit (PIU) of the parent project, the Eswatini COVID-19 Emergency Response Project, will implement the AF. However, implementation arrangements will be expanded to include the Deputy Directorate of Pharmaceuticals and the Expanded Program on Immunization (EPI) under the Public Health Unit, who have been tasked with the roll-out of the COVID-19 vaccines. To complement the agile PIU and ensure robust technical oversight, the MOH Senior Management Team, chaired by the Principal Secretary, will continue to hold overall responsibility for strategic implementation of the COVID-19 sector response and liaise with the Cabinet-level body for intersectoral coordination and steering, the National Emergency Management Committee (Cabinet sub-committee) chaired by the Deputy Prime Minister. Project Implementation Status 10. Progress towards achievement of the PDO and overall implementation progress were rated Satisfactory and Moderately Satisfactory respectively in the last Implementation Status and Results report of August 27, 2020 and the project continues to make good progress. The Eswatini COVID-19 Emergency Response Project in an amount of US$6 million IBRD prepared under the SPRP was approved on April 20, 2020 and became effective on April 30, 2020. Since then, the government has launched an admirable national response. As of January 13, 2021, disbursements Jan 14, 2021 Page 5 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) amount to US$ 4.56 million or 76 percent of commitments. This includes US$656,577 for a direct payment made on behalf of the GoKE for the supply of personal protective equipment (PPE) through Bank Facilitated Procurement (BFP). The project is expected to be fully disbursed by March 31, 2022. Progress toward the achievement of the PDO is also positive: three of the four PDO-level indicators have been achieved already or on track,6 and several intermediate result indicators7 indicate robust progress. 11. The PIU has been effectively coordinating project planning and procurement. In the first ten months of project implementation, the PIU -- assigned to support both the Eswatini COVID-19 Emergency Response Project and the Health System Strengthening for Human Capital Development in Eswatini Project (P168564) -- consisted mainly of MOH staff managed by Project Coordinators for the two operations. At the beginning of December 2020, all the technical experts comprising procurement, financial management, environment and social safeguards and M&E started their duties to complement MOH officials assigned to the PIU. The largest procurement to-date has been the PPE purchased through the BFP. The MOH has been effectively coordinating with the United Nations agencies, for example contracting the World Food Program to deliver the PPE. The PIU is also implementing the water, sanitation and hygiene related activities, completing a rapid assessment of secondary and tertiary health facilities in the four regions and finalizing the employment of ten plumbers for a six-month period who have been deployed to health facilities currently without a resident plumber. The project has also financed the activities of contact tracing teams and helped improve testing capacity by financing equipment, goods and the printing of testing protocols. C. Proposed Development Objective(s) Original PDO The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Eswatini. Current PDO The PDO remains the same with the AF. Key Results 12. To measure overall progress in the coverage and deployment of the COVID-19 vaccines, enhanced preparedness for future health emergencies, and the gender gaps the project can address, the Results Framework will be modified to reflect the changes in the scale and scope of the parent project. Modifications include adjustments to some of the original indicators and the addition of new ones to reflect the new activities proposed under the AF. Furthermore, the gender dimension of the project will be reflected in the project Results Framework along with a citizen engagement indicator as per World Bank corporate commitment on closing the feedback loop. Two PDO indicators (Percentage of the population vaccinated, as defined in the national plan; and Number of health emergency preparedness and response simulation exercises completed at the national, regional and local levels) are being added 6 Percentage of suspected cases reported that are tested according to national guidelines; number of public hospitals with COVID-19 triage capacity; number of individuals reached with tailored information; and percentage of confirmed COVID-19 cases managed as per national protocol. 7 COVID-19 in-country testing capacity; provision of hand-washing supplies to Rural Health Motivators (RHMs) for prevention of COVID-19; training of healthcare workers on COVID-19; ICU beds capacity; and laboratory personnel trained to conduct COVID-19 tests. Jan 14, 2021 Page 6 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) along with six Intermediate results indicators. The revised results framework for the project will also revise three indicators. A few indicators will be revised or dropped to reflect the evolving situation. D. Project Description 13. The proposed AF will form part of an expanded health response to the pandemic. The activities will build on the COVID-19 MPA-Program, the Eswatini COVID-19 Emergency Response Projects, and it is aligned with the Bank’s existing health portfolio that fosters broader system strengthening, the Health System Strengthening for Human Capital Development in Eswatini Project. The AF complements the support received from other DPs by co-financing vaccine procurement and strengthening the systems required to support effective and efficient vaccine deployment. 14. The PDO would remain unchanged, as the proposed activities to be funded under the AF for the Eswatini COVID-19 Emergency Response Project are aligned with the original PDO. Since the parent project has been implemented for less than 12 months, a blanket waiver (to the Investment Project Financing Policy, Section III, paragraph 28) has been granted given that all the parent MPA projects would have been under implementation for less than 12 months. The number of components, content of the components and the Results Framework of the parent project are adjusted to reflect the expanded scope and activities proposed under the AF. The implementation arrangements would remain the same. The Closing Date would be extended to March 31, 2024 to accommodate the additional activities, particularly with the market uncertainty on when a sufficient quantity of vaccines will be available to Eswatini. 15. The changes proposed for the AF entail expanding the scope of activities in the parent project, the Eswatini COVID-19 Emergency Response Project and adjusting its overall design. An increase in scope and cost will be required to support: (a) vaccine and drug purchase; (b) upgrading the cold chain for the vaccines; (c) strengthening service delivery to ensure effective vaccine deployment; and (d) monitoring, tracking of vaccines use and recording of any adverse reactions to vaccination. AF is also required to extend the testing, PPE, and sustained communications and promotions around non-pharmaceutical interventions which are essential to sustain throughout the vaccine roll-out. Furthermore, a new component has been added for activities to strengthen capacity in preparedness for future health emergencies supported by the HEPRTF grant. ▪ Component 1: Emergency COVID-19 Response (current allocation US$5.5 million; proposed AF of US$4.5 million for a total of US$10.0 million) will support COVID-19 vaccine procurement and deployment and continue activities under the Parent project including management of health care waste and infection prevention and control. ▪ Component 2: Strengthening Capacity in Preparedness for Health Emergencies (AF of US$3 million) supports the strengthening of Eswatini’s capacity in preparedness for health emergencies, including: (a) strengthening the surveillance system and enhancing analytical capacity for real-time rapid reporting and analysis of surveillance data; (b) supporting simulations to regularly evaluate and enhance health emergency preparedness; (c) preparing and equipping the health system and facilities to respond to future health emergencies; (d) strengthening capacity for national health emergency rapid procurements; and (e) strengthening capacity of frontline health workers to respond effectively to victims of violence through a training program that incorporated good practices. ▪ Component 3 (Component 2 in parent project): Implementation Management and Monitoring and Evaluation (current allocation US$0.5 million; proposed AF of US$0.5 million for a total of US$1.0 million) supports the Jan 14, 2021 Page 7 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) strengthening of public structures for the coordination and management of the project, including central and local arrangements for coordination of activities, financial management and procurement. .. 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 . E. Implementation Institutional and Implementation Arrangements Changes in Implementation/Institutional Arrangements. The existing PIU that is managing the parent project will continue to be used for the AF. However, capacity of the PIU will be enhanced to include technical expertise in logistics, procurement and vaccine implementation. The MOH is also working closely with other DPs located in-country, especially UNICEF and WHO, who are providing technical assistance on aspects that include procurement, vaccine registration and risk communication. This AF will coordinate with the other lending operations,8 including health, water and sanitation, education, energy and a development policy operation to harness cross-sectoral synergies, as presented in a cross-sectoral framework document,9 to guide Eswatini’s approach to investing in human capital. The need to invest in health systems to ensure the productive capabilities of the population is recognized, as is the challenge of overcoming a legacy of limited investment in human capital and social resilience systems. This AF and the parent project respond to the unprecedented COVID-19 outbreak, which has increased the importance and prioritization of health protection and care in the country. . CONTACT POINT World Bank Thulani Clement Matsebula Senior Economist, Health 8 Health System Strengthening for Human Capital Development (P168564), Network Reinforcement and Access Project (P166170); Water Supply and Sanitation Access Project (P166697); Basic Education and Skills Project (P173151); Eswatini Economic Recovery Development Policy Financing (P173337); Eswatini - Economic Recovery Development Policy Financing I (P174447, PE). 9 World Bank. 2019. Investing in Human Capital in Eswatini: A Framework for an Integrated Multi-sectoral Support. Draft, February 2020. Jan 14, 2021 Page 8 of 9 The World Bank Eswatini COVID-19 Emergency Response Project (P175875) Edit V. Velenyi Senior Economist Borrower/Client/Recipient Kingdom of Eswatini Ms. Sizakele Dlamini Principal Secretary, Ministry of Finance dlamini@gmail.com Implementing Agencies Ministry of Health Simon Dr. Zwane Principal Secretary, Ministry of Health smz1157@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 Thulani Clement Matsebula Task Team Leader(s): Edit V. Velenyi Approved By Practice Manager/Manager: Country Director: Asmeen M. Khan 18-Feb-2021 Jan 14, 2021 Page 9 of 9