The World Bank AF El Salvador COVID-19 Emergency Response (P176033) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 03/05/2021 | Report No: ESRSAFA136 Mar 05, 2021 Page 1 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) El Salvador LATIN AMERICA AND Republic of El Salvador Ministry of Health CARIBBEAN Project ID Project Name P176033 AF El Salvador COVID-19 Emergency Response Parent Project ID (if any) Parent Project Name P173872 El Salvador COVID-19 Emergency Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 3/5/2021 3/26/2021 Population Financing Public Disclosure Proposed Development Objective To respond to and mitigate the threat posed by COVID-19 and strengthen the national system for public health preparedness in El Salvador. Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] Mar 05, 2021 Page 2 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) The Additional Financing will respond to and mitigate the threat posed by COVID-19 and strengthen the national system for public health preparedness in El Salvador. The project includes the support for the prevention and mitigation measures to COVID 19 and support the National Vaccination Program and vaccine deployment. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The Parent Project, the El Salvador COVID-19 Emergency Response Project (P173872), was prepared under the World Bank’s Multiphase Programmatic Approach (MPA), approved by the Board on April, 2020. The project is being implemented with the aim of contributing to COVID-19 surveillance and response. The parent project focuses on strengthening the national COVID-19 response by supporting the Hospital San Salvador, the reference COVID-19 health facility in the country. No major civil works are expected under the parent project; if any works are supported, they should be minor and take place in existing facilities within existing footprints, and the use of all equipment and medical supplies will be within the existing Hospital San Salvador and its laboratories. To date, no works have been carried out and none are yet scheduled under the parent projects. The project will also finance and support a communications strategy which aims to slow the spread and mitigate the impacts of the virus. The Additional Financing (AF) will continue and expand these actions by supporting the COVID-19 vaccination roll-out which is expected to start by the end of February 2021, once the first shipment of vaccines arrives in El Salvador. The Government of El Salvador (GoES) has arranged different means to access vaccines, both through direct purchases with pharmaceutical companies (Pfizer and Astra Zeneca) and through the COVAX platform mechanism. On January 31st, 2021 COVAX confirmed El Salvador was selected to receive its first batch of vaccines starting in February and Public Disclosure periodically throughout the year. The primary objectives of the AF are to further strengthen preparedness and response activities under the parent project and to help ensure equitable and effective vaccine deployment in El Salvador through enhanced vaccination system strengthening. The PDO of the parent project will remain the same, as will the parent project component structure. An increase in scope and cost will be required to support: (i) vaccine and drug purchase; (ii) systems strengthening and service delivery efforts to ensure effective vaccine deployment; and (iii) monitoring, tracking of vaccines use and recording of any adverse reactions to vaccination. An intense focus on expanding immunization capacity is necessary to ensure that the health systems can effectively implement a comprehensive COVID-19 vaccine deployment strategy. This includes a critical assessment of and actions to ensure functional, end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management; rigorous cold chain expansion and control; robust service and coverage tracking systems; well trained, motivated and supervised vaccinators; tailored large-scale communication and outreach campaigns at household, community and national level; people-centered service delivery models that can reach different target populations effectively; and effective political leadership. El Salvador has prepared and disclosed a National Vaccination Roll-out Plan (NVRP), which sets out the institutional frameworks for the safe and effective deployment of vaccines, including the phased prioritization of vaccination groups. The NVRP lays out the coordinating entities that will hold responsibilities during the vaccination roll-out, led by the MoH and supported by the National Center of Pharmaceuticals, the National Directorate of Medicines and the National Institute of Social Security, all of which operate at national and local level. During the vaccination campaign the MoH is expected to receive support from UNICEF and PAHO, who have supported previous vaccination campaigns in the country. Mar 05, 2021 Page 3 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) It is expected that the AF will support the strengthening of this strategy, including regulatory standards for vaccine selection; guidelines for minimum standards for vaccine management including cold chain infrastructure; and policies to ensure robust governance, accountability, and citizen engagement mechanisms. The NVRP’s three first phases require beneficiaries to hold the Single Identification Document (DUI), a residence card or any official document in order to confirm the person’s age for eligibility, given the expected limited supply of vaccines. The plan does not specify if in later phases people without either of these documents would be denied vaccination. To support the vaccination program, an estimated 160 vaccinations centers will be established across the country. The AF is likely to support minor refurbishments to existing facilities to support the logistical, vaccine storage and handling needs associated with the implementation of the NVRP. The environmental and social risks associated with the generation and handling of medical waste, including expired and used vaccine vials, worker and community health and safety, and equitable access to the vaccine will be identified and assessed in the updated Environmental and Social Management Framework (ESMF). The ESMF will be updated to include an Infection Control and Waste Management Plan (ICWMP) for the vaccination program as well as a Medical Waste Management Plan (MWMP) for those vaccination centers located outside of existing health facilities such as schools. A recent World Bank project (Strengthening Public Health Care System, P117157) worked with selected hospitals to develop and implement bio- hazard waste management systems, including the establishment of environmental regulations that now provide biohazard diagnostics and norms that health facilities must follow nationwide. All 30 national hospitals in El Salvador follow an existing legal framework: El Salvador Technical Regulation for the Management of Bio-infectious Waste. National hospitals and regional offices have a Bio-infectious Waste Management Plan, updated every three years. Public Disclosure Waste management for hospitals and local clinics is covered in the facilities’ allocated budgets, although a large increment in waste volume would compromise the management plans and would require additional funding to manage the increased biological risk. All activities under the AF will take place within existing facilities and footprints with no new land acquisition or involuntary resettlement and no impacts on natural habitats or cultural sites expected. El Salvador’s population is disproportionately at risk to the effects of natural disasters and contextual crime and violence – aspects which may impact vaccination roll-out. The NVRP indicates that territorial distribution of vaccines will not be restricted in any area, whether rural or urban, and including all health centers currently located in gang-dominated neighborhoods. The MoH has built decades of experience with nation-wide vaccination campaigns in complex territories, which are usually accepted by gang affiliates. Among the more vulnerable groups are Indigenous People, who according to the national census are less than one percent of the population and are distributed across all regions in the country. IP groups have been historically discriminated and were not recognized in the Constitution until 2014. This discrimination is critical in the health sector, where traditional health practices are disregarded or misunderstood. The updated ESMF will assess these risks and mitigation measures will be documented in the project’s Emergency Preparedness and Response Plan. Training, monitoring and reporting requirements will be detailed in the ESMF and in the Environmental and Social Commitment Plan (ESCP). D. 2. Borrower’s Institutional Capacity The parent project and the Additional Financing (AF) will be implemented by the Ministry of Health (MoH) of El Salvador. The MoH has established a Project Coordination Unit (PCU) which will be responsible for the implementation, management, monitoring and reporting of project activities as well as for the environmental and social compliance measures. One environmental specialist and one social specialist responsible for the implementation and monitoring of the measures contained n the E&S instruments have been assigned by the MoH to Mar 05, 2021 Page 4 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) the PCU whilst the contracting process for dedicated specialists is underway. These dedicated specialists shall be in place by the Effective Date of the AF. As part of the parent project’s preparation, the hiring of PCU staff is progressing and the dedicated specialists are expected to be hired in time to comply with the effectiveness condition. Where relevant, the PCU will obtain the services of an Occupational Health and Safety and/or Waste Management consultant(s) to support the PCU in the definition of appropriate management and mitigation actions. The MoH has some prior experience implementing World Bank financed projects in compliance with the World Bank’s environmental and social safeguards policies. This experience draws upon a number of already completed health related projects, such as the Earthquake Emergency Recovery and Health Services Extension Project (P067986) and the Strengthening the Public Health Care Project (P117157). In addition, the MoH recently developed draft instruments for the Growing Up Healthy Together Project (P169677), which was developed under the World Bank’s Environmental and Social Framework (ESF). For the parent project, the MoH developed, consulted, disclosed and adopted an ESMF and a SEP, and prepared a draft LMP currently in the last stages of clearance for disclosure. The preparation of ESF instruments for the parent project was slower than expected; the original ESCP stated ESF instruments would be ready 30 days after the Effective Date, but this date was reviewed and the ESCP updated to give the PCU an additional 70 days to finalize the instruments. The establishment of a PCU took several months which slowed the preparation of ESF instruments, particularly the consultation process. Once the MoH’s technical teams began working on ESF instruments, there were several rounds of consultation with health personnel and other actors, including critical vulnerable groups. Among these, were sessions with Indigenous People organizations and LGBTI groups, which were the first instance of such Public Disclosure outreach led by the MoH. The PCU began the hiring process of the specialists that will be dedicated to the project; however, the MoH will provide technical support to update the parent project instruments to reflect the relevant risk management measures required by the AF until such time as the dedicated PCU environmental and social specialists are hired. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The Environmental risk rating is considered substantial given the emergency context and the fact that existing resources and capacity of health facilities continue to be stretched as the pandemic evolves. The parent project is focused on supporting the government’s plan to respond to COVID-19 and strengthen national systems for public health preparedness by investing in the provision of medical equipment and supplies as well as investing in communication and community awareness. Under the AF, the project aims to further strengthen preparedness and response activities and to enable affordable and equitable access to Covid-19 vaccines and help ensure effective vaccine deployment through enhanced vaccination system strengthening. Under the parent project, no civil works are planned, however, under the AF, it is possible that minor refurbishments to existing facilities may be required to meet logistical and vaccine storage and handling needs. With respect to environmental risks and impacts, the following are the primary concerns: (i) environmental and community health related risks from inadequate handling, storage, transportation and disposal of infected medical waste and expired and used vaccine vials; (ii) occupational health and safety issues related to the availability, supply and appropriate use of protective equipment (PPE) for Mar 05, 2021 Page 5 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) healthcare workers, including vaccination workers; and (iii) community health and safety exposure risks in the immediate vicinity of health care facilities and vaccination centers set-up at locations such as schools associated with increased risks of contagion from Covid-19, and (iv) ambient pollution and human health and safety risks stemming from cleaning and disinfection products, chlorine and other hazardous byproducts, including those associated with cold chain storage for the ultra-cold vaccine. For the activities under the AF, the ESMF for the parent project will be updated to include an Infection Control and Waste Management Plan (ICWMP) for the vaccination program, including corresponding training and monitoring requirements, as well as a Medical Waste Management Plan (MWMP) for those vaccination centers located outside of existing health facilities such as schools. The revised ESMF will outline comprehensive procedures and requirements for the safe handling, transportation, storage, and processing of COVID-19 treatment, testing and vaccination materials, safety of medical workers and hospital staff, as well as safe management of wastes, including biohazardous wastes, resulting from project activities. The relevant parts of the WHO COVID-19 guidelines and COVID-19 biosafety guidelines, and the World Bank Group’s Environment, Health and Safety (EHS) Guidelines will be reviewed so that relevant occupational and community health and medical worker safety risks and mitigation measures are addressed. Waste management for hospitals and local clinics is covered within the facilities’ allocated budgets, although a large increment in waste volumes associated with vaccination activities (to be assessed in the ESMF) could compromise the implementation of management plans and would require additional funding to manage the increased biological risk posed by the waste stream associated with vaccination activities. The revised ESMF will specify compliance Public Disclosure monitoring and reporting requirements and include Labor Management Procedures (LMP) detailing the rights and protections for project workers, including vaccination workers, as well as a dedicated labor grievance mechanism for workers. In addition to the ESMF, the MoH will meet those requirements detailed in the project’s Environmental and Social Commitment Plan (ESCP). Social Risk Rating Substantial The social risks are considered Substantial. The Project will not involve resettlement or land acquisition. The key social risk is that vulnerable and high-risk social groups are unable to access facilities, services and vaccination, due to their income, discrimination, lack of information and/or distance from health centers. Similarly, the risk of elite capture in a context of limited vaccine supply should be monitored closely. The Government of El Salvador has planned and implemented measures to execute the national vaccination roll-out, including setting-up a phased approach for the deployment of vaccination as response to COVID-19. However, there is need to develop adequate preparedness actions to ensure disadvantaged and vulnerable groups have awareness and are able to receive appropriate preventive support, including people living in rural communities with difficult access to the national health system, Indigenous People who face discrimination and have a historical mistrust of traditional health approaches, and other discriminated minorities such as LGBTI people, undocumented migrants and persons with disabilities, particularly those living in poverty. The MoH’s ‘National Plan for Vaccination Roll-out against SARS- COVID-19’ (National Vaccination Plan) is set to provide services including vaccination, supplies and communication based on the urgency of the need, in line with the latest data related to the prevalence of the cases and respective vaccination deployment strategy. The National Vaccination Plan, issued in January 2021, establishes the parameters for vaccine deployment, priority groups phases, and rollout to vaccinate at least 85% of each group, and close to 70% Mar 05, 2021 Page 6 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) of the country’s population. over several months. The prioritization of groups follows the advice set by the WHO SAGE unit, and is described below -First Phase: Health care workers, including volunteer health workers. 50,000 people (0.7%). -Second Phase: Essential workers, which include firefighters and first-responders. 70,000 people (1.0%). -Third Phase: Patients with co-morbidities or chronic diseases. 750,000 people (11.6%). -Fourth Phase: Population over 50 years old. 1,398,400 (21.6%). -Fifth Phase: Population between 18 and 49 years old. 2,231,600 people (34.6%). Total: 4,500,000 people (70% of population). Under the parent Project Emergency Response, there are several project activities concerned with communication strategies, including (a) supporting public health information and communication campaigns for disease prevention and management through mass media platforms; (b) instituting infection control guidelines and service standards in the San Salvador Hospital, which is the dedicated national hospital to manage COVID-19; and (c) training of key front- line staff, including emergency doctors, nurses and paramedical staff. The MoH has an ongoing communications strategy, producing infographics, media spots and social media information. Mobile networks send frequent information on prevention of the COVID-19 and exceptional measures in place during quarantine. However, the implementation of these activities have yet to explicity show diversity and inclusive messages. Component 2 of the project will support the national communication campaign, which will promote an inclusive language and differentiated messaging that addresses groups at risk. The SEP also contains tailored measures for different Public Disclosure stakeholders that ensure consultation before and during the vaccination program activities. In January 2021, the MoH disclosed the parent Project’s Stakeholder Engagement Plan (SEP) which is now being updated to reflect the additional engagement requirements associated with the AF funded roll out of the broad scale vaccination program. The National Vaccination Plan sets procedures regarding planning, deployment, storage and vaccination processes by health professionals. No forced vaccination is in place. 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: This standard is relevant. The project will have positive environmental and social impacts by improving the surveillance, monitoring and response capacity of El Salvador’s health system to respond to the COVID-19 and other emergencies. The adverse environmental, health and safety risks and impacts are likely to arise from exposure to the corona virus itself following the inadequate provision and use of personal protective equipment by health workers, increased risk of exposure to communities in the immediate vicinity of health care facilities and vaccination centers, and health and pollution impacts associated with the inadequate handling, treatment and disposal of cleaning products, biomedical waste and expired or open vaccine vials, including risks and impacts associated with incremental waste volumes resulting from large scale vaccination activities. To address environmental and social risks and impacts associated with the AF, the MoH will update the Environmental and Social Management Framework (ESMF) prepared for the parent project El Salvador Covid-19 Mar 05, 2021 Page 7 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) Emergency Response (P173872) by the AF Effective Date. The revised ESMF will outline comprehensive procedures and requirements for the safe handling, transportation, storage, treatment and disposal of COVID-19 treatment,testing and vaccination materials, the safety of medical workers, hospital staff, workers involved in vaccination activities and communities, as well as safe management of biohazardous wastes resulting from project activities, including the safe management of vaccination waste generated outside of health care facilities (such as for vaccination centers set-up in schools). The ESMF for the parent project was developed to primarily reflect project activities centered at a reference Covid-19 facility - the Hospital El Salvador in San Salvador. For the AF, the ESMF will be updated to include an Infection Control and Waste Management Plan (ICWMP) for the vaccination program, including corresponding training and monitoring requirements, as well as a Medical Waste Management Plan (MWMP) for those vaccination centres located outside existing health facilities such as schools, in accordance with national requirements. Should cold-chain logistics be confirmed as an activity to be financed by the project, then the ESMF will aseess the risks associated with these activities, with the ICWMP and the MWMP specifying requirements for the management of chemicals and other materials associated with cold-chains. Where relevant, the World Bank Group’s Environment, Health and Safety (EHS) Guidelines, the WHO’s specific COVID-19 guidelines on laboratory biosafety, the WHO’s Vaccine Management Handbook “How to Monitor Temperatures in the Vaccine Supply Chain” (2015) and other WHO and international good practice guidelines on COVID-19 medical waste management, diagnostic testing, administration of COVID19 health services, quarantine guidelines, handling of medical supplies, and healthcare occupational health and safety (OHS), including those requirements to support vaccination activities, will be referenced in the updated ESMF and Labour Management Procedures (LMP), as detailed further under ESS2. As part of the government’s emergency response, the Armed Public Disclosure Forces may be mobilized to secure the central vaccine storage depot in San Salvador and to assist with the transport logistics associated with the distribution of the ultra-cold vaccine. As detailed under ESS4, the ESMF will specify measures to identify risks associated with the deployment of such personnel (including sexual exploitation and abuse (SEA), sexual harassment (SH) or excessive use of force) and required mitigation measures. The ESMF will be updated to outline the implementation arrangements to support vaccination activities with regards to environmental and social risk management, training programs focused on COVID-19 biosafety as well as compliance monitoring and reporting requirements. Social risks for the parent project and the AF can emerge if access to vaccines and their corresponding allocation to priority groups are not adequately communicated or not fairly distributed. In addition, the communication plan that is part of the NVRP should clarify issues of informed consent and data protection regarding vaccination, particularly of vulnerable groups or communities with limited access to information. The final version of the NVRP will be disclosed in the MoH’s website in the coming days. The updated ESMF will determine how these risks will be mitigated, including measures to ensure: a (i) robust and coordinated national communication strategy promoting the Project’s objectives, including the vaccination roll-out, tailored to various audiences to address issues of access, discrimination, and ethnicity; (ii) continuous education and awareness raising campaigns based on the information included in the NVRP; (iii) development of materials (radio, infographics, TV broadcasts) in an inclusive and culturally sensitive manner, particularly when discussing the benefits of vaccination; (iv) consult and inform the public of the content in the NVRP, including the strategies that will be adopted regarding information disclosure, informed consent and measures of transparency; and (v) a grievance redress mechanism that will provide real time feedback. These aspects will be complemented with the actions included in the project Stakeholder Engagement Plan. In addition, the updated ESMF will also include provisions to support non-discrimination in provision of services and equal treatment Mar 05, 2021 Page 8 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) to all project beneficiaries, as well as identifying the barriers faced by poor, marginalized and ethnic minorities in accessing healthcare centers and treatment. The ESMF will also describe the procedures, protocols, or other measures that will be in place to ensure voluntary consent for vaccination and how policies will be developed to ensure that there is no forced vaccination. The parent project has not yet implemented activities, which reflects in the GRM having no queries or grievances to date. For the AF, a portion of the funds may be allocated for retroactive finance. The ESMF will detail the environmental and social requirements applicable to such financing – and will include the TORs for the E&S audit that would be necessary to allow retroactive financing – as they relate to occupational health and safety (OHS), waste management, capacity building and complaints management. In addition, the ESMF will include an exclusion list detailing goods, services or works that will not be financed by the project. ESS10 Stakeholder Engagement and Information Disclosure ESS10 is relevant. The MoH has prepared, consulted, disclosed and adopted a Stakeholder Engagement Plan (SEP) for the parent Project. An updated draft has been prepared and its final version will be disclosed, consulted and adopted by the AF Effective Date. The parent Project includes a subcomponent focused on strengthening national communication strategies and information support resources as part of project design. Activities for this subcomponent have yet to be implemented. In this context, the Project’s SEP has identified affected and interested parties as well as vulnerable groups, and outlines an initial strategy that includes timelines and methods for consultations and continuous engagement throughout project implementation that is based upon meaningful Public Disclosure consultation and disclosure of information, but which also takes into account the realities of advised physical distancing during the COVID-19 outbreak. Given that the most vulnerable groups such as the elderly and those with compromised immune systems or related pre-existing conditions are at an increased risk of contracting COVID-19, stakeholder engagement has been designed to minimize close contact. Outreach will primarily focus on the development and implementation of a structured communications plan to ensure consistent messaging around key issues, (prevention, mitigation, awareness raising, and how to access services available), considering the specific challenges associated with COVID-19. Authorities from El Salvador have been proactive in communication campaigns since early February 2020, with a strong online presence of COVID-19 related information. The AF will support the expansion of communication activities to inform the public of the rationale for vaccinating selected target populations; vaccine safety; the process for vaccine deployment; and possible side-effects to foster confidence in a new vaccine or the different types of vaccines that would become available. Effective communication and outreach will be imperative to increase awareness and “vaccine literacy”, build trust, and reduce stigma around any COVID-19 vaccine for a larger target population. To limit potential social risks and impacts, the SEP is complemented by other critical tools to help identify intervention points and communication strategies to reinforce the behaviors that limit transmission and to counter any likely rumors or misinformation that may circulate around COVID-19 vaccinations. This updated SEP will build upon the Government’s official communication site, https://covid19.gob.sv, which includes a detailed and regularly updated series of facts, data and official communications from the MoH and the office of the Presidency. The information in the site includes: (i) real-time information on the number of cases, distribution of people across the different containment centers, territorial distribution of patients or quarantined population; (ii) a preventive measures portal with infographics, videos and tip-sheets; (iii) a transparency portal showing the Government’s official Mar 05, 2021 Page 9 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) briefs detailing the socio-political measures that have been deployed to date; and (iv) a repository of WHO daily briefs, detailing COVID-19 impacts across the planet. With the vaccine rollout, the National Vaccination Plan establishes that once vaccines arrive, the portal will inform the number of vaccinated people and their geographic distribution. This information will be further supplemented with targeted outreach and engagement efforts, focusing in particular on how to reach the most vulnerable groups, including the elderly, people with underlying conditions, those in poverty, women, those who often care for their elderly parents and children simultaneously, and Indigenous People. Various approaches will be used to improve vaccine literacy among the general Salvadoran population, specially disadvantaged or vulnerable groups identified by the project. Some of the key priorities will include conducting online consultations regarding beneficiary perceptions and obstacles to vaccine uptake; sensitization to counter misconceptions about the disease, vaccine introduction and any negative perceptions and disseminating in due time vaccination-related information such as overview of the COVID-19 vaccine program, priority risk groups, commodity availability, and tracking of those who need to receive a second dose, etc. The AF will support activities targeted at the primary health care services, towards improving two-way communication with the public to reach targeted beneficiaries as well as citizens across the country. It will also targeted messages to prevent and respond to the risk of gender-based violence (GBV) or LGBTI discrimination, and/or train frontline health workers on how to identify, appropriately handle incidents and refer patients for additional services. Based on WHO guidance, the overall purpose of the stakeholder engagement and consultation process is to build trust in the prevention and response of misinformation that may interfere with decision-making in the population for Public Disclosure Coronavirus disease (COVID-19) and to adhere to public health advice. This will include scientifically sound information on relevant vaccines. This work would be based on WHO guidance (WHO Guidance - Risk Communication and Community Engagement) and would seek to provide proper awareness raising and timely information dissemination to (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. The initial beneficiaries of the vaccination program will be frontline health and essential workers at high risk of infection, followed by people at high risk of death because of underlying conditions like heart disease and diabetes. This will need to be communicated and managed carefully. The updated SEP will be shared with relevant stakeholders via culturally appropriate means (and having regard to logistical and technological constraints). The updated SEP will be disclosed at MoH website; the project’s PIU will ensure that there is no prejudice or discrimination toward project-affected individuals or communities, including other interested parties. The parent project’s GRM responds to complaints throughout the project lifecycle and has been designed to respond to any project grievances. The parent Project PIU will undertake day-to-day management of GRM which is supported by the MoH’s own grievance platforms; it defines ways in which users can submit their grievances, which may include submissions in person, by phone, text message, mail, email or via a website. The GRM also sets out the length of time users can expect to wait for acknowledgement, response and resolution of their grievances, transparency about the grievance procedure, governing structure and decision makers; and an appeals process (including the national judiciary) to which unsatisfied grievances may be referred when resolution of grievance has not been achieved. The project GRM is also enhanced by placing additional channel to register and respond to complaints/feedback linked with deployment of vaccination as the primary objectives of the AF is to enable affordable and equitable access to Mar 05, 2021 Page 10 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) COVID vaccines in El Salvador. Considering the expansion of activities and locations of the AF, the GRM will be updated to be accessible at a broader, national scale. Given the GRM is based on the MoH’s existing grievance platforms, scaling-up its operation should be feasible; the updated GRM will describe the additional measures and channels that will be made available at different sites and the means to socialize it with the public. As no project activities have been implemented, the effectiveness of the GRM has yet to be assessed. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This Standard is relevant. Labor provisions and requirements have been drafted in the parent project’s Labor Management Procedures (LMP), which is close to publication. To reflect relevant labor aspects related to the AF, the LMP will be revised, disclosed and consulted within 30 days of the AF Effective Date. Some of the activities supported by the parent project and the AF will be conducted by publicly employed health and laboratory workers. Additional project workers will include contracted suppliers (including those involved in transport, handling and delivery of procured goods), as well as potentially other contract staff to support vaccination activities. The key risk is contamination with COVID-19 (or other contagious illnesses as patients taken seriously ill with COVID-19 are likely to suffer from illnesses which compromise the immune system, which can lead to illness and death of workers). Emerging risks related to declining mental health and fatigue may impact project workers’ capacity to carry out core functions. Staff of health facilities, workers involved in vaccination activities, as well as all other workers involved in the procurement, delivery, training, use, supervision/monitoring, and/or handling and disposal of medical supplies, Public Disclosure equipment, or waste products within the scope of the project will receive necessary training on protecting themselves and others from COVID-19 infection, as well as other relevant OHS and mental health risks and management measures as part of project design. The Project will ensure the application of OHS measures as outlined in WHO guidelines which are referred to in the disclosed ESMF. The Government and the MoH have published on their websites the National Plan of Preparedness and Response to Novel Coronavirus (2019 – nCov), El Salvador 2020. This encompasses procedures for entry into health care facilities; 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 mandating hand hygiene and personal protective equipment (PPE); ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General EHSGs and industry specific EHSGs and following evolving international best practice in relation to protection from COVID- 19. During implementation, the ESMF will furthermore be regularly reviewed and updated to integrate the latest guidance by WHO as it develops over time and experience addressing COVID-19 globally. Staff of health facilities and those involved in vaccination activities will receive appropriate training under the project on how to use the medical equipment, supplies and vaccines financed through the Project in a way that protects their health and safety. The ESMF will identify and assess the new OHS risks to workers involved in vaccination activities, including risks such as declining mental health and fatigue, and ensure that mitigation measures are in place. The updated LMP will also outline key national laws and regulations protecting workers’ rights, include a code of conduct and a basic, responsive grievance mechanism to allow project workers to quickly inform management of Mar 05, 2021 Page 11 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) labor issues, such as a lack of PPE or unreasonable overtime. The use of child or forced labor will be forbidden in accordance with ESS2. ESS3 Resource Efficiency and Pollution Prevention and Management This Standard is relevant. Pollution prevention and management – specifically medical waste management – is an important activity under the Project. Medical wastes and chemical wastes (including water, reagents, infected materials, etc.) from health facilities and vaccination sites (drugs, supplies and medical equipment) can have an adverse impact on the environment and human health if not properly handled, transported and disposed. These wastes could include liquid contaminated waste, chemicals, expired or used vaccine vials and other hazardous materials, and other waste from health facilities, vaccination centers and laboratories, including sharp items used in diagnosis, treatment and vaccination. Despite recent investments in selected hospitals to develop and implement bio-hazardous waste management systems, existing capacity for ensuring proper medical waste management at hospitals across El Salvador varies, and will therefore be a key area of focus of training and supervision under the project, considering in particular the risks of further COVID-19 spread if waste is not handled properly. The ESMF for the parent project will be revised to identify the risks and detail mitigation measures relating to the management of hazardous, infectious, non-hazardous and non-infectious medical waste for an estimated 160 vaccination centers spread across the country to ensure the adequate handling, storage and disposal of waste. The ESMF will assess the bio-infectious waste measures detailed in the National Vaccination Roll-out Plan (NVRP) (January 2021) and document additional management measures where necessary, in keeping with Good International Industry Public Disclosure Practice (GIIP). The ESMF will assess the institutional, organizational and technical capacity of the MoH to manage wastes, including an assessment of the infrastructure, facilities and specialized service providers for the collection, treatment and disposal of hazardous and medical waste and propose measures to address any gaps where necessary. For the AF, the ESMF will also be updated to include an Infection Control and Waste Management Plan (ICWMP) for the vaccination program, including corresponding training and monitoring requirements, as well as a Medical Waste Management Plan (MWMP) for those vaccination centers located outside existing health facilities such as schools, in accordance with national requirements. Should cold-chain logistics be confirmed as an activity to be financed by the project, then the ICWMP and the MWMP will specify the requirements for the management of chemicals and other materials associated with cold-chains. To maximize climate co-benefits, the project will also promote the use of climate-smart technologies and the procurement and mobilization of energy efficient equipment including climate friendly refrigerators/freezers and the use of clean energy solutions (such as solar),where possible. Extreme weather and seismic events pose may pose risk to the implementation of vaccination activities. The ESMF will detail the requirements for emergency preparedness and contingency plans to manage this risk. ESS4 Community Health and Safety This Standard is relevant. In line with safety provisions in ESS2, it is equally important to ensure the safety of communities from infection with COVID-19. Medical wastes and general waste from laboratories, health and vaccination centers have a high potential of being contaminated with the coronavirus or other micro-organisms that can infect the community at large if they are not properly managed and disposed of. There is a possibility for these Mar 05, 2021 Page 12 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) infectious microorganisms to be transmitted to members of the public if not well contained within laboratories or appropriately isolated areas of medical facilities and vaccination centers, or due to accidents or emergencies (i.e. a fire or disasters such as seismic events). To reflect the new project activities under the AF, additional waste management measures to be included in the ESMF, as described under ESS1, will build on international good practice and WHO protocols to describe: i) how Project activities involving the COVID-19 pathogen or waste generated in its identification, treatment and vaccination will be carried out in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (such as WHO guidelines) ii) measures in place to prevent or minimize the spread of infectious diseases, and iii) emergency preparedness measures, including for those vaccination centers to be established outside of medical facilities, such as in schools. Information on preventive health measures to communities surrounding health facilities and vaccination centers will be provided periodically through continuous stakeholder engagement. To ensure vaccine safety and mitigate the potentially adverse health side effects of administering unsafe vaccines, the funds can only be used for the procurement of thoroughly tested and approved vaccines. The Bank’s COVID-19 vaccine approval criteria are: (a) has been approved by three (3) Stringent Regulatory Authorities in three (3) Regions; or (b) has received the WHO Prequalification and has been approved by one (1) Stringent Regulatory Authority. In addition, the ESMF will assess the planned measures to monitor and address the adverse impacts and side effects of the vaccines on recipients detailed in the NVRP, and where necessary will recommend measures to address any gaps. The NVRP describes the official vaccination protocol, which includes a mandatory 30 minutes post-vaccination observation period to assess any adverse reactions. For longer term adverse events following immunization, the ESMF will describe the monitoring measures enacted by the MoH, which currently include keeping a digital registry of Public Disclosure all vaccinated people and their contact information. The NVRP also foresees a robust communication campaign to inform the public of follow-up actions after vaccination; requests for information or complaints will also be supported by the project’s GRM. The ESMF will assess whether the MoH needs to further strengthen its strategy. The ESMF will also assess the vaccine storage and handling procedures detailed in the NVRP to assess whether systems are in place to adequately store, distribute and administer vaccines, including measures to secure storage and distribution and avoid the risk of theft and an ensuing black market of vaccines. The National Vaccination Roll-out Plan (NVRP) includes a Communication Plan aimed at obtaining support for and to promote the uptake of the Covid-19 vaccine, including sharing of information on its role in preventing infections and controlling its spread, thereby reducing the impact of the pandemic. The NVRP indicates that vaccination is voluntary and includes a procedure for obtaining voluntary and informed consent from persons receiving the vaccine. The ESMF will assess whether additional measures might be required to enhance the MoH’s communication strategy and process for obtaining informed consent prior to vaccinations. An assessment of the risks associated with the transportation of vaccines and associated supplies, as well as the transport of bio-infectious waste and expired or used vaccines vials to treatment and disposal facilities will be assessed in the ESMF to ensure that adequate road safety and emergency response management actions are documented in the relevant Medical Waste Management Plans and Emergency Preparedness and Response Plans. Sexual Exploitation and Abuse (SEA)/ Sexual Harassment (SH) risks will be assessed and addressed in implementation, including screening and putting in the corresponding measures to prevent and mitigate the SEA/SH risks. The Project will promote the avoidance of SEA by relying on the WHO Code of Ethics and Professional Conduct for all workers Mar 05, 2021 Page 13 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) related to the Project who will work as part of the emergency response. To secure the central vaccine storage depot in San Salvador, the Centro Nacional de Biologicos (CENABI) and to assist with the transport logistics associated with the distribution of the vaccine, the project may use the Armed Forces. In this case or where the Armed Forces are mobilized as part of the government’s response to the emergency in relation to this Project, the PIU will shall implement measures to ensure that, prior to deployment such personnel are: (i) screened to confirm that they have not engaged in past unlawful or abusive behavior, including sexual exploitation and abuse (SEA), sexual harassment (SH) or excessive use of force; (ii) adequately instructed and trained, on a regular basis, on the use of force and appropriate behavior and conduct (including in relation to SEA and SH), as set out in ESMF; and (iii) deployed in a manner consistent with applicable national law. All allegations of unlawful or abusive acts of any military/security personnel, should be reviewed, acted (or request appropriate parties to take action) to prevent recurrence and, where necessary, report unlawful and abusive acts to the relevant authorities through the project’s Grievance Redress Mechanism. The ESMF will therefore identify and assess the risks associated with engaging such personnel, define the standards and code of conduct to be adopted by such personnel, including training requirements on such standards and code of conduct, in line with the guidance provided in the WB’s Technical Note “Use of Military Forces to Assist in Covid-19 Operations”. The Project will also ensure via the above noted provisions, including stakeholder engagement, that health facilities and vaccination centers are operated effectively throughout the country, including in remote and border areas. Where storage, health and vaccination centers are to be protected by security personnel, it will be ensured that the security personnel follow a strict code of conduct and avoid any escalation of situation, taking into consideration the needs of project beneficiaries. Public Disclosure ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS5 is not currently relevant. The project will not support major construction or rehabilitation works and an initial E&S screening did not identify any potential risks and/or impacts relevant to ESS5. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources ESS6 is not currently relevant. The Project will not support any construction activities that might jeopardize the integrity of biodiversity or living natural resources. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is relevant. Since this is a national Project, Indigenous Peoples are present in the project’s scope of implementation. It is not expected that any of the activities related to the Project will have either direct or indirect negative impacts on Indigenous Peoples beyond providing support to any individual IPs who are at risk or have been exposed to COVID- 19 and will be provided access to project resources. According to the national census, El Salvador’s IP population accounts for less than one percent, although IP organizations estimate that percentage is higher. The Nahuat-Pipil comprise the most numerous of the three main indigenous groups in El Salvador today, which also include Lencas and Kakawiras. While virtually all of El Salvador’s Indigenous groups speak Spanish as their main language, Nahuat is the only indigenous language still spoken in the country, particularly in some traditional groups living in the western highlands near the border with Guatemala. Mar 05, 2021 Page 14 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) All the activities financed by the Project must ensure to respect the dignity, aspirations, identity, culture and livelihoods of Indigenous People. These groups have been historically underserved and are often living in rural and remote areas, where access to information and health services is limited. As outlined in the draft SEP, the Project will set up communication channels to appropriately inform these communities of the risks posed by COVID-19 and recommended preventive measures, and will provide information that is culturally sensitive, respectful and inclusive. The updated SEP and ESMF will be consulted upon in a manner consistent with ESS7, including meaningful consultations with IP communities and their representative bodies and organizations; culturally appropriate engagement processes; providing sufficient time for IPs decision making processes; and allowing their effective participation in the design of project activities or mitigation measures that could affect them either positively or negatively. Consultations and vaccination campaigns will be conducted through coordination between the MoH and relevant IPs organizations and traditional authorities. Consultations will clearly communicate that there are policies ensuring that there is no forced vaccination. In accordance with the provisions of ESS7, the elements of an IPPF have been included in the overall project design and the above-mentioned SEP. Community meeting, household visit or any other communication by project team to increase awareness on vaccination related activities must follow the health and safety protocols/guidelines issued by the MoH. No impact is expected on intangible cultural heritage due to vaccination under project activity. Indigenous communities’ beneficiaries will be informed and made accessible to use the GRM system set-up not only for the parent project related activities, but also activities related to vaccination carried-out by professional health specialists. The updated GRM will be culturally appropriate and accessible for IPs, taking into account their customary Public Disclosure dispute settlement mechanisms as outlined in the updated SEP. ESS8 Cultural Heritage ESS8 is not currently relevant. Project activities will not have any adverse impact on tangible or intangible cultural heritage. The potential works to refurbish health facilities to support vaccination activities will be minor and limited to existing footprints. However, some of the project beneficiaries will be IPs who have distinct cultural health practices. Official health providers should recognize these traditional methods when working with IP communities in health-related matters, which includes recognition of their own traditional governance structures and traditional medicine agents. The project will ensure these customs are taken into consideration when communicating with and treating these communities. ESS9 Financial Intermediaries This standard is not relevant. B.3 Other Relevant Project Risks None Mar 05, 2021 Page 15 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: None IV. CONTACT POINTS World Bank Contact: Roberto F. Iunes Title: Senior Economist, Health Public Disclosure Telephone No: +1-202-473-3427 Email: riunes@worldbank.org Borrower/Client/Recipient Borrower: Republic of El Salvador Implementing Agency(ies) Implementing Agency: Ministry of Health 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): Roberto F. Iunes Practice Manager Valerie Hickey Cleared on 05-Mar-2021 at 08:00:23 GMT-05:00 (ENR/Social) Mar 05, 2021 Page 16 of 17 The World Bank AF El Salvador COVID-19 Emergency Response (P176033) Angela Nyawira Khaminwa (SAESSA) Concurred on 05-Mar-2021 at 11:19:26 GMT- Safeguards Advisor ESSA 05:00 Public Disclosure Mar 05, 2021 Page 17 of 17