The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 02/23/2022 | Report No: ESRSAFA317 Feb 23, 2022 Page 1 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Central African Republic AFRICA WEST Central African Republic Ministry of Health and Population Project ID Project Name P177618 Central African Republic COVID-19 Preparedness & Response Additional Financing Parent Project ID (if any) Parent Project Name P173832 Central African Republic COVID-19 Preparedness and Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 1/11/2022 2/21/2022 Population Financing Public Disclosure Proposed Development Objective To prepare for and respond to the threat posed by COVID-19 in the Central African Republic. Financing (in USD Million) Amount Current Financing 7.50 Proposed Additional Financing 25.50 Total Proposed Financing 33.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The purpose of the Additional Financing is to provide financing to help the government achieve its objective of covering the population over 15 years of age, which represents 52 percent of the population. It will fund the purchase and deployment of COVID-19 vaccines that meet Bank’s vaccine approval criteria (VAC) and strengthen relevant Feb 23, 2022 Page 2 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) vaccination systems that are necessary for successful deployment. The country will provide free of cost vaccinations to the population. In addition to the purchase of vaccines, activities will include: a) the acquisition of consumables and other commodities related to immunization, b) support to the immunization system and deployment and help deliver COVID-19 vaccines at scale, c) communication, community sensibilization, and d) capacity building to strengthen vaccination deployment planning and management. By expanding the scale and scope of the parent project, the proposed AF would increase the effectiveness of the operation and response to COVID-19 in CAR and contribute to vaccination system 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] Located in the heart of the African continent, the Central African Republic forms a compact block of 623,000 km2 on the continental zone of Equatorial Africa. Its general appearance is that of a vast peneplain with slight undulations that are sometimes interrupted by a few rocky escarpments. It is located between 2°15 and 11° North latitude and between 13° and 27° East longitude. It is bordered to the east by Sudan, to the west by Cameroon, to the north by chad, and to the south by Congo and DRC. There are two climatic seasons in CAR, the rainy season which runs from May to October and the dry season from November to April. The alternation of these two seasons has an impact on the health of the population: in the rainy season, ponds are formed and flooding occurs in the neighbourhoods. This leads to the proliferation of mosquitoes and therefore a high prevalence of malaria. Rainfall is relatively high, with more than 1,500 mm of water on average per year. This makes CAR a malaria endemic zone, which is omnipresent regardless of the season. The dry season is Public Disclosure characterised by dry, cool air and above all the rise in dust that causes the development of respiratory diseases. The CAR has approximately 4.66 million inhabitants (Baya about 29%, Beta about 23%, Metjia about 10%, Sara about 8%, M'Baka about 8%, Mboum 6%, Peuhl 6% and other ethnic groups about 12%), which is an average density of 7.5 inhabitants/km2. The annual population growth rate is 1.4%. The distribution of the population is uneven, with a density ranging from 1 inhabitant/km2 in the east and north-east (area heavily occupied by armed groups) , 11 inhabitants/km2 in the west and north-west and up to 10,000 inhabitants/km2 in Bangui, which has a population of almost 800,000. The proposed AF will expand the scope of activities of the parent project and will be implemented at a national scale to address critical country-level needs for preparedness and response to COVID-19 including COVID vaccine initiatives. The project will engage at central and district level hospitals and laboratories and health centers Bangui and all selected health districts and surrounding communities. Specifically, the proposed AF will expand the scope of activities of the parent project to include financing for: a) vaccine and drug purchase; b) strengthening service delivery to ensure effective vaccine deployment; c) upgrading the cold chain for the vaccines where necessary; and d) monitoring, tracking of vaccines use and recording of any adverse reactions to vaccination. The AF will also include procurement of biomedical waste boxes and equipment for the management of biomedical waste. There is a risk that the project will have negative impacts on vulnerable groups, in particular the risk of GBV and the exclusion of women, indigenous peoples, and other people who are eligible to free vaccines in hospitals, laboratories and health facilities in the intervention areas. The negative impacts could be aggravated given that most of these groups live in rural areas and cannot access services due to lack of geographical access and insecurity, and or discrimination. Feb 23, 2022 Page 3 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) The AF is envisaging to expand access to vaccines and ensure that vulnerable persons are immunized. Given that most activities under the parent project were implemented without E&S instruments in place, a rapid E&S audit was undertaken with the objective of assessing potential impacts and taking corrective measures, if necessary. The rapid E&S audit made important discoveries and recommendations and these recommendations will be reflected in the AF’s ESCP. Learning from the mistakes of the parent activities, key E&S instruments for AF have now been prepared and disclosed. Further assessment of the main salient social risks that will have direct bearing on the project include a) persistent gender inequality, b) cultural barrier, c) historically underserved traditional local communities’ presence, d) political pressure and influence and, e) volatile security situation. Gender Inequality: Despite CAR’s progress in advancing gender equity, multiple gender gaps persist between men and women. It is important to note that the country is ranked 188 out of 189 countries on gender inequality index. On average, women in CAR have two-thirds of the years of schooling compared to males and 70% of women are not literate. In addition to the gender inequality that has been there for a while, the effects of COVID-19 will likely exacerbate pre-existing gender differences if concerted efforts are not made to ensure vaccination coverage disparity between men and women are addressed. It is also likely that women’s high Illiteracy rate will constrain their understanding of written educative posters messages and communication efforts on COVID-19. Cultural Barriers: Gender norms that restrict women’s mobility constrain women from access and getting vaccines. Women are often not released from taking care of her husband and children. As women are kept fully occupied during the day, they may not be able to access health and vaccination services due to lack of time, long distances to Public Disclosure reach health facilities. Most of them are confined in their residents because of restrictive gender norms that limits women’s mobility. Moreover, many women may not be reached by the relevant information campaign on the pandemic. These factors coupled with remote areas where majority of the population resides could result in limited access to testing centers and vaccine locations by women. These factors will likely increase the health care burden in ensuring vaccine access to most vulnerable women. Historically underserved traditional local communities: The project area includes underserved local communities in remote locations such as Nana-Mambere, Mambere-Kadei, Sangha Mbaere and Ombela-Mpoko. Taking vaccines to these remote and inaccessible communities might challenge health workers and the government. Even in places where access to these locations is made possible, communication and cultural practices may pose significant challenges. These challenges are also likely to be used as excuses to exclude these local communities from vaccine access. Pressure and influence: Political pressure and elite capture tendencies are likely to disturb or disrupt the vaccine rollout plan. Political pressures and powerful people are likely to influence and divert vaccines to groups that are not prioritized. Such pressures and interventions are likely to be based on gender, race, ethnicity, refugee status, religion, or other factors. This could lead to excluding the most vulnerable people in the society and will exacerbate the inequality gaps in accessing vaccine. These kinds of pressures and interventions by politicians and powerful people could result to public discontents and outrages. Volatile security situation: The security situation in CAR remains volatile. While the security situation is a risk that need to be watched closely, experience shows that health-related activities have for the most part been sustained despite the volatile security situation. The MOH have been monitoring security risks in the country and it is mandated Feb 23, 2022 Page 4 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) to raise alerts when conflicts arise. Health service providers are accustomed to the situation and will advance with vaccination campaigns where the security situation is stable. Vaccination sites, strategy and operational plans in the districts and communities will be adjusted according to the prevailing security and climate situations. Exact geographical locations of the districts in which the AF will be implemented are already known at this stage, and some of these beneficial districts have indigenous population among their communities (Nana-Mambere, Mambere- Kadei, Sangha Mbaere and Ombela-Mpoko). Negative impacts on vulnerable groups (indigenous people, poor groups minorities, and displaced persons and/or refugees) will be addressed through the measures identified in the ESMF and also by integrating gender equality and non-discrimination approach into project design and activities. As with the parent project, the proposed AF will continue to support the communications strategy. Both the government, UN agencies such as UNICEF, WHO and related NGOs will be contributing to this component. The overall coordination on risk community communication and community engagement of the COVID-19 project country-wide will be conducted by the Ministry of Health in collaboration with technical expertise from UNICEF. Slight rehabilitation works are envisaged for the COVID vaccination sites, and activities will take place in existing health facilities or temporary vaccination sites. These planned activities are likely to produce significant quantity of Public Disclosure biomedical waste. The ESMF of the parent project will be updated to integrate international protocols for infectious disease control and updated provisions regarding medical waste management. The Project is not expected to impact natural habitats or cultural sites. In addition, (ESCP and SEP) will be updated and be reflected in the project document based on the results of the preliminary E&S audit that was conducted to better address the risks related to the AF. D. 2. Borrower’s Institutional Capacity The Government of CAR has experience in managing the E&S risks and impacts under the Safeguards Operation Policies (OPs). However, is the institutions including MoH, have limited experiences in implementing projects under the ESF/ESSs. E&S preparation and implementation experiences from other Bank financed projects in CAR highlighted that the management of E&S risks and impacts in these institutions still requires considerable improvement, particularly in areas of E&S instruments preparation, supervision, monitoring and reporting. Moreover, Government’s vaccine deployment capacity is currently inadequate, especially for the anticipated scale of COVID-19 vaccination under the AF. Many internal governance changes have been made recently and these changes may have implications for advancing E$S works as well as for delivering equitable vaccine to vulnerable people who are residing in remote locations. The Ministry of Health and Population (MHP) is leading Project implementation through the PIU that currently oversees the implementation of 4 Bank-financed projects, namely: SENI-CAR Health System Strengthening (P164953) – CAR COVID-19 Response Project (P173832) - REDISSE IV CAR Regional Diseases Surveillance System Enhancement Feb 23, 2022 Page 5 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) (P167817) and CAR Health Service Delivery & System Strengthening (SENI-plus) (P177003) which is under preparation. However, other actors as the Ministry of Finance, Ministry of Planning, and Ministry of Education, and civil society will be associated in the implementation of COVID-19 vaccination. The Project will work with some partners as (GAVI, WHO, UNICEF and European NGO AEDESs) which some (WHO & UNICEF) have been involved in parent project and have acquired some experience in the implementation and monitoring of safeguard instruments and limited experience under ESF. The PIU’s current E&S team includes: 1 Environmental specialist, 1 Social specialist and 2 GBV/SEA/SH specialists (1 international & 1 national). However, this team will be strengthened by adding 2 E&S assistants and 1 GBV specialist through SENI-Plus Project to manage the E&S risk and impacts of Project activities. In addition, the PIU’s E&S team will receive regular capacity building training throughout the implementation of the project, in the form of clinics on specific issues; these include (proper management of biomedical waste, management and implementation of data from 1212 green line, etc). The current National Steering Committee of the Parent Project will be hosted by the MHP and chaired by the Cabinet Director at MHP. In addition, a coordination committee which was also put in place, represented by the Technical Support Committee for the Expanded Vaccination Program (Comité Technique d’appui au Programme Elargi de Vaccination, CTAPEV), chaired by the Director General of Population and Primary Health Care of the MHP will continue to be functional. Even though MHP currently leads 3 projects under ESF, it has not yet fully mastered the application of the ESF instruments. Thus, the E&S capacity of the MHP as well as that of other relevant institutions (Ministries, UN Agencies, INGO) involved in the Project will need to be strengthened at all levels to ensure their participation, especially given their limited knowledge of and experience with WB ESF requirements. Public Disclosure At the national level, the Director General for Environment (DGE) is the main institution in the Ministry of Environment (MEDD) that is responsible for conducting and coordinating the E&S assessment process in CAR (e.g., validation of ESIAs, ESMPs, field reports, inspection and E&S audit). At the departmental level, the DGE works in collaboration with local branches/ offices of the MEDD. However, the DGE implementing capacity is low, as it lacks the needed financial and technical resources. In the particular case of infrastructures rehabilitation, a health waste management arrangements will be put in place to ensure that appropriate OHS measures are monitored at the district/ local level, as well as community empowerment processes. This will be done through (i) training sessions for construction companies on the application of occupational health and safety measures, as well as related codes of conduct; (ii) sensitization and training of members of district/local management committees to ensure the adequate implementation of safeguards, access to the various GRM channels, protective measures on the various risks related to vulnerable and accidents, but above all to ensure the sustainability of these measures. Capacity building interventions will also target hazardous waste management firms, owners of isolation sites to be identified and contracted for quarantine interventions, etc. Given the need for a comprehensive communication and stakeholder engagement strategy, in addition to the activities of the Stakeholder Engagement Plan (SEP), which will be implemented with guidance from WHO and UNICEF in the area of public health awareness and communication, there will also be activities included in the GPSA proposal on citizen engagement. Other capacity building and training needs for stakeholders will be identified and reflected in the ESCP. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Feb 23, 2022 Page 6 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) Environmental Risk Rating Substantial The Environmental Risk Rating is substantial. The AF will fund a vaccination program that shall be implemented across the entire Central African Republic. The four major areas of risks for the project are: (i) occupational health and safety risks related to the rehabilitation for quarantine and care centers of temporary and fixed health facilities, recovery rooms and shelters, and other supplies, these interventions are expected to be site-specific and to be taken place on the property of existing facilities, and no greenfield works are envisaged; therefore, environmental risks and impacts are expected to be temporary, predictable, and manageable; (ii) risks related to management of biomedical waste resulting from vaccination across the entire country; (iii) the risk of spread of the virus among health care workers; and (iv) risks related to community health and safety including the risk of the spread of COVID- 19 among the population at large. The small-scale civil works will happen on existing footprints and will be moderate in their risks, which will mostly be related to the occupational health and safety of the project workers and contractors, and construction waste management. However, the project interventions will lead to the handling of COVID-19 related high-risk medical waste. Improper handling of hazardous and medical wastes can cause infection and health problems for workers and community, as well as environmental pollution. Wastes that may be generated from health care facilities and hospitals to be supported by the project interventions may include transmissible, infectious, hazardous materials and wastes. Proper and safe handling, managing, transporting, and disposing of the waste needs to be ensured; and that mitigation measures of risks associated with labor and working conditions are also predicted under work construction. Facilities that can comply with WHO guidelines for disposal (incineration) of biomedical wastes are limited and this poses an additional risks of improper elimination of biomedical waste. With the AF funding medical waste boxes, PPE and equipment for management of biomedical waste the risk rating will be Public Disclosure downgraded to moderate as these come on stream in CAR. Social Risk Rating Substantial The social risk rating for the AF is Substantial. While the parent project’s risks, potential impacts and mitigation measure remain the same, the AF social risks that will have direct bearing on the project include a) persistent gender inequality, b) presence of cultural barrier, c) exclusion of historically underserved traditional local communities, d) political pressure and influence, e) volatile security situation and, f) potential prevalence of SEA/SH incidents. Key social risks and impacts flagged under the parent project and still remain relevant to the AF includes: (i) excluding marginalized and vulnerable social groups (including the poor, , minorities, and internal displaced persons and/or refugees) who may not be able to receive vaccines, access facilities and services designed to combat COVID-19 because of their vulnerabilities. The exclusion risk is particularly expected to emerge due to lack of communication about covid-19 prevention measures among historically underserved traditional local communities as identified by the preliminary audit. Thus, the client will be required to develop an historically underserved traditional local community’s communication plan specific to COVID. (ii) social conflicts resulting from false rumors and misinformation on Covid-19 vaccines as well as inequity of access to vaccines; (iii) issues resulting from people being kept in quarantine, including stigma faced by those being admitted to treatment or isolation facilities and the risk of stigma between the refugees or displaced people, and the host communities; (iv) issues resulting from social distancing and confinement measures, including risk of intimate partner violence during the quarantine as a result of household stress over economic and health shocks, forced coexistence in narrow living spaces and social unrest owing to prolonged confinement measures especially for the economically vulnerable, including the poor and informal workers; and (v) GBV/SEA/SH risks for project to Project workers and beneficiaries, including attacks on female healthcare workers as well as community health workers who will be engaged in vaccine delivery under the Feb 23, 2022 Page 7 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) AF. Other social risks include the rise of social tensions that could be exacerbated by the lack of awareness regarding the behavior change required to decrease transmission (social physical distancing, quarantine, hand washing and hygiene). Mobilizing the health system in CAR around the response to COVID-19 wihtout ensuring the continuity of other daily health services could contribute to quality deterioration and poor access to other health services such as Maternity/Gynecology, ophtalmology, etc. The social risk classification also takes into account: (i) The Security risk: The project is intending to be implemented in urban, peri-urban or rural areas in the country where the presence of non-state armed groups in these areas could pose risks to health workers. Thus, the risk of attacks on project workers beneficiaries as well as their personnel should be considered. A project security assessment and management plan should be developed to define mitigation measures. (ii) The risk of transmission/spread of Covid- 19 by healthcare workers during the various activities in contact with population. 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 AF Project will have overall positive environmental and social impacts in that it will contribute to epidemic preparedness, monitoring, surveillance, and response, specifically regarding combatting COVID-19. Nonetheless, there are wide-ranging environmental and social risks and impacts that will need to be assessed and managed through a risk-based approach. Key environmental risks for the project are: (i) occupational health and safety risks Public Disclosure related to to the rehabilitation for quarantine and care centers of temporary and fixed health facilities, recovery rooms and shelters, and other supplies; (ii) management of biomedical waste (especially handling highly infectious medical wastes such as COVID-19); (iii) risks related to the electrification of health facilities; (iv) environmental and community health-related risks from inadequate storage, transportation and disposal of infected medical waste; and (v) occupational health and safety issues related to the availability and supply of personal protective equipment (PPE) for healthcare workers and the logistical challenges in transporting PPE across the country in a timely manner. Risks related to occupational and community health and safety are anticipated due to the dangerous nature of the COVID-19 virus and reagents and other materials to be used in primary health care facilities and hospitals. Diagnosis, testing, treatment, and providing isolation of patients can generate biological, chemical, hazardous medical wastes. The vaccination program will generate significant amount of waste syringes (sharps and non-sharps) at the different vaccination centers within CAR. Key social risks are those related to: (i) marginalized and vulnerable social groups (including the poor, Indigenous Peoples, minorities, and displaced persons and/or refugees) being unable to access facilities and services designed to combat the diseases, in a way that undermines the central objectives of the project; (ii) social conflicts resulting from false rumors and misinformation; (iii) issues resulting from people being kept in quarantine, including stigma faced by those being admitted to treatment or isolation facilities and the risk of stigma between the refugees or displaced people and the host communities; (iv) issues resulting from social distancing and confinement measures, including risk of intimate partner violence during the quarantine as a result of household stress over economic and health shocks combined, forced coexistence in narrow living spaces and social unrest owing to prolonged confinement measures especially for the economically vulnerable, including the poor and informal workers; and (v) SEA/SH risks for project workers and beneficiaries, including attacks on female healthcare workers and patients. Feb 23, 2022 Page 8 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) To mitigate these risks and impacts, the project updated, disclosed and approved the ESMF of the parent project in November 22, 2021. The ESMF outlined the implementation arrangement to be put in place for environmental and social risk management, as well as training programs focused on COVID-19 operations. The project will ensure that the medical isolation of individuals does not increase their vulnerability (for example, to intimate partner violence), especially in remote rural areas of CAR. Project components also entail risk communication, social mobilization and community engagement to raise public awareness and knowledge about prevention and control of COVID-19 among the general population and vulnerable groups. Beyond conflicts resulting from false rumors, vulnerable groups are at risk of being excluded from vital services, and quarantine interventions could increase the risk of intimate partner violence or SEA, as well as culturally inappropriate accommodation and services. To mitigate this, relevant capacity-strengthening measures have been included in the ESMF and reflected in ESCP. Other social risk mitigation measures will focus on: (i) prepare Labor Management Procedures (LMP), GBV/SEA Action Plan; (ii) prepare a Stakeholder Engagement Plan; (iii) mitigating social tensions through community involvement and engagement as well as establishment of an effective and functional GRM for the community members and project workers; and (iv) addressing gender dimensions. A preliminary E&S audit was conducted in December 2021. ESMF shall be updated based on the results of that audit and be disclosed by Effectiveness. However, to better address the risks related to the AF, ESMF, ESCP and SEP will be updated based on the results of the preliminary E&S audit. All these changes will be reflected in the project document and include amongs others following actions: • Management of biomedical waste to be an integral part of COVID 19 project given the increase in such waste Public Disclosure category and the risks of contamination associated to it handling • Hygiene teams at the health units to be retrained in proper management of biomedical waste • Reinforcement support of health units with biomedical waste bins is essential for proper management • Support of biomedical waste management with incinerators or reinforce MSF facility to handle extra capacity •BWMP (National) to be prepared, consulted upon, disclosed, and adopted one month after Effective Date, and before commissioning any project acquired incinerators • An Indigenous People Plan (IPP) including a communication plan specific to Covid19 to be prepared, consulted upon, disclosed, and adopted no later than 60 days after effectiveness • A Security Management Plan (SMP) to be prepared, consulted upon, disclosed, and adopted no later than 60 days after effectiveness • A Grievance redress mechanism should be implemented as the data from 1212 is not segregated into complaints logged, investigated and closed accordingly. Therefore, conducting a national grievance redress mechanism (GRM) workshop to ensure adequate operationalization of the GRM will be conditions of effectiveness. ESS10 Stakeholder Engagement and Information Disclosure In consultation with the Bank, the Borrower (under the technical guidance of SENI safeguard unit who had already acquired some experience in the preparation and implementation of SEP with REDISSE IV) has prepared and disclosed prior to appraisal a Stakeholder Engagement Plan (SEP) proportional to the nature and scale of the project and its associated risks and impacts, to be implemented and updated as needed throughout the project lifecycle. The objective of the SEP is to establish a systematic approach for stakeholder engagement, maintain a constructive Feb 23, 2022 Page 9 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) relationship with them, consider stakeholders’ views, promote and provide means for effective and inclusive engagement with stakeholders and beneficiaries throughout the project life cycle, and ensure that appropriate project information is disclosed to stakeholders in a timely, understandable, culturally accessible and appropriate manner, which is free of manipulation, interference, coercion, discrimination and intimidation. To ensure this, the Borrower would need, to engage in meaningful consultations with all stakeholders while paying attention to the inclusion of vulnerable and disadvantaged groups. In relation with IPs specific case, the approach to stakeholder engagement should be based on the principles of meaningful consultation and disclosure of appropriate information. The Borrower will undertake meaningful consultation in a manner that provides an opportunity for IPs to provide input on the risks, impacts and mitigation measures of the project, and for the Borrower to consider and respond to them in a culturally sensitive manner. These consultations will be carried out on an ongoing basis, as issues, impacts and opportunities evolve. If potential adverse effects on IPs are identified, those adverse effects are avoided, minimized, mitigated or compensated. Once project-specific sites and activities are determined, IPs’ Free, Prior and Informed Consent (FPIC) will be required if the project will : (a) have adverse impacts on land and natural resources subject to traditional ownership or under customary use or occupation; (b) cause relocation of IPs from land and natural resources subject to traditional ownership or under customary use or occupation; or (c) have significant impacts on IPs’ cultural heritage that is material to the identity and/or cultural, ceremonial, or spiritual aspects of the affected IPs’ lives. Given the COVID-19 crisis, measures will be put in place to prevent or minimize the community spread of COVID-19 Public Disclosure during rehabilitation and mass communication activities, and other various awareness or training sessions. These measures will include, among others, respecting social distancing measures as stated by the government in its press release of March 13, 2020. The concerns and needs of identified stakeholders would be related to their full participation in project activities and information sharing. The Borrower will maintain, and disclose, a documented record of stakeholder engagement, including a description of the stakeholders consulted, a summary of the feedback received, and a brief explanation of how the feedback was considered, or the reasons why it was not. Community consultations with (women, young girls, and women and female heads of households) that are related to SEA/SH risk mitigation will be conducted in safe and enabling environments, such as in sex-segregated groups and with female facilitators. The project will need to identify and consult with relevant stakeholders who could promote increased adhesion and encourage retention of young girls, women leading households and female workers (except pregnant and breastfeeding women), within the health activities. Such consultations will be focused on understanding women and girl’s risks and vulnerabilities, understand girl’s enrolment and engagement experience in awareness campaign, vaccination, and training concerns in relation to the project. Furthermore, the consultations will need to include the disabled groups, disadvantaged groups and minorities within project’s targeted communities, and be carried out in an accessible and appropriate manner, with information provided in accessible formats. The project will set up a project-specific Grievance Mechanism (GM), sensitive to SEA/SH issues, and the ethical treatment and resolution of such complaints that is proportionate of the potential risks and impacts of the project. Due to the considerable workforce involved in the project, and the potential for SEA/SH, the GM should refer to the Bank’s good practice note “Addressing Sexual Exploitation and Abuse and Sexual Harassment (SEA/SH) in Investment Project Financing involving Major Civil Works”. In relation to awareness campaign, vaccination, and training support and to enrolment of IPs and other vulnerable groups with respect to measures to reduce various violence including exclusion and discrimination against IPs and Feb 23, 2022 Page 10 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) especially on young girls and women (except pregnant and breastfeeding women), elderly aged over 65, the establishment of a GBV sensitive GM will also consider inclusion of IP counselor systems within the community workers committee and other community platforms. The GM will also serve as a platform for continuous feedback from project-affected communities, other interested stakeholders and implementing partners. The project specific GRM will be outlined in the SEP for people to report concerns or complaints. In order to be effective as noted above, the client will strengthen Green Line 1212. This will be initiated through the organization of a national grievance redress mechanism (GRM) workshop to ensure its adequate operationalization by effectiveness. The GRM manual for 1212 shall be developed after the workshop Staff will be trained on the manual and the GRM shall be implemented and maintained throughout the Project implementation period. 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 is relevant. The project is expected to encompass the following categories of workers: direct workers and contracted workers. In addition to the category of workers to be hired by the parent project, the AF will also involve community health agents to serve as vaccinators. Many activities supported by the AF project will be conducted by health care and laboratory workers and will include the treatment of patients as well as the assessment Public Disclosure of patient samples and therefore COVID-19 infection is a key risk for these workers. LMP covering AF activities have been updated and disclosed on Nov 22, 2021 prior to Appraisal. The LMP shall be implemented throughout project implementation and shall be revised/ updated as more information becomes available. The PIU has ensured the application of OHS measures as outlined in WHO guidelines and WB EHS guidelines: as well as the ESMF and a Labor Management Procedure (LMP). The ESMF measures include: procedures for monitored 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 post signage in all public spaces mandating hand hygiene and PPE; ensuring adequate supplies of PPE (particularly face masks, gowns, gloves, handwashing soap and sanitizer); and generally ensuring adequate OHS protections in accordance with the general and industry specific EHSGs and consistent with the evolving international best practice in relation to COVID-19 protection including vaccination. Also, the PIU will be constantly integrating the latest COVID-19 guidance by WHO. The LMP has provided guidance regarding the policies and procedures that will govern health care workers, project staff, community health agents and other direct workers hired under the project. Health consideration for front line medical personnel and workers involved in management of biomedical waste have to addressed with more regular screenings conducted given the greater exposures that they face. The LMP has also provided details regarding the establishment of a labor GRM to allow workers to quickly inform management of labor issues, such as a lack of PPE and unreasonable overtime via the PIU, the use of forced labor or the use of child labor for any person under the age of 18 in hazardous work situation (e.g. in health care facilities) which is prohibited, etc. The Infectious Control Waste Management Plan (ICWMP) is a more robust document to produce but Annex 2 of the ESMF provides the bases on which the project can operate while the ICWMP is being finalized. Feb 23, 2022 Page 11 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) ESS3 Resource Efficiency and Pollution Prevention and Management ESS3 is considered relevant to the project. Hazardous chemical wastes are expected to be generated from medical facilities, laboratories, and related facilities. The improper handling, transporting, and disposal of these hazardous and medical waste streams may result in adverse impacts to human health and the environment. The updated ESMF includes Annex 2 which provides a guide on Infection Control and Waste Management for health facilities and will be implemented. The guidelines is in accordance with WHO guidance documents on COVID-19 and other GIIP (Good Industry International Practices). However, the BWMP shall be prepared, consulted upon, disclosed, and adopted one month after Effective Date, and before commissioning any project acquired incinerators and will be implemented throughout implementation period of the Project. This BWMP will be a national instrument and will capture other health projects unit for better coordination. In addition, site-specific ESMPs will be prepared based on the provisions of the ESMF. The ESMF has included guidance for the preparation of site specific Environmental and Social Management Plans (ESMPs) which will need to be prepared prior to start of any civil works. Civil works under project interventions are: (i) establishing and/or rehabilitation of screening posts and rooms, (ii) establishing and equipping quarantine and treatment centers, (iii) establishing and equipping mobile clinics, and (iv) rehabilitating emergency operations centers at central and districts hospitals. The optimization of energy and rational use of other natural resources is guaranteed by ensuring that waste incinerators conserve energy and enhance internal combustion. The transport of biomedical waste from other centers to the elimination centers with project funded equipment has to be optimized. Public Disclosure ESS4 Community Health and Safety This Standard is relevant. Protecting communities from COVID-19 infection (through vaccination and other prevention measures) is the intention of the project but without adequate controls and procedures, project activities have the potential to contribute to the spread of the virus and may also generate social conflict. Medical waste and other waste from the labs, health centers, quarantine and isolation centers have a high potential of being contaminated with coronavirus and this can infect the community at large if not properly managed. Measures for industry standard waste management are outlined in Annex 2 of the ESMF which includes: (i) how Project activities involving the COVID-19 pathogen or waste generated will be managed in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (such as WHO guidelines); (ii) measures in place to prevent or minimize the spread of infectious diseases; and (iii) emergency preparedness measures. Information on preventive health measures to protect the communities surrounding health facilities will be provided through continuous stakeholder engagement and reflected in the SEP. Sexual Exploitation and Abuse (SEA)/ Sexual Harassment (SH) risks has been assessed and action plan developed and disclosed on Nov 22, 2021. Measures and actions identified including screening and implementing measures to prevent and mitigate these risks shall be maintained throughout Project implementation. The project will be implemented in whole country with insecurity in many regions. A Security Management Plan (SMP) will be prepared, consulted upon, disclosed, and adopted no later than 60 days after effectiveness. The role of NGOs, UN and other development partners and potential role of MINUSCA in the roll out will be clearly explained in SMP. If CAR’s military forces or any security forces are mobilized as part of the government’s response to the COVID- Feb 23, 2022 Page 12 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) 19 emergency, the PIU will take measures recommended in SMP to ensure that personnel assigned to the project sites are: (i) screened to confirm that they have not engaged in past unlawful or abusive behavior, including SEA, 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 applicable national law. The ESMF has provided guidance regarding how these measures will be integrated. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS5 is not currently relevant to the project. All eventual construction will be undertaken within existing facilities. No adverse impacts relating to land acquisition, restrictions on land use or involuntary resettlement are anticipated as a result of proposed project activities. In an unlikely event of an intervention where land acquisition would be necessary, resettlement action plans would be developed to the satisfaction of the Bank prior to the commencement of any land acquisition. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources ESS6 is not relevant to the project. No adverse impacts on natural resources or biodiversity are anticipated as a result of project activities. Public Disclosure ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is considered relevant to the project. Historically underserved traditional local communities of Aka communities are present in CAR and are considered vulnerable and disadvantaged. The project will be implemented in 35 health districts. The under served traditional local communities are present in some of those areas - namely in, Sangha- Mbaéré, Mambere-Kadei, Nana-Mambere and Ombella-Mpoko prefectures. In the context of COVID-19 vulnerable group in the under served traditional local communities will also include elderly persons, people with co-morbidity symptoms, health care workers who are at the forefront of the fight against the pandemic. The Social Assessment will, among other things, examine potential risks, impacts, and benefits for the IPs. Using a consultative approach, the Social Assessment will identify measures to mitigate risks and to ensure culturally acceptable benefits to IPs. However, no activity under this AF/project is expected to have an adverse effect on Indigenous Peoples (displacement, land, cultural heritage, habits & behaviors). The Stakeholder Engagement plan will then include outreach programs to ensure that under served communities, especially those living in remote areas, are aware of the availability of essential free services (vaccination, treatment of positive cases, information, etc.) as well as behavior change awareness/training sessions under the project. The potential social impacts on under served traditional local communities can be adequately managed/ mitigated through the development, implementation and monitoring of appropriate measures. This means that the government of the CAR should proactively engage with the IPs to ensure their ownership and participation in project design, implementation, monitoring, and evaluation. In addition, some measures provided under the project to ensure that IPs and other Feb 23, 2022 Page 13 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) groups will be able to share in project benefits are: Possibility to enroll beneficiaries without distinction and without discrimination in their participation in health committees, employment of animators and/or community health workers, etc. in the most equitable way. Here, particular attention will need to be paid to other vulnerable groups including IDPs, Peulhs Mbororos, etc., who may be excluded from project benefits. However, preliminary audit has raised among others findings that there is a lack of communication about covid-19 prevention measures among under served traditional local communities. The Social Assessment will also explore the appropriate consultation methods for these groups and examine culturally appropriate grievance mechanisms. These measures will be detailed in an under served traditional local communities plan and will be incorporated into the AF/project design including, but not limited to the Stakeholder Engagement Plan and the grievance mechanism. The GRM will be accessible to all regardless of gender, age, race, religion and social and economic status. In addition, IPP will include a communication plan specific to COVID. Once project sites and activities are determined the PIU will prepare an Indigenous Peoples Plan (IPP), acceptable to the Bank that sets out measures through which the project will ensure that: (i) IPs affected by the project receive culturally appropriate social and economic benefits; and (ii) if potential adverse effects on IPs are identified, those adverse effects are avoided, minimized, mitigated or compensated. The IPP (including communication plan specific to COVID) shall be prepared, consulted upon, cleared by the Bank and disclosed no later than 60 days after effectiveness. All limited civil works (rehabilitation) will be done on existing facilities. This means that the site-specific locations are already known. No activity will have significant impact on social norms/practices aspects of the affected Indigenous Peoples. The Free, Prior, and Informed Consent (FPIC) of IPs will not be required. The project will follow WHO guidelines for consultations during pandemics. However, IPs’ Free, Prior and Informed Consent (FPIC) will be required if the project Public Disclosure will : (a) have adverse impacts on land and natural resources subject to traditional ownership or under customary use or occupation; (b) cause relocation of IPs from land and natural resources subject to traditional ownership or under customary use or occupation; or (c) have significant impacts on IPs’ cultural heritage that is material to the identity and/or cultural, ceremonial, or spiritual aspects of the affected IPs’ lives. ESS8 Cultural Heritage ESS8 is not relevant to the Project at this time as the limited civil works (rehabilitation) are unlikely to affect cultural assets. In the unlikely event of construction or the movement of earth in connection with any project activities that have not yet been identified, the ESMF will include measures for “Chance Finds” of archaeological or other cultural heritage. ESS9 Financial Intermediaries There are no actions under the Project involving financial intermediaries, therefore there are no mitigation measures to be undertaken under this ESS9 Feb 23, 2022 Page 14 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: None IV. CONTACT POINTS World Bank Contact: Mahoko Kamatsuchi Title: Senior Health Specialist Public Disclosure Telephone No: +1-202-473-9370 Email: mkamatsuchi@worldbank.org Borrower/Client/Recipient Borrower: Central African Republic Implementing Agency(ies) Implementing Agency: Ministry of Health and Population 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): Mahoko Kamatsuchi Practice Manager (ENR/Social) Senait Nigiru Assefa Cleared on 21-Jan-2022 at 06:28:49 GMT-05:00 Feb 23, 2022 Page 15 of 16 The World Bank Central African Republic COVID-19 Preparedness & Response Additional Financing (P177618) Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Concurred on 07-Jan-2022 at 11:12:20 GMT-05:00 Public Disclosure Feb 23, 2022 Page 16 of 16