WB&G COVID-19 Emergency Response Project & Additional Financing - ESMF Palestinian Ministry of Health ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK (ESMF) For WEST BANK AND GAZA COVID-19 EMERGENCY RESPONSE PROJECT (P173800) and WEST BANK AND GAZA COVID-19 EMERGENCY RESPONSE PROJECT-ADDITIONAL FINANCING (P176403) December 2021 I Abbreviations and Acronyms AF Additional Financing BAT Best Available Techniques BSL Biosafety Level CAP Corrective Action Plan CDC Centre for Disease Control and Prevention COVID-19 Coronavirus Disease 2019 EA Environmental Assessment E&S Environmental and Social ESF Environmental and Social Framework ESIA Environmental and Social Impact Assessment ESHS Environmental, Social, Health and Safety EHS Environmental, Health and Safety ERP Emergency Response Plan EHSO Environmental, Health and Safety Officer EQA Environment Quality Authority ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan ESS Environmental and Social Standard EU European Union GBV Gender Based Violence GDP Gross Domestic Product GIIP Good International Industry Practice HEPRTF Health Emergency Preparedness and Response Multi-Donor Trust Fund HCF Health-Care Facility HCW Health-Care Waste HSO Health and Safety Officer HVAC Heating, Ventilation and Air Conditioning ICWMP Infection Control and Waste Management Plan IHR International Health Regulations IPCP Infection and Prevention Control Protocol LMP Labor Management Procedures MENA Middle East and North Africa MoH Ministry of Health MoLG Ministry of Local Government MoSD Ministry of Social Development MWMS Medical Waste Management System OHS Occupational Health and Safety OIP Other Interested Parties PPE Personal Protective Equipment Pt Palestinian territories RDNA Rapid Disaster and Needs Assessment SEA Sexual Exploitation and Abuse SEP Stakeholder Engagement Plan SOPs Standard Operating Procedures TA Technical Assistance UN United Nations II WB&G COVID-19 Emergency Response Project & Additional Financing - ESMF WBG World Bank Group WB&G West Bank and Gaza WHO World Health Organization WWTP Wastewater Treatment Plant III WB&G COVID-19 Emergency Response Project & Additional Financing - ESMF Table of ContentsExecutive Summary..................................................................................... 1 1. Background & Rationale for Additional Financing ........................................................... 4 2. Project Description ............................................................................................................. 8 2.1. Project Development Objective .................................................................................. 8 2.2. Parent Project .............................................................................................................. 8 2.3. Parent Project components .......................................................................................... 8 2.4. Additional Financing ................................................................................................. 10 2.5. Additional Financing Components............................................................................ 10 2.6. Project Beneficiaries ................................................................................................. 11 3. Policy, Legal and Regulatory Framework ........................................................................ 11 3.1. Policy Framework in Palestine .................................................................................. 12 3.1.1. Palestinian Environmental Law ......................................................................... 12 3.1.2. The Palestinian Environmental Assessment Policy, 2000 ................................. 12 3.1.3. The Public Health Law ...................................................................................... 13 3.1.4. The National Health Strategy 2017-2022 .......................................................... 13 3.1.5. Occupational Health and Safety (OHS) ............................................................. 14 3.1.6. Strategies, Action Plans for Solid Waste Management ..................................... 14 3.1.7. Medical Waste Bylaw (2012) ............................................................................ 15 3.1.8. COVID-19 Considerations................................. Error! Bookmark not defined. 3.2. Institutional Framework in Palestine......................................................................... 17 3.2.1. Environment Quality Authority ......................................................................... 17 3.2.2. Ministry of Health (MoH) .................................................................................. 17 3.2.3. National Institute of Public Health .................................................................... 18 3.3. World Bank Environmental and Social Framework ................................................. 18 3.3.1. Environmental and Social Standards (ESS) ....................................................... 18 3.3.2. World Bank Group Environmental, Health and Safety Guidelines ................... 26 3.3.3. WHO Guidelines ................................................................................................ 30 4. Environmental and Social Baselines ................................................................................ 30 IV WB&G COVID-19 Emergency Response Project & Additional Financing - ESMF 4.1. General ...................................................................................................................... 30 4.2. Baseline Environmental and Social Information ...................................................... 31 4.3. Economic situation in Palestine ................................................................................ 32 4.4. Status of the health care sector .................................................................................. 33 4.5. Collection, Treatment and Disposal of Medical Waste............................................. 33 4.6. Committees Formed In Relation To COVID-19 ....................................................... 35 4.7. Gender-Based Violence (GBV) ................................................................................ 35 5. Potential Environment and Social Risks and Mitigation .................................................. 37 5.1. Risk Related to Minor Works during the Installation of the New Equipment .......... 37 5.2. Weak Health and Safety Measures............................................................................ 38 5.3. Improper Healthcare Waste Management ................................................................. 38 5.4. Impact of COVID-19 Testing Laboratories .............................................................. 38 5.5. Risks Associated with Transportation Safety............................................................ 39 5.6. Inadequate Risk Communication and Community Engagement .............................. 40 5.7. Exclusion of the poor, elderly, those with disabilities and vulnerabilities ................ 41 5.8. Gender-Related Impacts ............................................................................................ 52 5.9. Environmental and Social Management Plan ........................................................... 53 6. Procedures to Address Environment and Social Issues .................................................... 54 6.1. The Environmental and Social Screening Process .................................................... 54 6.2. The Screening Process .............................................................................................. 54 7. Information Disclosure ..................................................................................................... 56 8. Stakeholder Engagement .................................................................................................. 56 8.1. Stakeholder Engagement Activities Conducted for the Additional Financing ......... 57 8.2. Methods, Tools and Techniques for Stakeholder Engagement ................................. 58 8.3. Stakeholder Engagement Plan (SEP) ........................................................................ 59 8.4. Resources and Responsibilities for Implementing SEP ............................................ 60 8.4.1. Resources and Budget ........................................................................................ 60 8.4.2. Management Functions and Responsibilities..................................................... 61 8.5. Grievance Mechanism ............................................................................................... 61 9. Institutional Arrangements, Responsibilities and Capacity Building ............................... 64 9.1. Institutional and Implementation Arrangements ....................................................... 64 9.1.1. Implementation Arrangements........................................................................... 64 V WB&G COVID-19 Emergency Response Project & Additional Financing - ESMF 9.1.2. Results Monitoring and Evaluation Arrangements ............................................ 65 9.1.3. Sustainability...................................................... Error! Bookmark not defined. 9.2. Monitoring Environmental and Social Issues ........................................................... 67 9.3. Capacity enhancement needs .................................................................................... 67 10. ESMF Implementation Budget ..................................................................................... 68 Annexes.................................................................................................................................... 69 I. Screening Form for Potential Environmental & Social Safeguards Issues ................... 70 II. ESMP Template ........................................................................................................ 73 III. Infection Control and Waste Management Plan (ICWMP) Template ...................... 77 VI. Infection and Prevention Control Protocol................................................................ 83 VI WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Executive Summary COVID-19 pandemic poses unique public health risks in Palestine given the already overburdened health system, the presence of specific at-risk populations, the uncertain political situation impacting impoverished groups especially chronically ill patients whose access to health care is limited due to system fragmentation and closures of the territories. Movement restrictions and containment efforts during 2020 and early 2021 within Palestine as well as between the Palestinian territories and Israel due to the COVID-19 pandemic have caused a significant income shock to many households. The global economic slowdown from COVID-19 had a significant impact on health services in Palestine, both because of the limited capacity of the health supply and the overreliance on out-of-pocket expenditures at the point of care. Hence, interventions to strengthen the health care system in the Palestinian Territories have the potential to mitigate negative impacts on public health and the economy. On April 2, 2020, the World Bank Group (WBG) created a dedicated, COVID-19 Fast Track facility to help developing countries address emergency response and impacts of the outbreak. The WBG’s COVID-19 Fast Track facility is a globally-coordinated, country-based response to support health systems. On May 19, 2021 the World Bank Group announced that its emergency operations to fight COVID-19 have reached 100 developing countries. The Palestinian Authority (PA) obtained financing from the World Bank Group to support national capacity to contain COVID-19 pandemic through the “West Bank and Gaza COVID-19 Emergency Response Project� herein known as the Parent Project. Specific areas of planned support for the Parent Project included: (i) purchase of goods such as fluoroscopy machines, Anesthesia machines, central public health lab equipment, Personal Protective Equipment (PPE), (ii) procurement of essential additional inputs for treatment such as ventilators, pulse oximeters, laryngoscopes, oxygen generators, and other equipment/supplies for COVID-19 case management; (iii) Supply of general vaccine as part of the regular immunization program in West- bank Gaza (WB&G) i.e. the Pneumococcal vaccines (PCV) vaccine which is provided as part of the ongoing basic health services for immunization (not a COVID-19 Vaccine) and, (iv) recruitment of workforce of direct labor, which included 271 staff hired through the project to strengthen the Ministry of Health’s efforts in containing the pandemic and providing medical care to the public. The Parent Project has a budget of US$ 5 Million and was designed based on 3 components: Component 1: Emergency COVID-19 Response (US$ 2.1 million) Component 2: Strengthening Overall Healthcare Services and Clinical Capacity to Respond to COVID-19 (US$ 2.1 million) Component 3: Project Implementation and Monitoring (US$ 0.8 million) During the 3rd quarter of 2021, preparations have been initiated for an Additional Financing for the West Bank and Gaza COVID-19 Emergency Response Project, herein referred to as the Additional Financing (AF). During July and August 2021 in the Palestinian Territories, a new wave hit the West Bank and Gaza with around 25,421 and 61,434 confirmed cases for each month respectively1, with Gaza having the higher share of recorded cases, indicating the concentration of 1 http://site.moh.ps/Index/covid19/LanguageVersion/1/Language/ar 1 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF the pandemic in the conflict-impacted strip. Cases have been rising recently, with 71% of total active cases in Palestine recorded in Gaza, attributable to the impact of the conflict in the strip, weak health system capacity, as well as spread of the more contagious Delta variant, highlighting remaining needs for effective pandemic response. Health system capacity remains stretched, with overall bed occupancy rate at 55 percent and intensive care unit (ICU) bed occupancy rate at 80 percent. Additionally, the recent conflict in Gaza has further amplified financing needs and gaps. In June 2021, following the May 2021 Gaza conflict, the World Bank Group (WBG) in collaboration with the European Union (EU) and United Nations (UN) published the Gaza Rapid Damage and Needs Assessment2 (RDNA). According to the RDNA findings, the sector that has been most impacted by the conflict is the Social Sector comprised of housing, health, education, social protection and jobs. Therefore, and based on the request of MoH to address the emergency in Gaza and West Bank, the AF to the project will build upon the parent project’s activities and an additional component will be added as further described in Section 2.5; - Component 3 of the Parent Project “Project Implementation and Monitoring� will be assigned as Component 4 in the AF. A new component 3 will be added: “Supporting Emergency Health Sector Needs and COVID-19 Response�. Specific areas of planned support for the AF include; (i) emergency medicines, focusing on treatment of health emergencies and chronic conditions; (ii) emergency medical devices and equipment, including defibrillators, V/S monitors, emergency trolleys, consumables, patient beds, Intensive Care Unit (ICU) beds, mobile clinics, mobile blood banks, flow cytometers, electrical supplies, freezers, and refrigerated vehicles (not ultra-cold chain). The AF is in the amount of US$2.5 million financed by the Health Emergency Preparedness and Response Multi-Donor Trust Fund (HEPRTF) and US$ 1.25 million in emergency funding earmarked to Gaza following the latest conflict in May 2021. The AF will not finance vaccine purchase but will support the infrastructure needed for vaccine deployment. Therefore, this updated Environmental and Social Management Framework (ESMF) is prepared to guide the West Bank and Gaza COVID-19 Emergency Response Parent Project and Additional Financing activities to comply with the national regulations and the World Bank’s Environmental and Social Framework (ESF). This ESMF outlines the framework and procedures for environmental and social screening, determining the required environmental assessment documents and assessment of environmental and social impacts arising from proposed project components/activities, and gives generic guidance on appropriate mitigation measures, and institutional arrangements for monitoring. This framework is needed since specific project locations under the AF are yet to be determined. Where necessary, based on the screening process (Section 6.2), site specific ESMPs, according to the guidance in Annex II, shall be prepared during project implementation. Additionally, this updated ESMF has taken into consideration the environmental and social ex- post audit which has been conducted for the parent project and has been disclosed on MoH and 2 https://documents1.worldbank.org/curated/en/178021624889455367/pdf/Gaza-Rapid-Damage-and-Needs- Assessment.pdf 2 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF the World Bank’s websites on September 30, 2021. The ex-post environmental and social audit was requested by the World Bank as most of the implementation of the parent project was conducted in an expedited pace during the emergency in 2020 prior to the hiring of the Environmental Health and Safety Officer (EHSO). As such, the commitments in the ESCP were not met in time, and due to the lack of the MoH’s E&S capacity at the time, E&S progress was very slow. Hence, the E&S audit has resulted in a Corrective Action Plan (CAP), which shall be implemented prior to the effectiveness of the AF. Key stakeholders that have been involved through the Parent Project and will continue to be involved with implementation or monitoring of the Additional Financing are: • Ministry of Health (MoH) • Environment Quality Authority (EQA) • Health workers in the participating Health facilities • Members of Vulnerable and Marginalized Groups Additionally, during the conducted consultation meetings for the Additional Financing, the Ministry of Social Development (MoSD) has been identified as a key stakeholder in the project. This arises from the updated GM for the project, which now includes MoSD as the referral channel for GBV related grievances submitted to the project. Further details are provided in section 8.5. Moreover, capacity building will be essential for effective implementation of the ESMF. During the implementation of the Parent Project, MoH has hired a full time EHSO. The PMU at MoH, at the moment is lacking a health specialist; however, announcements have been made in order to contract a part time health specialist who will support in the reporting on COVID-19 for the AF. As the contracting of the EHSO came late during the Parent Project’s implementation, the EHSO capacity will be enhanced through trainings that will be conducted during the implementation of the AF, to ensure effective monitoring of installation of equipment and operation phases, and the monitoring of environmental and social impacts as provided in this ESMF, the EHSO capacity enhancement is recommended in areas of: • Impact assessment • World Bank ESF– Implementation requirements of the specific/applicable Environmental and Social Standards • Environmental monitoring • Stakeholder engagement • Grievance management • Management of environmental and social aspects in health care facilities Health Care Waste ManagementMain generic impacts associated with the Parent Project and risks anticipated under the AF are discussed in Chapter 5, following a project life-cycle approach entailing planning, construction (if any needed), transportation, installation, and operation. Infection Control and Waste Management Plan (ICWMP) template is provided in Annex III, and the Infection Prevention and Control Protocol (IPCP) have both been updated for the AF to reflect the most recent findings and scientific updates with regard to the pandemic and the infection control and waste management measures related to COVID-19. At the start of the pandemic and for the preparation for the parent project, a consultation was held with entities below to obtain 3 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF views about issues related to COVID-19 Emergency Response operation including existing facilities/ resources, challenges, resource needs and general state of preparedness: • WHO, UNICEF and UNRWA; • Bank of Palestine; and • Ministry of Foreign Affairs After the contracting of the EHSO, and for the preparation of the AF, several stakeholder consultation meetings have been conducted to inform stakeholders of the progress done under the Parent Project and the proposed activities for the AF. A summary of the stakeholder engagement process is presented in Section 8 and more details are provided in the Updated Stakeholder Engagement Plan (SEP) which has undergone the updating to reflect stakeholder engagement requirements, engagement methodology, information dissemination, and conducted engagement meetings for the AF. Implementation of the project activities shall also follow operational guidance by the Ministry of Health (MoH), WBG ESH guidelines and the WHO guidelines on management of COVID-19 pandemic. Effective implementation of the ESMF will require adequate capacity enhancement for MoH. This is covered under sections 9.3 of this ESMF. The indicative budget associated with implementing the updated ESMF as well as monitoring of environmental and social risks associated with the project is estimated at US$195,000. The E&S instruments as required by the ESF, include the Stakeholder Engagement Plan (SEP) and the Labor Management Procedure (LMP) which were both prepared for the parent project and updated for the AF. The type of E&S instruments and the sequencing of development and implementation are defined in the Environmental and Social Commitment Plan (ESCP) of the Parent Project and its AF. 1. Background & Rationale for Additional Financing An outbreak of coronavirus disease (COVID-19) caused by the 2019 novel coronavirus (SARS- CoV-2) has been spreading rapidly across the world since December 2019, from Wuhan, Hubei Province, China to almost all counties and territories globally3. As of December 14, 2021, the outbreak has already resulted in nearly 441,882 confirmed cases and 4,465 deaths 4 in the Palestinian Territories. During July and August 2021, a new wave hits the West Bank and Gaza with around 25,421 and 61,434 confirmed cases for each month respectively5, with Gaza having the higher share of recorded cases, indicating the concentration of the pandemic in the conflict- impacted strip. During the end of 2021, registered cases in the West Bank and Gaza saw a decrease 3 John Hopkins University, Coronavirus Resource Center - https://coronavirus.jhu.edu/map.html 4 World Health Organization in occupied Palestinian territory, 7 October 2021. COVID-19 situation report 82. 5 http://site.moh.ps/Index/covid19/LanguageVersion/1/Language/ar 4 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF in the registered confirmed cases, but with also a decline in the number of testing conducted daily, with October having 19,710 confirmed cases, declining significantly in November and up to date in December to 7,017 and 4,301 cases consecutively. The majority of total active cases in Palestine are recorded in Gaza, attributable to the impact of the conflict in the strip, weak health system capacity, as well as spread of the more contagious Delta variant, highlighting remaining needs for effective pandemic response. Health system capacity remains stretched, with overall bed occupancy rate at 55 percent and intensive care unit (ICU) bed occupancy rate at 80 percent. Over the coming months, the outbreak has the potential for greater loss of life, significant disruptions in global supply chains, lower commodity prices, and economic losses in both developed and developing countries. The COVID-19 outbreak is affecting supply chains and disrupting manufacturing operations around the world. Economic activity has fallen in the past few months, especially in China, and is expected to remain depressed for months. The outbreak is taking place at a time when global economic activity is facing uncertainty and governments have limited policy space to act. The length and severity of impacts of the COVID-19 outbreak will depend on the projected length and location(s) of the outbreak, as well as on whether there is a concerted, fast track response to support developing countries, where health systems are often weaker. With proactive containment measures, the loss of life and economic impact of the outbreak could be arrested. It is hence critical for the international community to work together on the underlying factors that are enabling the outbreak, on supporting policy responses, and on strengthening response capacity in developing countries – where health systems generally are weak, and the population vulnerable. The World Bank Group (WBG) has created a dedicated, COVID-19 Fast Track facility to help developing countries address emergency response to and impacts of the outbreak. The WBGs COVID-19 Fast Track facility is a globally coordinated country-based response to support health systems and emergency response capacity in developing countries, focused largely on health system response, complemented by support for economic and social development. The WB’s support includes financing and technical assistance (TA). In terms of TA, to date, the WB has contributed to the WHO-led development of a Strategic Preparedness and Response Plan outlining public health measures for all countries to prepare for and respond to 2019‑nCoV. The strategic objectives of the Plan are to: limit human-to-human transmission; identify, isolate, and care for patients early; identify and reduce transmission from the animal source; address crucial unknowns regarding clinical severity, extent of transmission and infection, treatment options, and accelerate the development of diagnostics, therapeutics, and vaccines; communicate critical risk and event information to all communities, and counter misinformation; and minimize social and economic impact through multi-sectoral partnerships. To support these, the Plan relies on three pillars: (a) rapidly establishing international coordination to deliver strategic, technical, and operational 5 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF support through existing mechanisms and partnerships; (b) scaling up country preparedness and response operations, and (c) accelerating priority research and innovation. 1.2 Country Context The pandemic poses unique public health risks in Palestine given the already stressed health systems, the presence of specific at-risk populations, the uncertain political situation impacting impoverished groups especially chronically ill patients whose access to health care is limited due to system fragmentation and closures of the territories. Movement restrictions and containment efforts within Palestine as well as between the Palestinian territories and Israel due to the COVID- 19 pandemic have caused, and are still likely to cause a significant income shock to many households. The global economic slowdown from COVID-19 has impacted health services in Palestine, both because of the limited capacity of the health supply and the overreliance on out-of- pocket expenditures at the point of care. Hence, interventions to strengthen the health care system in the Palestinian Territories have the potential to mitigate impacts on the public health and the economy. 1.3 Sectoral and Institutional Context The public sector makes up the bulk of the health service delivery system in Palestine , especially the primary and secondary health care, through a network of governmental primary health care (PHC) centers and hospitals in the different governorates. With regard to tertiary health care services (specialized medical services), the MoH also plays a key role through specialized services offered in its hospitals on one hand, and by purchasing services not available in governmental hospitals from other national specialized hospitals and medical centers (East Jerusalem hospitals and private hospitals) on the other. The MoH is the main provider of secondary health services (hospital care) in Palestine, running 3,258 hospital beds in 26 hospitals throughout the country, out of 80 hospitals in Palestine with the capacity of 6,006 beds. Out of these, 50 hospitals are located in the West Bank with the capacity of 3,607 beds, accounting for 60% of total hospital beds in Palestine, and the rest are located in Gaza Strip. The health sector challenges in Palestine have been significantly exacerbated by the strain imposed on the health system by COVID-19, and it is classified as a high-risk setting with limited response capacity. First, the 2015 Report on International Health Regulations (IHR) Joint Assessment conducted by WHO and the Norwegian Public Health Institute indicated limited capacities in key areas. Second, given the limited fiscal space and low public health spending which constituted only 33% of total health spending in 20186, there is little space to increase public spending to 6 “Palestine Health System Financing: health expenditures and financial protection, trends, benchmarking and HSRS project implications� The World Bank, February 2019 6 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF allocate additional resources to COVID-19 without jeopardizing the already strained service delivery. Third, given the low health system capacity, particularly in Gaza, the response capacity remains limited: for example, with limited infrastructure and water and electricity cuts in Gaza putting patients at risk, the health system would not be able to respond to an increase in COVID- 19 cases. Additional strains have been put on the health sector due to the latest conflict in May 2021, and its impact on the COVID-19 emergency response. Finally, COVID-19 and the imposed closures during 2020 and early 2021 jeopardized mobility and referrals, implying the urgency to improve preparedness within the Palestinian territories. To avoid instituting an additional strain on the already strained health system, as witnessed during late 2020 and early 2021 where hospital occupancies ran over 100%, it is essential to take necessary preparedness and mitigation measures for COVID-19 in Palestine. Furthermore, although the vaccination campaign is underway, it will take time for West Bank and Gaza to fully vaccinate the majority of its population. As of December 15, 2021, 50% of the targeted population (citizens over the age of 12) have received at least one dose of a COVID-19 vaccine, and 42.5% of the population has been fully vaccinated against COVID-19 7 . The government’s National Vaccine Deployment Plan (NVDP) indicates a 60% full immunization target by the end of this year, which is unlikely to be reached given the current pace. The recent conflict in Gaza has further amplified financing needs and gaps. In June 2021, following the May 2021 Gaza conflict, the World Bank Group in collaboration with the European Union (EU) and United Nations (UN) published the Gaza Rapid Damage and Needs Assessment (RDNA). According to the RDNA findings, the sector that has been most impacted by the conflict is the Social Sector comprised of housing, health, education, social protection and jobs. The recent escalation of violence in Gaza has resulted in a significant impact on the health sector. Health infrastructure in Gaza has suffered significant damage, including damage to 6 hospitals, 7 clinics, one health center, and two laboratories. Total estimated impact of the conflict includes US$10-15 million in damages, US$15-20 million in losses, and US$30-40 million in recovery and reconstruction needs in the next two years just for the health sector. This corresponds to about 20% of total annual health spending in Gaza, highlighting the immense financing burden especially against the backdrop of COVID-19. The RDNA highlights the importance of delivering direct assistance and strengthening systems that deliver public and social services in the areas of social protection, health care, education among others. In order to address the emergency in Gaza and West Bank, the Ministry of Health (MoH) has requested that the Project needs additional financing to respond to the COVID-19 recovery and 7 Corona.ps/vaccine 7 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF resilience efforts in West Bank and Gaza as well as to the worsening socio-economic conditions in Gaza. The scope of the additional financing (AF) is described in Sections 2.4 and 2.5 below. 2. Project Description 2.1. Project Development Objective The PDO for the AF will remain the same as for the Parent Project: to prevent, detect, and support immediate response to the threat posed by the COVID-19 pandemic and strengthen the WB&G health system for public health preparedness. 2.2. Parent Project The WB&G Covid-19 Emergency Response Project (P173800), herein known as the Parent Project, is funded by the World Bank aiming at enhancing the national capacity of the PA and MoH in facing and containing the COVID-19 pandemic. The Project supported the MoH during the emergency conditions that have been imposed in the West Bank and Gaza (WB&G) due to COVID-19 situation. This emergency operation includes three components to strengthen the MoH’s capacity to respond to the COVID-19 outbreak and potential future pandemics by enhancing the capacity to prevent further transmission, detecting cases at early stages, and providing appropriate and timely care for those affected by current COVID-19 outbreak. The Parent Project also provided funding for streamlined and harmonized support to the MoH complementing and exploiting synergies with other partners’ support. The activities funded under the Parent Project helped to operationalize some elements that are part of the inter-agency plan, complementing, expanding and intensifying the responses rapidly. Parent Project components The “West Bank and Gaza COVID-19 Emergency Response� Parent Project, with a total budget of 5 USD million, comprises the following components: Component 1: Emergency COVID-19 Response (US$ 2.1 million) The aim of this component is to slow down and limit as much as possible the spread of COVID- 19 in the country. This will be achieved through providing immediate support to enhance case detection, confirmation, recording and reporting, as well as contact tracing and risk assessment and mitigation. Specifically, this component aims to strengthen epidemiological surveillance systems, including indicator-based, community event-based, and sentinel surveillance. It also develops guidelines and establishes standardized sample collection methods, channeling, and transportation, and determining sites in need for introduction of point of care diagnostics. Further, the component supports the procurement of essential equipment and consumables for laboratory and diagnostic systems, and Personal Protective Equipment (PPEs) for surveillance workers to 8 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF ensure prompt case finding and local containment. The Project only finances inputs aligned with WHO guidelines and standards for combating COVID-19. In addition, the component supports strengthening of detection capacity through updated training of existing surveillance workers and improving reporting by frontline health workers using existing surveillance information. Further, this component supports the design and implementation of effective public health measures to prevent contagion and will also support the development and implementation of associated communication and behavior change interventions to support key prevention behaviors. Community mobilization and participation in prevention and control measures will also take place through existing community institutions. Finally, the component supports activities to enhance multi-sectoral response and action, including inter alia: the operations of command rooms at the central and regional levels; implementation of risk commutations and community engagement campaigns; implementation of containment strategies, including port-of-entry interventions and operation of rapid response teams. Component 2: Strengthening Overall Healthcare Services and Clinical Capacity to Respond to COVID-19 (US$ 2.1 million) The aim of this component is to strengthen essential healthcare service delivery to be able to provide the best care possible for people who become ill despite a surge in demand. The component supports the strengthening of selected health facilities and establishment and equipping of quarantine and treatment centers, to better manage COVID-19 cases. In addition, strengthened clinical care capacity is aimed to achieve development (as needed) and training of health personnel on treatment guidelines, and hospital infection control interventions. This component further supported the procurement of essential additional inputs for treatment such as fluoroscopy machines, Anesthesia machines, central public health lab needs, Personal Protective Equipment (PPE), ventilators, pulse oximeters, laryngoscopes, oxygen generators, and other equipment/supplies for COVID-19 case management. I This component also supplies general vaccines as part of the regular immunization program in WB&G i.e., the Pneumococcal (PCV) vaccines which is provided as part of the basic ongoing health services delivery. The Project will only finance inputs aligned with WHO guidelines and standards for combating COVID-19, such as the procurement of Personal Protective Equipment (PPE), disinfectants and other commodities for infection prevention and control. Furthermore, under this component, inputs and investments needed to ensure continuity of clinical care, including safe access to waste management, electricity, safe water and sanitation of hospitals will be provided. This component also finances hiring medical and non-medical short-term consultants to respond to a surge in demand for services due to the COVID-19 pandemic in selected hospitals. Finally, this component is to ensure that investments will strengthen the overall health system readiness to respond to public health crisis following the recommendations of the IHR analysis conducted by WHO and the Norwegian Institute of Public Health. 9 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Component 3: Project Implementation and Monitoring (US$ 0.8 million) This component finances necessary human resources and running costs for the Project Management Unit at the MoH (MoH’s PMU). In case additional staff is needed, particularly in the first months for speedy and effective project management, additional support with short-term consultants for the PMU may be hired under this component. In addition, this component finances the financial and technical audits related to the Project. 2.3. Additional Financing During 2021, Additional Financing (AF) to the Parent Project has been proposed in order to expand upon Parent Project activities. It will be national in scope and is intended to strengthen the country’s capacity to respond to health emergencies in general, and to scale-up activities undertaken as part of the Parent Project to respond to the ongoing COVID-19 pandemic and potential future pandemics. The AF is in the amount of US$2.5 million financed by the Health Emergency Preparedness and Response Multi-Donor Trust Fund (HEPRTF) and US$ 1.25 million in emergency funding earmarked to Gaza following the latest conflict in May 2021. The AF will not finance vaccine purchase but will support investments needed for vaccine deployment, specifically through supporting the immunization infrastructure such as the cold chain including for transportation, storage equipment under components 2, as well as mobile clinics. No expansion of facilities or building of new facilities, building new incinerators, chemical disinfection, wet thermal treatment, microwave radiation, land disposal, wastewater processes or any healthcare activity that is a source of air emissions or effluents will be part of the project’s AF. The AF will not finance vaccine purchase as part of the project, but MoH will identify the risks and impacts associated with vaccines and ensure the implementation of the required mitigation measures related to the vaccine deployment. 2.4. Additional Financing Components The components of the Parent Project will remain the same. Components 1 and 2, namely “Emergency COVID-19 Response� and “Strengthening Overall Healthcare Services and Clinical Capacity to Respond to COVID-19,� will not be changed. Rather, the Additional Financing will include the addition of component 3, “Supporting Emergency Health Sector Needs and COVID-19 Response.� This new component will be added for the AF to ring-fence the HEPRTF funds. US$3.65 million of the US$3.75 million in additional financing will be added to component 3. A list of drugs, medical supplies, and medical equipment that would be procured under component 3, financed by the HEPRTF, has been shared with the World Bank by the MoH. All items have been technically reviewed and assessed as being relevant for COVID-19 response by the World 10 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Bank, and they are similar to the types of supplies financed under the Parent Project. This list includes: I) emergency medicines, focusing on treatment of health emergencies and chronic conditions; II) emergency medical devices and equipment, including defibrillators, V/S monitors, emergency trolleys, consumables, patient beds, Intensive Care Unit (ICU) beds, mobile clinics, mobile blood banks, flow cytometers, electrical supplies, freezers, and refrigerated vehicles (not ultra-cold chain). The project will thus finance additional essential, life-saving medical equipment to scale up its developmental impact. Moreover, as the former component 3 is now assigned as component 4 (formerly component 3, “Project Implementation and Monitoring, for the Additional Financing�). The remaining US$100,000 from the HEPRTF funds will be added to component 4: Project Implementation and Monitoring. The funds will be used to strengthen project implementation and monitoring, as well as audit costs and compliance with the ESCP. The PMU through this funding will continue financing an Environmental, Health, and Social Officer (EHSO) initially financed by the Parent Project. 2.5. Project Beneficiaries The expected project beneficiaries of the Parent Project and AF are the entire population, medical and emergency personnel, medical, laboratory and testing facilities, and health agencies across West Bank and Gaza (WB&G). The population size of the Palestinian territories (Pt) is 4.78 million (2017). For immediate response to stop the transmission and allocate necessary resources for treatment of cases, the project specifically targets governorates and communities that have seen local transmission 8 . The operation will also strengthen the MoH national response plan and capacity to mitigate any further outbreaks in other localities. 3. Policy, Legal and Regulatory Framework This chapter describes the following: • Country specific policy, legal and administrative frameworks relevant to the project; • World Bank environmental and social standards (ESS) relevant to the project; 8 State of Palestine. Preliminary Results of the Population, Housing and Establishments Census, 2017. Palestinian Central Bureau of Statistics. February; 2018. Accessed on March 12, 2020 at http://www.pcbs.gov.ps/portals/_pcbs/PressRelease/Press_En_Preliminary_Results_Report-en-with-tables.pdf 11 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF • World Bank Group Environmental, Health and Safety Guidelines (EHS Guidelines) relevant to the project; • Relevant international good practices technical references such as WHO guidelines. 3.1. Policy Framework in Palestine 3.1.1. Palestinian Environmental Law The Palestinian Environmental Law (PEL) No. 7 of 1999 was developed by EQA to protect environmental resources, including land environment; air environment; water resources and aquatic environment; and natural, archaeological and historical heritage. According to the PEL, the protection of these resources shall be addressed in all social and economic development plans to promote sustainable development and protection of the rights of future generations. The core issues of concern in the PEL are the protection of public health and social welfare, as well as the conservation of ecologically sensitive areas, biodiversity and rehabilitation of environmentally damaged areas. The PEL also sets penalties for violating any article presented under this law. 3.1.2. The Palestinian Environmental Assessment Policy, 2000 EQA developed the Palestinian Environmental Assessment Policy of 2000 as a leading authority for the approval of environmental assessment studies. This policy aims to achieve the following goals: • Ensure an adequate quality of life in all aspects, and ensure that the basic needs and social, cultural, and historical values of the people are not negatively impacted as a result of development activities • Preserve the capacity of the natural environment • Conserve biodiversity and landscape, and promote the sustainable use of natural resources • Avoid irreversible environmental damage and minimize reversible environmental damage from development activities. In accordance with the policy, project proponents are required to apply for environmental approval that informs the EQA and relevant approving authorities of the intended project activities. Subsequently, a determination is made whether an initial environmental evaluation (IEE) or a detailed environmental impact assessment (EIA) is required. 12 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF The IEE is for projects where significant environmental impacts are uncertain, or where compliance with environmental regulations must be ensured, whereas an EIA is required for projects which are likely to have significant environmental impacts. Stakeholder consultation is mandatory by PEAP for EIA. At the minimum, the proponent must meet with the principal stakeholders to inform them about the proposed project and to solicit their views. The methods and results of the consultations must be documented. 3.1.3. Relation to the project: This policy is the foundation of all environmental assessment requirement in Palestine. The Public Health Law, 2004 The Public Health Law of 2004 lists MoH functions and responsibilities, which include delivery of the government’s preventive, diagnostic, curative and rehabilitative health services; regulation of the health sector functioning to ensure high level of harmonized and integrated work between the different service providers and sectors; development of national health regulations, laws and policies; and reinforcement of the health financing system and optimal investment of the available resources. 3.1.4. The National Health Strategy 2017-2022 The National Health Strategy 2017-2022 is anchored in six national strategic objectives, as follows: • Ensure the provision of comprehensive health care services for all citizens towards nationalization of health services in Palestine. • Promote programs for the management of non-communicable diseases (NCDs), preventive health care, community health awareness and gender issues. • Mainstream quality systems in all aspects of health service delivery. • Enhance and develop the human resource management system. • Enhance health governance, including effective management of the health sector, enforcement of laws and legislations, cross-sectoral coordination and integration among service providers. • Enhance health financing and improve financial protection of Palestinian citizens against health costs. Relation to the project: The public health law and the national health strategy are the foundation of health laws in Palestine 13 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 3.1.5. Occupational Health and Safety (OHS) Many laws, resolutions, and ministerial instructions and decisions have addressed, inter alia, issues of occupational safety and health, and suitability of the working conditions. The Palestinian Labor Law No. 7 of 2000 guarantee workers' rights to occupational safety and health at workplace and regulate inspection of work conditions by the competent authorities, and other areas, as follows: Occupational Health and Safety Regulations Articles No. 90, 91, and 92 of the law provided that, the cabinet shall issue the regulations governing the occupational safety and health and work environment. Such regulations shall in particular provide for personal protection and prevention methods for workers from the work hazards and occupational diseases; the necessary health conditions in workplaces; first medical aid means at the establishment; and routine medical examinations of workers. The law also prohibits cutting any expenses or deductions from the workers’ wages in return for the provision of occupational safety and health requirements at the workplace. Following the Labor Law, several resolutions and ministerial instructions were issued detailing health conditions and standards related to occupational safety at different workplaces. These include: • The ministerial decrees No. 15, 17, and 21 of 2003 concerning health conditions and standards at workplaces, medical assistance procedures at the workplace, and safety standards at companies. • The Decision of the Council of Ministers No. (49) of 2004 concerning the preventive list of work hazards and career diseases and work accidents. • Instructions by the Minister of Labor no. (1) of 2005 concerning the precautions to protect workers in construction sites. • Instructions by the Minister of Labor no. 2-6 of 2005, defining the range of chemical exposure limits and standards, exposure to ionizing radiation, noise, and safe levels of brightness of light and temperature at the workplaces. 3.1.6. Strategies, Action Plans for Solid Waste Management The major strategies relevant to solid waste management include: the National Strategy for Solid Waste Management (2017-2022), the Environment Sector Strategy (2020-2023), the National Policies Agenda (2018-2022), the Strategic Framework for Ministry of Local Government (MoLG) (2010-2014) and the Cross Sectoral Strategy for Palestinian Local Government and Administration Sectors (2011-2013). Cross Sectoral Strategy for Palestinian Local Government and Administration Sectors 14 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF The National Strategy for Solid Waste Management for the period 2017-2022 is the second national strategy on solid waste management. The main goal of the strategy is continuous remediation of key issues, setting updated legislative, organizational, technical, and economical foundation for more efficient Solid Waste Management with the key issues and putting the same into force with the frame of a continuous process not only to alleviate the negative impact of Solid waste on health and environment, but also enhance investment in this section, and thus achieve the necessary development. The strategy includes (8) strategic Objectives and (18) policies. Strategic Objective 5 describes principles and mechanism suitable for managing medical, hazardous, and special waste. Policy 11entails establishing appropriate and unified inventory and tracking system for hazardous waste, and availability of necessary information, creating sound and safe systems (separation, collection, transfer and disposal processes) to manage it. Policy 12 includes the treatment of medical waste before its final disposal, according to the “polluter pays� principle, to limit its negative health and environmental impacts. And Policy 13 focuses on the need to manage special waste in a manner that ensures protection of health and environment. The Environment Cross-Sectorial Strategy (2017-2022) is one of the main cross sectorial strategies announced through the National Policy Agenda (2017-2022). It includes main development pillars, national priorities, and policies developed in coordination with international agencies. The Agenda is the reference document for the development of the cross sectorial development plans and programs and the development of the national agenda aiming to ensure social justice and enhancing quality service delivery to citizens. The National Policy considers the environment as a cross-sectorial theme to be integrated in all policies and programs. The Environmental Cross Strategy has (5) goals, the first is an efficient and environmental and health safe disposal of solid waste Solid waste management including hazardous waste including medical waste The Strategic Framework for MoLG (2010 - 2014) and the Cross Sectoral Strategy for Palestinian Local Government and Administration Sectors (2011 - 2013): of the sectoral strategic objectives identified in the Strategic Framework for MoLG (2010-2014), the following are related to the institutional aspects of solid waste management: (i) increase the level of decentralization between MoLG and Local Government Units (LGU’s); (ii) enhance the institutionalization of community participation; (iii) strengthen partnership between the LGU’s and the private and public sectors, as well as the civil society organizations in order to achieve sustainable development. Medical Waste Bylaw (2012) 15 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 3.1.7. The Medical Waste Bylaw (http://site.moh.ps/index/ArticleView/ArticleId/4416/Language/ar) related to medical waste management and handling is enacted by Ministerial Cabinet Decision No. 10 for the year 2012. The Medical Waste Bylaw identifies roles and responsibilities in medical waste management, definition of waste management, procedures and specifications for medical waste separation, storage, collection, transport, treatment as well as waste tracking.COVID-19 Considerations 3.1.7.1. Palestine’s COVID-19 Response Plan, April 2020 The purpose of this plan9 is to: Present the Government of Palestine’s (GoP) strategy and actions; Propose an aid coordination approach; Identify the critical support needs, including for: public health response to COVID-19; budget support to maintain government services; and diplomatic engagement with regional partners; and Describe the Government expectations of the longer-term economic impact of COVID-19 and required economic recovery actions. 3.1.7.2. Manual for procedures, working mechanisms and prevention of COVID-19 at Palestinian Hospitals, 2020 This manual was developed by MoH with reference to several WHO and CDC documents. The manual covers several topics including: preventive instructions, general instructions for health workers at hospitals, personal protective equipment (PPEs), the use of PPEs in health facilities, donning and doffing PPEs, locations methods of surveillance and classification of confirmed or suspected cases at hospitals, characteristics of a COVID-19 ward/section, swab collection and transportation, how to deal with the laboratory, at radiology department, how to deal with patients before service provision, in ambulance, with patients in operating theaters, and in hemodialysis wards. The Manual further includes methods to deal with patients’ bed covers, linens, etc., and clothes and disinfecting methods in hospital laundries; instructions for hospital cleaning companies and medical waste management and dealing with fatalities/death. 3.1.7.3. Prevention of Corona virus: an awareness manual about the virus. MoH (General directorates of PHC and PH); 2020 This manual provides information on the transmission methods of the virus, signs and symptoms of the infection, prevention methods, guidelines for travel, correct method for hand washing, instructions for home quarantine (for quarantined and family); and common questions about COVID-19 (questions and answers). 9 https://www.ochaopt.org/sites/default/files/covid-19-response-plan-inter-agency-opt.pdf 16 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 1. Several pamphlets and leaflets were developed by MoH with support from different international and local organizations, such as WHO, UNICEF, UNRWA, World Vision, Bank of Palestine, The Palestinian International Cooperation Agency (PICA), etc. Examples include: general information on Covid-19, preventive medicine contact persons and phone numbers, home quarantine for infected and contacts, proper method for donning a mask, guidelines in social events, etc. http://site.moh.ps/index/ArticleView/ArticleId/4941/Language/ar 2. Videos on Covid-19, such as prevention methods, preparation of quarantine centers and hospitals in different governorates, interviews with different departments of MoH and their working during Covid-19 pandemic, health protocols, support to the health sector during Covid-19,etc.: http://site.moh.ps/index/video/Language/ar 3. Corona surveillance system on MoH website which provides a summary of the situation of COVID-19 in Palestine: http://site.moh.ps/index/covid19/LanguageVersion/2/Language/ar 4. Corona in Palestine. This website provides daily update on the situation of Covid-19 in Palestine with detailed statistics: wwe.corona.ps Relation to the project: The sections listed above were prepared to response and combat the COVID-19 epidemic in Palestine. 3.2. Institutional Framework in Palestine 3.2.1. Environment Quality Authority (EQA) The Environment Quality Authority has replaced the former Palestinian Environment Authority and the Palestinian Environmental Affairs Authority, which were established in 1996 and 1998 by a decree from the President of the Palestinian National Authority. EQA plays an important role as the planning, coordinating and executive body to improve environmental standards and attitude in the Palestinian Territories. Being the central representative authoritative body responsible for all environmental issues in the Palestinian Territories, EQA addresses all environmental constraints, including natural resource depletion and environmental pollution, as an approach towards sustainable development. 3.2.2. Ministry of Health (MoH) The MoH is the responsible national institution for leading and regulating the functioning of the health sector and ensuring the necessary resources for its sustainability and development in response to the changing and increasing needs of the entire population. MoH is responsible to undertake policy formulation, quality assurance, coordination, monitoring and evaluation of health service delivery in Palestine. 17 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Relation to the project: Ministry of Health is the implementation agency responsible for execution of this project. 3.2.3. National Institute of Public Health The Palestinian National Institute of Public Health (PNIPH) plays a key role in promoting health research, analyzing health information and indicators, and participating in the development of various health surveillance programs. In doing so, it provides the scientific evidence required to institutionalize strategic planning and national policymaking by decision-makers. 3.3. World Bank Environmental and Social Framework 3.3.1. Environmental and Social Standards (ESS) In accordance with the World Bank Environmental and Social Framework (ESF) for WB&G COVID-19 Emergency Response Parent Project and the AF, MoH is responsible for preparation of an Environmental and Social Assessment (ESA) in accordance with environmental and social standards (ESS1-ESS10). For the Parent Project, at the time of preparation of the original ESMF, the specific locations and detailed information about the sub-projects were not available and only became known during implementation. However, even during implementation, MoH lacked the E&S capacity as the EHSO was not recruited until May 2021; hence, no ESA was prepared for the parent project, and are not to be conducted as the procurement activities have already been concluded. Instead, an ex-post environmental and social audit has been requested by the Bank which resulted in a list of corrective items defined in the Corrective Action Plan (CAP). For the AF, at the current moment, site locations of AF activities are not yet known. Nevertheless, during implementation, the EHSO shall conduct ESA for each site/sub-project once identified. Hence, this updated ESMF for AF has been prepared. The ESF further requires early consultations with the affected groups and relevant stakeholders. All these standards are investigated below, and it is determined that ESS1, ESS2, ESS3, ESS4, and ESS10 are relevant to this operation. Because small works for installation of equipment, if needed, will be on existing hospital grounds or other health care facilities which are government owned sites, therefore, no new land will be acquired or accessed. The Project’s AF will not finance new construction or expansion of existing ones. As such, AF activities are not expected to lead to involuntary resettlement issues, such as land acquisition, physical or economic displacement, or restriction of access to natural resources. Nonetheless, MoH will conduct regular E&S screening before the start of the works to ensure that the AF activities will not lead to any resettlement issues. All other standards will be investigated further during the preparation of follow-up instruments and their relevance will be determined. ESS1: Assessment and Management of Environmental and Social Risks and Impacts: Given that the AF will support the procurement of drugs, supplies and medical equipment, the environmental and social risks will mainly be associated with transportation and delivery of such 18 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF clinical supplies as well as indirect risks linked to operation of the laboratories or health care facilities receiving this support. As for the parent project, AF activities will generate medical wastes which can also include chemicals and other hazardous materials used in diagnosis and treatment. The contamination of the laboratory facilities and equipment may result from laboratory procedures: performing and handling of culture, blood specimens and other chemicals. If the contamination is due to a highly infectious agents such agents may cause severe human disease, present a serious hazard to workers, and may present a risk of spreading to the community. Environmental risks remain high during transportation and disposal of such waste if not achieved in line with international good practices and guidelines for healthcare waste acceptance and packaging. WHO has reported that 20% of total healthcare waste would be infectious waste, and improper handling of health care waste can cause serious health problem for workers, community, and the environment. Medical wastes have a substantial potential of carrying micro-organisms that can infect people who are exposed to them, as well as the community at large if they is not properly disposed of. Wastes that may be generated from laboratories, quarantine facilities and screening posts to be supported by the COVID-19 response project may include liquid contaminated wastes (e.g., blood, other body fluids and contaminated fluid) and infected materials (water used; lab solutions and reagents, syringes, bed sheets, majority of waste from laboratories and quarantine and isolation centers, etc.), which require special handling and awareness, as they may pose an infectious risk to healthcare workers and the public. It is also important to ensure that sharps and needles are properly disposed of. In sum, the medical wastes from COVID-19 could cause substantial environmental and social risks, if they are not properly handled, treated, or disposed of. The AF activities might also involve small-scale works in health care facilities during the installation of equipment and the small civil works, if needed, that will generate solid waste. Additionally, as the AF activities will support the infrastructure needed for vaccine deployment (indirectly), proposed activities include cold storage and refrigirated vehciles which could impose transportation safety risks. The AF will finance oxygen, oxygen cylinders and oxygen concentrators which are hazardous materials that must be managed in terms of their use, storage and handling. Risk of fire in the existing HCFs accessible to the public where project activities will be conducted is also of concern. Given the environmental risks involved and the limited capacity of the MoH to deal with those risks, the Environmental Risk Classification is “Substantial�. The social risks are considered moderate to substantial, mainly related to risk of the capture of project benefits by the elites, and exclusion of the poor, elderly, those with disabilities and vulnerabilities. The main challenge, therefore, is to make sure the procured items needed to prevent, detect and clinically manage COVID-19, are distributed in a transparent manner, ensuring equity and reaching the affected population. 19 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF To mitigate and manage the AF’s environmental and social risks as described above, this updated ESMF is being prepared to provide guidance on assessment and management of likely environmental and social impacts before commencement of the AF implementation. All proposed activities shall be subjected to environmental and social screening and where necessary, specific instruments shall be prepared before commencement of applicable/eligible activities. Specific mitigation measures will be outlined in the site specific ESIAs or ESMPs, as determined in the ESA, and implemented, when necessary. Safe work protocols shall be developed and implemented for hazardous tasks such as electrical circuits. Health screening and COVID-19 prevention measures for workers have been incorporated into the OHS procedures outlined in this ESMF. Emergency response and handling procedures shall be developed by contractors, if involved, to handle any accidents onsite. Construction waste, if small scale civil works are to be needed, shall be managed in line with the National Waste Management Plan and the World Bank’s Environmental, Health and Safety Guidelines. And the transportation activities shall be governed by the transportation safety measures, which if determined needed by the ESA, will be expanded to a Transportation Safety Plan. Oxygen, oxygen cylinders and oxygen concentrators must be managed in accordance with WBG EHSGs requirements from Section 1.5 “Hazardous Materials�. Their use must include a hazard assessment of the potential for uncontrolled reactions such as fire and explosions and actions to manage these materials safely and the safety specifications for these materials and equipment. All existing HCFs accessible to the public should implement life and fire Safety requirements by incorporating all local building codes and fire department regulations. In summary, the mitigation measures can be summarized as follows: (i) providing Infection Prevention and Control Protocol (IPCP) for the safe handling, storage, and processing of COVID- 19 materials and techniques for preventing, minimizing, and controlling associated impacts, including management of the minor civil works, if need to be undertaken at the selected Hospitals/Health Facilities (Annex IV); (ii) implementation arrangements to be put in place by the Ministry of Health; provisions for training programs focused on COVID-19 laboratory biosafety, operation of quarantine and isolation centers and screening posts, as well as compliance monitoring and reporting requirements; (iii) including relevant guidance on health care waste management in an Infection Control and Medical Waste Management Plan (ICMWP) based on the Palestinian waste management plan and Good International Industry Practice (GIIP), especially WHO guidance (Annex III); (iv)effective waste reduction and segregation, ensuring that the small quantities of solid waste are collected and properly disposed of in the municipal landfill. To mitigate the social risks there are provisions for stakeholder engagement, including public information disclosure and outreach as part of the COVID-19 Response Plan. In this context, the MoH has with support from WHO prepared and activated Critical Readiness and Response Action (2020). Project’s AF implementation also needs to ensure appropriate stakeholder engagement to (i) avoid conflicts resulting from false rumors, (ii) vulnerable groups not accessing services, or (iii) issues resulting from people being kept in quarantine. Additionally, as the Parent Project has been conducted in an expedited pace, and due to the lack of E&S management and monitoring capacity 20 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF at the PMU of MoH at the time, and ex-post environmental and social audit has been requested by the World Bank and has been conducted by MoH through contracting an external E&S Specialist. The audit has provided MoH with an outcome on the implementation status of the E&S commitments as per the ESCP and the project’s instruments. Additionally, the E&S audit resulted in a Corrective Action Plan (CAP) to guide MoH in implementing its commitments to the Parent Project, to the AF, and future projects. The E&S audit, with the CAP, has been disclosed on the Bank’s and MoH’s webpages on September 30, 2021. Hence, these social risks and impacts will be mitigated through a (i) robust and coordinated national communication strategy promoting the Project’s objectives, tailored to various audiences to address issues of access and discrimination; (ii) development of materials (radio, infographics, TV broadcasts); and (iii) a grievance mechanism that will provide real time feedback. These aspects are detailed in the updated Stakeholder Engagement Plan prepared for AF in November 2021. The updated SEP includes measures for the inclusion of vulnerable communities through information disclosure and outreach throughout project preparation and implementation. The updated SEP objectives shall be followed during all stages of planning, design, and implementation of the AF activities to inform the stakeholders on the intention of the project, ensure that affected communities and potential beneficiaries have input and ownership of the project, inform about the project’s GM, and identify and mitigate any additional risks revealed by the consultation. In addition, the ESMF includes measures to mitigate risks of GBV/SEA/SH. Labor issues are detailed in the updated LMP. The LMP of the Parent Project was finalized in March 2021 and updated in December 2021 for the AF and includes guidelines for the establishment of two functioning grievance mechanisms for both project level and for project workers. The project’s and workers’ GM shall also receive complaints related to GBV and Sexual Harassment cases, the GBV grievances redress will follow a dedicated channel separate from the general project GM, it will be conducted in cooperation with the Ministry of Social Development through the National Referral System. Information about the existence of the GBV grievance mechanism and of channels to accept and respond to anonymous grievances will be communicated to all stakeholders during engagement activities. In addition to the ESMF, MoH will implement activities set out in the ESCP, and in the CAP that was the outcome of the ex-post E&S audit for the parent project, and all project activities shall be subjected to environmental and social screening and additional site-specific instruments that will be developed, reviewed and approved by both Government and the World Bank. ESS2 Labor and Working Conditions: Project activities under both the parent project and AF are expected to employ different categories of labor. This includes (i) direct labor (PMU government staff and people employed under the parent project to be engaged with MoH to provide health care services including medical doctors, general practitioners, laboratory technicians, workers, X-ray technicians and nursesdand (ii) primary supply workers who will be engaged with the suppliers . Additionally, contracted workers 21 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF would include the contractors’ workers if some of the potential civil works will be outsourced to third parties. COVID-19 specific risks will relate to the activities being carried out by the workers, where the project activities are being conducted. The key Occupational Health and Safety (OHS) risks for workers are contamination/infection with COVID-19 which can lead to illness and death of workers. Staff of health facilities as well as all other workers involved in the procurement, delivery, training, use, supervision/monitoring, and/or handling and disposal of medical supplies, equipment, or waste products will receive necessary training on protecting themselves and others from COVID-19 infection. In addition, as the AF activities entail cold chain storage, refrigerated vehicles and mobile clinics, risks of transportation safety could arise, as well as other relevant OHS risks and management measures. The Project will ensure the application of OHS measures as outlined in WHO guidelines which are captured in the IPCP (Annex IV). This encompasses procedures for entry into health care facilities, including minimizing visitors and undergoing strict checks before entering; procedures for protection of workers in relation to infection control precautions; provision of immediate and ongoing training on the procedures to all categories of workers, and mandating hand hygiene and personal protective equipment (PPE); ensuring adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer); and overall ensuring adequate OHS protections in accordance with General EHSGs and industry specific EHSGs and following evolving international good practice in relation to protection from COVID-19. During implementation, the ESMPs, if required based on the ESA, will be regularly reviewed and updated to integrate the latest guidance from WHO as it evolves over time based on experience addressing COVID-19 globally. Staff of health delivery facilities will receive training under the project on how to use the medical equipment and supplies financed through the Project in a way that protects their health and safety. The codes of practice and Standard Operating Procedures (SOPs) implemented by MoH should be included in training requirements to workers to provide them with guidance on the requirements that they will be expected to observe in order to ensure their own safety from COVID-19 infection. During the implementation of AF activities MoH shall establish written procedures for protection of workers in relation to infection control precautions and include these in the labor management procedures (LMP) and in contracts as appropriate; provide immediate and ongoing training on the procedures to all categories of workers, and post signage in all public spaces mandating hand hygiene and PPE usage; the project level and workers’ GM shall remain responsive and be constantly updated to reflect recent findings to allow workers to quickly inform management of labor issues, such as a lack of PPE, delayed payment of salaries, unreasonable overtime, etc.; ensure adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer) are available; ensure 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; and require staff to follow protocols. The use of child or forced labor will be forbidden in accordance with ESS2 and Palestinian labor laws. 22 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF The updated LMP also includes HR policies and procedures in terms of employment, wages and benefits, hours of work, overtime arrangements and overtime compensation, annual and sick leave, vacation and holiday, health insurance and end of service benefits, responsive grievance mechanism as mentioned above and will also include provisions on restrictions to child labor and prevention of forced labor as well as commitment to non-discrimination and equal opportunities. More details are provided in the updated LMP. ESS3: Resource Efficiency and Pollution Prevention and Management, This standard is relevant for the parent project and AF. For the parent project, anticipated civil works were not required as equipment was installed in suitable locations without the need for any rehabilitation. However, for the AF, the possibility for needing minor civil works still stands. Solid Waste generated during the minor civil works for installation of equipment in the existing hospitals and health care facilities will mostly consist of municipal wastes that will be collected and disposed of in an authorized landfill. Medical wastes and chemical wastes (including water, reagents, infected materials, etc.) from the laboratories, quarantine, and screening posts to be supported (drugs, supplies and medical equipment) can have substantial impact on environment and human health. Wastes that may be generated from medical facilities/ laboratories could include liquid contaminated waste, chemicals and other hazardous materials, and other waste from laboratories and quarantine and isolation centers including of sharps, used in diagnosis and treatment. Each beneficiary medical facility/lab, following the requirements of the ESMF, WHO COVID-19 guidance documents, and other international good practices, will follow an Infection Control and Medical Waste Management Plan (ICMWP) and the MWMS to prevent or minimize such adverse impacts Annex III. This also provides guidance on site-specific instruments (ESMPs) covering key aspects such as transportation and management of samples and medical goods or expired chemical products. Resources (water, air, etc.) used in quarantine facilities and laboratories will follow standards and measures in line with WHO environmental infection control guidelines for medical facilities. Existing capacity for proper medical waste management at hospitals across Palestine is satisfactory, however considering the particular risks of further COVID-19 spread if waste is not handled properly, the medical waste management will be the key area of focus of capacity building and supervision under the project. ESS4 Community Health and Safety: This standard is relevant for the parent project and AF. In line with safety provisions in ESS4, it is equally important to ensure the safety of communities from infection with COVID-19 but also from the risks associated with workers. As noted under ESS2, medical wasteand general waste from the laboratories, health centers, and quarantine and isolation centers have a substantial potential of carrying micro-organisms that can infect the community at large if they are not properly disposed of. There is a possibility for the infectious microorganism to be introduced into the environment if not well contained within the laboratory or due to accidents/emergencies such as a fire response or natural phenomena event (e.g., seismic). The MWMS and the Infection 23 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Control and Waste Management Plan (ICWMP – Annex III) therefore describes how project activities will be carried out in a safe manner with (low) incidences of accidents and incidents in line with the MoH guidelines and Good International Industry Practice (WHO guideline & WBG EHS Guidelines). 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 workplace back into their communities. The project will thereby follow the provisions outlined in the ESMF, noted in ESS1. The operation of quarantine and isolation centers shall be implemented in a way that the hospital patients and the quarantined patients are treated in line with respective medical facilities, SOPs and international best practice as outlined in WHO guidelines. This includes the following requirements: Infrastructure: there is no universal social distance guidance regarding the infrastructure for a quarantine facility, but space should be respected not to further enhance potential transmission and the living placement of those quarantined should be recorded for potential follow up in case of illness; Accommodation and supplies: quarantined persons should be provided with adequate food and water, appropriate accommodation including sleeping arrangements and clothing, protection for baggage and other possessions and appropriate medical treatment. Further information is also included in the Centre for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in Healthcare Settings; Communication: establish appropriate communication channels to avoid panic and to provide appropriate health messaging so those quarantined can timely seek appropriate care when developing symptoms; Respect and Dignity: quarantined persons should be treated, with respect for their dignity, human rights and fundamental freedoms and minimize any discomfort or distress associated with such measures, including by treating all quarantined persons with courtesy and respect; taking into consideration the gender concerns of quarantined persons. The project will ensure the avoidance of any form of SEA/SH of patients and community members at large by relying on (i) the WHO Code of Ethics and Professional conduct for all workers in the quarantine facilities as well as the provision of gender-sensitive infrastructure such as segregated toilets and enough light in quarantine and isolation centers and (ii) World Bank guidelines on the mitigation of Sexual Exploitation and Abuse such as the signing of enforceable workers’ codes of conduct (CoC), A sample CoC is presented in the updated Labor Management Procedure (LMP) prepared for the project, sensitization of workers and affected communities, and establishment of referral pathways. Staff in PMU will sign Codes of Conduct. Codes of conduct need not be signed by other health service workers during crises if information on unacceptable behavior is 24 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF sufficiently disseminated. Publicly post or otherwise disseminate messages clearly prohibiting SEA/SH during the provision of health care, whether health service workers are perpetrators or survivors. The project will also ensure via the above noted provisions, including stakeholder engagement, that quarantine and isolation centers and screening posts are operated effectively throughout the country, including in remote and border areas, without aggravating potential conflicts between different groups including host communities and members of vulnerable and marginalized Groups. The project level GRM will include specific procedures for GBV, SEA/SH including confidential reporting and ethical documentation of GBV cases. In case quarantine and isolation centers are to be protected by security personnel, it will be ensured that the security personnel follow strict rules of engagement, taking into consideration the above noted needs of quarantined persons as well as the potential stress related to it. If the Palestinian police is mobilized as part of the government’s response to the emergency, the Project shall take measures to ensure that, prior to their involvement such personnel are: (i) screened to confirm that they have not engaged in past unlawful or abusive behavior, including sexual exploitation and abuse (SEA), sexual harassment (SH) or excessive use of force; (ii) adequately instructed and trained, on a regular basis, on the use of force and appropriate behavior and conduct (including in relation to SEA and SH); and (iii) deployed in a manner consistent with the national procedures. ESS5 Land Acquisitions, Restrictions on Land Use and Involuntary Resettlement This standard is Not Relevant. There are no locations where land acquisition or resettlement is required. The installation works of equipment will be in existing hospitals/HCFs grounds which are government owned sites. No expansion of facilities or building of new facilities will be part of the project, therefore, no new land will be acquired or accessed. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard is Not Relevant. During installation and operation stages, there are no natural or critical habitats sites already identified within the project sites which may be adversely affected since the minor works will be within the footprint of existing facilities and no excavation will be carried out. ESS7 Indigenous Peoples/ Local Traditional Communities and Sub-Saharan This standard is Not Relevant. ESS7 is not relevant to the project as there are no indigenous peoples/Sub-Saharan African Historically Underserved Traditional Local Communities in the project area. ESS8 Cultural Heritage This standard is not relevant. The project does not likely envisage any impacts on physical, cultural, and/or archaeological sites since the minor works will be within the footprint of existing facilities. 25 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF ESS9 Financial Intermediaries This standard is Not Relevant to the project as the project will not use financial intermediaries as an instrument for channeling funds. ESS10 Stakeholder Engagement and Information Disclosure The parent project and AF will establish a structured approach to engagement with stakeholders that is based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with COVID-19 (existing lockdown and social distancing guidelines). Similarly, it will provide affected persons and communities with accessible and inclusive means to raise concerns and grievances. The Project’s updated Stakeholder Engagement Plan describes the framework for these activities, following the guidance provided under ESS10 and by the WHO. The SEP encapsulates implementation progress under the parent project and reflects requirements for the activities of the AF. It is meant to ensure that information is meaningful, timely, and accessible to all affected stakeholders, using the whole range of available media (Television, Radio, mobile phone, etc.). It includes specific provisions to include (i) culturally appropriate methods, (ii) accessibility to those who might be illiterate or be limited by certain disabilities, vulnerable and marginalized groups including women and children and making the GRM accessible to these groups. In addition, project activities are meant to provide stakeholders with resources on how to deal with trauma from potential instances of GBV/SEA/SH that can result from the government-imposed measures to contain the spread of the virus (lockdown, quarantine, curfew, etc.). The approaches indicated in the updated SEP will ensure that information - to the extent feasible given Covid 19 constraints - is meaningful, timely, and accessible to all affected stakeholders as discussed above. ,The updated SEP which was prepared in November 2021includes resources and responsibility demarcation to ensure its implementation as well as guidelines for monitoring and reporting, along with Grievance Redress Mechanism for addressing any concerns and grievances raised in relation to the parent project and AF, during implementation. More details are available in the updated SEP. 3.3.2. World Bank Group Environmental, Health and Safety Guidelines The World Bank has several guidelines which are applicable to various components of the proposed project namely: • EHS Guidelines - WASTE MANAGEMENT • EHS Guidelines - HEALTH CARE FACILITIES • EHS Guidelines - HAZARDOUS MATERIALS MANAGEMENT • EHS Guidelines - CONSTRUCTION AND DECOMMISSIONING • Life and Fire safety aspects in the facilities to be supported by the project 26 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 3.3.2.1. WBG EHS Guidelines: “Waste management� a) General approach Regarding the parent project and AF, this section considers only construction waste originating from repairs, renovations and building of healthcare facilities. The guidelines advocate for waste management planning where waste should be characterized according to composition, source, types, and generation rates. These guidelines call for implementation of a waste management hierarchy that comprises prevention, recycling/reuse; treatment and disposal. The guidelines require segregation of conventional waste from hazardous waste streams. Examples of hazardous construction waste are waste oil from vehicles and machinery paint waste, thinners and concrete wash water (e.g. from cleaning concrete mixers). a) Implication for the parent project and AF 3.3.2.2. If minor civil works are to be included, improper management of construction waste would pose environmental and public health impacts. Contractors will have a contractual obligation to ensure proper construction waste management. Industry Specific WBG EHS Guidelines for “Healthcare facilities� a) Applicability The EHS Guidelines for healthcare facilities include information relevant to management of EHS issues associated with healthcare facilities (HCF) which includes a diverse range of facilities and activities involving general hospitals and small inpatient primary care hospitals, as well as outpatient facilities. Ancillary facilities may include medical laboratories and mortuary centers. These guidelines are applicable for planning new HCFs or renovation of existing facilities. b) Healthcare facility design considerations These guidelines advise that design and functional layout of HCFs should ensure the following: • Separation of clean / sterilized and dirty / contaminated materials and people flows; • Development and inclusion of adequate disinfection / sterilization procedures and facilities; • Adequate space for the storage of recyclable materials (e.g. cardboard and plastic) for pickup; • Ventilation systems that provide isolation and protection from airborne infections; • Design of water systems to provide adequate supplies of potable water to reduce risks of exposure to water borne pathogens; • Provision of hazardous material and waste storage and handling areas; 27 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF • Selection of easily cleaned building materials that do not support microbiological growth, are slip-resistant, nontoxic, and non-allergenic, and do not include volatile organic compound (VOC)-emitting paints and sealants. c) Waste management Waste from health care facilities (HCF) can be divided into two groups: • General waste similar in composition to domestic waste, generated during administrative, housekeeping, and maintenance functions. • Specific categories of hazardous healthcare waste. Health care facilities should establish, operate and maintain a health care waste management system (HWMS) adequate for the scale and type of activities and identified hazards but entailing: i. Waste minimization, reuse, and recycling ii. Waste segregation at the point of generation, iii. On-site handling, collection, transport and storage based on safe practices below; • Seal and replace waste bags and containers when they are approximately three quarters full. Full bags and containers should be replaced immediately. • Identify and label waste bags and containers properly prior to removal. • Transport waste to storage areas on designated trolleys / carts, which should be cleaned and disinfected regularly. • Waste storage areas should be located within the facility and sized to the quantities of waste generated. • Unless refrigerated storage is possible, storage times between generation and treatment of waste should not exceed (in Warm climate) 48 hours during cool season, 24 hours during hot season. • Store radioactive waste in containers to limit dispersion, and secure behind lead shields. • Packaging containers for sharps should be puncture-proof. These guidelines recognize incineration as a key source of air emission at healthcare facilities and pollutants emitted from incineration include: i. Heavy metals ii. Organics in flue gas iii. Various organic compounds (dioxins and furans) iv. Hydrogen chloride (HCl) and fluorides and potentially other halogens-hydrides (e.g. bromine and iodine) v. Typical combustion products such as sulfur oxides (SOx), nitrogen oxides (NOx), volatile organic compounds, carbon monoxide (CO), carbon dioxide (CO2), and nitrous oxide (N2O). 28 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF vi. Incineration residues such as fly ash and bottom ash may contain high concentrations of persistent organic pollutants (POPs). For being ineffective in regard to emissions control, these WBG Guidelines caution against use of single-chamber. Also, masonry (brick) incinerators should be used only as a last resort option. The Guidelines advise against mixing domestic and hazardous waste. Waste should be segregated at point of generation and non-hazardous waste, such as paper and cardboard, glass, aluminum and plastic, should be collected separately for possible recycling. Food waste should be segregated and composted. Infectious and / or hazardous wastes should be identified and segregated according to its category using a color-coded system. If different types of waste are mixed accidentally, waste should be treated as hazardous.d) Occupational health and safety HCF health and safety hazards may affect healthcare providers, cleaning and maintenance personnel, and workers involved in waste management handling, treatment and disposal. Typical hazards which should be prevented with proper safety gear and practices include: • Exposure to infections and diseases (blood-borne pathogens, and other potential infectious materials (OPIM)16 • Exposure to hazardous materials / waste • Life and Fire Safety • Exposure to radiation Occupational radiation exposure may result from equipment emitting X-rays and gamma rays (e.g. CT scanners), radiotherapy machines, and equipment for nuclear medicine activities. HCF operators should develop a comprehensive plan to control radiation exposure in consultation with the affected workforce. This plan should be refined and revised as soon as practicable on the basis of assessments of actual radiation exposure conditions, and radiation control measures should be designed and implemented accordingly. Implications for the project: 3.3.2.3. During project implementation, healthcare facilities will apply the National Health Care Waste Management procedures which inherently have provisions designed to satisfy WB EHS Guidelines discussed in this section. As in the comparison paper conducted for the ICWMP and MWMS of MoH, it was highlighted that the MWMS is in line with ICWMP and the EHS Guidelines for HCFs in terms of waste management.WBG EHS Guidelines: “Hazardous materials management� a) Application and approach 29 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF These guidelines apply to projects that use, store, or handle any quantity of hazardous materials (Hazmats), defined as materials that represent a risk to human health, property, or the environment due to their physical or chemical characteristics. Hazmats can be classified according to the hazard as explosives; compressed gases, including toxic or flammable gases; flammable liquids; flammable solids; oxidizing substances; toxic materials; radioactive material; and corrosive substances. b) General hazardous materials management Facilities which manufacture, handle, use, or store hazardous materials should establish management programs that are commensurate with the potential risks present. The main objectives of projects involving hazardous materials should be the protection of the workforce and the prevention and control of releases and accidents. These objectives should be addressed by integrating prevention and control measures, management actions, and procedures into day-to-day business activities. 3.3.3. WHO Guidelines The World Health Organization (WHO) has developed a number of country and technical guidance notes on coronavirus disease (COVID-19). These notes are accessible in detail from WHO website (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance). WHO guidance note on Water, sanitation, hygiene, and waste management for the COVID-19 virus Interim guidance (19 March 2020) instructs about safe management of health care waste and best practices for safely managing health care waste, including assigning responsibility and sufficient human and material resources to dispose of such waste safely. The guidance note indicates that while there is no evidence that direct, unprotected human contact during handling of health care waste results in transmission of the COVID-19 virus, all health care waste produced during the care of COVID-19 patients should be collected safely in designated containers, treated, and then safely disposed of or treated, or both, preferably onsite. If waste is moved off-site, it is critical to understand where and how it will be treated and destroyed. All persons who handle healthcare waste should wear appropriate PPE (boots, apron, long-sleeved gown, thick rubber gloves, mask, and goggles or a face shield) and perform hand hygiene after removing it. 4. Environmental and Social Baselines 4.1. General The West Bank has an area of 5820 km2 and populates about 3.5 million inhabitants distributed among 11 administrative governorates; the largest is Hebron at south, which extends at 20% of West Bank area. Gaza populates about 2.1 million living in an area of 365 km2, ranked the 3rd 30 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF most densely populated polity in the World. 4.2. Baseline Environmental and Social Information Baseline environmental and social information for Gaza Strip and West Bank are available in the already prepared Environmental and Social Assessment reports such as EIA, ESIA, EMSP, etc. These reports have good documentation about the general environmental and social issues including climate, air quality, roads, noise, available water resources, water quality, vegetation cover, agricultural resources, employment and income, occupational health and safety, natural habits and sanctuaries, resettlements, culture and heritage, recreation and tourism, marine life resources, issues. With respect to the recent changes in Gaza due to the recent conflict, the Rapid Damage and Needs Assessment (RDNA) serves as a significant resource to capture the impacts indicating between US$10-15 million in damages, US$15-20 million in losses, and US$30-40 million in recovery and reconstruction needs in the next two years just for the health sector. Examples of reports to refer to: • Gaza Rapid Disaster and Needs Assessment10 - June 2021 • ESIA for Environmental Assessment Report for Wastewater Treatment Plant Ramallah; • ESIA for Environmental Assessment Report for Northeast and Southwest Jenin Water Supply Projects Jenin Governorate – West Bank; • Environmental, Social, and Cultural Heritage Impact Assessment (ESCHIA) for Hebron Wastewater Management Project; • Feasibility Study and ESIA for Wastewater Management in Tubas, Tayasir, Aqqaba and Al Aqaba; • Environmental Impact Assessment for Alreehan Neighbourhood; • Environmental Impact Assessment for Rawabi Community ESIA for Hebron Solar Photovoltaic (PV) project. • Environmental Assessment in Relation to Biodiversity • Environmental and Social Impact Assessment (ESIA) & Environmental and Social Management Plan (ESMP) for Gaza Water Supply Rehabilitation and Expansion Project Gaza II Emergency Water Project (GEWPII); • Environmental and Social Impact Assessment (ESIA) for Gaza Solid Waste Management Project; • Environmental and Social Impact Assessment (ESIA) & Environmental and Social Management Plan (ESMP) for Gaza Water Supply and Sewage Systems Improvement Project (WSSSIP), including Additional Financing 1 (AF1); 10 https://documents1.worldbank.org/curated/en/178021624889455367/pdf/Gaza-Rapid-Damage-and-Needs- Assessment.pdf 31 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF • USAID INP II GAZA Sustainable Water Supply Program Environmental Assessment Report. 4.3. Economic situation in Palestine The Palestinian economy is suffering from volatile and unsustainable growth, and since the 2014 war in Gaza and the recent aggression on the strip in late May 2021, the economy has grown slowly, driven by unsustainable factors. 11 The structure of the economy has substantially deteriorated since the 1990s. For instance, the manufacturing sector, which is usually one of the key drivers of export-led growth, has largely stagnated and its share of Gross Domestic Product (GDP) has dropped from 19 percent in 1994 to 11 percent in 2015. The share of the agriculture sector has also declined from 12 to 4 percent over the same period. In relative terms, most growth has occurred in public sector services over the past two decades. Private investment levels, averaging about 15 percent of GDP in recent years, have been low and concentrated in low productivity activities less affected by political risk. The substantial amounts of financial assistance from the international community received over the last two decades have so far helped mitigate the impact of the restrictions on growth, but aid has significantly declined in recent years (from 32 percent of GDP in 2008 to about 6 percent of GDP in 2016) and cannot continue to substitute for lack of progress in the contribution of the private sector to growth, fiscal revenues, and jobs. The severe economic impact of the 2014 war pushed the Palestinian economy into recession in 2014. Since then, the economy has rebounded with real GDP growth reaching 3.5 percent in 2015 and an estimated 4.1 percent in 2016. Drivers of the recent growth, however, are not sustainable. The recent conflict in Gaza has further amplified the economic adversities in the Strip. According to the RDNA findings conducted jointly by the World Bank and the UN, the sector that has been most impacted by the conflict is the Social Sector comprised of housing, health, education, social protection and jobs. The escalation of violence in Gaza in May 2021 has resulted in a significant impact on the health sector. Health infrastructure in Gaza has suffered significant damage, including damage to 6 hospitals, 7 clinics, one health center, and two laboratories. Even though the Palestinian economy has made progress towards the WBG twin goals of eradicating extreme poverty and boosting shared prosperity in a sustainable manner, challenges remain both on poverty and inequality with regards to the stalled peace process and unresolved internal challenges. Poverty rates have been volatile during 2004-2011 (the latest period where numbers are available), rising sharply during each period of conflict and recovering slowly 11 This section is based on “Assistance Strategy FY 18-21 for the West Bank and Gaza� – World Bank, 2017 http://documents.worldbank.org/curated/en/339871512568083583/pdf/AS-1113-West-Bank-Gaza-Final-to-SECPO- 11142017.pdf 32 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF thereafter. According to the basic needs’ poverty line, 25.8 percent of the population lived in poverty in 2011 (latest data available). Poverty rates in Gaza are higher and more volatile than in the West Bank. A GINI coefficient of 40.3 percent indicates a significant level of income inequality in the Palestinian territories. Under a baseline scenario which assumes that the current Israeli restrictions remain in place and there is no improvement in the domestic economic and political environment, real GDP growth of the economy is projected to reach 3 percent in 2017: 2.7 percent in the West Bank and 4 percent in Gaza. This growth level implies a near stagnation in real per capita income and an increase in unemployment. Moreover, downside risks remain significant. In Gaza, more setbacks to the reconstruction process are possible. The resumption of armed conflict cannot be ruled out and if this happens, the Gaza economy is expected to slip back into recession. 4.4. Status of the health care sector The Palestinian territories lag in key indicators related to millennium development goals (MDGs). For example, 90 per 10,000 live births in 1990 to 64 in 2010. Moreover, aggregate indicators mask important geographic disparities. The general impoverishment of the population makes it vulnerable to health care expenditure, and the scarcity of good quality government health services makes them more prone to going to private, more expensive health providers. Expenditure on medications and due to chronic conditions, exacerbated by a lack of prevention and poor primary care, is a major contributing factor. Furthermore, the poorest groups are at greatest risk of impoverishment due to health spending; the poorest income group bears a higher share of out-of- pocket expenditure compared to their total share of income. Increase in injuries and trauma patients in Gaza has led to a shortage of emergency medicines, medical equipment and spare parts, hindering continuity of service delivery and management of chronic diseases such as cardiovascular disease, cancer, chronic respiratory disease and diabetes. While the West Bank and Gaza has a very high number of physicians and dentists per 10,000 people relative to Middle East and North Africa (MENA) countries, they lack facilities, equipment, drugs, and rare specialties. Furthermore, the distribution of health centers does not match the population distribution, and facility planning does not take the private or NGO sectors into account. Hospital beds sit empty at many specialized hospitals wards whereas others, such as the ICU and ER are overburdened. Referrals from primary care do not work and the population uses the ER of hospitals as the first entry into primary care. Unnecessary tertiary care is draining already depleted resources. 4.5. Collection, Treatment and Disposal of Medical Waste MOH refers to the medical waste management Act law number 10 that was published in 2012 by the Ministers’ Council http://site.moh.ps/index/ArticleView/ArticleId/4416/Language/ar. Mostly, hospitals do not have medical waste treatment. Within hospitals, it can be found that Palestine 33 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Medical Complex (PMC) (4 hospitals) has a central autoclave. In addition, three autoclaves are available in Bethlehem and Hebron governorates (private hospitals), and one autoclave in Bethlehem which is managed by MoH directorate. These autoclaves are for sharp boxes, lab tubes, blades, etc. During the COVID-19 Pandemic, the PA received assistance for purchasing additional autoclaves as well as incinerators to treat medical waste. Three incinerators were installed in the North, Middle and South of the West Bank, in addition to procuring 30 small-capacity autoclaves. Three hospitals are running uncontrolled incinerators. A microwave is installed to cover southern west bank hospitals. A specified area for disposal of medical waste has been assigned in Jericho within the area of the sanitary landfill (but outside the landfill cell), this landfill was only brought to operation during the peak of the COVID-19 pandemic as it yet faces technical and operational issues. Medical waste other than infectious is not currently treated in Palestine. Currently there are four operational incinerators in the West Bank, in Jenin (Zahret Al Finjan sanitary landfill), Qalqilya, Ramallah Municipality and Hebron (Al-Minia sanitary landfill). Three incinerators are in Jenin, Ramallah and Hebron which are within standards for waste treatment. Additionally, There is another incinerator in Qalqilia located at the UNRWA hospital. During the start of the pandemic there was an agreement between the municipality and MOH to have the Qalqilya incinerator serve the corona center, the governmental hospital in Qalqilya (Darweesh Nazal Hospital), and the UNRWA hospital itself. Moreover, MOH is expecting to receive a new incinerator from China and the recommendation is to install it in Salfeet hospital. Municipalities or Joint Service Councils (JSCs) are the main institutions collecting medical solid waste (70%); furthermore, the institution itself collects the medical waste in 19% of the medical centers. It can be observed that UNRWA collects in 2% of the centers (most probably UNRWA centers in the camps), whereas the remaining 6% is collected by private contractor. According to the survey of PCBS (2010) it can be observed that medical waste mostly ends in dumpsites, owned either by private or by local authorities, whereas about 1% are disposed randomly. The Ministry of Health has a program that involves the collection of sharp boxes from all their governmental primary health care centers. The ministry ensures that these sharps are burned (the burning process is uncontrolled for emission) to reduce risk of infections. In some areas, they send these sharps to transfer stations for municipal solid waste management. As for occupational health and safety, the Ministry of health provides free vaccination for all workers in the solid waste sector, provided that prior coordination between the municipality or JSC with the ministry has been conducted. Most of the medical waste, regardless of its characteristics is disposed of together with the municipal waste without prior treatment. Except for few cases, such as PMC has an autoclave, and 34 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF the facility in Hebron, medical waste is not disinfected, or processed as microwaving has a defect (dumping in special cells). 4.6. Committees Formed in Relation To COVID-19 The MoH formed the following committees to combat the COVID-19 epidemic in Palestine: o The National Corona committee o The National Protocol Committee o National Epidemiology Committee o Corona Cell at MoH 4.7. Gender-Based Violence (GBV) Gender Based Violence (GBV) is a key protection concern in Palestine. According to Palestinian Central Bureau of Statistics (PCBS) 2011, Violence Survey, an average of 37% of women are victims of GBV in Palestine. In the Gaza Strip, this percentage increases up to 51%. This percentage has declined by some 8%, referring to a similar survey conducted in 2019, Figure 1. Women in Palestine face multiple layers of violence and discrimination. The analysis made in the UN Special Rapporteur’s report on violence against women in 2005 found two main reasons for the GBV level in Palestine: • Traditional patriarchal norms and values; and • Occupation and its consequences. The protracted humanitarian crisis, and its impact on gender and family dynamics, has exacerbated GBV in all its forms, including sexual violence, intimate partner violence and child marriage. Distance, mobility restrictions, fragmentation of areas and services and reluctance to report GBV due to fear of stigma, social exclusion, so-called honor killings or reprisal limits survivors’ access to and utilization of critical services. Available services and capacity of service providers also remain limited, and survivors and communities have minimal information on existing services and how to access them. Only 0.7% of GBV survivors seek help due to the lack of confidential and compassionate services and fear of stigma and reprisal. 35 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Figure 1: Domestic Violence against Women in Palestine (2011 vs. 2019) 36 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 5. Potential Environment and Social Risks and Mitigation This section describes the potential environment and social impacts of the AF activities during implementation and operation phases. Based on project activities detailed in previous sections (2 and 3), the following key environmental and social aspects should be taken into consideration: • Proper installation of equipment within the hospitals and healthcare facilities, which may involve: (i) minor civil works and tools safety; and (ii) health care facilities infection control and necessary safety gear and protocols. • Weak health and safety measures. • Waste (medical, wastewater and solid wastes) management including handling, collection and transport. Estimate healthcare waste streams and quantities including wastewater, solid wastes including waste from testing laboratories and air emissions (if significant) in healthcare facilities. • Implementing appropriate measures to ensure safety in transportation and road safety as the AF includes the purchase of mobile clinics and blood bank, refrigerated vehicles, and indirect support to the vaccination infrastructure, which contains substantial logistical activities. Risks associated with the Mobile Blood Bank and Mobile Clinics include: (i) occupational health and safety risks related to safety in transportation that include unsafe driving practices, irregular maintenance of vehicles, accidents and spill of samples or hazardous material such as blood storage; (ii) waste management in terms of disposal of medical waste and the carrying of such waste until the final disposal; and (iii) infection hazards in relation to unsafe storage or accidents or pills especially when handling COVID- 19 samples and waste blood and other medical waste. • Risk associated with oxygen, oxygen cylinders and oxygen concentrators which are hazardous materials. • Risk of fire in the existing HCFs accessible to the public where the project activities will be conducted. • Inadequate communication and community engagement. • Exclusion of the poor, elderly, those with disabilities and vulnerabilities. Potential environmental and social impacts and mitigation measures are described below. 5.1. Risk Related to Minor Works during the Installation of the New Equipment As with the parent project, the AF includes interventions for installation of the new equipment to be purchased by the project at hospitals and health care facilities. This could include positioning of current light or electrical plug fixtures, laying of electrical wires to connect the new equipment, 37 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF etc. The anticipated potential environmental impacts may include: (i) generation of minor solid waste from the installation activities and from end of life of equipment; (ii) management and disposal of waste; (iii) nuisance related to vibration and noise during installation activities; and (iv) OHS risks related to installation activities including exposure to electrical hazards from the use of tools, noise and dust, lifting of heavy equipment and falling and falling objects. The impacts are expected to be site specific, short-term and reversible. Mitigation: Mitigation measures are detailed in the tables below. 5.2. Weak Health and Safety Measures Older people and people with pre-existing medical conditions (including asthma, diabetes, and heart disease) appear to be more vulnerable to becoming severely ill from COVID-1912. Mitigation: Mitigation measures are detailed in the tables below. 5.3. Improper Healthcare Waste Management Impact evaluation: Improper healthcare waste management poses a secondary infection risk to healthcare workers and the general public. Improper segregation of solid waste. Mitigation: It is recommended that the project follows the MWMS, ICWMP, and the EHS Guidelines and other required Health-Care Waste (HCW) management requirements. Health care facilities should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. 5.4. Impact of COVID-19 Testing Laboratories Impact evaluation: Improper management of laboratory waste (syringes, Gene Expert cartridges etc.) would lead to offsite COVID-19 transmission slowing effective containment of the outbreak. Mitigation Ministry of Health should: • Ensure incinerator for safe combustion of laboratory waste associated with COVID-19 emergency operations at higher than 850 °C. • Transportation of samples should not expose personnel to risk either during normal handling or in case of an accident. 12 The SARS-CoV-2 virus has been identified as the cause of COVID-19. 38 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 5.5. Risks Associated with Transportation and Road Safety Impact evaluation: As the AF activities entail the procurement of mobile clinics and mobile blood banks, in addition to refrigerated vehicles which will indirectly support the vaccination infrastructure, risks could arise from lack or improper maintenance of vehicles, unsafe driving practices, overloading the vehicles, loading/unloading OHS risks and causing nuisance or negatively contributing to traffic. Mitigation: The MoH should; • Ensure constant maintenance and inspection of vehicles as per the manufacturer’s recommendations • Provide drivers with orientation on inspection of vehicle prior to every trip, sound driving practices • Ensure that vehicles are not loaded beyond their acceptable limit as per the manufacturer’s recommendations • Provide workers with training on OHS aspects of loading/ unloading to avoid injuries and risks to wellbeing • Instruct the drivers to avoid trips during peak rush hours • Develop a transportation safety plan if contractors are to be involved 5.6. Inadequate Management of oxygen, oxygen cylinders and oxygen concentrators Impact evaluation: Poor management of oxygen, oxygen cylinders and oxygen concentrators, which are hazardous materials, may have potential of uncontrolled reactions such as fire and explosions. Mitigation Oxygen, oxygen cylinders and oxygen concentrators must be managed by MoH in accordance with WBG EHSGs requirements from Section 1.5 “Hazardous Materials�. Their use must include a hazard assessment of the potential for uncontrolled reactions such as fire and explosions and actions to manage these materials safely and the safety specifications for these materials and equipment. 5.7. Risk of Fire Impact evaluation: 39 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Risk of fire in the existing HCFs accessible to the public where the project activities will be conducted is unlikely but possible. Fire hazard constitute of all factors present in a building that can cause ignition (start fire) including the potential of uncontrolled reactions as mentioned above. The fire hazard can cause partial or complete collapse of the HCF, and incapacitation of building operations. Mitigation MoH should ensure: All existing buildings accessible to the public should implement Life and Fire Safety requirements by incorporating all local building codes and fire department regulations. A life and fire safety review of the building should be conducted by a suitably qualified professional and ensure that Operation and Maintenance (O&M) practices meet all local building codes and fire department regulations. This assessment may be performed by the competent authorities or by a third party if MoH has limited capacity. The General EHS Guidelines refers to US National Fire Protection Codes (NFPA) as one example of an internationally accepted L&FS standard and may be used to document compliance with the Life and Fire Safety objectives outlined in WBG General EHS Guidelines. 5.8. Inadequate Communication and Community Engagement Impact evaluation: Misinformation can endanger medical teams when their activities are misunderstood or not known. Therefore, effective public sensitization is essential for COVID-19 control and will particularly be important for hard-to-reach communities that lack access to formal communication channels (print and electronic mass media). Additionally, once people are not educated about COVID-19, its potency, how it is spread and control measures, they would not participate in its control. It would for example be difficult for families to isolate themselves or a relative or relegate their right to bury a deceased family member unless they are fully aware of inherent risk. Mitigation Ministry of Health should: • Involve local opinions from women Leaders, youth, and representatives of members of vulnerable and marginalized groups in COVID-19 risks communication strategies. • Intensify media campaigns mainly in rural areas, such as wireless radio and social media using cellular phones; • Maintain a team responsible for harmonizing media actions (broadcasting rates, dissemination formats, journalistic ethics control, etc.). 40 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 5.9. Exclusion of the poor, elderly, those with disabilities and vulnerabilities Impact evaluation: The capture of project benefits by the elites and exclusion of the poor, elderly, those with disabilities and vulnerabilities constitutes a major social risk. The main challenge, therefore, is to make sure the procured items needed to prevent, detect and clinically manage COVID-19, are distributed in a transparent manner, ensuring equity and reaching the affected population. The distribution of the procured equipment and devices shall also be combined with outreach and population sensitization. Mitigation: MoH has updated the Stakeholder Engagement Plan (SEP) in November 2021 and disclosed it on its website. Measure in the updated SEP have been tailored based on the current situation and lessons learnt from the execution of the parent project for the inclusion of the vulnerable communities and people throughout the consultations processes including public information disclosure and outreach. Project implementation also needs to ensure appropriate stakeholder engagement to (i) avoid conflicts resulting from false rumors, (ii) vulnerable groups not accessing services, or (iii) issues resulting from people being kept in quarantine. The following Tables (5.1-5.4) provide the health and safety risks and waste management associated with the project activities. Table (5.1) lists the health and safety risks and impacts associated with the minor works (if needed) during the installation of the new equipment. Table (5.2) lists the health and safety risks and impacts associated with goods financed by the World Bank in response to the COVID-19 outbreak. Table (5.3) lists the health and safety risks and impacts associated with technical assistance financed by the World Bank in response to the COVID-19 outbreak. Table (5.4) lists the health and safety risks and impacts associated with the supply of drugs under the AF. Potential mitigation measures and references to sources of additional advice and information are provided. Table 5.1: The health and safety risks and impacts associated with the minor works that might be needed during the installation of the new equipment. Activity Risks and Impacts Mitigation Measures Small-scale Generation of minor Ministry of Health will ensure that: works during solid waste the ✓ Installation sites properly isolated by the installation suppliers/contractors, where these installations will of the new take place. equipment. 41 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Management and ✓ Installation activities carried out within specified disposal of waste daylight hours and based on coordination with HCFs or site managers. ✓ Develop and implement waste management measures acceptable to MoH. Nuisance related to ✓ Designate a qualified professional as their OHS vibration and noise coordinator responsible for ensuring OHS and during installation reporting. activities ✓ Abide by all pertinent waste management and public health laws. ✓ Wastes will be stored in appropriate bins and removed periodically as required. ✓ All waste will be collected and disposed of properly OHS risks in approved landfills. ✓ Contractor/supplier shall adhere to health and safety local regulations, WBG EHS guidelines and GIIP (Good International Industry Practice). ✓ Contractors/suppliers are required to develop proper emergency responses in advance, which shall be coordinated and approved by the MoH, in a timely manner. ✓ Commitment to the MoH and WHO guidelines regarding protection measures from COVID-19 pandemic; ✓ Contractors/suppliers must ensure that OHS measures are in place to guide work activities and provide PPE and maintain a safe environment for workers. ✓ Contractors must ensure that all workers have received regular training to perform their job, as well as daily inductions prior to work activities h ✓ Contractors/ Suppliers must ensure the qualifications of their workers, especially in terms of electrical/mechanical works. And should not let anyone else operate or conduct machinery and works that require specific skills. ✓ Contractors/suppliers must ensure that all workers operate within a safe environment. All relevant Labor and Occupational Health and Safety regulations must be adhered to, to ensure worker safety. ✓ Workers must be provided with necessary equipment as well as protective gear as per their specific tasks such as overalls, gloves, goggles, boots, etc. 42 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF ✓ Contractors/suppliers must ensure that there are basic medical facilities, first aid kits, gloves, hand sanitizers, masks and other needs on site and that there are staff trained in basic first aid. Table 5.2: The health and safety risks and impacts associated with goods financed by the World Bank in response to the COVID-19 outbreak. Activity Risks and Impacts Mitigation Measures Purchase and Surfaces of imported Projects should ensure that adequate stocking and materials may be handwashing facilities with soap (liquid), installation of contaminated and water and paper towels for hand drying equipment in handling during (warm air driers may be an alternative), plus emergency rooms, transportation may closed waste bins for paper towels are clinics and other result in spreading. available. Alcohol-based hand rub should be medical facilities, and provided where handwashing facilities storage equipment cannot be accessed easily and regularly. under the AF including with The AF activities Also ensure awareness campaigns and Laboratory might involve small- reminder signs are regularly posted around equipment, supplies scale works in health site to encourage workers regularly wash or goods. care facilities during their hands when handling goods, and that the installation of they do not touch their face. equipment and the small construction and If concerned (for example when dealing with Transportation safety rehabilitation activities goods that have come from countries with risks associated with that will generate solid high numbers of infected people) a surface or mobile clinics, blood waste equipment may be decontaminated using bank and refrigerated disinfectant. After disinfecting, workers vehicles lack or improper should wash their hands with soap and water maintenance of or use alcohol -based hand rub vehicles, unsafe driving practices, Effective waste reduction and segregation, overloading the ensuring that the small quantities of solid vehicles, waste are collected and properly disposed of loading/unloading in the municipal landfill. OHS risks and causing nuisance or negatively Conduct ESA for the sites that the equipment contributing to traffic. will be installed in, the ESA should also investigate whether the equipment requires 43 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF stock chemicals, produce chemical waste or radiation. Ensure constant maintenance and inspection of vehicles as per the manufacturer’s recommendations Provide drivers with orientation on inspection of vehicles prior to every trip, sound driving practices Ensure that vehicles are not loaded beyond their acceptable limit as per the manufacturer’s recommendations Provide workers with training on OHS aspects of loading/ unloading to avoid injuries and risks to wellbeing Instruct the drivers to avoid trips during peak rush hours Develop a transportation safety plan if contractors are to be involved Purchase of PPE and Incorrect standard or Medical personal protective equipment consumables for quality of PPE leads to (PPE) includes: healthcare workers spread of infection to and health facility healthcare workers Medical mask cleaners and cleaners. Gown Apron Eye protection (goggles or face shield) Respirator (N95 or FFP2 standard) Boots/closed work shoes 44 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF WHO interim guidance on rational use of PPE for coronavirus disease 2019 provided further details on the types of PPE that are required for different functions. Distribution of goods A non-transparent and Attention should be given to the distribution or services on basis poorly managed system, to ensure effective and efficient use of need distribution system of the goods and services and avoid elite and practice could capture, powerful and privileged, particularly worsen the current at this time of short supply. shortage situation, affecting the maximum and efficient use of resources. Particular attention and efforts should be The disadvantaged and given to the disadvantaged and vulnerable vulnerable population groups to make sure that they have equal if groups, could face not better access to these resources. The disproportionate distribution of the procured equipment and difficulties in devices shall also be combined with outreach accessing the available and population sensitization. resources, exposing them to greater risks. Hand wash stations Inadequate Projects should ensure that adequate handwashing facilities handwashing facilities with soap (liquid), are provided for water and paper towels for hand drying handling. (warm air driers may be an alternative), plus closed waste bins for paper towels are available. If water and soap handwashing facilities are not possible, alcohol-based hand rubs may be provided. Alcohol-based hand Alcohol-based hand Alcohol-based hand sanitizers are not sanitizers rubs may not be as considered as effective as hand washing with effective at controlling soap and water and should therefore only be infection as hand used in locations where full hand washing 45 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF washing with soap and facilities cannot be provided. Advice should water. be provided to remind users where full handwashing facilities can be found. Medical waste The collection, The treatment of healthcare waste produced contaminated with processing, treatment during the care of COVID-19 patients should COVID-19 virus and disposal of be collected safely in designated containers medical waste and bags, treated and then safely disposed. becomes a vector for the spread of the virus. If small-scale incinerators are the only option available, the best practices possible should be used, to minimize operational impacts on the environment. Best practices in this context are: ✓ effective waste reduction and segregation, ensuring only the smallest quantities of combustible waste types are incinerated; ✓ an engineered design with sufficient residence time and temperatures to minimize products of incomplete combustion; ✓ siting incinerators away from health-care buildings and residential areas or where food is grown; ✓ construction using detailed engineering plans and materials to minimize flaws that may lead to incomplete destruction of waste and premature failures of the incinerator; ✓ a clearly described method of operation to achieve the desired combustion conditions and emissions; for example, appropriate start-up and cool-down procedures, achievement and maintenance of a minimum temperature before waste is burned, use of appropriate loading/charging rates (both fuel and waste) to maintain appropriate temperatures, proper disposal of ash and equipment to safeguard workers; ✓ periodic maintenance to replace or repair defective components (including 46 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF inspection, spare parts inventory and daily record keeping); and ✓ Improved training and management, possibly promoted by certification and inspection programs for operators, the availability of an operating and maintenance manual, visible management oversight, and regular maintenance schedules. Single-chamber, drum and brick incinerators do not meet the Best Available Techniques (BAT) requirements under Stockholm Convention.Small-scale incineration should be viewed as a transitional means of disposal for health-care waste. Alternative treatments should be designed into longer term projects, such as steam treatment methods. Steam treatment should preferably be on site, although once treated, sterile/non-infectious waste may be shredded and disposed of in suitable waste facilities. See WHO Safe management of wastes from health-care activities. Water, sanitation, COVID-19 virus is Apply WHO guidance on water, sanitation hygiene and waste transmitted through and waste management for COVID-19 for management for inappropriate guidance on control measures. COVID-19 sanitation arrangements or through drinking water and contaminated waste. Identification and Collection of samples Collection of samples, transport of samples diagnosis and testing for and testing of the clinical specimens from COVID19 could result patients meeting the suspect case definition in spread of disease to should be performed in accordance with medical workers or WHO interim guidance Laboratory testing laboratory workers, or for coronavirus disease 2019 (COVID-19) in during the transport of suspected human cases. Tests should be performed in appropriately equipped laboratories (specimen handling for molecular testing requires Biosafety Level 47 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF potentially affected (BSL)-2 or equivalent facilities) by staff samples. trained in the relevant technical and safety procedures. National guidelines on laboratory biosafety should be followed. There is still limited information on the risk posed by COVID-19, but all procedures should be undertaken based on a risk assessment. For more information related to COVID-19 risk assessment, see specific interim guidance document: WHO interim guidance for laboratory biosafety related to 2019-nCoV. Samples that are potentially infectious materials (PIM) need to be handled and stored as described in WHO document Guidance to minimize risks for facilities collecting, handling or storing materials potentially infectious for polioviruses (PIM Guidance). For general laboratory biosafety guidelines, see the WHO Laboratory Biosafety Manual, 3rd edition. Oxygen, oxygen Poor management of Oxygen, oxygen cylinders and oxygen cylinders and oxygen oxygen, oxygen concentrators must be managed by MoH in concentrators cylinders and oxygen accordance with WBG EHSGs requirements concentrators, which from Section 1.5 “Hazardous Materials�. are hazardous Their use must include a hazard assessment materials, may have of the potential for uncontrolled reactions potential of such as fire and explosions and actions to uncontrolled reactions manage these materials safely and the safety such as fire and specifications for these materials and explosions. equipment. References and sources of further information https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance https://www.cdc.gov/coronavirus/2019-ncov/lab/lab-biosafety-guidelines.html https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html 48 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF https://www.gov.uk/government/collections/coronavirus-covid-19-list-of-guidance#guidance- for-health-professionals Table 5.3: The health and safety risks and impacts associated with technical assistance financed by the World Bank in response to the COVID-19 outbreak. Activity Risks and Impacts Mitigation Measures Policy advice for Advice and guidance changes TORs to include specific strengthening health regularly as more becomes known requirements for regular services and primary about how the virus responds to review of information and health care, including treatment and is transmitted. guidance, including WHO, through training of front- CDC and other governmental line health workers websites. Access to global Information on COVID-19 is Refer to WHO, CDC expertise being updated regularly. The websites and other locations latest advice should be available as necessary to remain up to and taken during any Technical date on causes of spread and Assistance programs. treatment of infected patients. Improve access to Some vulnerable groups TORs should require specific support and treat the (especially the elderly or those actions to be identified to disadvantaged vulnerable with pre-existing medical ensure disadvantaged and groups conditions) may be severely vulnerable groups have affected by COVID-19, and may effective treatment, whether need additional support to access in medical facilities or in the treatment. community. Identification and Identification and diagnosis WHO guidance on transport diagnosis advice results in the spread of the of samples and on testing COVID-19. laboratories should be followed when advising on activities related to identification and diagnosis. References and sources of further information https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance https://www.cdc.gov/coronavirus/2019-ncov/lab/lab-biosafety-guidelines.html 49 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html https://www.gov.uk/government/collections/coronavirus-covid-19-list-of-guidance#guidance- for-health-professionals https://worldbankgroup.sharepoint.com/sites/wbsites/coronavirus/Pages/index.aspx Table 5.4: The health and safety risks and impacts associated with the regular Pneumococcal (PCV) vaccines financed by the World Bank and procurement of Drugs under the AF. Activity Risks and Impacts Mitigation Measures Distribution Wastes from the regular The treatment of healthcare wastes produced of General vaccination programs or during the use of regular immunization vaccines vaccines as treatment are not properly i.e the PCV vaccine should be collected safely in part of the dealt with and lead to further designated containers and bags, treated and then regular infection. safely disposed. immunizati on i.e. Packaging waste and Proper storage locations and temperatures need Pneumococ disposal of defective to be ensured by MoH. cal (PCV) medicines in an vaccines. inappropriate way could Open burning and incineration of medical wastes program to lead to pollution. Improper and pharmaceuticals can result in emission of avoid disposal of unused dioxins, furans and particulate matter, and result disruptions medicines also adds to the in unacceptable cancer risks under medium (two in basic trace levels of hours per week) or higher usage. health pharmaceuticals in the services environment. Disposal or incineration needs to be done in delivery. accordance with the MWMS, WHO regulations, and the WBG EHS guidelines. Supply and distribution If small-scale incinerators are the only option of drugs as available, the best practices possible should be part of the used, to minimize operational impacts on the AF environment. Best practices in this context are: activities ✓ effective waste reduction and segregation, ensuring only the smallest quantities of combustible waste types are incinerated; ✓ an engineered design with sufficient residence time and temperatures to minimize products of incomplete combustion; 50 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF ✓ siting incinerators away from health-care buildings and residential areas or where food is grown; ✓ construction using detailed engineering plans and materials to minimize flaws that may lead to incomplete destruction of waste and premature failures of the incinerator; ✓ a clearly described method of operation to achieve the desired combustion conditions and emissions; for example, appropriate start-up and cool-down procedures, achievement and maintenance of a minimum temperature before waste is burned, use of appropriate loading/charging rates (both fuel and waste) to maintain appropriate temperatures, proper disposal of ash and equipment to safeguard workers; periodic maintenance to replace or repair defective components (including inspection, spare parts inventory and daily record keeping); and improved training and management, possibly promoted by certification and inspection programs for operators, the availability of an operating and maintenance manual, visible management oversight, and regular maintenance schedules. Single-chamber, drum and brick incinerators do not meet the BAT requirements under Stockholm Convention. Small-scale incineration should be viewed as a transitional means of disposal for health-care waste. Alternative treatments should be designed into longer term projects, such as steam treatment methods. Steam treatment should preferably be on site, although once treated, sterile/non- infectious waste may be shredded and disposed of in suitable waste facilities. See WHO Safe management of wastes from health-care activities. 51 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF The disadvantaged and Particular attention and efforts should be given to vulnerable population the disadvantaged and vulnerable groups to make groups, could face sure that they have equal if not better access to disproportionate difficulties these resources. The distribution of procured in accessing the available goods, machines, and equipment shall be resources, exposing them to combined with outreach and population greater risks. sensitization. 5.10. Gender-Related Impacts Impact evaluation Sexual Exploitation, Abuse and Harassment: The risks of sexual exploitation, harassment, and abuse will be assessed, and mitigation measures put in place. Gender-Based Violence (GBV): Rates of GBV, especially partner violence may increase as people stay home and change behavior in response to COVID-19 movement restrictions. Other types of GBV are sexual assaults against children, disabled and elderly people. Additionally, GBV can occur between colleagues whether as direct workers or contracted or between project workers and the community Mental Health: Epidemics can cause stress, anxiety and fear. Sources of stress at households’ level may arise from children staying home and creating competing demands for time or when incomes diminish following job loss or wage cuts. Routine Health Care and Essential Services: Resources might be diverted from routine healthcare services toward containing and responding to COVID-19 outbreak. Mitigation and management With limited and commonly shared spaces (kitchens, bathrooms, living rooms) in COVID-19 Quarantine Centers, it is recommended to institute measures to prevent sexual harassment and gender-based violence in quarantine facilities. The project’s GRM will include special referral pathways for the GBV complaints and grievances, including grievances on sexual harassment and sexual exploitation and abuse. Channels to accept and respond to GBV grievances, while maintaining high confidentiality, will be communicated to the project’s affected parties during the consultation meetings and throughout the project implementation. 52 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 5.11. Environmental and Social Management Plan An Environmental and Social Management Plan (ESMP) for the proposed AF activities is intended to ensure implementation of environmental and social management of its activities. Site specific ESMPs will be prepared for each project activity, as determined by the ESA, implemented throughout project life-time. Ideally the ESMP should contain the following: • Summary of the potential impacts of the subproject; • Description of the recommended mitigation measures; • Description of monitoring activities and plan; • Institutional arrangement for implementation and training; • Implementation Schedule of the actions to be taken and reporting procedures; • Program for monitoring; and • Estimated related costs and sources of funds Example/Template for Generic ESMP matrix is provided in Annex II. The indicative outline of an ESMP, can be found in the ESF guidance notes (page 33) 53 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 6. Procedures to Address Environment and Social Issues This section defines steps, actions and responsibilities for screening potential environmental and social issues and classifying risk levels. 6.1. The Environmental and Social Screening Process The purpose of this screening process is to determine which activities are likely to have negative environmental and social impacts to; determine the level of required environmental assessment; determine appropriate mitigation measures for activities with adverse impacts; and incorporate mitigation measures into the subprojects as appropriate. The extent of environmental and social work that might be required prior to the commencement of the subprojects will depend on the outcome of the screening process described below. 6.2. The Screening Process The objectives of environmental and social screening are to: evaluate the environmental risks associated with a proposed operation; determine the scope of Environmental and Social Assessment (ESA); and recommend an appropriate ESA instrument(s) and level of assessment suitable for a given project. Criteria for classification include type, location, sensitivity, and scale of the project, as well as the nature and magnitude of its potential environmental and social impacts. Project screening will be prepared by the EHSO at PMU and site specific ESMP/ESIA will be prepared following the screening process as guided in this ESMF. Public consultations will take place during the environmental and social screening process, and the input from the public consultations will be reflected in the design of the mitigation and monitoring measures. The screening process shall be conducted according to the following steps: Step1: Screening including Checking Eligibility of subprojects At this stage the sub-projects will be subjected to a screening process by the EHSO to check their eligibility for the project financing. The following activities will not be eligible for this project financing (Exclusion list): • Laboratory activities that may require cause adverse health impact including serious/potentially lethal diseases, high containment, cause aerosol transmission; • Activities that may cause long term, permanent and/or irreversible (e.g. loss of major natural habitat) adverse impacts; • Activities that have high probability of causing serious adverse effects to human health and/or the environment not related to treatment of COVID-19 cases; • Activities that may have adverse social impacts and may give rise to significant social conflict; • Activities that may affect lands or rights of people or other vulnerable minorities; 54 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF • Activities that may involve resettlement impacts or land acquisition, adverse impacts on cultural heritage. In checking the eligibility of the sub projects, the questions in the Subproject Eligibility Screening Checklist (Annex I- Part 1) would be answered as “Yes� or “No�. If the answer to any one of the questions is ‘Yes’, then the subproject will be redesigned to be acceptable or stopped if redesigning is not possible. If on the contrary the answer is ‘No’ for all the above questions, then one must proceed to the next step. Furthermore, EHSO would assess the significance of potential impacts using environmental and social impact rating checklist below. The checklist must be filled, and number of potential impacts marked as None, Low, Medium, High and Unknown and will be used to determine individual and the overall impact rating of the sub-project. The table below is a guidance to determine what action would be taken before proceeding to the next level based on the results. Rating and classification of potential impacts of Sub-projects For sub-projects with no impact These types of subprojects would be labeled as ‘subprojects (All impact rating becomes of no environmental and social concern’. These types of ‘None’) sub-project without further delay will be approved and cleared by MoH and the WB For sub-projects with low and/or These types of subprojects would be labeled as ‘Sub-projects medium impact of medium environmental and social concern’. In this case, incorporate potential mitigation measures into the design of the subprojects would be integrated and ESMP would be prepared. Subprojects cause high potential These types of subprojects would be labeled as ‘subprojects impact (activities that will not be of high environmental and social concern’. In this case, eligible for this project financing these sub-projects will not be financed by the project. from the Exclusion list Step2: Screening including environmental and social actions/instruments The EHSO will complete the Environmental and Social Screening Form (Annex I-Part 2) to facilitate identification of relevant ESSs and due diligence action/instruments. After analyzing data contained in the environmental and social screening form and having identified the right environmental category and hence scope of the environmental assessment required, the EHSO will make a recommendation to MoH as to whether: (a) no ESIA will be required; (b) implementation of simple mitigation measures will be required and thus development of ESMP/Project Brief; or (c) a separate environmental impact assessment EIA will be carried out (such activities are not anticipated). In case 55 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF of activities under (a) and (b) above, project environmental and social mitigation measures checklist will be used (see Annex II): Using the checklist the environmental and social mitigation measures will be proposed by the MoH and an ESMP will be developed (as shown in Chapter 10). Step 3: Approval of the screening reports At this stage environmental and social screening reports will be reviewed and approved by the MoH. If the sub-project has medium environmental and social concerns, MoH would ensure that all the necessary mitigation measures are incorporated in the ES risk management tool before approval. World Bank requires disclosure of the environmental assessment report and/or ESMP both in- country by the MoH and at WB’s website. 7. Information Disclosure The MOH website http://site.moh.ps/will be used to disclose project documents including the SEP, and updated SEP for AF. During the parent project’s implementation, the website has been optimized to further facilitate access to the project information; http://site.moh.ps/Index/CategoryView/CategoryId/20/Language/ar. All future project related documents will be disclosed on this webpage. Project updates and information will be posted on the website. Details about the project Grievance Redress Mechanism will also be posted on the website. Further details on information disclosure and the proposed information disclosure strategy for the AF is available in the updated SEP. 8. Stakeholder Engagement A stand-alone document for Stakeholder Engagement Plan (SEP) as per the requirements of ESF and in accordance with ESS10 was prepared for the parent project in March 2020, and has been updated in November 2021 to reflect recent findings and requirements for the AF. A summary is provided in this section of the ESMF. Stakeholder engagement shall be carried out in compliance with the Technical Note on Public Consultations and Stakeholder Engagement in WBG-supported operations during COVID-1913. A detailed description of the consultation activities is provided in the updated SEP for AF. The parent project’s preparation and implementation occurred at the beginning of the pandemic, during a time at which the Palestinian Territories witnessed a concerning surge in registered 13 https://biwta.portal.gov.bd/sites/default/files/files/biwta.portal.gov.bd/page/f3ca1ff6_95b0_4606_849f_2c0844e455 bc/2020-10-01-11-04-717aa8e02835a7e778b2fff46f531a8c.pdf 56 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF confirmed cases. Measures implemented to combat the spread of the infection included restrictions on movement, temporary closure of businesses and institutes, and quarantine arrangements among others. World health institutions such as the WHO, CDC and others, as well as the PA recommended and imposed new regulations and restrictions on public gatherings and business meetings. Hence, traditional consultations were not possible at the time. As part of the project’s preparations, MoH, with support from the World Bank have prepared the original SEP and consultations requirements to engage the public, project affected parties, and interested parties. However, due to the worsening situation at the time in the WB&G and the surge in infections between the Ministry’s staff, in addition to the lack of capacity at MoH at the time in terms of E&S management as the EHSO was not yet on board, consultations as planned were not possible to be implemented and were assigned to be conducted at a later stage. Nevertheless, information dissemination and other forms than traditional stakeholder engagement meetings and sessions were conducted for the parent project to ensure public engagement with the available methods and instruments for information disclosure, taking into uttermost consideration avoiding public gatherings and limiting the spread of the virus, summary of information dissemination activities are available in the updated SEP in section 6.1. 8.1. Stakeholder Engagement Activities Conducted for the Additional Financing Since the hiring of an EHSO in late May 2021, MoH has been engaging with various project stakeholders in the last months as part of the continuous stakeholder engagement for the parent project, and also for the preparation of the additional financing. Moreover, MoH through its Public Relations Department has continued with the dissemination of information regarding the COVID- 19 pandemic which included daily updates in English and Arabic on statistics of confirmed cases, recovery, geographical distribution and situation in HCFs, among other information. Campaigns implemented by MoH included information about vaccines, vaccines availability, hotline for vaccines, awareness and educational campaigns, among many others that are disseminated daily through newspapers, social media, and MoH’s webpage. Moreover, as an E&S ex-post audit has been requested to be conducted for the project, the EHSO and the E&S audit consultant have carried out several meetings with MoH departments to inform them about the progress implemented during the parent project, as well as the preparations being implemented for the AF. Seventeen (17) meetings took place with MoH departments, public hospitals benefiting from the parent project, and some of the contracted staff hired under the parent project. Further details are available in the updated SEP and the E&S audit disclosed on MoH’s webpage and the World Bank’s external webpage on September 30, 2021. 57 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Moreover, and in order to enhance community participation and disseminate information about the Project’s activities, MoH prepared a timeframe for consultation activities for the parent project and additional financing and shared with the World Bank in September 2021, this plan was prepared inline with the SEP to provide a timeline for engagement and disclosure activities over the upcoming six months. The plan included the targeted stakeholders, engagement methodology, and information dissemination for the next 6 months for both the parent project and the AF. In accordance with the SEP and the consultations plan, several consultation meetings took place with MoH departments and other Interested Parties (OIPs) with regard to the parent project and the additional financing. The first batch of meetings were conducted starting September 30, 2021 and extended till the first week of November 2021 with relevant departments and MoH officials that have specific roles within the project, such as meetings with the Complaints Unit regarding the GM, meeting with the Women Health and Development Department (WHDD) regarding the GBV channels and handling mechanism in the GM, meeting with the Environment Health Department regarding the implementation of the MWMS and the ICWMP, among other meetings. Moreover, another consultation meeting was held on November 8, 2021 which included other stakeholders within MoH. The meeting targeted department and directorates that have an influence on the project and are directly or indirectly involved in it. The meeting aimed to raise awareness within the MoH staff with regard to the project, as the E&S audit raised an important finding that not many departments were aware of the project, and if they did, they were not clear on its activities. With respect to the OIPs and marginalized groups, a public consultation session was held on the 8th of November, 2021. The meeting targeted communities, institutions, and individuals who have been affected by the COVID-19 pandemic, in addition to stakeholders such as CBOs and NGOs working with Bedouin communities, marginalized groups, women headed households and other vulnerable groups, stakeholders also included international and local institutions working and involved in the medical and health sector. The meeting was conducted virtually via MS Teams. Details and summaries of the stakeholder engagement meetings are available in the updated SEP. 8.2. Methods, Tools and Techniques for Stakeholder Engagement The project intends to utilize various methods for consultations that will be used as part of its continuous interaction with the stakeholders. The format of every consultation activity should meet general requirements on accessibility. In order to control the risks of virus transmission, MoH will be advised, when conducting stakeholder consultation meetings, to take into account the national restrictions regarding public gatherings during COVID-19 pandemic, the World Bank’s Note on Public Consultations and Stakeholder Engagement in WB-supported operations and the WHO regulations. The details of the stakeholder engagement needs, methods, tools and techniques are available in section 6.3 in the updated SEP. 58 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 8.3. Stakeholder Engagement Plan (SEP) The table below provides various methods for consultations, targeted stakeholders. Project stage Topic of Method used Timetable: Target Responsibilities consultation stakeholders Location and frequency Introduction of the Correspondences MoH offices, Health MOH project activities (Phone, Emails, health agencies, Personnel, and information official letters) clinics, laboratories. Contractors, about time and service venue of training, An introductory providers, procurement of meeting with suppliers and equipment health officials, their workers supported by the monthly Preparation project, Health& meetings or as Stage safety (OHS) plans needed. and sub- management plans, GM tools for filing complaints and providing feedback Important Emails, official MOH offices. Government MOH highlights of letters and virtual agencies, Project, During Project meetings (if needed) governorates, launch announcements of with relevant municipalities, meetings. planned activities, organizations media, private associated risks and sector, mitigation measures. 1-Project status - Formal MOH offices / General MOH meetings social media / population, 2-Project progress - Press releases virtual including in containing and - Press meetings Vulnerable treating the conferences households infection On monthly - Communication Government basis or 3-Risks and materials agencies, periodic mitigation measures - Reports governorates, throughout the including risks and (including municipalities, implementation mitigation measures number of contractors phase associated with the public and workers, vaccine deployment grievances media, private received within sector Implementation 4- Additional Financing the reporting Stage period (e.g. monthly, quarterly, or annually) and 59 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF number of those resolved within the prescribed timeline 4-Information about - MOH Website MOH website. All MOH Project stakeholders development Updates to be done on regular updates, health and basis. safety, employment and procurement, environmental and social aspects, Project-related materials. Supervision& Project’s outcomes, - Formal MOH offices General MOH Monitoring meetings population, Overall progress Governorate - Press releases Vulnerable and major Offices - Press households, achievements. conferences Municipalities’ medical staff - Public meetings halls. Government - Reports agencies, After six (including governorates, months or so Number of municipalities, from the public media, private stability of the grievances sector operation or received within Contractors, provision of the reporting service services. period and providers, number of suppliers and those resolved their workers within the prescribed timeline 8.4. Resources and Responsibilities for Implementing SEP 8.4.1. Resources and Budget The Environment, Health and Safety Officer (EHSO) at the PMU will be responsible for implementing the stakeholder engagement activities including the AF. The budget for the SEP is estimated to be around US$15,000 included in the costing table under the operational expenses of the project. 60 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Unit Total Times/ Activities Quantity Cost Cost 5 years (USD) (USD) Stakeholder Engagement Activities Assessment and consultation visits 1,000 Communications materials (posters, pamphlets, 3 1,000 1 3,000 flyers… including design) Newspaper announcements and Radio spots 14 800 1 10,000 Sub-total - Stakeholder Engagement Grievance activities GM Communications materials (including design) 1,000 TOTAL 15,000 8.4.2. Management Functions and Responsibilities As mentioned above, the MoH through the EHSO at the PMU will be responsible for implementing the stakeholder engagement activities including the AF. MoH relevant departments shall have frequent and continuous communication and follow up with the district offices during the design and implementation phase. The stakeholder engagement activities will be documented through timely reports which shall also be included in the annual and semiannual reporting to the WB. 8.5. Grievance Mechanism The main objective of a Grievance Mechanism (GM) is to assist to resolve complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Specifically, it provides a transparent and credible process for fair, effective and lasting outcomes. It also builds trust and cooperation as an integral component of broader community consultation that facilitates corrective actions. Specifically, the GM: ▪ Provides affected people with avenues for making a complaint or resolving any dispute that may arise during the course of the implementation of projects; ▪ Ensures that appropriate and mutually acceptable redress actions are identified and implemented to the satisfaction of complainants; and ▪ Avoids the need to resort to judicial proceedings. Grievances will be handled at the project’s level by the EHSO at the PMU/MoH. The GRM will be accessible to all project’s stakeholders, including affected people, community members, health 61 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF workers, civil society, media, and other interested parties. Stakeholders can use the GRM to submit complaints related to the overall management and implementation of the project. Along with the updating the project’s E&S instruments including the ESMF, SEP and LMP, the GRMs for both the community and project workers’ have also undergone an update to reflect the recent situation, findings, and updates that occurred during the implementation of the parent project. The updated GRMs (community & workers) reflect the needs and requirements under the AF and its proposed activities. Notable updates are with respect to GBV grievances where it was agreed with the Ministry of Social Development (MoSD) that GBV related grievances shall be referred to them and are to be handled and processed in accordance with the National Referral System for GBV Incidents. Hence, the GRM guidelines that will be utilized by the EHSO who shall manage grievances have been updated. Project GRM and Workers’ GRM briefs have been prepared and are disclosed on MoH’s webpage, the briefs are the simplified versions of the guidelines for public use that contain details of the channels, timelines, phone numbers, email and other contact details and brief descriptions of the project and the GRM. The briefs are prepared in Arabic language and are simple and easy to understand so they could be utilized by anyone despite their position, educational level, or location. The EHSO will communicate GRM details about the existence of the GBV grievance mechanism and of channels to accept and respond to anonymous grievances to all stakeholders during the consultation meetings and through appropriate methods. The EHSO will keep a log at hand of all complaints rincluding date received, date responded to, and type of response provided. Reports on grievances and complaints will be consolidated into semi-annual project progress reports prepared by the PMU for the World Bank. A detailed description of the GRM is included in the updated SEP. The following tools will be used for lodging grievances: • By completing a written grievance registration form that will be available at the PMU in the MoH offices or online14. In order to control the risks of virus transmission during Covid-19 pandemic, the complainants will be advised to submit their complaints electronically, by post, fax, or via telephone. Postal Address: P6009262 Fax: 022966260 • By submitting the complaint electronically via email at grm@hsrsp.ps • By reaching out to the EHSO through telephone and mobile numbers assigned for complaints at the PMU. The following number at the PMU will be used for submitting complaints: 0562402198. 14 https://drive.google.com/file/d/1iCs2uM-LJnyeNqiHoezWgQiStmlIUqIi/view?usp=sharing 62 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF • By personal visit to the PMU offices at the World Bank Projects Management Unit, 3rd floor, MoH headquarters, Ramallah. Where possible it is desirable that complaints are submitted in writing by the complainant. Should the complainant not wish to comply with this request and submit the complaint verbally, then the complainant information and the details of the complaint should be entered in the GM log. The GM system will include special pathways for the GBV complaints and grievances, including grievances on sexual harassment and sexual exploitation and abuse. Channels to accept and respond to GBV grievances, while ensuring high confidentiality, will be communicated to the project’s affected parties during the consultation meetings and throughout project implementation. Training will also be provided by a GBV expert for the EHSO on detection of cases of gender- based violence and handling of inquiries, complaints and grievances related to GBV. The following sexual harassment and sexual abuse grievance procedures, in line with the MoH GBV regulations15, will be followed: The GRM through the PMU will accept GBV related grievances through the available channels. Telephone information line, email address and procedures will be communicated to beneficiaries during consultation and induction sessions. The telephone number can also be used by employees/workers to discuss questions or concerns about the harassment without having to express an identity. The following sexual harassment and sexual abuse grievance procedures, in line with MoH regulations and in line with the Ministry of Social Development (MoSD) referral mechanism and the National Referral System for GBV incidents will be followed: I- Accept the grievance/ complaint through the GRM available channels. II- Provide the complainant with the option of anonymity as described in section 4.1.2. And request their consent to be contacted by the EHSO. III- Upon agreement from the victim, refer the victim to MoSD’s Women Affairs Directorate; 15 In order to respond to GBV gaps in the local laws, the MoH has joined the GBV Sub-Cluster to enhance the health system’s preparedness to address and respond to gaps related to gender -based violence (GBV) through the provision of a number of multi-sectoral GBV services. The GBV Sub-Cluster includes more than 40 national and international NGOs, 8 line ministries including the MoH and 11 UN agencies. 63 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF IV- In case the survivor decides to seek justice, the National Referral System for GBV incidents will be followed. V- Follow up with the complainant, if they have provided their consent, to ensure just and proper care is provided to them. And obtain feedback from MoSD regarding the case for filing and closure. 9. Institutional Arrangements, Responsibilities and Capacity Building This section describes the institutional arrangements to implement the updated ESMF from the screening of subprojects for environment and social issues, preparation of and consultation for subproject instruments, disclosure, review and clearance of subprojects to monitoring the implementation of the ESMP. For procurement of equipment and operation stages, the following aspects should be considered, • Definition of roles and responsibilities along each link of the chain along the cradle-to- grave infection control and waste management process; • Ensure adequate and qualified staff are in place, including those in charge of infection control and biosafety and waste management facility operation. • Stress the chief of an HCF takes overall responsibility for infection control and waste management; • Involve all relevant departments in a healthcare facility, and build an intra-departmental team to manage, coordinate and regularly review the issues and performance; • Establish an information management system to track and record the waste streams in HCF; and • Capacity building and training involving medical workers, waste management workers and cleaners by the EHSO. 9.1. Institutional and Implementation Arrangements 9.1.1. Implementation Arrangements The AF will be implemented within the Ministry of Health. The institutional arrangement of the AF will be the same to the parent project. The project’s full time EHSO will be responsible for the monitoring of the implementation of the project Environmental and Social requirements as well as progress in the implementation of the recommendations of the environmental and social audit and the regular reporting. The E&S performance of the parent project was downgraded to Moderately 64 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Unsatisfactory due to ESF non-compliance. The primary reason for the non-compliance was the disbursement of over 70% of the project’s funds to finance mobilization of human resources and procurement of laboratory and hospital equipment and vaccines of the routine immunization program to avoid disruptions in basic health services delivery due to the pressing need to provide immediate assistance to the population during COVID-19. The E&S rating is raised to Moderately Satisfactory, according to the latest project’s ISR in November 2021, in view of the measures already taken to strengthen E&S performance and the commitment given in the ESCP to implement the corrective action plan, recommended in the E&S audit, during the life of the parent project and the additional financing. The PMU will finance one additional Financial Management (FM) Specialist and will continue financing the EHSO as financed by the parent project. The PMU at MoH will be responsible for coordination and implementation of the project- funded activities. Fiduciary activities for the project will be managed by the procurement and financial specialists at PMU in coordination with the accounting and procurement units at the MoH. Name of focal point at MOH: Ms. Maria Al-Aqra Director of International Cooperation Telephone: 00972 9 2387275 Email: alaqra@yahoo.com The PMU and the Project Coordinator will be responsible for the overall implementation of the environmental and social instruments of the project as well as reporting back to the Bank. The PMU’s Environment, Health and Safety Officer (EHSO) will be responsible for ensuring the project’s compliance with this ESMF as well as the LMP, SEP, and ESCP prepared for the project. The EHSO will also be responsible for screening and preparing the site specific ESMP following the screening process as guided in this ESMF, monitoring and reporting on compliance of the environmental and social issues. The EHSO is also responsible for submitting the ESMP to the Bank for clearance. In addition, the EHSO is expected to create awareness among all hospitals/HCFs on environmental and social compliance and training necessary for its effective implementation. The PMU at MOH has a health specialist who will support the EHSO in the reporting on the project. The role of hospitals/HCFs, the recipient of the project equipment and goods to be supplied by the project, is to assign a focal point for implementing, monitoring and reporting to the ESHO at the PMU the environmental and social requirements as per the environmental and social instruments. 9.1.2. Results Monitoring and Evaluation Arrangements Monitoring during implementation provides information about key environmental and social aspects of the project, particularly the environmental and social impacts of the AF activities and the effectiveness of mitigation measures. This allows the Project to evaluate the success of 65 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF mitigation measures as part of project supervision and allows corrective action to be taken when needed. As a lessons learned, the E&S audit recommended in the corrective action plan (CAP) to enhance monitoring and reporting of E&S implementation. The EHSO will be responsible for monitoring the implementation of mitigation measures, set out in the ESMP’s. Relevant practical indicators to enable effective monitoring will be identified by the EHSO such as number of mitigation measures implemented; functional GRM system is in place; complaints received have been completed for a reasonable period; using the results of E&S monitoring to guide subsequent implementation, stakeholders concerns during consultations on possible impacts of sub-project activities and taken into consideration during the preparation of ESMP, E&S monitoring reports are produced on time according to the ESCP, etc. Monitoring is to be conducted on continuous basis. The flow of monitoring proceeds is presented in Table 9: Table 9: West Bank and Gaza COVID-19 Emergency Response & AF Monitoring, Evaluation, and Reporting Framework Type of Who Description M&E Constant Focal point at The focal point at hospital/HCF will be responsible monitoring hospital/HCF for implementing, monitoring and reporting on a monthly basis to the ESHO at the PMU the environmental and social requirements as per the environmental and social instruments Monthly EHSO The EHSO will compile the monthly report monitoring received from the focal points at hospitals/HCFs reports and address all environmental and social issues relevant to the project in a monthly monitoring report and submit it to the PMU director. Quarterly ESHO/MoH, The EHSO will prepare a quarterly progress report Progress and submit it to the PMU Coordinator Report From MoH to the (QPR) World Bank The director will submit this report to the World Bank as per the ESCP 9.1.3. Sustainability The sustainability of the parent project-supported activities and the AF activities will hinge on government commitment; enhanced institutional capacity and predictable financing. The commitment of Palestinian government to protecting health and well-being of the population and 66 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF putting in place robust public health measures has been strong and augurs well for sustainability. Palestinian Authority continues to demonstrate strong ownership to contain outbreaks swiftly. Institutional capacity has been built over time with the proposed project further strengthening critical disease outbreak response. However, further work is needed to ensure financial sustainability to contain COVID-19 outbreak. 9.2. Monitoring Environmental and Social Issues MoH will be the responsible authority for monitoring the environmental and social aspects of the project. In addition, MoH’s EHSO will take lead in guiding and implementing the environmental and social requirements of the project. The capacity of the EHSO will be enhanced by induction training at the beginning of the AF activities’ implementation. This will facilitate a better understanding and appreciation of safeguard requirements through discussion with the World Bank safeguard team for implementation of the project ESMF provisions. 9.3. Capacity enhancement needs Currently, MoH has contracted an EHSO who joined the PMU late May 2021. In order to ensure stronger capacity to manage E&S aspects of the AF, and based on the E&S ex-post audit’s recommendations and its CAP, the capacity building for the EHSO will be provided by the safeguard Bank team and should include: • Impact assessment • World Bank ESF requirements– Implementation requirements of the specific/applicable Environmental and Social Standards • Environmental monitoring • Stakeholder engagement • Grievance management • Management of environmental and social aspects in health care facilities • Healthcare waste management 67 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 10. ESMF Implementation Budget The quantities, specifications and estimated costs of design measures to avoid or mitigate negative impacts of each project component site will be assessed by the PMU staff together with their EHSO and incorporated into bidding/procurement documents. The contractor/supplier will execute all required works and reimbursed through pay items in the bill of quantities financed by the project. The cost expected under this ESMF will be for the fulltime EHSO’s salary who will have certain tasks to be carried out with the MOH involved departments. The Table below summarizes the estimated costs and schedules for the items associated with the implementation of the ESF. The budget for the SEP is estimated to be around US$15,000 as determined in the updated SEP and included in the costing table below. The EHSO will also be responsible for the implementation of the updated SEP. The EHSO will review the SEP every six months to determine if any changes to stakeholder categories or engagement activities are required. The budget will be revised accordingly. Item Schedule Cost (US$) Implement ESMF Throughout project No additional cost, this is implementation embedded in EHSO cost Site specific ESMPs Throughout project No additional cost, this is implementation embedded in EHSO cost Preparing CoC to regulate By project effectiveness No additional cost, this is conduct of workers at the embedded in EHSO cost installation sites, consultation and logistics aspects, etc. Recruit EHSO Full-time throughout project 5 years @ 36,000 USD per year Implementation US$180,000 Assign focal points at Throughout project Government in-kind contribution hospitals/HCFs implementation Implementation of updated Throughout project US$ 15,000 SEP implementation Total US$195,000 68 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Annexes I. Screening Form for Potential Environment and Social Issues II. Template for Environmental and Social Management Plan (ESMP) III. Template for Infection Control and Waste Management Plan (ICWMP) IV. Infection and Prevention Control Protocol (IPCP) V. Consultation and Stakeholder Engagement 69 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF I. Screening Form for Potential Environmental & Social Safeguards Issues This form is to be used by the Implementing Agency to screen potential environmental and social risk levels of a proposed subproject, determine the relevance of Bank environmental and social standards (ESS), propose its E&S risk levels, and the instrument to be prepared for the sub project. Subproject Name Subproject Location Subproject Proponent Estimated Investment Start/Completion Date Part 1: Subproject Eligibility Screening Checklist No Will the sub-project: Yes No 1 Cause adverse health impact including serious/potentially lethal diseases, high containment, cause aerosol transmission 2 Cause long term, permanent and/or irreversible (e.g. loss of major natural habitat) adverse impacts 3 Have high probability of causing serious adverse effects to human health and/or the environment not related to treatment of COVID-19 cases 4 Have adverse social impacts and may give rise to significant social conflict 5 Affect lands or rights of indigenous people or other vulnerable minorities and would require Free Prior Informed Consent. 6 Involve permanent resettlement or land acquisition, adverse impacts on cultural heritage 70 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF 7 Involve civil works including new construction, expansion, upgrading or rehabilitation of healthcare facilities and/or associated waste management facilities 8 Involve any external waste management facilities such as a sanitary landfill, incinerator, or wastewater treatment plant for healthcare waste disposal Recommendations: • If one of answer is Yes, the Sub-project is not eligible and rejected: _________ • If All the answers are No, Sub-project is eligible identify potential environmental and social risks and the relevant ES instruments: _________ Part 2: Identification of Relevant ESSs and Due Diligence Action/Instruments Questions Answer ESS relevance Due diligence / Actions yes no Does the subproject involve small-scale ESS1 ESMP, SEP civil works during the installation of the new equipment. Is there sound regulatory framework, ESS1 ESMP, institutional capacity in place for healthcare ICWMP, SEP facility infection control and healthcare waste management? Does the subproject involve recruitment of ESS2 ESMP, LMP, workforce including direct, contracted, SEP primary supply, and/or community workers? Does the subproject involve transboundary ESS3 ESMP, transportation of specimen, samples, ICWMP, SEP infectious and hazardous materials? Is the subproject located within or in the ESS6 Activity vicinity of any ecologically sensitive areas? excluded 71 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Are there any vulnerable groups present in ESS10 Vulnerable the subproject area and are likely to be Groups Plan affected by the proposed subproject negatively or positively? Is the subproject located within or in the ESS8 Activity vicinity of any known cultural heritage excluded sites? Does the project area present considerable ESS1 ESMP, SEP Gender-Based Violence (GBV), Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) risks? Conclusions: 1. Proposed Environmental and Social Risk Ratings (High, Substantial, Moderate or Low). Provide Justifications. 2. Proposed E&S Action/Instruments. 72 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF II. ESMP Template Introduction Environmental and social management plan (ESMP) is an instrument that details set of mitigation, monitoring, and institutional measures to be taken during implementation and operation of a project to eliminate adverse environmental and social risks and impacts, offset them, or reduce them to acceptable levels. The ESMP also includes the measures and actions needed to implement these measures. The MoH will (a) identify the set of responses to potentially adverse impacts; (b) determine requirements for ensuring that those responses are made effectively and in a timely manner; and (c) describe the means for meeting those requirements. The ESMP includes the following components: Introduction An overview of the project and the proponent including information such as: i) project name and general description; ii) background; iii) objectives of the ESMP. Policy and Legal Framework Brief outline relevant policies, guidelines and laws that apply to the project and the approvals that need to be obtained from different government agencies Project description and Justification Brief description of the development proposal including project location and footprint (including maps), summary of key design features, resource requirements and source, predicted type and quantify of waste outputs, work force size and accommodation, and implementation schedule Brief justification including benefits accruing to the local area, and project relevance in light of local or national needs Description of the project area A brief description of the environmental, socio-economic and cultural characteristics relevant to the project and its area of influence Consultation and Information Dissemination A summary of consultation and information dissemination activities during the ESMP process and including general issues raised, and responses to those issues; Impact Assessment and Mitigation Measures 73 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF The ESMP identifies measures and actions in accordance with the mitigation hierarchy that reduce potentially adverse environmental and social impacts to acceptable levels. The plan will include compensatory measures, if applicable. Specifically, the ESMP: a) identifies and summarizes all anticipated adverse environmental and social impacts; b) describes—with technical details—each mitigation measure, including the type of impact to which it relates and the conditions under which it is required, together with equipment descriptions, and operating procedures, as appropriate; c) estimates any potential environmental and social impacts of these measures; and d) takes into account, and is consistent with, other mitigation plans required for the project. Environmental Mitigation Plan Activi Potential Proposed Responsibilit Period for Mitigation ty Environmental Mitigation y for Implementati Measures Impact Measures Implementati on of Implementati on of Mitigation on Costs Mitigation Measures (and who Measures bears it) Procurement of equipment and installation phase 1 2 Operational Phase 1 2 Decommissioning phase (if applies) 1 2 Monitoring 74 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF The ESMP identifies monitoring objectives and specifies the type of monitoring, with linkages to the impacts assessed in the environmental and social assessment and the mitigation measures described in the ESMP. Specifically, the monitoring section of the ESMP provides (a) a specific description, and technical details, of monitoring measures, including the parameters to be measured, methods to be used, frequency of measurements, limits (where appropriate), and definition of thresholds that will signal the need for corrective actions; and (b) monitoring and reporting procedures to (i) ensure early detection of conditions that necessitate particular mitigation measures, and (ii) furnish information on the progress and results of mitigation. Monitoring Plan What Where How When Who Cost parameter is is the is the is the monitors the of to be parameter to parameter to parameter to parameter monitoring monitored? be be be monitored (responsibilit the monitored? monitored? (time and y)? parameter frequency)? (and who bears it) Procurement of equipment and installation phase 1 2 Operational Phase (and decommissioning if applies) 1 2 Institutional Arrangements, Capacity Development and Training The ESMP provides a specific description of institutional arrangements, identifying which party is responsible for carrying out the mitigation and monitoring measures (e.g., for operation, supervision, enforcement, monitoring of implementation, remedial action, financing, reporting, and staff training). The hospitals/HCFs is to assign a focal point for implementing, monitoring and reporting to the ESHO at the PMU the environmental and social requirements as per the environmental and social instruments. 75 WB&G COVID-19 Emergency Response Project and Additional Financing - ESMF Implementation Schedule and Cost Estimates For all three aspects (mitigation, monitoring, and capacity development), the ESMP provides (a) an implementation schedule for measures that must be carried out as part of the project, showing phasing and coordination with overall project implementation plans; and (b) the capital and recurrent cost estimates and sources of funds for implementing the ESMP. These figures are also integrated into the total project cost tables. . 76 COVID-19 Response ESMF – ICWMP III. Infection Control and Waste Management Plan (ICWMP) Template 1. Introduction 1.1 Describe the project context and components; 1.2 Describe the targeted healthcare facility (HCF): - Type: E.g. general hospital, clinics, inpatient/outpatient facility, medical laboratory; - Special type of HCF in response to COVID-19: E.g. existing assets may be acquired to hold yet-to-confirm cases for medical observation or isolation; - Functions and requirement for the level infection control, e.g. biosafety levels; - Location and associated facilities, including access, water supply, power supply; - Capacity: beds 1.3 Describe the design requirements of the HCF, which may include specifications for general design and safety, separation of wards, Heating, Ventilation and Air Conditioning (HVAC), autoclave, and waste management facilities. 2. Infection Control and Waste Management 2.1 Overview of infection control and waste management in the HCF - Type, source and volume of healthcare waste (HCW) generated in the HCF, including solid, liquid and air emissions (if significant); - Classify and quantify the HCW (infectious waste, pathological waste, sharps, liquid and non-hazardous) following WBG EHS Guidelines for Healthcare Facilities and pertaining GIIP. - Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non-hazardous may be considered hazardous. It’s likely the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak. Special attention should be given to the identification, classification and quantification of the healthcare wastes. - Describe the healthcare waste management system in the HCF, including material delivery, waste generation, handling, disinfection and sterilization, collection, storage, transport, and disposal and treatment works; - Provide a flow chart of waste streams in the HCF if available; - Describe applicable performance levels and/or standards; - Describe institutional arrangement, roles and responsibilities in the HCF for infection control and waste management. 2.2 Management Measures - Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety consideration. 77 COVID-19 Response ESMF – ICWMP - Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of the hazardous medical goods. - Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. - Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. Workers need to be trained on the safe and timely disposal of such waste when the plan is developed. An induction and training workshop shall be given. - Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out, and the plan should include a suggested schedule to be discussed and implemented by the HCF. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours. - Onsite waste treatment and disposal (e.g. an incinerator): Many HCFs have their own waste incineration facilities installed onsite. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended. For new HCF financed by the project, waste disposal facilities should be integrated into the overall design and ESIA developed. Good design, operational practices and internationally adopted emission standards for healthcare waste incinerator can be found in pertaining EHS Guidelines and GIIP. - Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well-performed incinerator onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government or private sector are probably needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. - Wastewater treatment: HCF wastewater is related to the hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged. In cases where municipal sewage system is not in place, HCF should build and proper operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of 78 COVID-19 Response ESMF – ICWMP the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There’re also cases HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted. 3. Emergency Preparedness and Response Emergency incidents occur in an HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, community, HCF’s operation and the environment. Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed. The key elements of an ERP are defined in ESS 4 Community Health and Safety (para. 21). 4. Institutional Arrangement and Capacity Building A clearly defined institutional arrangement, roles and responsibilities should be included. A training plan with recurring training programs should be developed. The following aspects are recommended: - Define roles and responsibilities along each link of the chain along the cradle-to-crave infection control and waste management process; - Ensure adequate and qualified staff are in place, including those in charge of infection control and biosafety and waste management facility operation. - Stress the chief of an HCF takes overall responsibility for infection control and waste management; - Involve all relevant departments in a healthcare facility, and build an intra-departmental team to manage, coordinate and regularly review the issues and performance; - Establish an information management system to track and record the waste streams in HCF; and - Capacity building and training should involve medical workers, waste management workers and cleaners. Third-party waste management service providers should be provided with relevant training as well. 5. Monitoring and Reporting Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams. HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, 79 COVID-19 Response ESMF – ICWMP transport carts/vehicles, to treatment facilities. HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow. As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing system should be in place. Externally, reporting should be conducted per government and World Bank requirements. Table ICWMP 80 COVID-19 Response ESMF – ICWMP Activities Potential E&S Issues and Proposed Mitigation Measures Responsibilities Timeline Budget Risks General HCF operation – General wastes, wastewater Environment and air emissions General HCF operation – Physical hazards OHS issues Electrical and explosive hazards Fire Chemical use Ergonomic hazard Radioactive hazard HCF operation - Infection - control and waste management plan Waste minimization, reuse - and recycling Delivery and storage of - specimen, samples, reagents, pharmaceuticals and medical supplies - Storage and handling of - specimen, samples, reagents, and infectious materials Waste segregation, - packaging, color coding and labeling Onsite collection and transport 81 COVID-19 Response ESMF – ICWMP Waste storage Onsite waste treatment and disposal Waste transportation to and disposal in offsite treatment and disposal facilities HCF operation – transboundary movement of specimen, samples, reagents, medical equipment, and infection materials Emergency events - Spillage, Emergency response plan - Occupational exposure to infectious - Exposure to radiation, Accidental releases of infectious or hazardous substances to the environment, - Medical equipment failure, - Failure of solid waste and wastewater treatment facilities, -fire -Other emergent events Operation of acquired assets for holding potential COVID-19 patients To be expanded 82 COVID-19 Response ESMF – ICWMP VI. Infection and Prevention Control Protocol (adapted from the CDC Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in Healthcare Settings) – updated to reflect changes in the CDC recommendations as of February 10, 2021. HEALTH CARE SETTINGS 1.Minimize Chance of Exposure (to staff, other patients and visitors) • When scheduling appointments for routine medical care, enforce the use of telehealth strategies, and advise patients to put on their own well-fitting face masks. • Upon arrival, make sure patients with symptoms of any respiratory infection to a separate, isolated and well-ventilated section of the health care facility to wait, and issue a facemask • During the visit, make sure all patients adhere to respiratory hygiene, cough etiquette, hand hygiene and isolation procedures. Provide oral instructions on registration and ongoing reminders with the use of simple signs with images in local languages • Provide alcohol-based hand sanitizer (60-95% alcohol), tissues and facemasks in waiting rooms and patient rooms. • Isolate patients as much as possible. If separate rooms are not available, separate all patients by curtains. Only place together in the same room patients who are all definitively infected with COVID-19. No other patients can be placed in the same room. • If suspecting or having confirmed case of Covid-19, healthcare workers shall be excluded from work and visitors shall be restricted from entering the facility. • Screening of fever and symptoms should be incorporated into daily assessments of all admitted patients to the HCF. • Personnel shall adhere to the use of PPEs, preferably N95 masks or any meeting similar standards, masks with nose wires, and preferably double masking. Eye protection should be worn during patient care encounters, gloves, and other PPEs as required. 2.Adhere to Standard Precautions • Train all staff and volunteers to undertake standard precautions - assume everyone is potentially infected and behave accordingly • Minimize contact between patients and other persons in the facility: health care professionals should be the only persons having contact with patients and this should be restricted to essential personnel only • A decision to stop isolation precautions should be made on a case-by-case basis, in conjunction with local health authorities. 3.Training of Personnel • Train all staff and volunteers in the symptoms of COVID-19, how it is spread and how to protect themselves. Train on correct use and disposal of personal protective equipment (PPE), including gloves, gowns, facemasks, eye protection and respirators (if available) and check that they understand 83 COVID-19 Response ESMF – ICWMP • Train cleaning staff on most effective process for cleaning the facility: use a high-alcohol based cleaner to wipe down all surfaces; wash instruments with soap and water and then wipe down with high-alcohol based cleaner; dispose of rubbish by burning etc. 4.Manage Visitor Access and Movement • Establish procedures for managing, monitoring, and training visitors • Limit and monitor entry points to the HCF. And establish a procedure to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of Covid-19 symptoms. Such measures may include measuring body temperature for fever detection with a defined threshold and procedure. • Limit visitors to the facility to only those essential for patient’s physical or emotional well- being and care. • Encourage other mechanisms such as video call applications. • All visitors must follow respiratory hygiene precautions while in the common areas of the facility, otherwise they should be removed • Encourage physical distancing and remind personnel and visitors with posters in clear and visible places. Arrange seating in waiting rooms so patients can maintain safe distances. • Restrict visitors from entering rooms of known or suspected cases of COVID-19 patients Alternative communications should be encouraged, for example by use of mobile phones. Exceptions only for end-of-life situation and children requiring emotional care. At these times, PPE should be used by visitors. • All visitors should be scheduled and controlled, and once inside the facility, instructed to limit their movement. • Visitors should be asked to watch out for symptoms and report signs of acute illness for at least 14 days. 5. Environmental Infection Control • Dedicated medical equipment should be used when caring for patients with suspected or confirmed Covid-19 cases. • All non-disposable medical equipment used for patient care should be cleaned and disinfected in accordance with the manufacturer’s instructions and the HCF’s policies. • Infectious and highly infectious waste should be dealt with in accordance with implemented medical waste management procedures. • Routine cleaning and disinfection procedures shall be implemented. • Implement procedures and facilities for handling laundry, linen and contaminated clothing. CONSTRUCTION SETTINGS IN AREAS OF CONFIRMED CASES OF COVID-19 1.Minimize Chance of Exposure • Any worker showing symptoms of respiratory illness (fever + cold or cough) and has potentially been exposed to COVID-19 should be immediately removed from the site and tested for the virus at the nearest local hospital 84 COVID-19 Response ESMF – ICWMP • Close co-workers and those sharing accommodations with such a worker should also be removed from the site and tested • Project management must identify the closest hospital that has testing facilities in place, refer workers, and pay for the test if it is not free • Persons under investigation for COVID-19 should not return to work at the project site until cleared by test results. During this time, they should continue to be paid daily wages • If a worker is found to have COVID-19, wages should continue to be paid during the worker’s convalescence (whether at home or in a hospital) • If project workers live at home, any worker with a family member who has a confirmed or suspected case of COVID-19 should be quarantined from the project site for 14 days, and continued to be paid daily wages, even if they have no symptoms. 2.Training of Staff and Precautions • Train all staff in the signs and symptoms of COVID-19, how it is spread, how to protect themselves and the need to be tested if they have symptoms. Allow Q&A and dispel any myths. • Use existing grievance procedures to encourage reporting of co-workers if they show outward symptoms, such as ongoing and severe coughing with fever, and do not voluntarily submit to testing • Supply face masks and other relevant PPE to all project workers at the entrance to the project site. Any persons with signs of respiratory illness that is not accompanied by fever should be mandated to wear a face mask • Provide handwash facilities, hand soap, alcohol-based hand sanitizer and mandate their use on entry and exit of the project site and during breaks, via the use of simple signs with images in local languages • Train all workers in respiratory hygiene, cough etiquette and hand hygiene using demonstrations and participatory methods • Train cleaning staff in effective cleaning procedures and disposal of rubbish 3.Managing Access and Spread • Should a case of COVID-19 be confirmed in a worker on the project site, visitors should be restricted from the site and worker groups should be isolated from each other as much as possible; • Extensive cleaning procedures with high-alcohol content cleaners should be undertaken in the area of the site where the worker was present, prior to any further work being undertaken in that area. 85