The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 03/15/2022 | Report No: ESRSAFA327 Apr 05, 2022 Page 1 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Comoros AFRICA EAST Government of the Union Ministry of Health of Comoros Project ID Project Name P178615 AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening Parent Project ID (if any) Parent Project Name P175840 Support to COVID-19 Vaccine Purchase and Health System Strengthening Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 4/12/2022 5/12/2022 Population Financing Public Disclosure Proposed Development Objective This Project’s Development Objective is to support the Government of the Union of Comoros to acquire and deploy COVID-19 vaccines, to strengthen national systems for public health preparedness Financing (in USD Million) Amount Current Financing 21.00 Proposed Additional Financing 25.00 Total Proposed Financing 46.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The proposed AF will form part of an expanded health response to the pandemic. The activities will build on COVID-19 MPA-Program Vaccine Purchase and Health System Strengthening Project, as well as on the Bank’s existing health Apr 05, 2022 Page 2 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) portfolio in the country, including the COMPASS project (P166013) the Women Empowerment project (P174887) under development, and the inter-islands connectivity infrastructure project (P173114). Component 1: Vaccines and related supplies provision and deployment (US$1 million) Under this component, the AF will finance purchase of booster vaccines and deployment costs to achieve up to 60% coverage of the population. This component will provide funding for (i) additional recruitment and deployment of vaccination teams; (ii) additional cold chain equipment for health facilities, and (iii) additional support to COVID response by improving the availability of oxygen in facilities managing severe COVID cases. Component 2: Health system strengthening for a stronger COVID-19 response (US$24 million) Under this component, the AF will finance activities related to health system strengthening, including technical assistance to the El Maarouf hospital and other referral hospitals. This will include: (i) institutional strengthening for MOH to support implementation of activities; (ii) strengthening the capacity of the national pharmaceutical office (OCOPHARMA) to manage the additional logistics associated with health emergencies associated with the COVID pandemic; (iii) strengthening the capacity of regional hospitals to better play their role as COVID-19 treatment centers; (iv) support to the strengthening of the health information system; and (v) co-financing of the Multiple Indicator Cluster Survey (MICS) to get baseline data for the project’s monitoring. This AF will provide funding to the El Maarouf hospital to ensure an efficient and functional hospital is put in place after the construction phase. The support will allow the government to optimize the hospital size and structure to reduce overall investment costs and to manage future operational costs. Public Disclosure Component 3: Contingent Emergency Response Component (CERC). D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The Union of Comoros is a small volcanic archipelago off the coasts of Mozambique and Madagascar. Home to the second most diverse coral reefs in the world after Indonesia, Comoros has about 1,800 square kilometers of land and a maritime Exclusive Economic Zone 70 times the size of its land area. About half of its 887,929 population live on Ngazidja, the largest island, where the capital city Moroni is located. While the country is prone to natural disasters (tsunami, cyclones, seismic and volcanic activities), its capacity to respond to emergencies remains weak. In Comoros, from 3 January 2020, there have been 8,033 confirmed cases of COVID-19 with 160 deaths, reported to WHO. As of February 2022, a total of 637,961 vaccine doses have been administered. This AF would support the costs of expanding activities of the Comoros COVID-19 Vaccine Purchase and Health System Strengthening Project (P175840) under the COVID-19 Strategic Preparedness and Response Program (SPRP) using the Multiphase Programmatic Approach (MPA). The project intervention will take place across all islands of the country. The project will support the government of Comoros 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. Apr 05, 2022 Page 3 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) This project is aligned with the NDVP, that was developed by the Government with support from WHO, UNICEF and GAVI. The Sourcing of any vaccines will be purchased through COVAX in accordance with WB guidelines. Vaccines acquired through COVAX, the African Vaccine Acquisition Task Team (AVATT) convened by the African Union, is in the process of negotiating, through UNICEF, additional access to vaccines that would contribute to taking the total population covered up to 60%, in countries that request it. When firm contracts are in place between UNICEF, as the appointed procurement agent, and the manufacturers, UNICEF will conclude contracts with participating countries for the supply of the vaccines. E&S risk management will be streamlined and be carried out under a similar framework with different financing partners. The WB take the leading role in E&S due diligence will inform and guide future investments by partners on vaccines. The Project will be implemented at the national level, including some urban, rural and peri-urban areas. Interventions will involve all health access levels from the national, through regions-districts-communes, to the community level. The exact locations of the project activities are not known at this stage but the interventions are nationwide. The activities being extension of those in the original projects and minor, the activities AF will be covered by existing E&S instruments that were developed for the parent project, considering the necessary updates. D. 2. Borrower’s Institutional Capacity The Project will build on the successful implementation of ongoing parent project and other World Bank health and nutrition projects with the Ministry of Health (MoH) in Comoros, which currently include the Comprehensive Approach to Health System Strengthening (COMPASS) Project (US$30M, P166013) with its additional financing (Covid- 19 response-CERC replenishment (P174227). The MoH has several years of experience working with World Bank Safeguards and over 10 years implementing donor funded projects, but still initiating experience in implementing the Public Disclosure ESF through the COVID-19 Vaccine Purchase and Health System Strengthening Project (P175840) . The MoH has maintained a satisfactory record implementing WB environmental and social risk management policies and has regulations, practices, and oversight mechanisms consistent with the current Environmental and Social Standards of the Bank. The technical implementation of the activities of the Project would be under the responsibility of the Ministry of Health (MOH). The Health PIU (Project Implementation Unit / UGP or Unité de Gestion du Projet) will oversee the fiduciary execution, procurement, and E&S management of the project, while the technical aspects will be dealt with the various sectors and at all levels. The current PIU has a dedicated an operational environmental safeguard specialist in N'gazidja, a social mobilization specialist and one E&S assistant for each of the two other islands (Ndzouani and Mwali) . The current UCP is increasing experience in managing and monitoring the National Medical Waste Management Plan which has been updated to incorporate relevant guidance on vaccines, and to include a process for any effects of vaccine rollout. The current staff still have limited familiarity with ESF requirements and therefore need relevant ESF training and capacity building. The results of the capacity assessment and the respective capacity building plan are included in the parent project ESMF; staffing and capacity building obligations are included in the ESCP. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS Apr 05, 2022 Page 4 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial Environmental risk rating for this Project remains Substantial because of inherent occupational and community health and safety risks and the issue of medical waste management. The main environmental risks are: (i) the occupational health and safety (OHS) issues related to testing and handling of supplies and the possibility that they are not safely used by medical teams; (ii) the OHS issues related to the treatment of COVID-19 patients; (iii) medical waste management; (iv) road safety risks during transportation and distribution of vaccines; (v) community health and safety issues related to the handling, transportation, storing and disposing of healthcare waste as well as the potential for increased public exposure to Covid-19 associated with vaccination; and (vi) increased risk of COVID-19 transmission and adverse events following immunization. This includes waste resulting from vaccine delivery such as sharps and the disposal of used and expired vaccine vials as a result of the project financed activities. Waste materials generated from screening, treatment and vaccination facilities to be supported by the parent project require special handling and awareness, as they may pose an infectious risk to healthcare workers in contact or handle the waste. Other risks associated with the project activities include (1) management of environmental and social risks and impacts of the Associated Facilities related to the hospital under construction and funded by the IsDB, (2) community health and safety risks from inadequate vaccine storage, handling and transportation practices leading to vaccine quality deterioration, and (2) minor rehabilitation of health facilities and national and regional vaccine warehouse and to improved cold chain storage for the distribution chain that may include dust, noise, air emissions, erosion, waste and traffic disturbance. The latter are localized, temporary and easily manageable through good practice construction environmental management procedures. Technical Assistance activities (institutional Public Disclosure strengthening including the strengthening capacities of key administrative and clinical personnel at different levels, the update of the contingency plans for health emergencies and training, the strengthening of the Medicines Regulation Agency, etc.), health system strengthening, including technical assistance to the El Maarouf hospital and other referral hospitals will be consistent with the ESS requirements, and their key direct and downstream risks are those related to safety services. Social Risk Rating Substantial In line with the World Bank ESF guidelines, the social risks rating remains substantial. The Project will mainly have long term positive social impacts as it will enable affordable and equitable access to Covid-19 vaccines and play a critical role in further strengthening the health system. Project activities of the AF consist mainly of purchase of booster vaccines and deployment, technical assistance to the El Maarouf hospital and other referral hospitals; and will not involve involuntary resettlement and cultural heritage issues. The key social risks are under component 1 : (i) risk of inequity in access to vaccines due to limited accessibility of remote rural areas and political pressures to provide vaccines to groups that are not prioritized, or corruption and elite capture in vaccine procurement and distribution, (ii) risk of . discrimination and stigma faced by those admitted to treatment or isolation facilities; and for Component 1 and 2: (iii) risks of GBV/SEAH to project workers and beneficiaries; and (iv) labor management and OHS related risks. Such risks will be reassessed and updated as part of the updated Environmental and Social Management Framework (ESMF). Another particular risk that has come to the fore based on the ongoing implementation experience of the Global COVID-19 MPA is the increased incidence of reprisals and retaliation, especially against healthcare workers and researchers. The measures put in place to address the pandemic such as quarantining and physical distancing that affect livelihoods and access to services are likely to increase the risks of Apr 05, 2022 Page 5 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) women and girls experiencing violence. Project implementation will also involve different types of workers including PIU staff, health civil servants, local CSOs staff, and community health workers which may raise OHS concerns. Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) Risk Rating Moderate Based on the information available at this stage, the risk associated with the SEA/SH is assessed as “moderate”. The project needs to put in place recommended SEA/SH mitigation measures, including code of conduct for all workers. In addition, all project workers and health care workers may be trained to properly identify SEA/SH risks and cases, as well as to facilitate appropriate and timely referrals if and when required. 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: Key E&S risks include: (i) OHS issues as workers in healthcare facilities and laboratories may be exposed to infectious disease contagion. The future infection spread risk is significantly associated with the management of medical waste generated in laboratories and other facilities. If not adequately handled and treated, medical waste can turn into a vector in spread of new infections; (ii) can cause environmental pollution if vaccines and healthcare products are mismanaged; (iii) community health and safety related risks; (iv) potential downstream environmental and social risks associated with the TA activities. All project activities, ranging from operation of health centers and vaccine Public Disclosure distribution to community engagement interactions, present a risk of disease transmission in the community. The operation of health centers have a high potential of infecting the wider population if not systematically managed and well controlled; (v) potential risks around exclusion of vulnerable groups to access project supported services and facilities and/or vaccines and risk of elite capture. Real or perceived inequities also have the potential to lead to conflicts and citizen unrest; (vi) SEA-SH risks. No cases of SEAH/SH has been recorded with the implementation of the parent project, the risk associated with the SEA/SH remains “moderate”. The project will continue to implement recommended mitigation measures, including code of conduct for all workers. All project workers and health care workers may be trained to properly identify SEA/SH risks and cases, as well as to facilitate appropriate and timely referrals if and when required As the project plans to provide vaccines to specific/identified beneficiaries of the population, certain hesitancies remain regarding efficacy, side effects, geographical distribution and choice of target groups to be vaccinated, safety storage and transport and social acceptability and the introduction of the Covid-19 vaccine can cause social controversy and tension on a large scale. Are considered disadvantaged or vulnerable: groups living in dense urban areas (slum dwellers or informal settlements around Moroni, Mutsamudu or Fomboni); communities in remote and inaccessible areas; older people defined by age-related risk, people living in poverty, especially extreme poverty; older people living in high-risk living situations (long-term care facilities, people unable to physically move away); groups with co-morbidities or health conditions (pregnancy/breastfeeding) deemed to be at significantly higher risk of serious illness or death; social groups unable to maintain physical distance (geographically distant clustered populations, detention centers, dormitories, military personnel living in restricted areas; women in situations of economic and social vulnerability; female-headed households; women victims of GBV. These groups may face barriers to accessing health services or health information campaigns, may distrust government health programmes, and may be reluctant to accept health Apr 05, 2022 Page 6 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) interventions such as vaccinations for cultural reasons. The NDVP includes measures to ensure a fair, equitable and inclusive access to vaccines for the target groups : (i) a combination of fixed vaccine strategy in the existing 62 vaccination sites of the EPI program and outreach vaccination strategy using additional ad-hoc sites, home vaccinations, and other needed special arrangements for individuals with low mobility capacity (elders and individuals with comorbidities), and population in hard to reach areas; (ii) mobilization of community healthcare workers to establish a list of the priority populations to be vaccinated through the outreach strategy, including individuals with comorbidities who cannot get to the fixed vaccination sites. To adequately assess the risks of inequitable access and exclusion, the project conducted a SIA as part of the ESMF , which provides specific information on vulnerable groups (including ethnic minorities, SOGI, etc.), barriers they might face and mitigation measures. To assess and manage these risks and impacts consistent with the ESF, UGP has prepared ESMF under the parent project and this document remains valid for activities under AF project. The ESMF outlined the procedure for screening, classifying, assessing, monitoring and reporting each project activity, commensurate to the risk. The ESMF describes practices for handling, storing, treating, and disposing of hazardous and non-hazardous waste, as well as types of worker training required including training of staff to be aware of all hazards they might encounter. The ESMF evaluates and addresses risks associated with cold chain in managing hazardous/medical materials or agents as needed. The ESMF has been disclosed in December 21, 2021. The management of medical and biomedical waste is addressed in the existing NMWMP. The NMWMP that has been prepared and disclosed for the COMPASS Project in July 2020, has been updated and disclosed in December 21, 2021 for the Covid-19 Vaccines parent project to include particular measures related to COVID-19 vaccines such as risks related to the transport, storage, handling and disposal of vaccines. All project activities shall be subject to environmental and social screening and, where necessary, specific instruments shall be prepared before Public Disclosure commencement of applicable project activities. Specific mitigation measures will be outlined in the site-specific ESMPs and implemented, when necessary. This will provide for the application of best practices in COVID-19 diagnostic testing, vaccine distribution and handling the medical supplies and disposing of the generated waste. Safe work protocols shall be developed and implemented for hazardous tasks. Health screening and COVID-19 prevention measures for workers shall be incorporated into the OHS procedures. Emergency response and handling procedures shall be developed to handle any accidents onsite. Road safety risks may increase during transport and distribution of vaccines and this concern should be taken into account by this project. The ESMF developed minimal technical standards including the general requirements for the vehicles, minimal standards for safe journey, road safety awareness with defensive driving elements, requirements for drivers (age and experience; training requirement, medical fitness; roles and responsibilities, etc. There are no civil works expected in this project, other than potential cold chain improvement, the activities will take place in the existing area of health service facilities. No proposed activities have the potential to lead to involuntary resettlement issues. Increased technical capacity for testing, vaccine distribution, use of medicines or medical waste could lead to downstream risks; these will be managed through the implementation of the national waste management plan and guidance on destruction of expired medicines as well as a hazardous waste management plan that will be annexed to the ESMF to be updated integrating the new activities under the FA before the project implementation. The NMWMP was updated to ensure to address the E&S risks and impacts foreseeable from the parent project’s components and in particular with the deployment of a COVID-19 vaccine campaign. Component 2 will focus on technical assistance working for health system strengthening for a stronger COVID-19 response. An IsDB loan will finance the gap for the finalization of the construction of the El Maarouf hospital. The requested IDA grant is to provide technical assistance to develop and implement a masterplan on the efficient hospital size and operations and to support hospital management to implement the masterplan recommendations, purchase basic hospital management information systems, and Apr 05, 2022 Page 7 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) support the Government in its COVID response after hospital construction. However these two activities doesn’t fully satisfy the criteria for associated facilities. Indeed, the IsDB financing is not conditional upon additional TA grant, and even though the construction is directly and significantly related to the project and is being carried out  contemporaneously with the project, the fact that the construction of the hospital is already underway and will continue even if the IDA project would not exist, implies that the third criterium is not fulfilled and that the hospital would not be considered an associated facility to the project. However during project implementation, the Bank team will continue to support the borrower in harmonizing E&S instruments to clearly define project boundaries and ESF scope of application for activities. Under the component 3 (CERC), the project will facilitate access to rapid financing by allowing reallocation of uncommitted project funds in the event of a natural disaster, either by a formal declaration of a state of emergency or upon a formal request from the Government of Comoros. Prior to the start of emergency response activities, the request to activate this part shall come from the implementer with prior No Objection from the Association. The ESMF included section to screen an indicative list of activities related to emergencies likely occur in the country. If proposed activities fall within the scope of the positive list agreed in the CERC Manual and considered in the Project ESMF, no additional E&S work is needed. If not, the Borrower must update this section to conduct an E&S assessment of emergency activities before they are initiated. The updated ESMF shall be consulted upon and disclosed. Measures are taken to support CE, including the existing GM and to address SEA/SH. Community sensitization and capacity building activities will be carried out in order to engage the project's key stakeholders in E&S risks management and to ensure project ownership. In line with ESF requirements, the disclosed E&S instruments under parent project remains valid. ESS10 Stakeholder Engagement and Information Disclosure Public Disclosure ESS10 is relevant to the project components. Stakeholder engagement is a critical tool for social and environmental risk management, project sustainability and success. To ensure a participatory, inclusive, and culturally appropriate approach during the project’s life cycle, the Borrower has prepared and updated the Stakeholder Engagement Plan (SEP) consistent with ESS10 requirements. The updated SEP will be disclosed prior to appraisal. A range of stakeholders have been identified, among which disadvantaged or 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 reasons. Consultations were carried out during the preparation phase, which identified inputs that will inform the design and implementation of the project. The SEP also provides with information disclosure principles and activities, and planned consultations. The SEP included guidelines to ensure that the risk of spread of COVID-19 among stakeholders during consultations is minimized. It focuses on clear and accessible messaging on safety of vaccines, principles of fair, equitable and inclusive vaccines access and allocation, as well as rationale for prioritizing certain groups. The project will continue to build on the GRM of the COMPASS project, which has the same PIU. Thus, the SEP outlines an updated Grievance Mechanism (GM) with specific consideration to vaccination. The GM will integrate GBV-sensitive measures, including multiple channels to initiate a complaint and specific procedures for SEA/SH, such as confidential and/or anonymous reporting with safe and ethical documenting of GBV and SEA/SH cases. Apr 05, 2022 Page 8 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) Through the SEP, the project will ensure that information is meaningful, timely, and accessible to all affected stakeholders and, particularly, populations that are most at risk, project sites, neighboring community, health workers, waste handlers and the project workers. The project will continue to collaborate with civil society actors to strengthen their involvement in accountability and monitoring of budget execution of the project, as planned in the parent project. This is an important project commitment to citizen engagement. 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 ESS2 is relevant to the project. The project activities will be carried out by a Project Implementation Unit (PIU/UGP) under the Ministry of Health. The PIU team includes direct workers, which could be civil servants and consultants hired to support the technical areas for which weak institutional capacities were assessed. The project workforce is also expected to include regional primary caregivers, health administrators, contractors and subcontractors, including potential workers from neighboring communities, primary supply workers as well as CSO staff engaged at the local level to enhance transparency and accountability. Workers can be exposed to a wide variety of risks such as: (i) occupational health and safety risks at the workplace due to hazardous chemicals, unsafe machines; (ii) occupational safety risks from work-related accidents; (iii) pathogen exposure, infection and associated illness, and death; (iv) passing on infections to family and community; (v) non-respect of workers' rights, illegal and untenable overtime, psychological distress, fatigue, occupational burnout and; (vi) SEA/SH risks. The government will ensure that all project workers are adequately instructed and trained, on a regular basis, on prevention and reporting procedures Public Disclosure available for SEA and SH as set out in ESMP and SEP. To manage risk related to Project workers, the government has developed under the parent project the Labor Management Procedures (LMP) which has been disclosed in December 21, 2021 which (i) respond to the specific health and safety issues posed by COVID-19, and (ii) protect workers’ rights as set out in ESS2 . The terms and conditions of the contracts of all the workers involved in the project need to be made in accordance with the national labor law and meet the requirements described in ESS2 to ensure that working conditions be acceptable. The LMP has included the terms and conditions of employment, non-discrimination and equal opportunities, workers' organizations, measures to prohibit child labor and forced labor, grievance redress mechanisms for labor disputes, and occupational safety and health measures for the workers, including SEA/SH for both direct and contracted workers. OHS measures will be included in activity/site specific ESMP, while for contract workers common risks and impacts has be assessed in the ESMF and an OHS management program will be implemented according to guidance outlined in the ESMF and subproject instruments, e.g. ESMPs. There are OHS risks associated with the project including elevated risks of COVID-19 transmission and transmission of other communicable diseases due to pricks from sharps. The risks will be managed through OHS guidance outlined in the ESMF, and site/activity specific ESMPs, and in GIIP. ESS3 Resource Efficiency and Pollution Prevention and Management ESS3 standard is relevant to the parent and the AF project components. Pollution prevention and management – specifically medical waste management – will be particularly important under the project activities in accordance Apr 05, 2022 Page 9 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) with good international practices. Medical wastes (including water, reagents, infected materials, etc.) from health facilities to be supported (vaccines, supplies and medical equipment) can have significant impact on the environment and human health. Additionally the project will generate a high volume of sharps. Liquid contaminated waste may find its way to the soil or any nearby water body if not properly managed. Support for cold chain improvements may include procuring and installing warehouses, cold rooms, fridges, freezers, cold boxes, vaccine carriers to focus not just on COVID-19 vaccine but the upgrade of the entire cold chain (including routine vaccines) should lead to energy efficiency savings as facilities are modernized or fitted with more energy efficient equipment resulting in reductions in energy savings and positive GHG reducing impacts. Analysis of the cold chain management has been included in the ESMF. The installation of equipment will be required to follow the requirements of site specific ESMPs for the Project, COVID-19 guidance note documents, and other best practices to prevent or minimize such adverse impacts. New site specific ESMPs will be prepared for screened activities that require them. The ESMP will include guidance related to transportation and management of samples and medical goods or expired chemical products. Resources (water, air, etc.) used in the facilities and labs will follow standards and measures in line with guidelines on the management of medical waste. A hazardous waste management plan has been annexed into the ESMF to ensure appropriate management of pollution that may contaminate the air, water or soil. GHG Emissions and Energy Efficiency. The Project is not anticipated to generate significant quantities of GHG emissions. It will aim to improve the electricity supply of health facilities by equipping them with the renewable energy supply. Where possible, measures to increase efficiency of energy use. In the case of cold chain equipment, Public Disclosure this means procuring and installing Solar Direct Drive Refrigerators and WHO PQS certified climate friendly refrigerators/freezers to reduce greenhouse gas emissions from fossil fuels. In any activities to install cold-chain equipment in healthcare facilities, emphasis will be place in using clean energy solutions (such as solar and battery systems) to provide continuous power to health facilities and cold-chain equipment, and to reduce operating costs. In order to manage hazardous waste, infectious waste, non-hazardous and non-infectious medical waste, a National Medical Waste Management Plan (NMWMP) was prepared and disclosed in June 2020, revised and updated under the Covid-19 vaccines parent project in December 2021 and is currently being implemented by the UGP that will implement the current project. The NMWMP outlines procedures for sorting, handling and disposing of medical waste and also for managing waste generated in response to Covid-19 based on WHO and WB guidance. The technical capacity of the Borrower to manage hazardous and medical waste in line with GIIP, i.e., infrastructure, facilities and specialized companies for collection and treatment of hazardous and medical waste which operate in the country, was low. Through the financing of the COMPASS project, capacity building activities were carried out. However, additional measures for vaccine related transport, storage, handling and disposal of vaccines will be financed to ensure that there are sufficient resources dedicated managing the vaccine deployment. There is no procurement of pesticides foreseen in the project, the project is not considered to be significant user of water. ESS4 Community Health and Safety Apr 05, 2022 Page 10 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) ESS4 is relevant to the project components because it is equally important to ensure the safety of communities from disease infection. Medical waste and general waste from health centers, as well as from vaccine distribution, have a high potential of carrying micro-organisms that can infect the community at large if they are not properly disposed of. There is a possibility for infectious microorganisms to be introduced into the environment and the surrounding communities if not well contained within the laboratory or due to accidents and/or emergencies. Medical/health centers 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 workplace back into their communities. Additional risks concern increased risk of COVID-19 transmission, adverse events following immunization and forced vaccination. To address those risks, the ESMF includes (i) procedures protocols and other measures to ensure voluntary consent/no forced vaccination and due process in case of mandatory vaccination, (ii) capacity of the national system to monitor, investigate and respond to adverse events following immunization, and (iii) available infrastructure and capacity of the Borrower to established and implement vaccine cold chain temperature monitoring. Road safety risks may increase during transport and distribution of vaccines and this concern should be taken into account by this project. The ESMF has developed minimal technical standards including the general requirements for the vehicles, minimal standards for safe journey, road safety awareness with defensive driving elements, requirements for drivers (age and experience; training requirement, medical fitness; roles and responsibilities, etc.). The government has a protocol to monitor adverse events following immunization (AEFI) that is part of the national vaccine deployment plan that was finalized and adopted in 2021. The ESMF has reference measures to be applied in Public Disclosure the course of the project outlined in the AEFI. In line with the WB SEA/SH Good Practice Note, the Bank has undertaken a SEA/SH risk screening of potential risks and impacts induced by the project, and the risk has been classified as moderate. Indeed, SEA/SH may be an obstacle to acceptability of reproductive health services. To mitigate those risks, the project will ensure the avoidance of any form of SEA/SH by relying on code of conduct all workers implementing the project. The government will ensure that all project workers are adequately instructed and trained, on a regular basis, on prevention and reporting procedures available for SEA and SH as set out in ESMP and SEP. The community neighboring will also be made aware of the GM that can be utilized to raise concerns or complaints regarding the conduct of project related workers, and also GM specifically for SEA/SH. The project has elaborated a SEA/SH Prevention and Response Action Plan (including a mapping of existing service providers) which has been annexed to the ESMF. There will be no use of military security forces in the implementation of the project as vaccination teams were organized to have someone in charge of organizing people and maintaining order. However, if the use of security forces is considered during the implementation of the project, a Security Risk Assessment (SRA) will be conducted to ensure security for communities, and subsequently a Security Risk Management Plan (SRMP) will be prepared by the Recipient, approved by the Association, disclosed prior to the launch of the related activities and implemented throughout the project intervention. Dry storage and cold chain capacity and infrastructure of the Borrower were assessed at all levels with associated costing for the cold chain equipment needs. The analysis revealed minimal needs for vaccines requiring normal refrigeration (+2 - +8 C) for an initial 20% coverage of the population. For this project, the Borrower will need a more Apr 05, 2022 Page 11 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) substantial increase in cold chain capacity. The project will finance the strengthening of the cold chain under the component 1 throughout the country. In order to ensure safe cold chain management during power outages and natural disasters, the project will support the acquisition and use of clean energy solutions (such as the solar system) to provide continuous power to health facilities and cold-chain equipment. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This ESS5 standard is currently considered not relevant. The project will not include any activities which require land acquisition, physical and/or economic displacement. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources The standard is not relevant. The project will not include any activities which could have an impact on Biodiversity Conservation and Sustainable Management of Living Natural Resources. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities The standard is not relevant. There are no Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities that meet the criteria of IP/SSHAUTLCs, per the requirements of this Standard, in Public Disclosure Comoros ESS8 Cultural Heritage This standard is currently considered not relevant. The project will not include any activities which could have impact on Cultural heritage. The project will not include any activities which could have impact on Cultural heritage. Nevertheless, ESIA related to the Hospital El Maroof construction and E&S performance to date will be reviewed to ensure that there are no legacy issues that need to be addressed. E&S measures will be adjusted if required to ensure their compliance to the Bank standards and to avoid any potential reputational risk. ESS9 Financial Intermediaries This standard is currently considered not relevant. The project will not include any activities which could have impact on Cultural heritage. Apr 05, 2022 Page 12 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: N/A IV. CONTACT POINTS World Bank Contact: Enias Baganizi Title: Senior Health Specialist Public Disclosure Telephone No: 5358+6069 / 251-011-51766069 Email: ebaganizi@worldbank.org Borrower/Client/Recipient Borrower: Government of the Union of Comoros Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Enias Baganizi Practice Manager (ENR/Social) David Seth Warren Cleared on 15-Mar-2022 at 07:21:52 GMT-04:00 Apr 05, 2022 Page 13 of 14 The World Bank AF for Comoros Support to COVID-19 Vaccine Purchase and Health System Strengthening (P178615) Public Disclosure Apr 05, 2022 Page 14 of 14