The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 02/16/2022 | Report No: ESRSAFA334 Feb 23, 2022 Page 1 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Ghana AFRICA WEST Republic of Ghana Ghana Health Services, Ministry of Health Project ID Project Name P178054 Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing Parent Project ID (if any) Parent Project Name P173788 Ghana COVID-19 Emergency Preparedness and Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 3/3/2022 3/31/2022 Population Financing Public Disclosure Proposed Development Objective To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Ghana Financing (in USD Million) Amount Current Financing 165.00 Proposed Additional Financing 60.60 Total Proposed Financing 225.60 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] Feb 23, 2022 Page 2 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) Under the COVID-19 Fast Track Facility, this Project is the health sector operations to respond to the COVID-19 pandemic. The project will address both short-term rapid respond to the COVID-19 pandemic, including COVID-19 vaccination, and national health systems strengthening. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The AF3 will have national coverage and will be implemented in all the 16 regions and 270 health districts in Ghana. As of November 3, 2021, more than 3.1 million out of 8.1 million available doses were administered, which has allowed for only 2.7 percent of the total population to be fully vaccinated. About 7.9 percent of the population has received at least one dose. Over time, the rest of the population will be vaccinated as more vaccines are procured. The AF3 will play a key role for the Government of Ghana to acquire an additional 2.4 million doses of Janssen vaccines through the African Vaccine Acquisition Trust (AVAT). The AVAT, convened by the African Union (AU), has agreed with the World Bank to provide the AU member states with additional COVID-19 vaccines through the United Nations Children’s Fund (UNICEF) as a procurement agency. These additional doses would increase the COVID-19 vaccination coverage up to 82.35 percent of the total population, which exceeds the initial national target of vaccinating 17.5 million people or 56.5 percent of the total population. The overall environmental and social performance as of November, 2021 is rated as Moderately Satisfactory (MS). The E&S Focal Officers at MOH/GHS have undertaken field visits to some sites where construction and rehabilitation Public Disclosure activities are ongoing. MOH/GHS needs to further improve and intensify field supervision to these sites and continue to improve on E&S reporting. The AF3 will allow for re-vaccination efforts if they are warranted by peer-reviewed scientific knowledge at the time. In the case that re-vaccination is required, limited priority populations (such as health workers and the elderly) will need to be targeted for re-vaccination given constraints on vaccine production capacity and equity considerations (i.e., tradeoffs between broader population coverage and re-vaccination). The Government of Ghana (GoG) will continue to provide free COVID-19 vaccination and there are no-cost barriers to access the vaccines to the population. However, broader social risks relating to barriers to physical access, gender inequalities and disparities due to socio-cultural beliefs, and geographic and functional proximity to sites for vaccination still exist. There are also potential risks to supply chain issues relating to the disruptions to or constraints on the distribution, and delivery of vaccines to some hard to reach locations. Attitudinal barriers to vaccine uptake are associated with perceived risks of vaccines (beliefs that vaccines are harmful). Other social risks include likely communication gaps in access to information sources and absorption level of correct information about COVID-19 among women compared to men as illiteracy rates are higher among women. Misinformation, misperception, and inequitable information dissemination may also give rise to COVID-19 vaccine hesitancy, reduced access to vaccine services (especially among vulnerable groups), reprisals and retaliation against healthcare workers and researchers related to both suspicions of the motives and legitimacy of the vaccinators. Many of these barriers have been identified and are being addressed by the Ministry of Health (MOH) and the Ghana Health Service (GHS) in the National COVID-19 Deployment Plan and COVID-19 and the National Communication Strategy for Feb 23, 2022 Page 3 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) COVID-19 Vaccine Introduction to complement the updated SEP for project. The strategy includes channels and measures to ensure equitable and inclusive engagement and crisis communication approach. The MOH and GHS have been enlisting social influencers, traditional leaders, celebrities and opinion leaders among others, to promote vaccination. These people share their experiences on traditional and social media platforms and encourage individuals to get the vaccine. There is also a risk of creating or exacerbating poor conditions with an impact on community health and safety due to the potential risks of improper disposal of medical waste (e.g., in open waste dumps and discharge of contaminated water that may contaminate land and surface water or injury to waste pickers). Voluntary consent and mandatory vaccination: The National COVID-19 Vaccine Deployment Plan has also been developed. The vaccination policy emphasizes voluntary uptake and there will be no forced vaccination. The project will continuously engage stakeholders to identify and mitigate any risk related to any aspects of the national COVID- 19 vaccination program and whether and how cultural, social and traditional community practices and values will impact on vaccine uptake. Environmental and Social Management Framework (ESMF): The ESMF for the Vaccine Additional Financing (AF2) and the ESMF for the Additional Financing One (AF1) and the parent project were approved by the World Bank and disclosed on June 30, 2021 and November 10, 2020 respectively. The ESMFs for the Parent Project, AF 1 and the Vaccine Additional Financing (AF2) remain relevant for the AF3. Public Disclosure Stakeholder Engagement Plan (SEP): The SEP for the AF2 which was approved by the World Bank and disclosed on May 5, 2021, remains relevant for the AF3. Environmental and Social Commitment Plan (ESCP): The ESCP will be updated and redisclosed prior to appraisal. D. 2. Borrower’s Institutional Capacity The AF3 follows the same implementation arrangements as the parent project. The Ministry of Health (MOH) and the Ghana Health Service (GHS) remain the implementing agencies for this project. The two institutions have experience implementing World Bank Project under the Environmental and Social Framework (ESF) with satisfactory results. Under the parent project, the MOH and GHS established a Project Implementation Unit (PIU) and has appointed one Environmental and one Social focal point for environmental and social risk management and stakeholder consultations. The focal points have the expertise and are responsible for managing E&S issues. E&S implementation under the parent project and the first and second AFs has been limited to refurbishment of existing health facilities, procurement and distribution of medical equipment, management of COVID-19 medical waste, stakeholder consultations, grievance resolution, preparation of E&S reports and updating of existing instruments under the parent project. Lessons learned from the parent project include the need to enhance institutional coordination modalities within the MOH/GHS and provide resources for coherent implementation of environmental and social risk management. The MOH/GHS has committed to conducting joint field monitoring and reporting by relevant departments and the environment and social focal persons. Feb 23, 2022 Page 4 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) The MOH and GHS have benefitted from World Bank-organized ESF capacity building initiatives (orientation, hands-on training and experience). Thus, institutional capacity is gradually improving and overall E&S performance has been rated moderately satisfactory. Notwithstanding, the capacity of the implementing agencies would be further strengthened to ensure compliance with the E&S requirements of the Third Additional Financing project. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The environmental risks rating of the AF3 remains Substantial, the same as for the AF 1&2 and Parent Project, due to concerns relating to: (i) occupational health and safety on testing, vaccinating and handling of supplies and potential unsafe use of these supplies by health workers and laboratory technicians; (ii) medical waste management at health facilities treating COVID-19 patients and improper handling and disposal of medical waste and biohazards could injure human health; and (iii) community health and safety issues related to the handling, transportation and disposal of healthcare waste . Improper disposal of empty vials, sharps, needles, packaging, and unused and expired vaccines can be harmful to humans, environment, and wildlife. Project activities such as civil works related to the construction and or rehabilitation/refurbishment of health infrastructure can create temporary unintentional environmental, health, and social challenges when not properly managed. The environmental risks that are associated with these activities may include: (i) loss of vegetation and fauna, disturbance to natural habitat, soil and Public Disclosure cultural heritage typically associated with civil works, (ii) occupational health and safety (OHS) hazards for civil workers, and (iii) safety hazards for communities during construction and operations of new infrastructure, intermittent noise and air pollution from power back-up generators and exposure to electromagnetic fields given community proximity to transmitting antennas. The potential OHS risks and hazards may include: (iv) exposure to dusts, fumes, and gases which can cause breathing problems and lung diseases, (v) exposure to loud noise due to frequent or excessive use of vibrating tools which can cause cognitive hearing impairments, (vi) stress and fatigue due to frequent or excessive manual handling of loads, and (vii) physical injury. Procuring unsafe vaccines and inadequate vaccine storage, handling and transportation practices may deteriorate vaccine quality and affect public health. Improper disposal of the waste will lead to the pollution of waterways and thereby the drinking water sources. Transmission of disease through infectious waste is the greatest and most immediate threat from healthcare waste. Although sharps pose an inherent physical hazard of cuts and punctures, the much greater threat comes from syringes or needles that can infect people with HIV/AIDS and the hepatitis B and C viruses through accidental pricks or reuse of syringes/needles. Again, vaccination campaigns will increase the environmental repercussions of plastic waste including syringes, which adds to the waste already generated by single-use personal protective equipment (PPE) — the masks, suits and shields used to protect people and medical staff from the virus. Waste materials generated from laboratories, quarantine facilities, screening, treatment and vaccination facilities to be supported by the parent project and AF3 require special handling and awareness, as they may pose an infectious risk to healthcare workers in contact or handling the waste. There are also risks of COVID-19 infection among workers and the general public due to mobilization of groups for mass vaccination and the associated infectious waste materials generation and management. Minor construction or rehabilitation of cold-chain infrastructure may be anticipated in this project and all these works will be limited to existing rural and peri-urban government health facilities; hence the environmental footprint is expected to be minimal. The key environmental issues associated Feb 23, 2022 Page 5 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) with these construction activities are: (i) nuisance related to air and noise emissions; (ii) ) health and safety of health workers; (iii) disposal and management of rehabilitation and construction waste; (iv) traffic management; (v) workers occupational health and safety; (vi) community health and safety, and; (vii) erosion of debris (especially if works are carried out in Social Risk Rating Substantial The social risk rating for the AF3 remains substantial, same as the Parent Project and the First and Second AFs. The national scale of the planned COVID-19 vaccine rollout under the AF3 can introduce some social dimensions with potential significant social risks. Negative social risks and impacts will be related to a broad risk of inequality in access to vaccines resulting from exclusion of vulnerable and marginalized groups from vaccination due to gender inequalities, socio-cultural and religious beliefs, disability and geographical location (e.g., people in hard to reach communities and slum communities); and political pressure to provide vaccines to groups not prioritized leading to elite capture. People living in remote or isolated communities, persons with disabilities, the elderly, homeless, slums communities, and women could potentially miss out on vaccination due to elite capture, distance and poor road networks to health facilities, and barriers in communication. If not well managed, vaccine targeting may lead to social conflict among interested groups and exclusion of marginalized groups (women, elderly, poor). Ghana’s National Deployment and Vaccination Plan does not discriminate against foreign nationals. Communication risks due to disinformation, misperception, false rumors, and inequitable information dissemination may give rise to COVID- 19 vaccine hesitancy, reduced access to vaccine services (especially among vulnerable groups), refusals within communities and reprisals and retaliation especially against healthcare workers. There is also a risk that people may not receive information about access and services unless communication is adequately managed. There is also a risk of theft and commercialization of PPEs and vaccines, resulting in shortages. Other social risks relate to potential for Public Disclosure creating or exacerbating poor conditions with impacts on community health and safety due to improper disposal of medical waste (e.g., in open waste dumps and discharge of contaminated water that may contaminate land and surface water or injury to waste pickers). Other potential social risks include increased incidence of reprisals and retaliation, especially against healthcare workers and researchers related to both suspicion of the motives and legitimacy of the vaccinators. There are likely gaps in access to information sources and absorption level of correct information about COVID-19 among women as compared with men as education and illiteracy rate are higher among women. Some women may need to get authorization from their husbands to get vaccinated. Moreover, pandemics can create or exacerbate the conditions that especially put women and girls at greater risk of SEA/SH. For instance, loss of household income due to job losses can increase intimate partner violence; women and girls may be forced into exchanging sexual favors for access to testing, treatment, vaccines or even supplies. All construction and or rehabilitation/refurbishment of health infrastructure proposed under the AF 3 will be undertaken within existing government health facilities which are encumbrance free, therefore physical and economic displacement are not anticipated. If land acquisition and involuntary resettlement leading to displacement of people and livelihood losses in connection with any project activities that have not yet been identified becomes necessary during implementation, mitigation measures would be developed to the satisfaction of the Bank prior to commencement of any land acquisition. Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) Risk Rating Low The project-related SEA/SH risk rating is low. However, the project ESMF includes SEA/SH prevention measures including requirements for Contractor workers to sign the contractor workers Code of Conduct. In addition, The GHS in collaboration with the Ministry of Gender, Children and Social Protection has established the 3-2-1 Platform to create awareness about COVID-19 and gender-based violence and stigma, and to provide confidential support to Feb 23, 2022 Page 6 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) SEA/SH complainants in collaboration with the Domestic Violence and Victims Support Unit [DOVVSU] of the Ghana Police Service. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: The potential social and environmental risks and impacts associated with AF1&2 and the Parent Project remain relevant to AF3. Environmental and Social Management Framework (ESMF): The ESMF for the Vaccine Additional Financing (AF 1&2) and the ESMF for the Additional Financing One (AF1) and the parent project which were approved by the World Bank and disclosed on June 30, 2021 and November 10, 2020 respectively. The ESMFs for the parent project AF 1&2 remains relevant for the AF3. Stakeholder Engagement Plan (SEP): The SEP for the AF2 which was approved by the World Bank and disclosed on May 5, 2021 remains relevant for the AF3. E&S Reporting: Despite the delay in the project's E&S reporting process, the MOH submits reports on the Public Disclosure implementation of the Environmental and Social Commitment Plan (ESCP), Environmental and Social Management Framework (ESMF) and Stakeholder Engagement Plan (SEP) The E&S Focal Officers at MOH/GHS have undertaken some field visits to the sites where construction and rehabilitation activities are ongoing and has reported to the World Bank on progress of implementation. Notwithstanding, MOH/GHS needs to further improve and intensify field supervision to these sites. The project also needs to further improve on E&S reporting. For the management of E&S risks associated with minor construction or rehabilitation of cold-chain infrastructure and other health facilities, the ESMF for AF1 and Parent Project offers procedures for screening AF3 environmental and social risks. Where considerable risks are identified under the AF3, an Environmental and Social Management Plan (ESMP) will be developed to mitigate potential impacts of the proposed works. Potential impacts of the AF3 would be site specific, limited to the immediate surroundings and can be managed through the implementation of cost-effective mitigation measures that would be outlined in the ESMP. Once the specific locations of AF3 subproject activities have been identified, ESMPs will be prepared to address the site-specific risks. These risk factors are largely predictable and reversible, although controlling them and addressing their impacts are routinely constrained due to budgets, logistics and technical constraints. For infection prevention and control, the project will continue to implement the National Health Care Waste Management Policy and the National Guideline for Health Care Waste Management. The project will implement occupational health and safety standards and specific infectious-control strategies, guidelines and requirements as recommended by WHO and CDC. Effective administrative and infectious-controlling and engineering controls would be put in place to minimize these risks. Climate change can affect the trajectory of the COVID-19 pandemic and impact groups that are most susceptible to the virus including healthcare workers, the elderly, those with pre-existing Feb 23, 2022 Page 7 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) conditions, people with disabilities and other disadvantaged groups. These vulnerabilities will be addressed through targeting and improving health care interventions described above as well as the surveillance monitoring. The Ghana COVID-19 Vaccine Deployment and Vaccination Plan provides the targeting criteria and implementation plans to manage the risk of exclusion and provides explicit, contextually appropriate, and well-outlined criteria for access to vaccines. There is consensus to first target Health personnel (health providers and administrators), security personnel and persons with known underlying medical conditions; followed by adults above 60 years, secondary and tertiary students, teachers, specialized groups on national assignment, executive and legislature, civil servants, and journalists; and other residents of the country excluding children under 16 years and pregnant women. Over time, the rest of the population will be vaccinated as more vaccines are procured. In line with ESS2, the ESMF for AF1 and Parent Project includes a Labor Management Procedures (LMP) which emphasizes non-discrimination and equal opportunity and protection of project workers. In line with ESS 10, the SEP included a National Communication Strategy for the COVID-19 vaccine shall serve as a complementary document to address stakeholder information needs and misinformation and distrust as a barrier to vaccination and to ensure timely disclosure of relevant information on disease surveillance, vaccine risks and benefits, and the environmental and social impacts that may occur. No land acquisition or involuntary resettlement is expected. The AF3 will support government to ensure plans are continuously subjected to timely and meaningful consultations required by Environmental and Social Standard (ESS) 10. The capacity of the MOH to manage the environmental and social risks, including risks related to SEA/SH, is being enhanced through ongoing support and Public Disclosure training during project implementation, as well as dedicated MOH/ GHS designated Environment and Social focal points and Stakeholder Consultations focal point at the PIU who oversees environmental and social due diligence and consultations/Risk Communication and Community Engagement (RCCE). To ensure inclusion, the Government of Ghana under its National Vaccine Deployment Plan is committed to adopt differentiated strategy for vaccine administration based on each target group's peculiar characteristics. To date, about 1,900 persons with disabilities have received medical and psychosocial care for COVID-19 related illnesses. A significant amount of COVID-19 information material has also been provided to persons with disabilities, including brailed communication materials to provide information on COVID-19. The parent project and AF 1, 2 and 3 support community outreach programs for over 10 million people accessing primary health services, particularly in deprived areas. Vulnerable groups are targeted to be vaccinated at the closest health facility. Vaccination points are established at districts and community level and mobile teams to reach remote locations. Inclusion is fundamental to improved social development outcomes. Given the importance of inclusive COVID vaccine to all, it is critical to ensure that: a) parts of the population are not excluded and, b) the overall efficacy of vaccine deployment will not be compromised. Vaccines provided by the government are provided free of charge to the population and no user fees are levied. To prevent COVID-19 infection among workers and general public due to mobilization of groups for mass vaccination, the Ghana Health Service will ensure adherence to all COVID-19 prevention measures at vaccination centers. To prevent disinformation, misperception, false rumors, inequitable information dissemination, the AF3 will continue to support communication campaigns. A COVID-19 Vaccine Communication Plan has been developed. This plan, Feb 23, 2022 Page 8 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) together with the Stakeholder Engagement Plan will guide effective communication through provision of reliable and timely information through the most trusted sources and far reaching channels to the general public and targeted communities and vulnerable groups. The project also supports multiple agencies for extensive mass communication and community engagement to prevent and control misinformation and to promote COVID-19 vaccination nationwide, which are critical in scaling up COVID-19 vaccination. Misinformation and fake news are rigorously monitored with the “Brand 24” software, and prevention of stigma against suspected and/or infected persons. Specific guidance on the selection of priority population groups to be vaccinated and monitoring of adverse health effects from vaccination have been included in the National COVID-19 Deployment Plan in accordance with emerging WHO guidance and the AF3 will comply accordingly. Measures to ensure the quality of vaccines is maintained throughout the supply chain in accordance with WHO guidance for storage and transportation of vaccines have also been incorporated in the deployment plan and ESMF. Gender and SEA/SH considerations: The proposed AF3 will support addressing the gender gaps and ensuring the implementation of equitable COVID-19 vaccine distribution and information dissemination during the national COVID-19 vaccine campaign. There will be clear messaging to prohibit SEA/SH during provision of health care whether healthcare providers are perpetrators or survivors. The project will make information available to health service providers on where GBV psychosocial support and emergency medical services can be accessed (within the health system). Additional rapid guidance on how to deal with SEA/H complaints within existing GRMs will be Public Disclosure communicated throughout implementation. The AF3 will also further support strengthening Infection Prevention and Control (IPC) measures at the healthcare settings and vaccination centers to prevent the infection. Use of Security Personnel: The project is not likely to employ security forces in any aspects of the vaccine deployment. However, if it becomes necessary, the project will assess and establish their terms of engagement with the community and and vaccination centers. Mandatory vaccination: The planned mandatory vaccination announced by the government for a defined group of people (e.g., health workers and security agencies) has been suspended. If mandatory vaccination is introduced during implementation, regulations will be integrated into the National COVID-19 Vaccination Plan. Forced vaccination: There will be no forced vaccination as the National COVID-19 Vaccine Deployment Plan emphasizes voluntary uptake. The project will continuously engage stakeholders to identify and mitigate any risk related to cultural, social and traditional community practices and values that may impact on vaccine uptake. ESS10 Stakeholder Engagement and Information Disclosure This standard remains relevant for the AF3 since stakeholder engagement is a critical tool for social and environmental risk management, project sustainability and success. Feb 23, 2022 Page 9 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) A significant risk in the proposed AF3 relates to the potential for vaccine hesitancy and mistrust about the benefits of the COVID-19 vaccines. There are potential risks of exclusion of persons with disabilities such as the blind and visually impaired and deaf; and of illiterates by mainstream information dissemination of the government. As such, this standard is considered relevant to support communication, mobilization, and community engagement campaigns to raise public awareness and knowledge on prevention and control of COVID-19 among the general population and vulnerable population and contribute to strengthening the capacities of community structures in promoting coronavirus prevention and vaccine deployment messages. The ESCP will capture the action needed to be taken to address vaccine hesitancy and mistrust in parallel with the vaccine campaign and the national vaccination exercise. Component 3 will support Risk Communication and Community Engagement component of the project and this will be fundamental to the success of the AF. It is imperative that the information disclosure takes place in an on-going and satisfactory manner, with clear and accessible messaging on safety of vaccines, principles of fair, equitable and inclusive vaccines access and allocation, as well as rationale for prioritizing certain groups . The project’s component 3 includes activities to inform the public of the rationale for vaccinating selected target populations; vaccine safety; the process for vaccine deployment; and possible side-effects, if any, to foster confidence in a new vaccine. Effective communication and outreach remains imperative to increase awareness and vaccine literacy, build trust, and reduce stigma around the COVID-19 vaccine. Information in reports or surveys on citizen perceptions and obstacles to vaccine uptake in the country is tracked and will continue throughout implementation to help improve the existing risk communication strategy. The project will ensure communications are adapted to varied urban / rural contexts and population groups (e.g., people living in remote or isolated communities, persons with disabilities, the elderly, Public Disclosure homeless, slums communities, and women), distributed across high-penetration platforms, and foster support and endorsement through trusted community representatives and national leaders. Verifying that such stakeholder representatives are legitimate and genuine advocates of the community they represent remains an important task. The MOH/GHS updated the Project SEP for AF2 to include stakeholder engagement requirements for vaccine deployment. The updated SEP for AF2 which was approved by the World Bank and disclosed on May 5, 2021 remains relevant for the AF3. The stakeholder engagement takes place in an ongoing manner, at different levels, with different partners, and in a culturally appropriate manner. The Project’s Stakeholder Engagement Plan (SEP) will be updated throughout project implementation to ensure continuous and meaningful and safe consultations on the project (including grievances) with all stakeholders throughout the project life cycle, and provide stakeholders with timely, relevant, understandable and accessible information. The parent project grievance redress mechanism (GRM) will be used to respond to complaints throughout the project lifecycle. The Ghana Health Service has Emergency Numbers 112 and +233 55 843 9868 /+233 50 949 7700 for people to submit complaints and to promptly respond to any grievances. In collaboration with the Ghana Food and Drugs Authority (FDA), Ministry of Health and Ghana Health Service continue to monitor Adverse Events Following Immunization (AEFI). The FDA has set up a hotline (0551112224/ 0551112225) to receive, register, and address concerns on vaccination and AEFIs. A total of 1,733 persons have reported adverse events following immunization (AEFIs). The complaint resolution period is within one and two days of submission of the complaint (http://fdaghana.gov.gh/covid19.php). The GRM will be enhanced to register and respond to complaints/feedback linked with the deployment of the COVID- 19 vaccination since the primary objective of the AF3 is to enable affordable and equitable access to COVID-19 Feb 23, 2022 Page 10 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) vaccines in the country. Stakeholders activities will be financed from component 3 of the AF3. Feedback received from stakeholders engagement will be used to improve vaccine rollout, expand reach out and, improve project performance. In situations where MOH/GHS capacity for implementation are assessed, gaps identified, and short- term action plan will be prepared to fill the capacity gaps. The parent project GRM is equipped to handle cases of SEA/SH, as rapid guidance on how to respond to these cases has been developed and shared with operators. To date, the call centers have recorded and responded to 134,850 calls and complaints. The AF 3 will use the existing Grievance Mechanism to address complaints and further strengthened and to follow a survivor-centered approach. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This standard remains relevant for the AF3. Project activities financed by the AF3 will be performed by mostly healthcare and laboratory personnel except the rehabilitation and civil works in existing health facilities which will be undertaken by contractors. Thus, most of the proposed project activities will be undertaken directly by about 171,280 government civil servants of the Ministry of Health and Ghana Health Service across the country, especially public health workers, laboratory technicians, technical consultants – full and part-time, health interns, volunteers and other support staff; and civil servants from other relevant line ministries, department and agencies(e.g., Ministry of Information and National Commission for Civic Education). Public Disclosure Under the parent project, a health and life insurance package were provided to health workers to secure the necessary workforce in combatting this crisis. Workers under the project could be exposed to OHS risks due to the dangerous nature of the pathogen (COVID-19) and reagents and equipment used in the project-supported activities. Health facilities treating patients or administering vaccines may also generate biological, chemical waste, and other hazardous by-products that could be injurious to human health. Transportation of COVID-19 vaccines from one location to the other and operation of light and refrigerated vehicles, use of medical drone technology to supplement rapid delivery of COVID-19 vaccines to hard-to-reach communities in Ghana may present risks of accidents to drivers, drone operators; albeit marginal and insignificant risk. These risks will be mitigated through adherence to the occupational health and safety standards and specific infectious-control strategies, guidelines and requirements as recommended by WHO and CDC and other recommended OHS measures based on the World Bank EHS guidelines provided in the updated parent project ESMF. In line with WHO Interim Guidance (February 12, 2020) on “Laboratory Biosafety Guidance related to the novel coronavirus (2019-nCoV)”, WHO standards on the management of waste related to COVID-19 vaccination outlined in the Interim Guidance on Developing a national deployment and vaccination plan for COVID-19 vaccines (16 November 2020) and other guidelines and incorporated in the updated parent project ESMF. The ESMF includes training of staff to be aware of all hazards they might encounter in the COVID-19 response and provides for the application of international best practices in COVID-19 diagnostic testing and handling of medical supplies, disposing of the generated waste, and road safety. Other measures include posting of signages in all public spaces mandating hand hygiene and use of PPEs (particularly face masks, gowns, gloves, hand washing soap and sanitizers and detergents). The AF3 will support the procurement of PPEs. Feb 23, 2022 Page 11 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) Construction and minor rehabilitation and civil works envisaged to be carried out to equip existing facilities will be carried out by contractors who may hire and use local labor as no large-scale labor influx is expected. During implementation, the client will include the existing Labor Management Plans (LMPs) in contracts that will set out the way in which project workers will be managed in accordance with the requirements of national law and the ESS2. During implementation, the project will ensure that the contractors put in place adequate OHS measures to protect workers from injuries, accidents and COVID-19 infections and establish workers grievance mechanism to resolve workers complaints. All workers will be required to sign workers code of conduct, upon signing their contracts, to prevent incidents of SEA/SH among others. Government civil servants working on the parent project and AFs, whether full-time or part-time, will remain subject to the terms and conditions of their existing public sector employment agreement or arrangement, unless there has been an effective legal transfer of their employment or engagement to the project. ESS2 will not apply to such government civil servants, except for the provisions of paragraphs 17 to 20 (Protecting the Work Force) and paragraphs 24 to 30 (Occupational Health and Safety). In line with ESS2 and the Ghana Labour laws, the use of forced and child labor in the project is prohibited. Persons under the age of 18 are not allowed to work on any of the facility or site that is being financed by the project. Age verification (using certified birth certificates, nationally recognized identification cards and other legitimate identities) will be carried out as a precondition for employment. The planned mandatory vaccination announced by the government for a defined group of people (e.g., health Public Disclosure workers and security agencies) has been suspended. If mandatory vaccination is introduced during implementation, regulations will be integrated into the National COVID-19 Vaccination Plan including any provisions for exceptions, due process, grievance redress and restrictive measures, such as measures that may interfere with labor and working standards described in ESS Labor and Working Conditions (ESS2). ESS3 Resource Efficiency and Pollution Prevention and Management This standard remains relevant for the AF3. Vaccination rollout will result in the increase in medical waste, including used vials, sharps, needles, and other infected materials. This will overwhelm the prevailing limited capacity for management of health care waste. Indiscriminate disposal of unused and expired vaccines can be harmful to humans, environment, and wildlife. The project will apply the National Health Care Waste Management Policy and the National Guideline for Health Care Waste Management in disposing of used vials, syringes, and other vaccine-related waste. Potentially adverse health effects from procuring unsafe vaccines and inadequate vaccine storage, handling and transportation practices may lead to vaccine quality deterioration. If unused, expired, and unsafe vaccines are discarded in waterways and drinking water sources, this will cause a serious and multifaceted human and environmental issue. Again, vaccination campaigns will increase the environmental repercussions of plastic waste including syringes, which adds to the waste already generated by single-use personal protective equipment (PPE) — the masks, suits and shields used to protect people and medical staff from the virus. To reduce vaccine rollout related wastes, the project will adopt the World Health Organization guidelines on stock records management for immunization and Monitoring vaccine wastage at country level. Feb 23, 2022 Page 12 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) Transporting vaccines from labs to everyone who needs them across the country requires a system of refrigeration that works every step of the journey. While the cold chain is an integral part of achieving immunization targets, it comes with an environmental cost, including energy consumption and indirect emissions. Cold-chain infrastructure might require multiple increases in cooling demands with associated greenhouse gas (GHG) emissions. The project will identify opportunities for incorporating efficient, sustainable cooling technologies. Ghana has a good legal and policy framework and guidelines for the management of Hazardous Medical waste. The Hazardous and Electronic Waste Control and Management Act, 2016 (Act 917) which has medical waste management as one of its schedules provides for the control, management and disposal of hazardous, electrical, and electronic waste and related purposes. The Hazardous waste regulation has also been developed and being implemented to ensure effective implementation of the Act by all stakeholders. The regulation prescribes duties of waste generators, waste transporters and waste managers; and prescribes requirements for the disposal of wastes. Ghana also has a Health Care Waste Management (HCWM) policy and guidelines which provides direction for effective, efficient and safe management of Health Care Waste (HCW) through the adoption of Best Available Techniques (BAT) and Best Environmental Practices to prevent injuries, infections and other hazards; protect and promote public health and the environment for sustainable development. Infrastructure and technology that deal effectively with hazardous health waste is limited but there are facilities (e.g., Autoclave treatment system, Hydroclave treatment system, and Incineration System) across the country that could be used. Many health facilities have small-capacity waste incinerators and vaccine waste and used sharps are incinerated. The daily quantity of waste being generated at these treatment centers (especially PPEs) is high that the existing incinerators or autoclaves Public Disclosure cannot handle the high volume of waste generated. Where there is no incinerator, sharp boxes are temporarily stored and later transported to the nearest health facility with incinerator. Through training, the project would strengthen capacity to effectively manage hazardous health waste. ESS4 Community Health and Safety This standard remains relevant for the AF3. Protecting the safety of communities from increased risk of COVID-19 transmission and adverse events following vaccination is a central part of Ghana’s National Deployment and Vaccination Plan (NDVP). The MOH and GHS have developed a Plan of Action (POA) to guide health workers on the delivery of COVID-19 vaccines to identified population groups across the country and plan to deploy the support of community volunteers, private providers, and Civil Society Organizations (CSOs) to complement its efforts for COVID- 19 vaccination campaigns. Community health and safety risks identified for the COVID-19 Vaccine Deployment Plan include: (i) environmental and community health related risks related to the inadequate storage, transportation and disposal of infectious medical waste; (ii) community health and safety risks given close social contact and limited sanitary and hygiene services (clean water, soap, disinfectants); (iii) community health and safety risks that will be associated to the construction of minor infrastructure (iv) possible risks around social exclusion related to access to healthcare facilities and services, especially for the poorest, those living far from health facilities, the elderly or those living with disability who may not have access to the vaccination centers; (v) risks of corruption that could lead to diversion of vaccine from the most marginalized and SEA/SH risks for women and girls; (vi) sociopolitical risks related to residency Feb 23, 2022 Page 13 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) requirements and demands of citizenship for vaccination; (vii) potential adverse side effects from the vaccine; (viii) requirement of vaccination record/certification for any health, occupational, education and travel purposes; and (viii) misinformation and conspiracy theories about vaccine efficacy coupled with low trust in the government which could lead to the rejection of public health intervention/information and violence against those providing services. These identified risks will be managed in several ways through the existing ESMF, risk communication strategy, SEP, (SEA/SH prevention measures), National Communication Strategy for COVID-19 Vaccine Introduction where applicable. The ESMF follows WHO and CDC guidelines for assuring quality control of the vaccines during storage, transportation, handling, and disposal throughout the country. The vaccine Deployment Plan of Action includes a safety monitoring system for new vaccines that would employ enhanced spontaneous reporting, active surveillance of adverse events of special interest and post authorization studies by marketing authorization holders. The MOH will closely monitor the potential side effects of vaccines. Capacity building sessions for health workers on AEFI (Adverse Events Following Immunizations) will be conducted. Emergency drugs for AEFI management will be available at each post. Supervisors at all levels will monitor investigation and management of AEFIs during the campaign. Laboratories, health and vaccination centers and screening posts, will 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 MOH will address the concerns of health care professionals and maintain community confidence by creating and sharing a COVID-19 vaccine safety communication plan with communities and relevant stakeholders. The various stakeholders and the appropriate communication channel and format will be outlined in the Stakeholder Engagement Public Disclosure Plan (SEP) and in the Risk Communication Strategy. Residency requirements, including official documentation in the form of an identification or residency card prior to receiving the vaccine, might affect not only undocumented migrants and refugees but also nationals in rural areas who may not be able to produce the required documentation. Such requirement will be in non-compliance with the ESF’s provisions on social inclusion under ESS1 and ESS4, and might affect the productive purposes and objectives of the project to prevent and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness. Whereas the National Vaccine Deployment Plan does not clearly outline need for residency requirements for vaccination, the project will ensure that neither such requirements nor forced vaccinations are included in the Bank financed vaccination project. Training will be provided for all community workers involved in the vaccination campaign and stakeholders involved in the safety monitoring of COVID-19 vaccines to ensure the safety of the vaccine recipients and also obtain accurate data for decision. Supportive supervision to ensure that activities are being carried out as expected and data generated will be performed. The ongoing vaccine rollout, does not involve the use of security forces to ensure law and order around the Vaccination Centers or to force vaccination; but if the situation changes, the project will undertake a Security Risk Assessment (SRA) to review the security force’s rules of engagement with the community and identify the specific risks related to providing increased security at the various health and vaccination centers. The project would then propose adequate mitigation measures, and strengthen existing measures, where necessary, to ensure that the use of the security forces will not result in adverse consequences to community health and safety, including in matters Feb 23, 2022 Page 14 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) relating to GBV and SEA/SH. The project will ensure that the security personnel follow a strict code of conduct and avoid any escalation of situation, taking into consideration the protocols included in the ESMF and SEP, and the guidance provided in the World Bank technical note, “Use of Military Forces to Assist In Covid-19 Operations Suggestions on How to Mitigate Risks". That said, Ghana's Police and Military have experience with extensive UN missions and are aware about basic human rights issues in humanitarian missions and are regularly trained on mission-related protocols. As such, the risks related to human rights abuses through the proposed vaccination programs is considered moderate and manageable. The project will continue to promote the avoidance of SEA/SH by relying on the WHO Code of Ethics and Professional Conduct for all workers in the quarantine facilities. The risks and mitigation measures are addressed in the ESMF, drawing on input from project stakeholders, as documented in the SEP and the National COVID-19 Vaccine Communication Strategy. The ESMF incorporates an accountability and response framework, including a worker code of conduct, worker and community training and sensitization, and adaptation of the project GRM to ensure ethical and confidential management and resolution, including timely service referrals, of SEA/SH claims. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This standard remains not relevant as all renovations and civil works under the parent project and AF 3 are expected to be undertaken within existing government health facilities. The AF3 is not expected to lead to any land acquisition as it is not expected to invest in activities that will cause land acquisition and involuntary resettlement or restrictions Public Disclosure on land use and access to natural resources. In the unlikely event of land acquisition and involuntary resettlement leading to displacement of people and their livelihood in connection with any project activities that have not yet been identified, this standard will become relevant and used to inform the preparation and implementation of Resettlement Action Plan(s) to address compensation and livelihood needs of Project-Affected Persons (PAPs). ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard remains not relevant for the AF3 since the construction activities that may be anticipated in this project will be conducted within existing health facilities. Hence, the likely impacts of the project on natural resources and biodiversity are low. The ESMF requires prior screening of activities for project support and will determine activities that will be implemented making sure that activities that present risks to sensitive biodiversity will be excluded. The MOH will undertake verification of project sites using the ESMF screening checklist and will submit report to the World Bank. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard remains not relevant for the AF3. There are no distinct social and cultural groups in the project area who exhibit characteristics akin to the criteria for indigenous or traditionally under-served communities as spelled out in the ESS7. Feb 23, 2022 Page 15 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) ESS8 Cultural Heritage This standard remains not relevant for the AF3 since construction activities will occur within existing health facilities and will not impact tangible cultural heritage. In the unlikely event tangible cultural heritage are identified, a chance finds procedure contained in the existing ESMF of the project will be followed for the project. ESS9 Financial Intermediaries This standard is remains not relevant for the AF3 as no financial intermediaries will be used. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways OP 7.60 Projects in Disputed Areas B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Public Disclosure Areas where “Use of Borrower Framework” is being considered: None IV. CONTACT POINTS World Bank Contact: Kazumi Inden Title: Senior Health Specialist Telephone No: 5220+82530 Email: kinden@worldbank.org Contact: Anthony Theophilus Seddoh Title: Senior Health Specialist Telephone No: 5269+4612 / 233-30-221-4612 Email: aseddoh@worldbank.org Borrower/Client/Recipient Borrower: Republic of Ghana Implementing Agency(ies) Implementing Agency: Ghana Health Services Feb 23, 2022 Page 16 of 17 The World Bank Ghana COVID-19 Emergency Preparedness and Response Project Third Additional Financing (P178054) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Anthony Theophilus Seddoh, Kazumi Inden Practice Manager (ENR/Social) Senait Nigiru Assefa Cleared on 16-Feb-2022 at 21:34:3 GMT-05:00 Public Disclosure Feb 23, 2022 Page 17 of 17