The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 02/18/2021 | Report No: ESRSAFA107 Feb 22, 2021 Page 1 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Rwanda AFRICA EAST Ministry of Finance Rwanda Biomedical Center (MINECOFIN) Project ID Project Name P176304 Additional Financing to the COVID-19 Emergency Response Project Parent Project ID (if any) Parent Project Name P173855 Rwanda COVID-19 Emergency Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 3/8/2021 Population Financing Public Disclosure Proposed Development Objective The objective of the Project is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in the Republic of Rwanda. 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] Feb 22, 2021 Page 2 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) This Additional Financing is being proposed at a crucial juncture in the Government’s response to COVID-19 with the recent surge in cases and the imminent availability of vaccines. The AF will play a critical role in enabling affordable and equitable access to vaccines for Rwanda. There is broad based recognition that economies will not recover fully until people feel they can live, socialize, work, and travel with confidence. Given the importance of limiting the spread of COVID-19 to improve health outcomes and support economic recovery, providing access to COVID-19 vaccines will be critical to accelerate economic recovery and restore growth in Rwanda. COVID-19 has upended Rwanda’s strong economic performance. The government expects that GDP will fall by 0.2 percent for 2020, compared to a projected expansion of 8 percent before the COVID-19 outbreak. Unemployment soared from February to May 2020 from 13 to 22 percent of the labor force, while nearly 60 percent of workers who kept their jobs through the lockdown reported receiving lower salaries. The Additional Financing involves changes that are fully aligned with the original PDO and fall under existing components. Hence, both the PDO and the project components will remain unchanged with new activities incorporated into existing components: (i) Case Detection, Confirmation and Contact Tracing; (ii) Public Health Measures and Clinical Capacity; (iii) Program/Project Implementation and Monitoring and Evaluation; and (iv) Contingency Emergency Response Component. The AF will cover both the procurement and deployment of vaccines and systems strengthening activities required for effective distribution. The AF will also provide an opportunity to increase development effectiveness of the parent project by addressing emerging gaps, such as oxygen therapy. The implementation arrangements would remain unchanged, as these have proven robust and resilient. The government has set a bold target of vaccinating 30 percent of the population during the initial phase (2021) and the remaining 30 percent during a second phase (2022), to reach the African Union target of vaccinating 60 percent of the population, Public Disclosure that is considered critical for herd immunity. Rwanda expects to cover the cost of vaccinating the first 20 percent of the population (2.5 million people) through COVAX. Rwanda has also been recently approved to receive additional supplies of vaccines through the African Union sponsored African Vaccine Acquisition Task Team (AVATT) that would reach another 10 percent of the population. Finally, the World Bank will finance up to 1.3 million additional people (additional 10 percent) during the life of the project. Given the Bank’s comparative advantage to provide flexible financing, a sizable proportion of the IDA credit will be used for the procurement and deployment of the vaccines, including operational costs. The AF will enhance the capacity of the country’s routine immunization system through additional investments in cold chains, human resources, transport, and risk communication to ensure a strong uptake of the vaccines. Discussions are underway with the Global Financing Facility (GFF) to secure a grant for Rwanda to protect essential health and nutrition services that would complement the IDA financing. The proposed AF is being prepared under the Additional Financing to the existing COVID-19 Strategic Preparedness and Response Program utilizing the Multiphase Programmatic Approach (“Global COVID-19 MPA AF”), approved by the World Bank’s Board of Executive Directors on October 13, 2020 (R2020-0193/2). New requirements to be tracked for all COVID-19 operations approved in FY21 will apply to this AF, namely: Gender Tag, Citizen Engagement Framework, and Climate and Disaster screening requirement and climate co-benefit commitments. The Results Framework indicators will be modified to reflect the new activities. The closing date will be extended by one year to June 30, 2023, to allow sufficient time for implementation, given continued uncertainties around the global availability of vaccines. The section below provides details on the proposed changes activities. Proposed Changes/Additional Activities The AF is expected to support the following activities and interventions within the existing project components. Feb 22, 2021 Page 3 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) Component 1. Case Detection, Confirmation and Contact Tracing - This component supports the government to enhance disease surveillance, improve sample collection and ensure rapid laboratory confirmed diagnoses to promptly detect all potential COVID-19 cases and carry out contact tracing to quickly contain COVID-19. • Continuation: The focus will be on: (i) screening travelers at 31 Ports of Entry as well as priority communities and targeted health facilities; (ii) diagnosing cases and referring them for treatment; (iii) carrying out contact tracing to minimize risk of transmission; (vi) conducting risk assessments to identify hot spot areas of transmission; and (v) carrying out multi-sectoral simulation exercises for COVID-19 and other disease outbreaks. Component 2: Public Health Measures and Clinical Care Capacity - This component supports the reinforcement of public health measures and establishment of critical clinical care capacity at a network of public sector district hospitals. • Continuation: The main public health policies to be enforced include social distancing measures; personal hygiene promotion; and risk communication to disseminate messages about the risks associated with COVID-19. Clinical care and isolation capacity is being strengthened at select national and district hospitals responsible for triaging and treating COVID-19 cases to ensure health personnel are well protected and work in a safe environment. • Proposed New Activities: In line with the government’s long standing strategy of using a health systems approach to tackle major public health challenges, the roll out of the COVID-19 vaccines will leverage the immunization infrastructure and play a catalytic role in building capacity of the health care system to immunize adults and the most vulnerable groups across the life cycle and address underlying risk factors. To this end, the AF will support: • Vaccine deployment, including: (i) procurement of COVID-19 vaccines to complement financing under the Public Disclosure COVAX facility; (ii) strengthening the supply chain and logistic systems to comply with the cold-chain requirements of different vaccines; (iii) supporting training of health providers, community health workers and other personnel responsible for the delivery, storage, handling, transportation, tracking and safety of vaccines; (iv) conducting assessments to inform the deployment of the vaccines; and (v) strengthening the policy environment through production of guidelines, standard operating procedures and protocols; reinforcing the regulatory capacity of the Rwanda Food and Drugs Authority to expedite the registration and approval processes, in line with WHO prequalification procedures and World Bank requirements for financing of vaccines; supporting planning and coordination of the vaccine deployment leveraging existing coordinating mechanisms under the national immunization program; and health care waste management and occupational health. To this end, the AF would support procurement of vaccines; cold chain equipment; vehicles; medical supplies and consumables (e.g. PPE, syringes and safety boxes, vaccine sharp disposal containers); technical assistance; and operating costs. • Vaccine communication campaign, to ensure acceptance and uptake, and take into account lessons learned from Rwanda’s pioneer work on the HPV and Ebola vaccine, through support to the Rwanda Health Communication Center to: (i) conduct communication campaigns which are well targeted to increase awareness, foster demand, and address hesitancy through mass media, radio, social media and outreach; (ii) track and monitor correct knowledge of COVID-19 vaccination, and identify views, perceptions, attitudes in order to continually improve implementation strategies and tailor communications; and (iii) facilitate citizen engagement mechanisms for feedback and grievance redressal. To this end, the AF will fund technical assistance; and operating costs. • Screening high-risk groups, to maximize the impact of the COVID-19 vaccination program, it will be critical to identify and reach individuals living with NCDs, as a sizable proportion are not aware of their condition(s) and go undiagnosed. To this end, the AF will support the following activities: (i) conducting community sensitization and mobilization to encourage people to be screened and vaccinated; (ii) screening for hypertension and diabetes (two Feb 22, 2021 Page 4 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) key NCDs) which together affect over one-third of the population; and (iii) referral and initial treatment for these conditions. To this end, the AF will fund: equipment, drugs and supplies; staff training; and operating costs. • Oxygen therapy: Given the rise in severe cases and in light of the findings from a recently completed assessment of respiratory care capacity in Rwanda, the AF will include: (i) procurement of basic respiratory therapy equipment and supplies (i.e. oxygen cylinders and concentrators, pulse oximeters, patient monitors, and additional ventilators) for district hospitals located in remote, rural areas and medicalized health centers operating in high population density locations; and (ii) related training. The AF will fund equipment and supplies and staff training. Component 3. Program/Project Implementation and Monitoring & Evaluation - The third component supports program coordination, management and monitoring; operational support and logistics; and project management. • Continuation: This includes support for the COVID-19 Incident Management System Coordination Structure; operational reviews to assess implementation progress and adjust operational plans; and provide logistical support. • Proposed New Activities: In addition to the core activities described above, the AF will support COVID-19 vaccination specific M&E and surveillance strengthening, including: (i) conducting disease surveillance to monitor the coverage and safety; (ii) monitoring coverage, effectiveness and safety; and (iii) providing vaccination certificates to all people vaccinated. To this end, the AF will fund technical assistance; and operating costs. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Public Disclosure The Rwanda COVID-19 Emergency Response Project (US$14.25 million, P173855) was approved on April 7, 2020 and became effective on April 20, 2020. The parent Project has contributed to the implementation of the government’s National COVID-19 Plan providing the speed and flexibility required for a rapid response. This AF will also have considerable positive outcomes including the implementation of Rwanda’s National Deployment and Vaccination Plan for COVID-19 Vaccine. However, there are potential environmental and social risks associated with Component 1 and 2 of the AF. The activities to be financed by Component-1 include COVID-19 screening travelers at 31 Ports of Entry as well as priority communities and targeted health facilities; diagnosing cases and referring them for treatment; carrying out contact tracing to minimize risk of transmission; conducting risk assessments to identify hot spot areas of transmission; carrying out multi-sectoral simulation exercises for COVID-19 and other disease outbreaks; conducting disease surveillance activities to monitor the impact of the COVID-19 vaccination program and make corrections during implementation. These activities can have significant environment, health and safety risks if an appropriate arrangement for the identification and management of the risks is not put in place. Similarly, Component 2 which will finance procurement of vaccines; cold chain equipment, medical supplies and consumables (e.g. PPE, syringes and safety boxes, vaccine sharp disposal containers) which entails proper disposal of medical wastes and proper handling, transportation and administration of COVID-19 vaccines so that can unintended environment, health and safety risks could be avoided or mitigated. COVID-19 vaccines to be financed by the project should maintain their quality from production, transportation, storage and time of administration so that they could not lose their potency. The vaccines should be distributed using appropriate cold chain based on WHO standards. No major civil works are expected in the AF project and any works will take place in existing health facilities. As result, the AF project is not expected to cause any harm to biological diversity, natural habitats, or cultural heritage. Feb 22, 2021 Page 5 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) Immunization program entails safe injection practices which include measures taken to perform injections in a safe manner for patients and healthcare personnel, and others. Unsafe injection practices that can result in disease transmission. Regarding safety of injection, the Government of Rwanda developed the injection safety policy and adopted since 2001 the systematic and exclusive use of AD syringes and safety boxes both for routine vaccination and for all mass vaccination campaigns. Rwanda’s National Deployment and Vaccination Plan for COVID-19 Vaccine (2021) indicates that health care providers were trained on injection safety, supplies of injection equipment and safety boxes were improved and modern incinerators were constructed for most health facilities. In the COVID-19 context, the possibilities that new vaccination technologies may be introduced combined with the need to vaccinate target populations that differ from those that immunization programs are most familiar with, may further increase the risk of human errors. Providing additional and refresher training for vaccinators on the importance of safe injection practices and waste management will be important to ensure vaccination safety. Additional injections will also increase the quantities of safe injection supplies needed, such as auto-disable syringes and safety boxes. Modern vaccines are safe. However, no vaccine is entirely without risk as adverse reactions might occasionally occur following vaccination. Adverse Events following Immunization (AEFIs) are caused by the vaccine or by an error in the administration or handling of the vaccine. Thus, though COVID-19 vaccines are expected to be safe, their deployment and administration may involve more vaccines with different presentations, from different manufacturers, and use of new technologies never licensed, against a novel pathogen with many unknowns. This highlights the complexity of COVID-19 vaccines safety monitoring requiring the establishment of a robust AEFI surveillance system with capacities to timely respond to COVID-19 vaccine AEFIs cases (National Deployment and Vaccination Plan for COVID-19 Vaccine, Public Disclosure 2021). Rwanda’s National Deployment and Vaccination Plan for COVID-19 Vaccine (2021) recognizes that an effective management of supply chain is crucial to the successful deployment of COVID-19 vaccines. The Kigali International Airport is the only port of entry to receive vaccines from the manufacturers. The cold chain capacity at the airport includes 5 cold rooms with +2oC to +8 o C of 24 M3 as net capacity and 6M3 with -20 o C. The transportation of vaccines from the airport to the Central Vaccine Store (CVS) located nearby the airport (15 minutes driving) is ensured by EPI refrigerated trucks. There are three levels of vaccine supply chain stores including one (1) central vaccine store, 45 district vaccine stores and 507 health centres stores. At the District vaccine store (DVS), storage capacity has been increased with refrigerators and freezers through Gavi- Cold Chain Equipment Optimization Platform (CCEOP) project. There are 4 newly established DHs that need to be equipped with CCE as they will be offering vaccination services including COVID-19 vaccination. The country has increased capacity for ultra-cold chain storage by purchasing additional 5 deep freezers; the ultra-cold chain equipment is paramount in receiving the vaccines. The National Immunization Logistic Working Group (NLWG) will be in charge of this area directly reporting to the NTWG. The cold chain capacity at CVS, is sufficient considering the new cold rooms (+2oC- +8oC) procured recently to equip the new warehouse and would be ready to accommodate COVID-19 vaccines that fulfil that storage conditions. Considering the storage capacity and condition at central and district levels, there may be a need to increase the capacity of storage condition of -20 oC at district hospitals stores, and -20, -60 oC to -80 oC at CVS in the event of supplied vaccines requiring the above storage conditions. Passive containers (long-term ultra-cold storage maintaining the vaccines to -60 oC to -80 oC) shall be used for transportation from central stores to districts in case of Feb 22, 2021 Page 6 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) the vaccine to be used requires such temperature ranges. Currently, vaccine and vaccine devices supply chain system uses the “PUSH” system to ensure the distribution of vaccines and vaccine devices from Central Vaccine Store (CVS) to District Hospitals (DHs) stores, and central level staff are responsible for the distribution. The “PULL” system is applied from DHs to Health Centres and health centre staff collect vaccines from DHs. Distribution frequency is monthly with a plan to change to quarterly basis from CVS to DH stores. During transportation of COVID-19 vaccines, long term ultra-cold storage (Arktek) containing frozen phase change material (PCM) may be required. Reports on vaccines management are collected by HCs on a monthly basis. A web-based vaccine logistic management information system (VLMIS) is being developed into the District Health Information Software 2 (DHIS2) and will integrate COVID-19 vaccine management (Rwanda’s National Deployment and Vaccination Plan for COVID-19 Vaccine, 2021). There is no expected use of security forces in the distribution of vaccine or in the entire administering process. The MoH has already purchased vehicles equipped with refrigerators to be used for this purpose and the Department of vaccination at the MoH will be responsible for this activity. The vaccine will be rolled out nationally and the targeted The vaccine will be rolled out nationally and the targeted beneficiaries are as follows; Health frontline workers/managers, social workers and security organs (391,553), Elderly people (>65 years) (449,069), Persons with underlying chronic health conditions, 35-64 years old (1,228,300) People with disabilities (15-64 years old), and people HIV (538,718) Refugees (144,920), Inmates (65,259), Other frontline and high-risk workers (262,401), Remainder with no high-priority qualifying conditions (815,606) in 2021 and (3936973) in 2022. The total targeted population for 2021 to 2022 is 7,832,799. Public Disclosure The bank AF will contribute to 10% of the targeted population which accounts for 1,300,000 beneficiaries fully vaccinated. The GoR is currently soliciting financing from other development partners and using its own budget. D. 2. Borrower’s Institutional Capacity The parent Project has a satisfactory performance in terms of its E&S compliance with the requirements of the ESCP, SEP and ESMF. The implementing agency (RBC) has assigned one Environment and one Social risk management and one Occupational Health and Safety Specialist to support the project. The current safeguards implementation arrangement at RBC with the assigned staff was found to be inadequate. To ensure proper implementation of AF, the existing Project Implementation Unit (PIU) need to be expanded and staffed with relevant experts including recruitment of full time safeguards staff for the COVID-19 Emergency Response AF Project. The assigned ES staff from MoH and RBC are already overstretched with the on-going COVID19 contact tracing, other on-going programs and with the additional workload with the vaccine AF, and the need to monitor and report one ES requires a full-time staff at RBC, dedicated to this project. To strengthen Environment and Social risk management at RBC/SPIU level, one full-time environment and social specialist will be recruited or a suitable staff from within RBC shall be assigned the duties and responsibilities for environment and social risk management on full-time basis throughout project implementation. The full-time staff will be responsible for overall coordination of the environment and social risk management for the parent project and the AF. In case of assigning a full-time staff from within RBC, the latter will share with the Bank the proposed profile and ToRs for review. In daily implementation of planned activities and reporting, the full-time staff at central level will be complemented by Environmental Health officers located at hospital level as well as Community Environmental Health officers located at Health Center level. The full-time staff will ensure overall ES coordination, GRM operationalization, trainings, monitoring and reporting on the implementation of ESF instruments (SEP, ESCP, ESMF) Feb 22, 2021 Page 7 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) quarterly. This will strengthen regular monitoring and reporting on ES compliance as per the ESCP and all other ESF instruments for the parent project and this AF. The RBC, the nation's central health implementation agency under the Ministry of Health, will remain implementing agency of the AF project. In addition to its contribution to improving the client’s EHS risk management capacity, the parent Project has also contributed to the following key achievements: (i) established a strong national COVID-19 command post with a multidisciplinary team of over 400 people to spearhead the government’s response; (ii) set up provincial level command posts to accelerate decentralization of the COVID-19 response; (iii) implemented swiftly and enforced forcefully a comprehensive set of public health measures (i.e. social distancing, mask wearing, hand washing); (iv) introduced an effective COVID-19 testing strategy with a total of roughly 800,000 tests performed and a cumulative positivity rate of only 1.3 percent (one of the lowest in the region); (v) expanded the number of laboratories with capacity for COVID-19 PCR testing from one to ten; (vi) increased rapidly the number of treatment centers from one to 26; and (vii) introduced a home-based care strategy for asymptomatic and mild cases to minimize the impact on the health system. Rwanda has been pioneering to introduce several new vaccines over the past years and the country has experience with the compassionate use of rVSV ZEBOV vaccine (Ebola Vaccine) for which logistic and storage conditions is similar to the Pfizer and BionTech Covid-19 Vaccine. The rVSV ZEBOV Vaccine was used to vaccinate frontline workers from districts sharing borders with DRC. This experience has exposed EPI Staff at central and local levels to the new skills Public Disclosure for the implementation of vaccination emergency use of in terms of coordination, logistics and supply chain management, service delivery, safety surveillance and monitoring, infection prevention and control (IPC), risk communication and operational support. Based on the past vaccine introduction experience, existing political will, well-functioning and responsive health system, Rwanda is prepared to receive, deliver, and manage the coming COVID-19 vaccine (Rwanda’s National Deployment and Vaccination Plan for COVID-19 Vaccine, 2021). Immunization programs in Rwanda has strengthened its capacity on Monitoring and Surveillance of Adverse Events following Immunizations (AEFIs) for the last decade and there have been several trainings at both national and subnational levels. Recently, Rwanda Food and Drugs Authority (FDA) has been established and operationalized, and vaccine pharmacovigilance is being strengthened at all levels of the health system. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial Support to COVID-19 vaccine purchase and related health system strengthening will have considerable positive outcomes as it aims to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness. However, the COVID-19 vaccination activities can also have potential adverse environmental, health and safety (EHS) risks if an appropriate system for collection, transportation and disposal of medical wastes is not put place. Vaccination programs or vaccines are not entirely without risk as adverse reactions Feb 22, 2021 Page 8 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) /adverse events following immunization might sometimes occur following vaccination which may be due to the vaccine or by an error in the administration or handling of the vaccines. Hence, there should be an appropriate COVID-19 vaccines safety monitoring system to respond to adverse events following immunization (AEFIs) cases, if any. Taking into consideration the uniqueness and complexity of the vaccine safety monitoring of COVID-19 vaccine, the client’s capacity to identify, report, investigate, and analyze adverse events following immunization and determine the cause of and respond to safety issues should be given due attention. Furthermore, an appropriate cold chain system should be in place so as to maintain the potency of the vaccines and the quality of the immunization service. Immunization programs also entail safe injection practices so that potential risks to the patients, healthcare personnel, and others could be avoided or minimized as unsafe injection practices that can result in disease transmission. The implementing agency should therefore establish and maintain an appropriate EHS risk management system for monitoring and surveillance of AEFIs; safe injections ; for proper collection, transportation, and disposal of hazardous medical wastes; and for minimization of occupational health and safety risks. Considering the client’s capacity to manage the EHS risks associated with the AF activities, the environmental risk of the AF is therefore rated as substantial at this stage. Social Risk Rating Substantial The social risks are also considered Substantial. The AF 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 access to vaccination, due to their income, and distance from health centers. The measures put in place to address the pandemic such as confinement and physical distancing that affect livelihoods and access to services are likely to increase the risks of women and girls experiencing violence especially in Kigali. Full societal inclusion is not only fundamental to improved social development outcomes, but given the nature of COVID, if parts of society (by Public Disclosure geography, income, gender or any other measure) are excluded, the overall efficacy of the engagement will be compromised. While the Government of Rwanda is planning and implementing robust measures including setting-up higher-level coordination mechanism to prevent and deployment of vaccination as response to COVID-19, there is need to develop adequate preparedness actions to ensure disadvantaged and vulnerable groups have awareness and able to receive appropriate preventive support (such as awareness of basic hygiene etc) or treatment in health center's, homes and in rural areas. The MoH committed to the provision of 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. In the COVID-19 National deployment and Vaccination Plan (NVDP), the priority group selected for receiving the first batch of vaccine covers 20 percent of the population. The prioritized and targeted groups for COVID-19 vaccination in Rwanda is to vaccinate at least 60% of the population (in 2 years) in line with African Union goal; including high risk groups that include the following below the formal Rwanda prioritization list: a) Health frontline workers/managers, social workers and security organs b) Elderly people (>65 years) c) Persons with underlying chronic health conditions, 35-64 years old d) People with disabilities (15-64 years old), and people living with HIV e) Refugees f) Inmates g) Other frontline and high-risk workers h) Other people without high risk (Very important to reach the herd immunity) Feb 22, 2021 Page 9 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) The 60% constitutes the AU goal but also the required population coverage rate to ensure herd immunity; and the expected coverage is only for people above 16 years as so far the COVID-19 vaccines expected to be used in Rwanda did not consider children below 16 years in clinical trials. The project implementation will continue to ensure appropriate stakeholder engagement to (i) avoid conflicts resulting from false rumors, and (ii) vulnerable groups not accessing services. The project can thereby rely on the RCCE framework and activities set out in the disclosed SEP, to facilitate appropriate stakeholder engagement and outreach towards a differentiated audience (concerned public at large, suspected cases and patients, relatives, health workers, etc.) to ensure widespread sharing of project benefits (COVID-19 prevention and treatment) as well as avoidance of potential rumors and social conflicts. Further, the project will use the Grievance Redress Mechanism established for the parent project to resolve any issues related with the project implementation. There will be no use of security forces in the distribution or administration of the vaccine. The MoH has already purchased vehicles equipped with refrigerators to be used for this purpose. The Department of vaccination at the MoH will be responsible for this activity. 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: Public Disclosure The potential adverse environment, health and safety risks and impacts associated with the AF activities include: i) Adverse Events following Immunization (AEFIs) which may be caused by the vaccine or by an error in the administration or handling of the vaccine; ii) unsafe injection practices that can result in disease transmission.; iii) risks associated with inappropriate collection, transportation and disposal of medical wastes; iv) COVID-19 infections due to inadequate adherence to occupational health and safety standards that can lead to illness among healthcare workers; v) drawbacks in the cold chain system of the country, if any, that could compromise the potency of the vaccines. No civil work will be financed by the AF. Working closely with different stakeholders, GoR have recently finalized the National Deployment and Vaccination Plan for COVID-19 Vaccine with a bold target of vaccinating 30 percent of the population in a first phase (i.e. with many or most to be vaccinated during 2021) and has identified priority target groups, namely health personnel and other frontline essential workers; elderly (>65 years); people with underlying chronic conditions (35-64 years old), and those living in high population density settings (refugees and inmates), in line with the WHO SAGE Roadmap for Prioritizing Uses of COVID-19 Vaccines in the Context of Limited Supply. The AF interventions are an integral part of the recently completed National Deployment and Vaccination Plan for COVID-19 which was produced in a participatory fashion with key stakeholders in Rwanda. Under the government’s leadership, a number of development partners are playing key roles in the vaccine deployment process that include WHO, UNICEF, GAVI, USG/CDC and Belgium Government. The GoR used the combined Vaccine Readiness Assessment Framework (VRAF) and Vaccine Introduction Readiness Assessment Tool (VIRAT) to conduct a comprehensive assessment of country readiness. The assessment benefited from technical support from a number of key development partners (e.g., WHO, UNICEF, CDC, CHAI, WBG, PIH). Feb 22, 2021 Page 10 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) Vaccine equitable distribution and access: risks of elite capture or inability to distribute the vaccine safely to the more remote areas could lead to vulnerable people missing out on vaccination. A social assessment is integrated within the ESMF that is currently being finalized. This social assessment addresses the relevant project risks and impacts, including the (i) risk that project-related impacts fall disproportionately on individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable; and (ii) risk of prejudice or discrimination toward individuals or groups in providing access to development resources and project benefits, particularly in the case of those who may be disadvantaged or vulnerable. Prioritization and selection of population groups to be vaccinated first will be conducted in accordance with emerging WHO Framework for Allocation and Prioritization of COVID-19 Vaccination , and, the Roadmap for Prioritizing Population Groups for Vaccines against COVID-19 and the Fair Allocation Framework. Examples of target priority groups include frontline health and care workers at high risk of infection, older adults, and those people at high risk of death because of underlying conditions like heart disease and diabetes. Rwanda has set a target to vaccinate 30 percent of total population in 2021 and an additional 30 percent in December 2022 in accordance with the African Union target of reaching 60 percent in line with WHO guidance. Targets have been communicated to key stakeholders. The MoH will conduct consultations with key stakeholders to agree on strategies for identifying and reaching the target groups, and for getting accurate estimates of people with underling chronic conditions. Community engagement and advocacy. The Rwanda Health Communication Center (RHCC), which is responsible for Public Disclosure developing and coordinating effective strategies and tools to promote healthy behaviors and monitor their impact, has helped identify a detailed set of activities for the national COVID-19 vaccine plan. Over the past few months, the authorities have used different communication channels to raise awareness about the COVID-19 vaccine and the government’s targets. Most recently, the Rwanda Biomedical Center (RBC) has conducted a COVID-19 Knowledge, Attitude and Practice (KAP) survey to ascertain correct knowledge and views. The KAP survey found that 85 percent of respondents are ready to accept the vaccine once available. The MoH has scheduled to update and disseminate risk communication materials to include COVID-19 vaccine; conduct community outreach to explain how complaints may be lodged and how they will be resolved; review existing data collection tools to include social media listening and rumor management. Vaccine points of delivery. Points of delivery have been mapped taking into account the characteristics of target groups, travel time, costs, and logistics. These points of delivery will need to be adapted based on the vaccines which are ultimately selected, given different storage requirements, such as the ultra-low temperature standards for the Pfizer vaccine. Other factors considered include distance between district vaccine storage sites and points of delivery, including fixed and outreach sites. The national COVID-19 vaccine plan defines the following delivery strategies and vaccination sites, by target group. The Health frontline workers/managers and security organs, refugees and inmates will have fixed delivery sites. The Elderly people (>65 years), People living with NCDs and other underlying conditions and other high-risk workers /populations, these will have fixed, outreach sites and mobile strategy, and nearest Health facility, designated site for outreach and mobile clinics will be allocated for these categories. The MoH plans to conduct refresher training on good immunization practices, including injection safety and acceptance protocols; upgrade vaccination monitoring tools (vaccination cards/certificates, facility-based nominal Feb 22, 2021 Page 11 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) registers and/or tally sheets, vaccination reports); develop and disseminate COVID-19 vaccine protocols; and put in place COVID-19 vaccine delivery and acceptance monitoring arrangements, including training of supervisory focal points at each facility. There is also the risk that marginalized and vulnerable groups, including women and the disabled, face barriers to access COVID-19 services and information. This risk has been mitigated through the explicit inclusion of all these groups in the national deployment and vaccination plan which adopts a equitable approach. During the implementation phase, the Ministry of Health will closely monitor and track progress, and conduct campaigns, to enhance knowledge and promote vaccination uptake. The client has prepared a Stakeholders Engagement Plan (SEP) that outlines stakeholder engagement strategies for the parent project. To ensure effective communication, the WHO has developed a Risk Communication and Community Engagement (RCCE) readiness and response strategy to guide governments. The document provides checklists for RCCE strategies that will help protect public health. To support these efforts, the project will fund RCCE, encompassing behavioral and sociocultural risk factor assessments, production of communication materials, media and community engagement, and documentation, that will now be applied to the COVID-19 national vaccination campaign. The approach being taken will ensure that information is relevant, timely, and accessible to all affected stakeholders, including use of materials in the local language, addressing cultural sensitivities, as well as challenges deriving from illiteracy or disabilities. The project SEP outlines a structured approach to engagement with stakeholders that is based upon meaningful Public Disclosure consultations and disclosure of appropriate information, considering the specific challenges associated with COVID- 19. In cases of the most vulnerable – the elderly and those with compromised immune systems due to pre-existing chronic health conditions, stakeholder engagement will minimize close contact and follow the recommended hygiene procedures, as outlined in the CDC Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in healthcare settings. People affected by project- supported activities will be provided with accessible and inclusive means to raise concerns and grievances. Furthermore, during implementation, authorities will ensure appropriate stakeholder engagement to: (i) avoid conflicts resulting from false rumors; (ii) facilitate access to vulnerable groups; and/or (iii) address issues resulting from people being kept in quarantine. This will ensure voluntary consent for vaccination eliminate potential for forced vaccination . In order to address the anticipated risks, the implementing agency shall update the Environmental and Social Management Framework (ESMF) (including Infection Control and Waste Management Plan) so that it cover risks and mitigation measures for the AF. The updated ESMF will be used as a basis for the identification and management of EHS risks associated with the AF. The client will adopt and use COVID-19 Vaccines Safety Surveillance Manual (2020) developed by the World Health Organization. Furthermore, the EHS risk management arrangement that has been put in place for the parent project could also be used for the AF for compliance monitoring and reporting. The Environmental and Social Commitment Plan (ESCP) and the Stakeholder Engagement Plan (SEP) for the parent project will be updated for the AF and resources shall be allocated for the implementation of the ESCP, the updated ESMF and the SEP to address the potential EHS risks. Feb 22, 2021 Page 12 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) ESS10 Stakeholder Engagement and Information Disclosure The project has established a structured approach as per the on-going parent project to engage with stakeholders based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with COVID-19 and vaccine AF activities will follow the similar arrangement. In instances where there is a likelihood of more vulnerable groups in attendance, such as the elderly and those with compromised immune systems or related pre-existing conditions, vulnerable groups who have barriers to access to health services or health information campaigns, groups who may have distrust of government health programs, and groups who may be hesitant of health interventions such as vaccinations for cultural or religious reasons, stakeholder engagement should minimize close contact. People affected by Project activities should be provided with accessible and inclusive means to raise concerns and grievances. To ensure this approach, the project has included support for “Risk communication and Community Engagement” (RCCE), encompassing behavioral and sociocultural risk factors assessment, production of RCCE strategy and training documents, production of communication materials, media and community engagement, and documentation. The prepared Stakeholder Engagement Plan (SEP) describes the framework for these activities, following the guidance provided in WHO found at https://www.who.int/emergencies/diseases/novel- coronavirus-2019/technicalguidance/risk-communication-and-community-engagement. The SEP will be updated with information on clear and accessible messaging on principles of fair, equitable and inclusive vaccines access and allocation, as well as rationale for prioritizing certain groups, and re-disclosed at least 30 days after AF approval. The approaches taken will thereby ensure that information is meaningful, timely, and accessible to all affected stakeholders, including usage of different languages, addressing cultural sensitivities, as well Public Disclosure as challenges deriving from illiteracy or disabilities, as well as challenges of public meetings during the current emphasis on social distancing. Due to the expected country-wide implementation of vaccine activities, the differences of areas and socioeconomic groups will equally be taken into consideration during rollout of the SEP. It will be important that care management in quarantine and isolation centers, vaccination areas is managed systematically, allowing patients to access information as well as patients’ relatives to get necessary information about the quarantined; if feasible by enabling two-way communication. The project has established and operationalized a Grievance Redress Mechanism, which includes a hotline, which is detailed in the final SEP for the parent project. Recent consultations with the RBC-SPIU (PIU) indicated that no grievances have so far been registered for the on-going operation. This is understandable as most of the ERP activities have entailed logistical support for Command Post activities and acquisition of medical supplies. To ensure effective citizen engagement, the client will survey to determine the percentage of beneficiaries reporting community engagement and outreach meet their needs. Various approaches will be used to improve vaccine literacy among the general 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. Feb 22, 2021 Page 13 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) Due to the emergency situation, and the need to address issues related to COVID19, no dedicated consultations beyond public authorities and health experts, including Africa CDC, have been conducted so far for the parent project. However, the project has prepared a SEP and publicly disclosed it to ensure early, continuous and inclusive stakeholder engagement (including vulnerable/disadvantaged groups). The Rwanda Health Communication Centre (RHCC), a unit of the RBC/MoH mandated with the coordination of health promotion interventions, handling media and public relations within the country’s health sector is fully deployed in the implementation of Rwanda’s RCCE. The RHCC disseminates COVID-19 relevant messages through national radio, megaphone broadcasts, TV, mobile phone SMS and social media platforms and obtains feedback as appropriate. 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 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 project can thereby rely on standards set out by WHO as well as international good practice to (i) facilitate noted appropriate stakeholder engagement and outreach towards a differentiated audience (concerned citizens, suspected cases and patients, relatives, health care workers, etc.); and (ii) promote the proper handling of quarantining interventions (including dignified treatment of patients; attention to specific, culturally determined concerns of Public Disclosure vulnerable groups; and prevention of Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) as well as minimum accommodation and servicing requirements) The initial beneficiaries of the vaccination program will be frontline health and care workers at high risk of infection, older adults, and those 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 is based on existing information and rapid qualitative and/or quantitative assessments to learn about the communities (knowledge, attitudes and perceptions about COVID-19 and vaccines, most at risk population, communication patterns and channels, language, religion, influencers, health services and situation) . Upon this assessment, a plan of action will be prepared which will include responsible parties, period and needed financial and human resources. The updated SEP will be shared with relevant stakeholders via culturally appropriate means (and having regard to logistical and technological constraints). The SEP will be disclosed at MoH website and printed copies will be placed in health centers in all provinces and hospitals in Districts. The RBC- PIU will ensure that there is no prejudice or discrimination toward project-affected individuals or communities, including other interested parties. Particular consideration will continue to be given to the disadvantaged and vulnerable groups including elderly and people with pre-conditions during the life of the project, especially where adverse impacts may arise, or development benefits are to be shared. The GRM will respond to complaints throughout the project lifecycle and has been devised to promptly respond to any project grievances. The existing RBC project unit will undertake day-to-day management of GRM; 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 ; and includes a log where grievances are registered in writing and maintained as a database, publicly advertised procedures, setting out the length of time users can expect to wait for acknowledgement, Feb 22, 2021 Page 14 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) 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 COVID vaccines in Rwanda. Details of the GRM operation are described in final SEP. 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 The AF will be implemented in accordance with the applicable requirements of ESS 2, in a manner acceptable to the Association, including through, inter alia, implementing adequate occupational health and safety measures (including emergency preparedness and response measures), setting out grievance arrangements for different categories of workers. Most activities supported by the AF project will be conducted by health-workers employed by the Government of Public Disclosure Rwanda. The key potential OHS risk is exposure to COVID-19 (or other contagious illnesses as patients taken seriously ill with COVID-19 are likely to suffer from illnesses which compromise the immunes system), which can lead to illness and death of workers. The project will ensure the application of OHS measures as outlined in the ESMF). This encompasses procedures for procedures for protection of workers in relation to infection control precautions; provision of immediate and ongoing training on the procedures to all categories of workers, and post signage in all public spaces mandating hand hygiene and PPE; ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General EHSGs and industry specific EHSGs and follow evolving international best practice in relation to protection from COVID-19. Also, the project will regularly integrate the latest guidance by WHO as it develops over time and experience addressing COVID-19 globally. The Labor Management Procedures (LMP) that has been included in the parent project’s ESMF will be updated along with the ESMF so that it could cover the AF as well. ESS3 Resource Efficiency and Pollution Prevention and Management Medical wastes and chemical wastes such as reagents, infected materials, etc. from the health facilities can have significant impact on environment and human health. Wastes that may be generated from medical facilities/ labs Feb 22, 2021 Page 15 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) could include liquid contaminated waste, sharps, chemicals and other hazardous materials. Each beneficiary medical facility, following the requirements of the ESMF, WHO COVID-19 guidance documents, shall prepare and follow the Infection Control and Medical Waste Management Plan (ICMWP) to prevent or minimize such adverse impacts. The cold chain system should be energy efficient and should also try to rely on sustainable energy sources whenever practicable. The implementing agency shall comply with CDC requirements for vaccine management, including storage and handling, temperature monitoring at all times, complying with instructions for dealing with temperature excursions, and monitoring expiration dates (CDC- COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, Oct 2020). If vaccines, sharps, vaccine vials and other supplies have to discarded/disposed of, the client shall follow the medical waste management procedure specified in the ESMF and WHO guidelines. An effectively managed supply chain is crucial to the successful deployment of COVID-19 vaccines. Based on the current information, it is assumed that most vaccines will be stored at +2 °C to +8 °C, with exceptions that some vaccines that would require ultra-cold chain (UCC) equipment (-70 °C). Either frozen phase change material or dry ice in lieu of traditional cold packs could be used during transport. The client will need to conduct assessment of the existing supply chain system to be able to identify and address gaps, such as in storage, distribution, temperature monitoring and tracking, tracking and reporting vaccine stocks. The client will also undertake the following to ensure effective deployment of the vaccines. The deployment plan and standard operating procedures (SOPs), including on maintaining cold chain, will be communicated to all levels of the supply chain managers. Health professionals, including vaccinators, will be trained on infection prevention control measures and cold chain maintenance. In addition, continuous monitoring of data recording and reporting mechanism for vaccines and cold chain equipment and robust oversight and data-driven management, including systems for monitoring adherence to cold chain Public Disclosure practices will be in place. ESS4 Community Health and Safety In line with safety provisions in ESS2, it is equally important to ensure the safety of communities in relation to the pandemic. As noted above, medical wastes and general waste from health centers and quarantine and isolation centers have a high potential of carrying micro-organisms that can infect the community at large if they are is not properly disposed of. Health facilities, laboratories, quarantine and isolation centers, and screening posts, will thereby have to follow respective procedures with a focus on appropriate waste management of contaminated materials as well as protocols on the transport of samples and workers cleaning before leaving the work place back into their communities. The project will thereby follow the provisions outlined in the ESMF, noted in ESS1. Secondly, the operation of quarantine and isolation centers needs to be implemented in a way that both the wider public, as well as the quarantined patients are treated in line with international best practice. This includes addressing avoidance of any form of Sexual Exploitation and Abuse as well as protocols in case of use of security personnel (as set up under the parent project). Specifically, to the AF and the vaccine campaign, first of all it should be stated that quality control for the vaccine will be organized globally and medical risk management for the vaccine itself shall not be done on the national level (i.e. in reference to vaccine reliability as well as potential side effects). That being said, the establishment of feasible cold Feb 22, 2021 Page 16 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) chains within the country is a risk to be managed by the client and details will be included in the updated ESMF, as much as the appropriate provision of vaccines to beneficiaries. It is important to consider the following infection control measures that are currently necessary when selecting COVID-19 vaccination clinic settings : • Providing specific appointment times or other strategies to manage patient flow and avoid crowding and long lines. • Ensuring sufficient staff and resources to help move patients through the clinic flow as quickly as possible • Limiting the overall number of clinic attendees at any given time, particularly for people at higher risk for severe illness from COVID-19 • Setting up a unidirectional site flow with signs, ropes, or other measures to direct site traffic and ensure physical distancing between patients • When feasible, arranging a separate vaccination area or separate hours for people at increased risk for severe illness from COVID-19, such as older adults and people with underlying medical conditions • Making available a point of contact for any reasonable accommodation needs for people with disabilities • Selecting a space large enough to ensure a minimum distance of 6 feet between patients in line or in waiting areas for vaccination, between vaccination stations, and in postvaccination monitoring areas The quantity of COVID-19 vaccine transported to a satellite, temporary, or off-site COVID-19 vaccination clinic should be based on the anticipated number of COVID-19 vaccine recipients and the ability of the vaccination provider to store, handle, and transport the vaccine appropriately. This is essential to minimizing the potential for vaccine wastage and spoilage. • COVID-19 vaccines may be transported—not shipped—to a satellite, temporary, or off-site COVID-19 vaccination Public Disclosure clinic setting using vaccine transportation procedures outlined in the upcoming COVID-19 addendum to CDC’s Vaccine Storage and Handling Toolkit. The procedures will include transporting vaccines to and from the provider site at appropriate temperatures, using appropriate equipment, as well as monitoring and documenting temperatures. • Upon arrival at the COVID-19 vaccination clinic site, vaccines must be stored correctly to maintain appropriate temperature throughout the clinic day. There will also inspection of the receiving facility to ensure correct storage and a set up protocol in case the conditions are not appropriate. • Temperature data must be reviewed and documented according to guidance in the upcoming COVID-19 addendum to CDC’s Vaccine Storage and Handling Toolkit. • At the end of the clinic day, temperature data must be assessed prior to returning vaccine to fixed storage units to prevent administration of vaccines that may have been compromised. • As with all vaccines, if COVID-19 vaccines are exposed to temperature excursions at any time, the temperature excursion should be documented and reported according to the national immunization program’s procedures. The vaccines that were exposed to out-of-range temperatures must be labeled “do not use” and stored at the required temperature until further information on usability can be gathered or further instruction on disposition or recovery is received. There will be no use of security forces in the distribution or administration of the vaccine. The MoH has already purchased vehicles equipped with refrigerators to be used for this purpose. The Department of vaccination at the MoH will be responsible for this activity. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Feb 22, 2021 Page 17 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) This standard is not relevant for the parent project and AF as there are no land acquisition, and involuntary resettlement expected at this stage. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources No major construction or rehabilitation activities are expected in the parent project and all works will be conducted within existing facilities. Under the AF, no civil works are proposed to be financed. Hence, likely impacts of the project on natural resources and biodiversity are low. However, if medical and chemical wastes are not properly disposed of, they can have impacts on living natural resources. Site specific waste management plans will be prepared following the requirements of the ESMF. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities The vaccination process will be voluntary not mandatory, and this will be clearly communicated to the targeted population Country wide through the vaccination campaigns. No situations which would require FPIC are foreseen for the AF. ESS8 Cultural Heritage No construction or rehabilitation activities are expected in this project. Hence, the likely impact of the project on cultural heritage is low. Public Disclosure ESS9 Financial Intermediaries This standard is not relevant for the suggested project interventions. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways OP 7.60 Projects in Disputed Areas B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: none Feb 22, 2021 Page 18 of 19 The World Bank Additional Financing to the COVID-19 Emergency Response Project (P176304) IV. CONTACT POINTS World Bank Contact: Miriam Schneidman Title: Lead Health Specialist Telephone No: +1-202-473-9391 Email: mschneidman@worldbank.org Contact: Amparo Elena Gordillo-Tobar Title: Senior Economist Telephone No: +1-202-458-9761 Email: agordillotobar@worldbank.org Borrower/Client/Recipient Borrower: Ministry of Finance (MINECOFIN) Implementing Agency(ies) Implementing Agency: Rwanda Biomedical Center V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Public Disclosure Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Miriam Schneidman, Amparo Elena Gordillo-Tobar Practice Manager (ENR/Social) Helene Monika Carlsson Rex Cleared on 18-Feb-2021 at 11:01:7 GMT-05:00 Feb 22, 2021 Page 19 of 19