The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 06-May-2021 | Report No: PIDA31808 May 06, 2021 Page 1 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Liberia P176336 Liberia COVID-19 P173812 Emergency Response Project Additional Financing on Vaccines Parent Project Name Region Estimated Appraisal Date Estimated Board Date Liberia COVID-19 Emergency AFRICA WEST 03-Jun-2021 25-Jun-2021 Response Project Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Republic of Liberia Ministry of Health Financing Proposed Development Objective(s) Parent The development objective is to prepare and respond to the COVID-19 pandemic in Liberia Components Component 1: Emergency Preparedness Response Component 2: Supporting Preparedness through Laboratory System Strengthening Component 3: Case Management and Clinical Care Component 4: Community Engagement, Risk Communication and Advocacy Component 5: Project Management and Coordination, Monitoring and Evaluation PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 8.00 Total Financing 8.00 of which IBRD/IDA 7.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing May 06, 2021 Page 2 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) International Development Association (IDA) 7.00 IDA Grant 7.00 Non-World Bank Group Financing Trust Funds 1.00 Health Emergency Preparedness and Response Multi-Donor Trust 1.00 Environmental and Social Risk Classification Substantial Other Decision (as needed) B. Introduction and Context Country Context 1. This Project Paper seeks the approval of the World Bank’s Board of Executive Directors/Regional Vice President to provide a grant in the amount of US$ 7.0 Million for an Additional Financing (AF). This AF would support the costs of expanding activities of the Liberia Emergency COVID-19 Response Project (P173812) 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, 20201. The primary objectives of the AF are to enable the affordable and equitable access to COVID-19 vaccines and to ensure effective vaccine deployment in Liberia through vaccination system strengthening. The parent project, the Liberia COVID-19 Emergency Response Project (P173812) with a total credit financing amount of US$7.5 million was approved on April 9, 2020 and declared effective on April 22, 2020. The project closing date is April 30, 2022. 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 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 proposed additional financing will help vaccinate 60% of the 52 % of the country’s eligible population. This is inclusive of the 20% coverage that will be provided by the COVAX facility vaccines initiative. Bank financing for the COVID-19 vaccines and deployment will follow Bank’s VAC. On April 16, 2021, the Board approved a revised Vaccine Approval Criteria. “The 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 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 (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. May 06, 2021 Page 3 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) 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).� 3. The need for additional resources to expand the COVID-19 response was formally conveyed by the Government of Liberia (GoL) on January 24, 2021. A revised request was conveyed on March 22, 2021. 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 Liberia. 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 Liberia. The government of Liberia through the Honorable Ministers of Health and Finance and Development Planning signed off on the request before transmission to the COVAX FACILITY. The vaccine is expected to be delivered in Liberia through UNICEF Supply Division. The first batch of 27,000 doses has already been delivered and initial rollout on April 1, 2021. 4. Critically, the additional financing seeks to enable the acquisition of vaccines from a range of sources to support Liberia’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 proposed IDA financing will build on this to expand Liberia’s access. 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 vaccines is unlikely to be immediate. 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. 5. Liberia reported its first confirmed case of COVID 19 on March 14, 2020 in Monrovia, the country’s capital and by April 20, 2021, a staggering 2061 COVID-19 cases, including 85 deaths, were reported2. 49 (11%) health care workers have been infected with COVID-19, and 85 (4.06%) have died. Most cases are concentrated in the capital city, Montserrado county (1592 cases, 76.13%), where more than 45% of the 4.45 million population of Liberia reside (Figure1)3. The risk of infection among health care workers and the community remains high, largely due to the frequent and high volume of travel across counties with active transmission. Figure 1 below highlights the trends in COVID -19 cases from Mach 14, 2020 to date. As can be seen the overall trends in COVID -19 may be going down but the threat of new waves remains and hence the importance of ensuring increased protection measures including through vaccination of the population to reach as close to herd immunity as possible. 2 . Source: SITREP401. April 20, 2021, MoH GoL May 06, 2021 Page 4 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Figure 1: Weekly Epi Curve for Confirmed cases and Deaths April1, 2020 -March 18, 2021 Source: SITREP 401. April 20, 2021, MoH GoL 6. Along with the COVID-19 related morbidity and deaths, Liberia has also experienced significant secondary impacts of the outbreak which include (i) shortages of essential medical supplies and commodities due to disruptions in the global supply chain; (ii) hospitals and health facilities providing routine health services have closed following exposure to cases of COVID-19; (iii) health facilities providing routine health services have turned patients away for fear of the virus and (iv) recovered patients have been stigmatized and shunned by their communities when returning home. The social distancing measures and lockdown implemented by the Government to reduce the spread of the virus have had a negative social and economic impact, directly impacting the livelihoods of households, especially among the poor . Figure 2: Distribution of CVOD cases by County, April 11, 2021 May 06, 2021 Page 5 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Source: Source: SITREP 401 April 20, 2021, MoH GoL 7. The Ebola Virus Disease (EVD) outbreak of 2014 devasted a health system which was already weakened by conflict, and recovery has been slow. Following the end of the second civil war in 2003, Liberia’s health system slowly recovered to the point where health outcomes started improving. Between 2003-2012, life expectancy increased from 54 to 61 years, child deaths declined from 149 to 88 deaths per 1,000 live births, and Liberia became one of the first countries in Sub-Saharan Africa to achieve the child- related Millennium Development Goal11. However, the EVD crisis devastated the healthcare system and severely constrained the GOL’s ability to deliver essential health services, which led to many preventable deaths. 8. The increasing rates of COVID-19, coupled with the rising fear of the community and health care workers, and travel restrictions instituted by the Government, have negatively impacted the delivery and utilization of routine reproductive, maternal, neonatal, child, and adolescent health and nutrition services (RMNCAHN). For example, between January –April 2020, national rates of utilization of routine health services declined by 36% (Figure 2)4. Curative consultations declined by 36%; immunization coverage declined by 39% (including a 94% decline in Margibi county), and first antenatal care visits (ANC) declined by 38%. Montserrado county, which has the largest number of COVID-19 cases, has seen a 67% decline in immunization coverage, a 43% decline in ANC4 visits, and a 27% decline in deliveries by skilled 4 Liberia MOH/HMIS 2020 May 06, 2021 Page 6 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) birth attendants5. These results are particularly concerning, given Liberia’s already high maternal (661 per 100,000)6 and child mortality (33 deaths per 1000 live births)7 rates, which are estimated to increase by 30% and 15% over the next year due to disruptions in essential services8. Figure 3: Impact of COVID-19 vs Utilization rate of routine health facilities 100.0 83.9 50.0 0.0 0.0 0.0 0.0 0.2 0.2 0.2 0.4 1.1 5.0 1.6 0.9 2.7 2.0 6.5 0.0 -50.0 -12.0 -12.0 -20.0 -21.0 -5.0 -26.0 -21.0 -20.0 -30.0 -34.0 -40.0 -48.0 -55.0 -100.0 -62.0 Prevalence of COVID-19 (June 12, 2020) Utilization rate of health Facility (Jan-April 2020) Source: 1 GFF. (2020). Preserve essential health services during the COVID-19 Pandemic, Liberia 9. Following the confirmation of the first case on March 14, 2020, the Government of Liberia (GOL)activated the Public Health Emergency Operation Center (PHEOC). The GOL is implementing its National COVID-19 Response Plan, which promotes early detection, active case finding, contact tracing, infection prevention and control (IPC), and the care of suspected and confirmed cases of COVID-19. Specific containment measures instituted include: (i) a lockdown strategy, with closures of land, air, and sea borders; (ii) deployment of surge staff at various ports of entries (POEs), and strengthened screening at POEs; (iii) 500 contact tracers deployed to counties; (iv) dissemination of community engagement and risk messaging; (v) training of health workers in counties on case management and IPC; and (vi) the President has mandated that all citizens wear masks when leaving home. The World Bank is contributing US$17 Million to the GOL’s national response plan, through the new Liberia COVID-19 Emergency Response Project (P173812), REDISSE-II Project (P159040) and activation of the REDISSE-CERC. Other partners in the sector are also providing financial and technical contributions to the response. A. Consistency with the Country Partnership 10. This Project was not included in the Borrower’s CPF, but the pandemic has increased the priority of health protection and treatment in Liberia. However, the AF is consistent with CPF’s Pillar 1 (Human Capital and Resilience) objectives of improving nutrition, hygiene, and reducing the still high under-five mortality rates. 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 5 Idem. 6 WDI 2017 7 Liberia Demographic and health survey 2019-2020 8 GFF. (2020). Preserve essential health services during the COVID-19 Pandemic, Liberia May 06, 2021 Page 7 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) resilience systems. By building the strength of the health system and its resilience to shocks, it is aligned with the focus of the CPF Objective 2, which focuses on improving health services. The AF, like the parent project, is also aligned with both global health priorities and IBRD/IDA priorities on improving pandemic preparedness. B. Project Design and Scope 11. The World Bank is contributing US$17 million to the GOL’s national response plan, through the Liberia COVID-19 Emergency Response Project (P173812), the Regional Disease Surveillance Systems Enhancement Program (REDISSE) – Phase 2 (P159040) and the activation of the REDISSE II Contingency Emergency Response Component (CERC). The Liberia COVID-19 Emergency Response Project (P173812) with a total credit/grant financing amount of US$7.5 million prepared under the COVID-19 Strategic Preparedness and Response Program (SPRP) using the Multiphase Programmatic Approach (MPA) was approved by the Board through RVP delegated authority on April 2, 2020 and declared effective on April 22, 2020. The Project Development Objective (PDO) of the COVID-19 Emergency Response Project is to prepare and respond to the COVID-19 pandemic in Liberia. The project supports the implementation of the ten (10) thematic pillars of the GOL’s COVID-19 Plan9, as presented on March 20, 2020. This plan is complementary to areas supported by the ongoing World Bank REDISSE-Phase 2 project (P159040) which supports Liberia’s efforts to enhance its disease surveillance and response systems. D. Project Performance 12. The project’s progress towards achievement of the PDO and overall Implementation Progress (IP) was rated as Satisfactory in the last Implementation Status and Results Report (ISR) of October 14, 2020 and the project continues to make good progress. As of April 1, 2021, the disbursements amounted to US$6.02 million or 78.9% of project financing. The project has contributed greatly toward implementation of COVID -19 response in Liberia as it is the main source of financing for COVID-19 in-country. The project has supported and contributed to the following: o Strengthening of the National Public Health Institute of Liberia (NPHIL) as the national lead body in responding to COVID-19 pandemic through support for the EOC pillars. o Strengthening of the Project Implementation Unit (PIU), through strengthening capacity of both programs, fiduciary and safeguards. o Strengthening of laboratory capacity for testing of COVID-19 through increasing number of testing sites and procurement of laboratory test, reagents and including support for laboratory staff. o Procurement of 8 ambulances, 34 motorcycles to enhance community support for contact tracing renovation of treatment centers at 14 Military and Jordanian Hospital and management and including renovation of three primary health centers. 9 Ten thematic pillars of GOL’s COVID-19 Plan: (I) Coordination (command and control and continuity of operations, EOC, official communication, Finance, HR); (II) Case management (including isolation, referral); (III) Point of Entry (including cross border surveillance); (IV) epidemiology/surveillance; (V) Health promotion and communication (community engagement, risk communication, social mobilization; (VI) Laboratories; (VII) WASH/Dead body management; (VIII) Infection Prevention & Control; (IX) Supply Chain and logistics; (X) Rapid Response Team. May 06, 2021 Page 8 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) o Purchase of ventilators and ICU medical beds and the procurement of fuel to support operations and ensure reliable power at health facilities and EOC. o Strengthening of surveillance at both county and community level including implementation of IPC in facilities. o Strengthening of information management through integrated Disease surveillance system (IDSR) and introduction of electronic IDSR (eIDSR) 13. The MOH and PIU have since finalized the Environmental and Social Management Framework (ESMF) and Health Care Waste Management Plan (HCWMP) in accordance with the Environmental and Social Commitment Plan (ESCP). The MOH will review and update ESCP, SEP and ESRS. The Project will integrate within the ESCP the timelines for updating the ESMF, LMP and MHCWMP in the ESCP. The ESMP used to manage the environmental and social risks and impacts and the contract’s waste management plan in line with vaccine ESS instrument guidance. Moreover, the MoH will develop an action plan of core ESS activities and contribute to strengthening the grievance redress mechanism (GRM). 14. The Ministry of Health (MOH), through the NPHIL is the responsible implementing agency for the project. The institutional arrangements for the parent project are the same as for the ongoing Regional Disease Surveillance Systems Enhancement Project Phase II (P159040) (REDISSE II) Project. The REDISSE II project is being implemented by the NPHIL, under the oversight of the MOH. The Minister of Health chairs the National Steering Committee of REDISSE II. The Project Implementing Unit (PIU) – established within the MOH – manages the entire Bank health sector portfolio in Liberia, including the REDISSE II project. The PIU includes designated Technical Coordinators under different Bank health projects including for REDISSE II. The REDISSE II project coordinator manages PIU specifically for REDISSE II. The REDISSE II PIU also manages the COVID-19 Preparedness and Response Project. The Proposed Additional Financing will also be managed under similar implementation arrangements. However, the project will make provision to strengthen all areas of the PIU in line with the increased need arising from inclusion of COVID—19 vaccine financing. E. Rationale for Additional Financing 15. This AF is being proposed at a crucial juncture in the Government of Liberia’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 successful development and expanding production of COVID-19 vaccines (see Annex 1 for status). A key rationale for the proposed AF is to provide upfront financing for safe and effective vaccine acquisition and deployment in Liberia, thus enabling the country to acquire the vaccine at the earliest, recognizing that there is currently excess demand for vaccines from both high- income and lower-income countries. 16. Liberia has identified its 20 % priority population or target groups in accordance with the guidance from EPI Technical Working Group (EPI TWG), and HSCC members . This is contained in the NDVP road map for rolling out COVID-19 vaccines. As part of attaining herd immunity, Liberia has decided that it will have to immunize the entire eligible population of 52%. However, due fiscal constraints, the Country has prioritized 60% of the 52% eligible population. Clear delivery strategies have been developed and May 06, 2021 Page 9 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) prioritized. The EPI TWG has also provided guidance on the phasing of the distribution of the initial 20% COVAX FACILITY financed vaccine. The scale-up of project activities with a focus on vaccination will be implemented in close coordination with other development partners in Liberia as shown in Table 1. The first 1 to 3% have been determined based on the vaccine availability. The table 2 shows the priority groups for COVID-19 vaccination. Sectoral and Institutional Context 17. Government’s activation of the emergency management mechanisms and request for Bank financing. Although Liberia had successfully contained disease outbreaks such as at the West Africa Ebola Virus Disease (EVD) in 2014-2016, similarly to other countries, COVID-19 cases have spread rapidly across the country. However, Montserrado has remained the epi centre of the pandemic. In November 2020, a second wave emerged and recent estimates (as of April 14, 2021) show cumulative number of confirmed cases at 2071 including 1927 recoveries, 59 patients under treatment, and 85 deaths. A total of 9575 contacts have been followed with only 3 lost to follow up. With EVD cases re-emerging in the neighboring country of Guinea (Conakry) 10, disease surveillance and ensuring effective COVID-19 vaccination deployment will be even more critical. As a complement to the proposed AF, the ongoing REDISSE II project (P159040) will continue to support the strengthening of community-level disease surveillance and health systems to contain any suspected EVD cases. Table 1: COVID-19 Pandemic in Liberia in comparison to other countries of West Africa. New Attack rate Cumulativ Recover Activ Cumulativ % of Cumulativ Country cases /100,000 CFR e y rate e e cases cases e deaths (24hrs) popln. Recovered (%) cases Mali 312 11,705 0.37 57 405 3.4 7,101 60.7 4,199 Equatorial 160 7,219 0.29 745 6,799 1.4 7,799 94.2 314 Guinea Nigeria 155 163,736 5.2 163 2,060 1.2 154,098 94.1 7,578 Ghana 151 91,260 2.9 298 754 0.8 89,092 97.6 1,414 Togo 133 11,947 0.3 145 116 0.9 8,985 75.2 2,846 Guinea 61 20,807 0.6 145 133 0.6 18,473 88.8 2,201 Cote 56 45,145 1.4 176 261 0.6 44,473 98.5 411 D'Ivoire Liberia 4 2,071 0.07 40.1 85 4.1 1,927 93 59 Sierra 0 3,993 0.13 56 79 2.0 2,828 70.8 1,086 Leone Source: WHO Global update on COVID -19 Liberia Country Office Report, WHO, 2021 18. Although women and girls are less likely to die from COVID-19 in Liberia compared to their male counterparts, they bear a heavy burden of the pandemic in other ways. For instance, women account for 65 percent of nurses in Africa and most of the 10WHO. 14 February 2021. New Ebola outbreak declared in Guinea. Available at: https://www.afro.who.int/news/new-ebola- outbreak-declared-guinea May 06, 2021 Page 10 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) healthcare workforce in Liberia which puts this group at greater risk of infection. In Liberia women remain the main caregivers, having to care for ill family members, taking care of children that are home due to school closures, and carrying out other domestic care such as cooking and cleaning. Lockdown measures, quarantines, and travel restrictions adopted to respond to the COVID-19 pandemic have also impacted businesses where women are overrepresented such as in tourism, restaurant/catering, and hairstyling. In rural areas, a sharp decline has been observed since the beginning of the pandemic in agricultural, fishing and livestock activities, which women are heavily involved in. An increased risk of gender-based violence (GBV) in Liberia is very likely in 2020 due to financial uncertainty and other stresses exacerbated by lockdown measures. The proposed AF will continue to address gender disparities that make women and adolescent girls more vulnerable during this pandemic 19. The COVID-19 pandemic has also created significant disruptions in essential health services, particularly impacting women, adolescent girls and children. Both supply side (e.g., declining government revenues and health budgets, disruptions in global markets for essential medications and supplies, health work force challenges due to large numbers of providers becoming ill and demand side (e.g., unwillingness to seek care out of fear of becoming infected with COVID-19; lack of resource to pay for healthcare due to declining incomes; mobility restrictions) challenges have been observed11. Under the COVID-19 pandemic, Liberia has experienced major disruptions in the delivery and utilization of essential RMNCAH health services. In April 2020, the Ministry of health reported that national utilization rates of routine health services declined by 36%12. Curative consultations declined by 36%; immunization coverage declined by 39% (including a 94% decline in Margibi county), and first ANC visits declined by 38%. Montserrado county, which has the largest number of COVID-19 cases, saw a 67% decline in immunization coverage, a 43% decline in ANC4 visits, and a 27% decline in deliveries by skilled birth attendants. The proposed AF will provide additional resources that will address the urgent COVID-19 needs enabling the Bank-financed Investing in Maternal, Child and Adolescent Health (IFISH) project (P169641) to focus on continuity of care to reverse the trends of reduced utilization of essential RMNCHA+N services 20. COVID-19 vaccinations have begun in Liberia as of April 1, 2021. This will enable the country to return to some sense of normalcy as the number of vaccinated people move close to attaining herd immunity. The Government of Liberia was been able to purchase vaccine from COVAX facility. Liberia received its first allocation of the vaccines through the COVAX AMC (27 ,000 doses of the AstraZeneca vaccine) and begun deployment on April 1 2021. Additional doses will also be procured through COVAX (to cover 60 percent of the 52 percent eligible population). Through the African Vaccine Acquisition Task Team (AVATT) convened by the African Union and through MTN Mobile company, fully subsidized 27,000 doses of AstraZeneca vaccine have been received by the country. 11 https://www.worldbank.org/en/country/liberia/overview 12 Liberia MOH/HMIS 2020 May 06, 2021 Page 11 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) C. Proposed Development Objective(s) Original PDO The development objective is to prepare and respond to the COVID-19 pandemic in Liberia Current PDO Same as for parent project Key Results 21. The Results Framework will be modified to reflect the changes in project scope. This will include two PDO indicators on vaccine procurement and four intermediate indicators on training human resources for health im delivery of COVID-19 vaccines, Strengthening of the Cold Chain in ensuring viability of vaccines and community engagement on risk and mitigating vaccine hesitancy. 22. To measure the overall progress of the coverage and deployment of the COVID-19 vaccines and the gender gaps the project can address, six new indicators are being proposed and two indicators from the parent project are being dropped (see Table 6 for more information). Some indicators in the parent project will have revised targets to account for the increased financing (see Section VIII: Results Framework and Monitoring). Table 9: Summary of changes to PDO and Intermediate Results Indicators under the AF Indicator Level Status Rationale/ Comments To document contribution Number of COVID-19 vaccines doses toward in procurement and PDO New procured/ distributed distribution of COVID -19 vaccines using Bank funds. to measure progress in Percentage of population vaccinated, prioritizing of the most which is included in the priority PDO New vulnerable for COVID-19 population targets defined in national vaccines. Also, disaggregated plan [by gender]. by gender. Number of National, sub-national, ensure proper training takes facility-based and mobile staff trained in Intermediate/ Component 1; place for proper handling of New COVID-19 vaccine cold chain, storage, sub comp 1.3. COVID-19 vaccines. and handling Pharmacovigilance System (PVS) ensure proper follow-up is adapted to detect Adverse Events Intermediate/ Component conducted for patients that New Following Vaccination (AEFI) for the 1;sub comp 1.3. experience unusual side COVID-19 vaccine (Yes/No) effects. to ensure proper follow-up is Number of AEFI cases reported via the Intermediate/ Component conducted for patients that New electronic notification system 1;sub comp1.3 experience unusual side effects. May 06, 2021 Page 12 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Number of health facilities equipped Intermediate Subcomponent New Ensure we responding to with energy-efficient storage facilities 1.3 clean energy and reduced for storing specimens and temperature- carbon footprint. sensitive medical supplies Community engagement plan for To ensure to measure increasing demand creation for the Intermediate/ Component whether COVID-19 vaccine New COVID-19 vaccine by the population 1;sub comp 1.4 preparedness plans include (Yes/No) community engagement. Number of counties with at least two To ensure access to Intermediate/Subcomponent facilities providing COVID-19 vaccination New vaccination services by county 1.3 services D. Project Description 23. The proposal for AF is fully consistent with the Liberia COVID-19 Emergency Response Project (P173812) and does not require a change of the PDO or project components. The World Bank’s COVID- 19 Vaccine Readiness Assessment Framework (VRAF) is being used by Liberia to assess its readiness to deliver COVID-19 vaccines and optimize vaccine delivery and use within the ambit of the existing Project. Using the results of the Assessment, the AF will address some of the priority gaps identified including through financing technical assistance, equipment (including cold storage equipment), as well as the purchase of vaccines. 24. The proposed AF will finance new activities for the procurement and deployment of safe and effective COVID-19 vaccines, including vaccine-related Cold Chains, communication, and outreach, planning and management, supply and distribution, and digital health information and other supporting systems. As the proposed activities to be funded under the AF are aligned with the original PDO, the PDO will remain unchanged. The components will be revised to two; Component 1: COVID 19 Preparedness and Response which will five subcomponents and component 2; Programme Management and coordination, Monitoring Evaluation and Research. The Results Framework will be revised to include new indicators responding to the new activities at both PDO and intermediate Outcome level. The project management will remain the same, and the project will leverage the capacity of the existing PIU, within the MOH, to ensure effective implementation of the AF. New inclusion as part of capacity Building in the PIU will the vaccines and vaccine logistic specialist who will be the technical liaison officer support on EPI focus for vaccines in the PIU. A. Project Components and Costs Proposed Changes 25. The changes proposed for the AF entail expanding the scope of activities in the parent project the Liberia COVID-19 Emergency Response Project (P173812), adjusting its overall design. As the proposed activities to be funded under the AF for the Liberia COVID-19 Emergency Preparedness and Response Project are aligned with the original PDO, the PDO would remain unchanged. The content of the components remain unchained but the overall components will be reduced to two (02): COVID-19 Response as component one which will include all the new activities on Vaccine procurement as sub May 06, 2021 Page 13 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) component 1 and sub component 2 as vaccine logistics and distribution. All other components will become subcomponents and will be expanded in line with the new scope and expansion of the AF. Component 2 remains Programme Management M&E. The Results Framework of the parent project (Annex 4) are to be adjusted to reflect the expanded scope and new activities proposed under the AF. 26. The AF will also include the extension of the closing date from the current September 30, 2022 to September 30, 2024. This takes cognizance of the new activities being added, the uncertainty in times of the vaccine time frame, global challenges in the supply chain and uncertainty in vaccine availability. 27. The AF is structured around the five original complementary components of the parent project, which will assist the Government of Liberia to continue implementing mitigation measures to contain the second wave of the pandemic in the country and to operationalize the national COVID-19 deployment plan. (i) Proposed Activities: 28. The Additional Financing will have to major components. These components will leverage on what is already being done in term of parent project and at the same time introduce new activities specific to vaccine procurement and roll out. Component 1: COVID-19 Emergency Preparedness and Response This component will have five sub-components: 1) Sub-Component 1.1: Vaccine Procurement: This sub-component will support financing for Procurement of extra vaccines. The financing will happen either through the COVAX facility, direct country arrangements or through the AU/MTN mechanism. This component will finance procurement of extra vaccines to reach 60% of the 52% eligible population as part of progress towards herd immunity. This takes cognizant of the agreed global vaccine estimate and supply chain uncertainties, Table7: Summary of vaccine sourcing and Bank financing May 06, 2021 Page 14 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Source of vaccine financing and population coverage Doses National purchased Estimated Bank-financed Other plan target Specific vaccines with Bank allocation (population COVAX Through Through and sourcing plans finance of Bank %)13 grant other direct (2 doses financing mechanisms purchase assumed) 97,0000 3.2% - - N/A (COVAX AMC) - 96 000 Stage 1 GoL/AU/MTN - - - AU/MTN TBD 27,000 1,400,00 1.0% - World Bank - - Astra Zeneca 200,000 20% TBA- N/A COVAX AMC) - - - - GPOL GoL/AU/MTN - Stage 2: World Bank - - AZ COVAX AMC 200,000 1,400, 000 20% TBA Astra Zeneca - - - - - TBA COVAX AMC) - - Stage 3 World Bank 4- - - AZ COVAX AMC 200,000 1,400,000. 20% 2) Sub-component 1.2: Vaccine logistics and roll out: This sub-component will contribute to the financing and support for vaccine roll out and logistic arrangements as part of the delivery to the last mile. It will contribute to the implementation of the prioritized phasing of vaccine distribution, support for transport, support for cold chain and consumables to the last mile, support for staff deployment. The component will also support financing for the review and prioritization, eligibility criteria, listing of facilities, roll out plans and management of the roll out time frame. As part of roll out activities, the financing through the sub-component with finance support IEC &BCC on vaccine management and action on reducing hesitancy to vaccine uptake. It will contribute to the implementation of the national and county communication plans, support stakeholder engagements including working with community champions and religious leaders across all levels. The sub- component will also finance measure to ensure equitable distribution of vaccine across all priority groups with special focus to people with disabilities and those most vulnerable. 3) Sub-component Component 1.3: Laboratory system strengthening, clinical care and vaccine pharmacovigilance: This component will support financing for laboratory system strengthening which will include strengthening of the laboratories for diagnosis of COVID- 19 and other infectious diseases of public health importance, procurement of tests and consumables including procurement of medicines of proven value as recommended by WHO and other stringent regulatory authorities. The subcomponent will support acute clinical care of COVID-19 patients. Vaccine pharmacovigilance remains critical to overall vaccine roll out. Being new vaccines and on the need to understand them better, the AF will support financing to monitor occurrence of vaccine side effects. Activities will include development of registers of vaccinated individuals, tracking of vaccinated individuals, tracking of complaints, and recoding of possible vaccine related side events and their 13 Includes 3% wastage; adding Stage 1 and 2 comes to a total larger than 57.3% because of population growth May 06, 2021 Page 15 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) response. 4) Sub-component 1.4: Community Engagement and Risk Management and Surveillance: This subcomponent will support community advocacy activities and risk management approaches including activities to improve uptake of vaccines. It will support community to improve behavior change for COVID-19 prevention and control and vaccine management. The subcomponent will also support community surveillance and multi- stakeholder engagement including engagement with local traditional leaders, political and religious leaders. The component will also support financing of advocacy and messaging to counter vaccine hesitancy. It supports developing messages and materials to be used in the COVID-19 vaccination roll out and further enhancing infrastructures to disseminate information from national to counties and local levels, and between the public and private sectors. The sub-component will also support financing of risk engagement for awareness of social distancing measures, seen as an effective way to prevent contracting the COVID- 19, vaccination exercises. Support will also be provided for information and communication activities to increase the attention and commitment of government, private sector, and civil society, and to raise awareness, knowledge, and understanding among the general population about the risk and potential impact of the COVID-19 pandemic and importance of vaccination n the prevention and control of the disease. 5) Sub-component 1. 5: ESS, WASH, Gender and SEA/SH: This sub-component will continue to finance. The sub-component will also support and address matters of vaccine equity and gender inclusion and GRM to deal with matters affecting prioritization and SEA . The subcomponent will also support gender and including mitigation for sexual exploitation and abuse as part of Vaccine roll out. Given the challenges noted in the implementation of the parent project, The AF will directly finance activities on ESS to ensure compliance in ESS instruments The lack of budget in support of ESS stakeholder management and actualizing the ESCP has been a serious challenge in the parent project. WASH activities as part of streamlining the implementation of vaccination activities in permanent, mobile, and semi- permanent health facilities will be financed. Component 2: Program Management, Coordination, Research Monitoring and Evaluation and Learning 28. The component has been revised and will support financing of project management, monitoring including digital information management and research and learning tracking. Specific areas will include program support, monitoring of implementation, development of tracking electronic dashboards, digital registration and tracking, production of weekly progress reports and support for rolling out eIDSR. It will comprise two sub-components. 1. Sub- component 2. 1: Coordination and Programme Management. This sub-component will finance activities on coordination and programme management. It will also finance engagement of personnel to support Vaccine activities at both county and central level. 2. Sub-Component 2.2: Monitoring and Evaluation, research, and Learning. This subcomponent will finance activities related to monitoring and data generation and May 06, 2021 Page 16 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) supervison of the project. It will support the introduction of viable IT technology for remote sensing as appropriate. The subcomponent will also support some research and learning activities. (ii) Financing Arrangements 29. The increase in scope as outlined above will be reflected in an increase in indicative component allocation from {insert US$7.5 million to US$14.5 million}, with the full amount of the AF being added under the revised Components 1 and 2 (see Table 2 below). The revision of the components to sub- components allows the project to respond to two strategic themes in the COVID-19 response. The revision of components entails reallocation of resources from old components to fit in the two new revised components. Table 8: Project Cost and Financing Current HEPRTF* Revised Component AF allocation allocation Component 1: Emergency Preparedness 0.80 6.75 6.50 14.05 and Response for COVID-19 Sub-component 1.1. Vaccine Procurement 0.00 0 4.30 4.30 Sub-component 1. 2: Vaccine logistics and 0.25 0 0.75 1.00 roll out: Sub-component 1. 3: Laboratory system 0.00 4.75 0.75 5.50 strengthening, clinical care and vaccine pharmacovigilance: Sub-component 1.4: Community 0.20 1.50 0.40 2.10 Engagement and risk management and Surveillance, 0.35 0.50 0.30 1,15 Sub-component 1.5: Wash GBV-SEA/SH and ESS Component 2: Program Management, 1.45 0.75 0.50 Coordination, Research Monitoring and 0.20 Evaluation and Learning. 0.375 0.25 0.725 Sub-component 2.1: Coordination and 0.10 Programme Management 0.375 0.25 0.725 Sub-Component 2.2: Monitoring and 0.10 Evaluation, research, and Learning Total (US$ million equivalent) 7.5 7.0 1.00 15.5 * Health Emergency Preparedness Response Trust Fund (iii) Changes in Institutional Arrangements NDVP Implementation and Oversight B. Sustainability May 06, 2021 Page 17 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) 30. There is strong political commitment from the Government of Liberia to mobilize financial resources for COVID-19 response, including for vaccine purchase and deployment. Securing the funds through the proposed AF for vaccine purchase and deployment will establish an enabling environment for other donors, multilateral development banks and UN agencies to also support efforts in the country. Investments under the parent project and the AF are expected to strengthen the health system in the country, ensuring institutional sustainability to deal with infectious diseases of public health importance. . . 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 . 31. The overall risk to achieving the PDO in line with the number of activities for vaccination will be revised from substantial in the parent project to High due to the uncertainties with the COVID-19 vaccine acquisition and deployment. 32. The large-scale acquisition and deployment of COVID-19 vaccines entails certain significant risks. First, the initial vaccines that meet the Bank’s VAC may not be the most effective for the specified context of Liberia or they may not be purchased in a timely manner. Second, a mass vaccination effort stretches capacity, in low- capacity environments such as Liberia entailing risks. The proposed Bank support for Liberia to develop vaccination acquisition strategies and investment in deployment system capacity specifically aim to mitigate these risks. The World Bank will work with Liberia to partner with service providers that can acquire and/or deliver the vaccines. The World Bank will also work with the country to consider trade-offs and to determine the appropriate approach and risk balance. The remaining risk must be considered against the risk of resulting in the country having less timely and effective deployment of vaccines, potentially exacerbating development gaps and eroding past development gains. 33. Political and governance risks have been raised to Substantial. Political pressures may create pressure on Liberia to purchase vaccines before they have been appropriately certified. In the case of Liberia, the Global COVID-19 MPA AF mitigates this risk as financing will only be used for vaccines adhere to the Bank’s VAC. The other risk relates to the commitment and ability of the authorities to ensure appropriate targeting of the vaccines to priority populations, based on objective public health criteria, and to avoid elite capture. This risk will be mitigated through the assurance mechanisms that this AF will support such as the establishment of an acceptable policy and plan for prioritized intra-country allocation. 34. In addition, there are risks associated with fraudulent attempts to gain access to vaccines to be administered not following approved protocols of priority populations or for personal gain and to use sensitive data from the electronic registry to restrict certain individuals/groups from accessing the vaccines. This will be mitigated through a rigorous inspection regime and Anti-Corruption Guidelines (ACGs) for vaccine purchase and May 06, 2021 Page 18 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) deployment. This includes traceability of supply. To guard against abuse of that data, the proposed AF will incorporate best international practices for dealing with such data in such circumstances. There are also risks related to indemnification. Liberia plans to have specific indemnification and liability clauses when purchasing vaccines directly from manufacturers. As an AMC country, Liberia also has access to the regional no-fault compensation scheme for vaccines acquired through COVAX. The Government will revise the VRAF/VIRAT and the NVDP to ensure clear arrangements are included as it relates to indemnification and liability issues. 35. Macroeconomic risk remains Moderate as Liberia is experiencing fiscal pressures and faces the risk of not having additional fiscal space for the purchase of vaccines at scale and other COVID-19 related response interventions. The proposed AF specifically aims to mitigate this risk by providing financing for vaccine purchase and promoting prioritized deployment to vulnerable groups. Residual macroeconomic risk will remain as the country aims to scale vaccine access to higher coverage levels. 36. The AF is designed to address key institutional capacity risks related to vaccine deployment and distribution, but the residual risks remain Substantial. Notwithstanding the moderate to high performance of the immunization program in Liberia, vaccine deployment cold-chain and distribution capacity are currently inadequate and need to be strengthened given the anticipated scale and population group coverage for COVID-19 vaccination. This risk will be mitigated by this AF financing and technical support for immunization system strengthening, including capacity assessments in coordination with the WHO, GAVI, UNICEF, and other partners, and coordinating with other partners in their provision of systems strengthening support. 37. Stakeholder risk remains Moderate. Liberia must be prepared to address hesitancy and build vaccine literacy so that the public will accept immunization when appropriate. The accelerated pace of vaccine development has further heightened public anxieties and could compromise acceptance. Therefore, there are risks related to the continuation of the COVID-19 pandemic and the roll-out of the NVDP. These include (i) set of challenges related to the implementation of preventive responses and control measures and (ii) pressure from groups being unable to access vaccines in the initial phases due to limited availability of vaccines and/or limited deployment capacity. The Government’s policy will be to promote voluntary COVID-19 vaccinations. Support for community uptake will include publicization of higher-level government officials being administered the vaccine. Credible and culturally appropriate health and risk communication will be developed to support positive health behaviors among the priority vaccination groups. 38. Fiduciary risks associated with the parent project remain Substantial . The procurement and FM risks initially assessed for the parent project cover risks associated with the procurement and distribution of vaccines, including fraud and corruption risks. Risks specific to the vaccines include: • Procurement: The key procurement risk associated with vaccines relates to: (i) the complexity of the vaccines market given the significant market power enjoyed by vaccine manufactures; (ii) inability of the market to supply adequate quantities of vaccines to meet the demand; (iii) the limited market access due to advance orders by developed countries; and (iv) weak bargaining power by individual countries and (v) delays in triggering emergency procurement procedures which could delay procurement and contract implementation including payments. The risks under this AF will be mitigated by providing options to support the country’s needs for direct or advance purchase, including technical assistance. May 06, 2021 Page 19 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) • Fiduciary Management (FM): The key FM risk relates to lack of adequate controls over the transparent prioritized distribution and application of vaccines, particularly for the most vulnerable population groups. This AF will use the same options as in the parent project to assess and strengthen control systems, facilitate the timely flow of funds, and ensure adequate liquidity to finance project activities. 39. Technical design remains Substantial. These risks arise from the uncertainties around the timing when COVID-19 vaccines will be available and the supply chain capacity to implement such a large vaccination effort, which may compromise the achievement of project’s objectives. Additionally, there are risks related to the limited supply of medical equipment, COVID-19 tests, PPEs and other medical inputs necessary to control the pandemic and address the health needs of the general population during a pandemic. The World Bank will work closely with government officials (MoH), as well as UN agencies involved in the pandemic response (WHO UNICEF, e.g.), to support the process of acquiring and delivering the COVID-19 vaccines as well as other necessary supply of medical equipment, tests and PPEs. 40. The anticipated overall environmental and social risks remain Substantial. Key social and environmental risks are those related to (a) medical waste management and disposal; (b) the spread of the virus among health care workers and the population at large; (c) occupational and community health and safety issues related to testing, handling, transporting, disposing of supplies and medical samples, and upgrading of designated health facilities/laboratories; (d) marginalized and vulnerable social groups being unable to access vaccines provision, facilities, and services designed to combat the disease; (e) social conflict, and risks to human security resulting from diagnostics testing, limited availability of vaccines and social tensions related to the difficulties of a pandemic situation; (f) SEA/SH risks among patients and health care providers, especially in relation to distribution of lifesaving vaccines; (g) labor influx, related to the rehabilitation of existing health facilities; (h) inappropriate data protection measures and insufficient/not effective stakeholder communication on the vaccine roll-out strategy; and (i) risks associated with AEFI. The Government does not intend to use the military or security personnel for the implementation of this proposed AF. 41. Possible risks and impacts are considered mostly temporary, predictable and/or reversible, but they could become widespread given the highly infective nature of the COVID-19 virus. These risks are covered by ESS 1, ESS 2, ESS 3, ESS 4 and ESS 10. To mitigate these risks the MoH is currently updating the SEP, ESCP and ESRS prepared for the PP, which will be consulted upon, finalized, and disclosed by negotiations. Then n one month after the AF’s Effectiveness, the project will finalize the amended ESMF, LMP and MCWMP. The ESMF will contain provisions for storing, transporting, and disposing of contaminated medical waste and will outline guidance (in line with international good practice and WHO standards on COVID-19 response) on limiting viral contagion in health care facilities. The MoH will also update the SEA/SH Prevention and Response Action Plan (SEA/SH AP) originally prepared for the PP and currently included in the ESMF to properly address SEA/SH risks related to the AF activities. 42. These risks will be mitigated through several measures to ensure vaccine delivery targets the most vulnerable populations, particularly women, elderly, poor, refugees, and minorities in accordance with criteria specified in this AF. First, the Bank will support Senegal to develop and adapt an explicit, contextually appropriate, and well-communicated targeting criteria and implementation plan (e.g., the national vaccination program and any subsidiary programs) including criteria for access to vaccines. The Borrower should ensure that this plan be subject to timely and meaningful consultations in accordance with ESS 10. There should be consensus May 06, 2021 Page 20 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) to first target heath workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly, people with co-morbidities, and people in high-population density location such as slums and refugee camps. The Bank will also continue to provide technical and implementation support to mitigate this risk 43. All targeting criteria and implementation plans will be reflected in country’s national vaccination program. Another potential risk is the increased incidence of reprisals and retaliation especially against healthcare workers and researchers. This risk will be mitigated through explicit inclusion in robust stakeholder identification and consultation processes. Further, and linked to the social risks stated above, it is important to have clarity on the risks that may arise related to any mandatory aspect of the national program and whether and how this mandatory element relates to cultural, social and traditional community practices and values. Such risks need to be considered considering the mitigation hierarchy and balanced against the health-related requirements of any mandatory vaccination program. In addition, the grievance mechanisms required under the ESF should be in place and equipped to address community, worker, and/or individual grievances related to such issues. This includes requirements related to being able to have GRMs in place to address labor and working conditions, and SEA/SH. May 06, 2021 Page 21 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) E. Implementation Institutional and Implementation Arrangements 44. The Government of Liberia (GoL) aims to immunize 60% percent of eligible adults (individuals over 18 years) of the 52.0% of the total eligible population (4 555 023). The rollout of vaccines to this target population is expected to occur in three stages across CY21 and CY22. Table 3 presents the cost of purchasing vaccines and transport to Liberia, including freight, through the available sources, based on a 1.03 percent-wastage assumption, as suggested by the COVAX Unit Cost Working Group. First, COVAX indicated has already arrived is providing 96 000 doses of AstraZeneca to Liberia free of charge. In total, the number of doses that will be provided by COVAX will be enough to cover 38.0 percent of the total population, considering the 1.03% wastage assumption. Based on assumptions, during Stages 1, 96 000 doses will be enough to cover 3.8 percent of the total eligible population. The Government asked for the AstraZeneca vaccine because it is currently the cheapest on the market and much easier to handle on cold chain in line with existing EPI system. The GoL anticipates a pricing of US$7 per dose. 45. Vaccine deployment, supply chain and service delivery were considered. Supply chain include cold chain equipment, syringes, safety boxes, vehicles and fuel and management of adverse events following immunization and waste. Service delivery include indemnities for vaccinators, training, program management, and social mobilization. Based on the Liberia national COVID-19 vaccines deployment plan, it brings the total World Bank’s contribution to vaccine purchasing, shipping and deployment at US$10.0 million. 46. The PIU established within the MOH is the implementation agency for the parent project and will lead the coordination and implementation of activities under the AF. The PIU manages the entire Bank health sector portfolio in Liberia, including the REDISSE II project. The PIU includes designated Technical Coordinators under different Bank health projects including for REDISSE II. The REDISSE II Project Coordinator manages PIU for REDISSE II and COVID -19 Response Project and will also manage the AF. 47. The MoH will remain the implementing ministry of the proposed AF. The MoH will remain the implementation Ministry and the National Public Health Institute of Liberia (NPHIL) will continue to be responsible for the overall coordination and oversight of the implementation of the project. Under the MoH, the PIU for World Bank projects will coordinate implementation oversight. In line with the mandate given to EPI Department and TWG, the EPI will lead the implementation of vaccine related activities. The PIU will be strengthened to ensure there are vaccine specialists to guide the development of workplans and procurement plans for implementation. The PIU and EPI Department will take the operational lead for the preparation, deployment, and monitoring of COVID-19 vaccines and all related logistic matters. The EPI working group will provide requisite technical guidance and recommend actions for implementation through the office of the Deputy Minister Administration. The office of the Deputy Minister will guide the PIU on the recommendation of the EP working group for inclusion in the workplan and procurement plan. 48. The Multisectoral Steering Committee of REDISSE II, also known as the One Health Platform, will continue to be responsible for the overall governance of the project, including the development of plans and monitoring of project implementation. The Steering Committee is chaired by the MoH and May 06, 2021 Page 22 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) includes representatives from other ministries such as the Ministry of Agriculture, the Ministry of Environment the Ministry of Water and Sanitation. The National COVID-19 Vaccine Plan under preparation is being developed under the guidance of the Steering Committee. The PCU will continue to be responsible for the day-to-day management of the project by: (a) coordinating the project activities; (b) ensuring the proper fiduciary management of project activities in all components under oversight of the MoH EPI(c) preparing consolidated annual work plans, updating the PP , ESF quarterly reports, budgets, and M&E; and (d) preparing the implementation report of the project to be submitted to the Steering Committee and the WBG. Additional staff will be recruited within the PCU, such as environmental and social specialists and the extension of the contract of the current environmental and social specialist to support all ESF related matters. The proposed institutional arrangements are based on lessons learned from coordination and implementation of the ongoing health projects (REDISSEII- P159040) and the parent project. Changes in the disbursement categories 49. The project’s disbursement categories will remain the same. Disbursements will be frontloaded as much as possible, however, delays may be experienced due to availability of the vaccines from direct purchase, COVAX, and AVATT/UNICEF Facilitated process. For instance, the AVATT/UNICEF Facilitated process is expecting the first shipment of vaccines in the country towards the end of Q1 2022 (March 2022). An update on expected arrival of vaccines in the country will be provided in the second half of 2021. In the meantime, the Government continues to have discussions directly with manufacturers to ensure vaccines arrive in-country in a timely manner. . CONTACT POINT World Bank Noel Chisaka Senior Health Specialist Anthony Theophilus Seddoh Senior Health Specialist Opope Oyaka Tshivuila Matala Senior Health Specialist Borrower/Client/Recipient Republic of Liberia Samuel D. Tweah Jr. Honorable mfdp@gov.lr May 06, 2021 Page 23 of 24 The World Bank Liberia COVID-19 Emergency Response Project Additional Financing on Vaccines (P176336) Implementing Agencies Ministry of Health Matthew T.K. Flomo Mr. matt77us@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 Noel Chisaka Task Team Leader(s): Anthony Theophilus Seddoh Opope Oyaka Tshivuila Matala Approved By Practice Manager/Manager: Country Director: Pierre Frank Laporte 10-Jun-2021 May 06, 2021 Page 24 of 24