Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD4783 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT PAPER ON A PROPOSED ADDITIONAL CREDIT IN THE AMOUNT OF SDR 14.3 MILLION (US$20.0 MILLION EQUIVALENT) TO THE ISLAMIC REPUBLIQUE OF MAURITANIA FOR THE MAURITANIA COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROJECT DECEMBER 23, 2021 UNDER THE COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROGRAM (SPRP) USING THE MULTIPHASE PROGRAMMATIC APPROACH (MPA) WITH A FINANCING ENVELOPE OF UP TO US$6 BILLION APPROVED BY THE BOARD ON APRIL 2, 2020 AND UP TO US$12 BILLION ADDITIONAL FINANCNG APPROVED BY THE BOARD ON OCTOBER 13, 2020 Health, Nutrition & Population Global Practice Western and Central Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective November 30, 2021) Currency Unit = Mauritania Ouguiya (MRU) US$1 = MRU 36.26 US$1 = SDR 0.714 FISCAL YEAR January 1 - December 31 Regional Vice President: Ousmane Diagana Country Director: Nathan M. Belete Regional Director: Dena Ringold Practice Manager: Gaston Sorgho Fatoumata Binta Maama Barry, Mohamed Vadel Taleb El Task Team Leaders: Hassen ABBREVIATIONS AND ACRONYMS AEFI Adverse Event Following Immunization AF Additional Financing AMC Advance Market Commitment APA Advance Purchase Agreement AU African Union AVAT African Vaccine Acquisition Trust BFP World Bank Facilitated Procurement CCE Cold Chain Equipment COVAX COVID-19 Vaccines Global Access COVID-19 Coronavirus Disease 2019 CPF Country Partnership Framework CY Calendar Year DP Development Partner EPI Expanded Program on Immunization ESCP Environmental and Social Commitment Plan ESF Environmental and Social Framework ESMF Environmental and Social Management Framework ESS Environmental and Social Standards EUL Emergency Use Listing FM Financial Management FTCF Fast Track COVID-19 Facility FY Fiscal Year GAVI Global Alliance for Vaccines and Immunizations GBV Gender-based Violence GHG Greenhouse Gas GRM Grievance Redress Mechanism GRS Grievance Redress Service GWP Global Warming Potential HEIS Hands-on Expanded Implementation Support HMIS Health Management and Information System HR Human Resources IBRD International Bank for Reconstruction and Development ICAP International Center for AIDS Care and Treatment Program ICU Intensive Care Unit IDA International Development Association IFC International Finance Corporation IFR Interim Financial Report INAYA Health System Support Project (Projet de Renforcement du Système de Santé) IPF Investment Project Financing ISR Implementation Status and Results Report J&J Johnson and Johnson LMP Labor Management Procedures M&E Monitoring and Evaluation MoH Ministry of Health MPA Multiphase Programmatic Approach MRU Mauritania Ouguiya NDVP National Deployment and Vaccination Plan NFCS National Fund Compensation Scheme OECD Organization for Economic Co-operation and Development OHS Occupational Health and Safety PCU Project Coordination Unit PDO Project Development Objective PP Project Paper PPE Personal Protective Equipment PPP Purchasing Power Parity PPSD Project Procurement Strategy for Development PQ Prequalification PrDO Program Development Objective RCCE Risk Communication and Community Engagement REDISSE III Regional Disease Surveillance Systems Enhancement Program, Phase III SDR Special Drawing Rights SEA Sexual Exploitation and Abuse SEP Stakeholder Engagement Plan SOP Standard Operating Procedures SORT Systematic Operations Risk-Rating Tool SPRP COVID-19 Strategic Preparedness and Response Program SRA Stringent Regulatory Authority TOR Terms of Reference UAE United Arab Emirates UN United Nations UNICEF United Nations Children’s Fund USA United States of America VAC Vaccine Approval Criteria VIRAT Vaccine Introduction Readiness Assessment Tool VRAF Vaccine Readiness Assessment Framework WBG World Bank Group WHO World Health Organization Islamic Republic of Mauritania Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ........................................ 9 A. Introduction ................................................................................................................. 9 B. Consistency with the Country Partnership Framework (CPF) .................................. 10 C. Project Design and Scope .......................................................................................... 11 D. Project Performance .................................................................................................. 11 E. Rationale for Additional Financing ............................................................................ 12 F. National Capacity and COVID-19 Vaccination Plan .................................................. 15 II. DESCRIPTION OF ADDITIONAL FINANCING .................................................................... 26 A. Proposed Changes ...................................................................................................... 26 B. Sustainability .............................................................................................................. 34 III. KEY RISKS ..................................................................................................................... 34 IV. APPRAISAL SUMMARY .................................................................................................. 37 V. WORLD BANK GRIEVANCE REDRESS .............................................................................. 48 VI SUMMARY TABLE OF CHANGES ..................................................................................... 50 VII DETAILED CHANGE(S) .................................................................................................... 50 VIII. RESULTS FRAMEWORK AND MONITORING ................................................................... 55 ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS .............. 67 ANNEX 2: LATEST COVID-19 SITUATION IN THE COUNTRY .................................................... 68 ANNEX 3: SUMMARY OF THE PROJECT COMPONENTS.......................................................... 70 LIST OF TABLES Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment .............. 16 Table 2: National Vaccine Coverage and Acquisition Plan .................................................................. 22 Table 3: Priority Groups for Vaccination in Mauritania ...................................................................... 29 Table 4: Project Cost and Financing .................................................................................................. 30 Table 5: Summary of COVID-19 Vaccine Sourcing and World Bank Financing ..................................... 31 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) BASIC INFORMATION – PARENT (Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) - P173837) Country Product Line Team Leader(s) Mauritania IBRD/IDA Fatoumata Binta Maama Barry Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P173837 Investment Project HAWH3 (9542) AWCF1 (6550) Health, Nutrition & Financing Population Implementing Agency: Ministry of Health ADD_FIN_TBL1 Is this a regionally tagged project? No Bank/IFC Collaboration No Expected Approval Date Closing Date Guarantee Environmental and Social Risk Classification Expiration Date 02-Apr-2020 30-Apr-2023 Substantial Financing & Implementation Modalities Parent [✓] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [ ] Hands-on Expanded Implementation Support (HEIS) Page 1 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Development Objective(s) MPA Program Development Objective (PrDO) The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Project Development Objectives (Phase 092) To strengthen the national public health preparedness capacity to prevent, detect and respond to the COVID-19 pandemic in Mauritania Ratings (from Parent ISR) RATING_DRAFT_NO Implementation Latest ISR 11-Nov-2020 20-May-2021 07-Dec-2021 Progress towards achievement of PDO MS S S Overall Implementation Progress (IP) MS MS MS Overall ESS Performance S MS MS Overall Risk M M H Financial Management S S S Project Management S MS MS Procurement MS MS MS Monitoring and Evaluation MS MS MS BASIC INFORMATION – ADDITIONAL FINANCING (Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) - P178100) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P178100 Second Additional Scale Up No Financing for the Mauritania COVID-19 Strategic Preparedness and Page 2 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Response Project (SPRP) Financing instrument Product line Approval Date Investment Project IBRD/IDA 23-Dec-2021 Financing Projected Date of Full Bank/IFC Collaboration Disbursement 31-Dec-2024 No Is this a regionally tagged project? No Financing & Implementation Modalities Child [✓] Multiphase Programmatic Approach [MPA] [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [✓] Hands-on, Enhanced Implementation Support (HEIS) [ ] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments IBRD % IDA 20.20 6.27 13.78 31 % Grants % MPA Financing Data (US$, Millions) Financing MPA Program Financing Envelope 18,000,000,000.00 MPA FINANCING DETAILS (US$, Millions) Page 3 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) MPA FINA NCI NG DET AILS (US$, Millions) Approve d Board Approved MPA Financing Envelope: 18,000,000,000.00 MPA Program Financing Envelope: 18,000,000,000.00 of which Bank Financing (IBRD): 9,900,000,000.00 of which Bank Financing (IDA): 8,100,000,000.00 of which other financing sources: 0.00 PROJECT FINANCING DATA – ADDITIONAL FINANCING (Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) - P178100) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFi n1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 20.20 20.00 40.20 Total Financing 20.20 20.00 40.20 of which IBRD/IDA 20.20 20.00 40.20 Financing Gap 0.00 0.00 0.00 DETAILS - Additional Financing NewFinEnh1 World Bank Group Financing International Development Association (IDA) 20.00 IDA Credit 20.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Mauritania 20.00 0.00 0.00 20.00 National PBA 20.00 0.00 0.00 20.00 Page 4 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Total 20.00 0.00 0.00 20.00 COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ✔ ] Yes [ ] No Explanation This project is being processed using the following waiver(s) granted through the Global SPRP MPA Project (P173789): (i) Waiver to enable Management approval of individual projects under SPRP rated Substantial for Environmental and Social (ES) risks. Has the waiver(s) been endorsed or approved by Bank Management? Approved by Management [✔] Endorsed by Management for Board Approval [ ] No [ ] Explanation The waiver has been already approved for the Global Coronavirus Disease 2019 (COVID-19) Strategic Preparedness and Response Project (SPRP) using the Multiphase Programmatic Approach (MPA), approved by the Board on April 2, 2020, and the vaccines AF to the SPRP approved on October 13, 2020, and its relevant to this AF. Page 5 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) ESStandards Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance Assessment and Management of Environmental and Social Risks and Impacts Relevant Stakeholder Engagement and Information Disclosure Relevant Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and Management Relevant Community Health and Safety Relevant Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Not Currently Relevant Local Communities Cultural Heritage Not Currently Relevant Financial Intermediaries Not Currently Relevant ESStandardsNote NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Page 6 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) PROJECT TEAM Bank Staff Name Role Specialization Unit Fatoumata Binta Maama Team Leader (ADM Health Specialist HAWH3 Barry Responsible) Mohamed Vadel Taleb El Team Leader Health Economist HAWH3 Hassen Procurement Specialist (ADM Brahim Hamed Procurmenent EAWRU Responsible) Financial Management Angelo Donou Financial Management EAWG1 Specialist (ADM Responsible) Financial Management Fatou Fall Samba Financial Management EAWG1 Specialist Environmental Specialist (ADM Joelle Nkombela Mukungu Environmental specialist SAWE1 Responsible) Mame Safietou Djamil Social Specialist (ADM Social Development SAWS4 Gueye Responsible) Aissatou Chipkaou Team Member Operation Analyst HHNGE Charlotte Pram Nielsen Team Member Health Specialist HHNGF Cheikh Hamallah Diagana Social Specialist Social Safeguards SAWS4 Djibrilla Karamoko Team Member Sr. Health Specialist HAWH3 Faly Diallo Team Member Finance Officer WFACS Helene Bertaud Counsel Country Lawyer LEGAM Johanna van Tilburg Safeguards Advisor/ESSA Safeguards AFWDE Maimouna Toure Procurement Team Program Assistant AWCF1 Mamadou Samba Sow Team Member Environmental specialist SAWE1 Moussa Dieng Team Member Sr. Health Economist HAWH2 Nejma Cheikh Team Member Health Specialist HHNGE Nina Chee Safeguards Advisor/ESSA Safeguards EAPOS Samuel Lantei Mills Team Member Sr. Health Specialist HAWH3 Samuel Ruben Alexander Procurement Team EPSPA Garoni Sariette Jene M. C. Jippe Team Member Operations & Administrative HAWH3 Page 7 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Sophie Lo Diop Environmental Specialist Environmental Specialist SAWE1 Wolfgang Mohammad Team Member WFACS Taghi Chadab Yahya Ould Aly Jean Team Member Program Assistant AWMMR Extended Team Name Title Organization Location Page 8 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING A. Introduction 1. This Project Paper (PP) seeks the approval of the Regional Vice-President of the World Bank to provide a credit in the amount of US$20 million equivalent from the International Development Association (IDA) for a Second Additional Financing (AF). The second AF would support the costs of expanding activities of the Mauritania COVID-19 Strategic Preparedness and Response Project (P173837) and its first AF (P176526), under the COVID-19 Strategic Preparedness and Response Program (SPRP) using the Multiphase Programmatic Approach (MPA), approved by the Board on April 2, 2020, and the vaccines AF to the SPRP approved on October 13, 2020.1 The primary objectives of the second AF are to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccine deployment in Mauritania through vaccination system strengthening, and to further strengthen preparedness and response activities under the project. The COVID-19 Strategic Preparedness and Response Project (P173837) in an amount of US$5.2 million equivalent was approved on April 2, 2020 and the first AF (P176526) in an amount of US$15.0 million was approved on June 30, 2021. 2. The purpose of the proposed second AF is to provide upfront financing to help the Government of Mauritania purchase and deploy COVID-19 vaccines that meet the World Bank’s Vaccine Approval Criteria (VAC) and strengthen relevant health systems that are necessary for successful deployment and to prepare for the future. The Government of Mauritania’s target for COVID-19 vaccinations is to have 63 percent of the total population vaccinated (16 years of age and older) by the end of CY22.2 The proposed second AF will help vaccinate an additional 14.05 percent of the total population,3 which will enable the country to progress towards its coverage target. The second AF will support the purchase and deployment of vaccines through the African Vaccine Acquisition Trust (AVAT). World Bank financing for the COVID-19 vaccines and deployment will follow the World Bank’s VAC. The country will continue to provide vaccinations free of charge to the population. As of April 16, 2021, the World Bank will accept as threshold for eligibility of International World Bank for Reconstruction and Development IBRD/IDA resources in COVID-19 vaccine acquisition and/or deployment under all World Bank-financed projects: (i) the vaccine has received regular or emergency licensure or authorization from at least one of the Stringent Regulatory Authorities (SRAs) identified by the World Health Organization (WHO) for vaccines procured and/or supplied under the COVAX Facility, as may be amended from time to time by WHO; or (ii) the vaccine has received WHO Prequalification (PQ) or WHO Emergency Use Listing (EUL). The country will continue to provide vaccinations free of charge to the population. 1 The World Bank approved a US$12 billion World Bank Group (WBG) Fast Track COVID-19 Facility (FTCF or “the Facility”) to assist IBRD and IDA countries in addressing the global pandemic and its impacts. Of this amount, US$6 billion came from IBRD/IDA (“the Bank”) and US$6 billion from the International Finance Corporation (IFC). The IFC subsequently increased its contribution to US$8 billion, bringing the FTCF total to US$14 billion. The AF of US$12 billion (IBRD/IDA) was approved on October 13, 2020 to support the purchase and deployment of vaccines, as well as strengthening the related immunization and healthcare delivery system. 2 As of December 10, 2021, only populations 18 years of age and older are eligible. 3 The first AF aimed to cover the vaccine deployment costs of the COVAX AMC vaccines to be donated to the country (20 percent) and the vaccine acquisition and deployment costs for an additional 10 percent of the population. Page 9 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) 3. The need for additional resources to expand the COVID-19 response was formally conveyed by the Government of Mauritania on October 11, 2021. The Government has requested support to provide financing to cover the US$20 million gap to reach their national target for COVID-19 vaccinations. Other than financing of vaccines, the request considered funding needs for the necessary investments in operational support of the National Center for Emergency Operations in Public Health, a digital vaccination platform, technical assistance and Human Resources (HR) at the regional level to support vaccinations, communication and community engagement and other operational costs. The proposed second AF will be part of an expanded health response to the pandemic, which is being supported by Development Partners (DPs) under the coordination of the Government of Mauritania. Additional World Bank financing will provide essential resources to enable the expansion of a sustained and comprehensive pandemic response that will appropriately include vaccination in Mauritania. 4. Critically, the second AF seeks to enable the acquisition of vaccines from AVAT to support Mauritania’s objective to have a portfolio of options to access vaccines under the right conditions (of value-for-money, regulatory approvals, and delivery time among other key features). The proposed IDA financing will build on this to expand Mauritania’s access. The availability and terms of vaccines remain fluid and prevent the planning of a firm sequence of vaccine deployment, especially as the actual delivery of vaccines is unlikely to be immediate. Rather, the proposed second AF financing enables a portfolio approach that will adjust during implementation in response to developments in the country pandemic situation and the global market for vaccines. 5. Latest COVID-19 situation in the country. Mauritania registered its first COVID-19 case on March 14, 2020, and as of December 9, 2021 there were 39,704 confirmed cases and 846 deaths (see Annex 2 for more information). The initial confirmed COVID-19 cases were few with only eight cases reported in the first two months and fewer than 100 cases confirmed until May 20, 2020. Similarly, to other neighboring countries, Mauritania experienced a third wave in July 2021, registering 401 daily confirmed cases on July 29, 2021 (peak). There is a potential fourth wave developing as confirmed cases are rising in the eastern part of the country. Mauritania is ranked fifth out of 15 in the highest number of cases and third out of 15 in the highest number of deaths due to COVID-19 in West Africa (see details in Annex 2). Mauritania’s COVID-19 Vaccination campaign started on March 24, 2021 with priority groups as planned in the National Deployment and Vaccination Plan (NDVP). By June 2021, the vaccination was extended to people over 18 years of age due to low turnout. As of December 9, 2021, 701,537 people or 27.0 percent of the eligible target population (18 years of age and over) were reported to be fully vaccinated. Mauritania is considered one of the leading countries in the region in terms of vaccine deployment and coverage. B. Consistency with the Country Partnership Framework (CPF) 6. This project was not included in the Recipient’s CPF for the period FY18–FY23 (Report no. 125012-MR), but the pandemic has increased the priority of health protection and treatment in Mauritania. The need to invest in health systems to ensure the productive capabilities of the population is recognized, as is the challenge of overcoming a legacy of limited investment in human capital and social resilience systems. The parent project was prepared to allow the country to respond to urgent preparedness and response needs related to the COVID-19 outbreak. It complements the Regional Page 10 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Disease Surveillance Systems Enhancement Program – Phase III (REDISSE III -P161163), which aims to strengthen human health, animal health, and the disaster response systems in West Africa to ensure resilience to outbreaks and health emergencies. The parent project and the first AF support Mauritania in establishing a coordinated approach to detecting and swiftly responding to regional public health threats and to strengthening health information systems, including disease surveillance capacity for early detection and response to disease outbreaks. The second AF, like the parent project4 and first AF5, is also aligned with both global health priorities and IBRD/IDA priorities on improving pandemic preparedness. C. Project Design and Scope 7. The Project Development Objective (PDO) of the Parent Project, the first AF and this proposed second AF is to strengthen the national public health preparedness capacity to prevent, detect, and respond to the COVID-19 pandemic in Mauritania. The Parent Project and the first AF include the components listed below and summarized in Annex 3: (a) Component 1: Emergency COVID-19 Response; Subcomponent 1.1: Case Detection, Confirmation, Contact Tracing, Recording, Reporting; Subcomponent 1.2: Health System Strengthening; Subcomponent 1.3: Communication Preparedness; and Subcomponent 1.4: COVID-19 Vaccine Purchase and Deployment; (b) Component 2: Implementation Management and Monitoring and Evaluation (M&E); Subcomponent 2.1: Implementation Management; and Subcomponent 2.2: Project M&E. The proposed second AF will scale up activities in all subcomponents in Component 1 and several new activities will be financed to support the COVID-19 response. Detailed description of the parent project can be found at https://projects.worldbank.org/en/projects-operations/project- detail/P173837. 8. The Mauritanian Ministry of Health (MoH) will remain the implementing agency for the project. The MoH is responsible for project coordination through the Office of the Secretary General with the Directorate General for Public Health responsible for the technical coordination. Project oversight will be provided through a COVID-19 Steering Committee that has been established at the MoH presided by the Office of the Secretary General. The Committee will meet on a regular basis to review the progress of the project, to ensure coordinated efforts by all stakeholders, and to conduct annual reviews of the project. Through its central departments and regional directorates, the MoH is responsible for the overall implementation of the parent project and first AF. The fiduciary arrangements for the proposed second AF will be based on the arrangements in place under the parent project and the first AF. D. Project Performance 9. The project’s progress toward achievement of the PDO is rated satisfactory and overall implementation is rated Moderately Satisfactory in the last Implementation Status and Results Report (ISR) of December 7, 2021 and the project continues to make substantial progress. The parent project became effective on April 6, 2020 and has disbursed 93.65 percent of its funds (December 10, 2021). All remaining funds have been committed within the scope of the project activities. Due to the recent effectiveness of the first AF (August 6, 2021) and disbursement condition that was met in October 2021, 4 https://projects.worldbank.org/en/projects-operations/project-detail/P173837 5 https://projects.worldbank.org/en/projects-operations/project-detail/P176526 Page 11 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) the disbursement rate is at 9.6 percent as of December 10, 2021. Progress towards achievement of the PDO is satisfactory. Out of the five PDO indicators, two have reached or surpassed their objectives: (i) suspected cases of COVID-19 reported and investigated per approved protocol and (ii) health facilities with trained staff in COVID-19 infection prevention and control per MoH approved protocol. The remaining PDO indicators have positive trends towards achieving the intended targets. Of the thirteen intermediate indicators, nine have already been achieved - one of which has surpassed its target (reference and district hospitals have submitted complete monthly reports on the number of suspected cases identified, tested and contacts traced). 10. The Project Coordination Unit (PCU) has been effectively coordinating project planning and procurement. The PCU has updated, finalized, and disclosed the Environmental and Social Framework (ESF) Instruments that were required for the first AF and trained the healthcare workers as stipulated in the Environmental and Social and Commitment Plan (ESCP). The Administrative and Financial Manual of Procedures as well as the Vaccine Delivery and Distribution Manual were also finalized. The PCU has customized its project accounting software for the first AF and updated the 2021 Annual Work Plan and Budget. A Social Specialist was recruited to support the project. The PCU has recently finalized the recruitment of the Project Officer and is evaluating the candidates that have applied to the M&E Specialist position. The internal auditor’s Terms of References (ToR) have yet to be updated but is planned to be completed by December 31, 2021. The updated ToRs for the external auditor are not yet due. E. Rationale for Additional Financing 11. The proposed second AF will provide critical financing for COVID-19 response, with a specific focus on affordable and equitable access to vaccines in Mauritania. COVID-19 vaccination, along with improved diagnostics and therapeutics, is essential to protecting lives and enabling recovery. The second AF will play a significant role in enabling affordable and equitable access to COVID-19 vaccines for an additional 14.05 percent of the total population. It will also enable more support for vaccine deployment. This will allow the country to use World Bank financing to progress towards their national target of 63 percent. There are several lessons learned from the COVID-19 vaccination rollout in the country. First, due to low-turnout for COVID-19 vaccinations and the short shelf-life of some of the vaccine doses received in the initial phase, the Government opened vaccinations to all adults over the age of 18 years. Similarly, to neighboring countries, the low turnout was mainly due to misinformation about the safety of vaccines across the country. However, with increased communication and community engagement using a vaccination campaign strategy to reach the last mile, the country has been able to reach 27.0 percent of vaccination coverage of the target population before the end of CY2021. This mobile strategy enabled populations that live far from fixed health facilities to get vaccinated. This has particularly encouraged women and those that are most vulnerable to get vaccinated due to the constraints of reaching a health facility for vaccinations with work and family obligations as well as lack of transportation. Moreover, the Government instituted mandatory vaccinations for certain localities (i.e, public sector workplaces, public transportation, access to schools/universities) to increase the demand of COVID-19 vaccines. However, not all regions are enforcing this policy. Therefore, additional communication with leaders as well as in communities will be needed. Second, in the initial phase of the vaccination campaigns, men were being vaccinated at higher rates, with women only accounting for 38.0 percent of doses administered by June 1, 2021. This was mainly due to a larger proportion of men as part of the priority groups particularly, the Page 12 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) military, police, and teachers. To ensure equitable administration of COVID-19 vaccines among women, the Government ensured women-led cooperatives and non-governmental organizations participated in the communication, community engagement and supported the deployment of vaccines. As of December 12, 2021, the percentage of women fully vaccinated has increased to 49.0 percent. 12. To ensure that the demand of vaccines continues to increase, the MoH would like additional support in communication activities, particularly in the rural areas. Furthermore, the COVID-19 pandemic has increased the obligations on personnel in the health sector and to ensure adequate vaccine deployment, the MoH would like additional support for technical assistance as well as HR for the Expanded Program on Immunization (EPI). This will be particularly important at the regional level where there is a recent trend towards a potential fourth wave, particularly in the eastern part of the country. The support will enable better case detection as well as increase vaccine coverage. Finally, more support to operationalize the National Center for Emergency Operations in Public Health, which will enable the country to respond more effectively during and after public health emergencies. The Government will receive technical support from the International Center for AIDS Care and Treatment Program (ICAP)/Columbia University6 to strengthen the MoH’s pandemic preparedness and response. Last, there was a vaccine platform that was developed, but it is unable to collect critical data across all regions including information on the priority groups vaccinated, particularly at the vaccination sites. Therefore, the MoH would like to revamp this platform to enable an efficient digital vaccination platform, which will allow the Government to collect important data for M&E and populations will be able to access their vaccination cards online. The latter is important in case of loss of paper records. 13. The proposed second AF will form a part of an expanded health response to the pandemic. The activities will build on the parent project and its first AF (P173837; P176526) as well as on (a) the World Bank’s existing health portfolio in the country (INAYA - Health System Support - Projet de renforcement du système de santé [P156165], INAYA AF [P170585], and REDISSE III [P161163]); and (b) the support of other DPs in the context of the Government’s overall COVID-19 response. The second AF is part of the overall support mobilized by the United Nations (UN) system, which is aligned with the National Response Plan according to various key pillars for actions, each one under the leadership of a UN agency and its partners (Incident Management System). This support also aims to mitigate the socioeconomic impact of the measures taken to contain the epidemic in the country. The overall coordination response is ensured by the Representative of the World Health Organization (WHO), the lead agency, who is working closely with the MoH, and providing technical assistance through its various areas of expertise. Part of the funding mobilized through the COVID-19 and REDISSE III projects is executed through WHO and the United Nations Children’s Fund (UNICEF). Donors such as the French Development Agency and other UN agencies are providing parallel financing to some of the World Bank-supported interventions. Therefore, continuing World Bank engagement is essential to enable an expanded, sustained and comprehensive pandemic response in Mauritania. This second AF will complement the support of other partners to finance the purchase of sufficient vaccines for the target population and to ensure effective deployment. 6 ICAP is based in the Mailman School of Public Health in Columbia University (New York, USA) with the objective to deliver transformative solutions to strengthen health systems around the world. ICAP has provided technical support for several countries in Sub-Saharan Africa to support their National COVID-19 Surveillance System, COVID-19 treatment centers and the purchase of medical equipment and supplies for the COVID-19 response. Some of the countries they have supported include: Lesotho, Sierra Leone, Zimbabwe, the Democratic Republic of Congo, Mozambique, Central African Republic, Ethiopia, Kenya and Sierra Leone. Page 13 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Box 1 : Ongoing Supportive Roles for Partner Agencies in Implementation of Vaccine Strategy WHO’s role Financing amount • Prioritization, Targeting, and COVID-19 Surveillance: Estimate potential numbers of target Not applicable populations that will be prioritized for access to vaccines stratified by target group and geographic location, that is, prepare first to define, identify, and estimate number of Health Community Workers. • Training and Supervision: Developed a training plan to prepare for COVID-19 vaccine introduction that includes key groups of participants, content topic areas, key training partners, and training methods (in-person or virtual). • M&E: Develop and/or adapt existing surveillance and monitoring framework with a set of recommended indicators (coverage, acceptability, disease surveillance, and so on) for COVID-19 vaccine; determine whether registration and reporting will be individual or aggregate, and to what extent existing tools and systems can be re-used. • Safety Surveillance: Plan active surveillance of specific COVID-19-vaccine-related adverse events; if this is not possible, develop provisions that allow reliance on active surveillance data, decisions, and information from other countries or regional or international bodies. UNICEF’s role Financing amount • Support the development of a roadmap to integrate COVID-19 vaccine deployment, Not applicable quantification and forecasting of supply needs, cold chain assessment, supply, and maintenance; UNICEF acts as a supply agent for the COVID-19 vaccine through the COVAX facility, facilitating purchase and delivery of vaccines. • Demand Generation and Communication: Assess behavioral and social data quickly and support the communication strategy and community engagement. • Vaccine, Cold Chain, and Logistics: Reinforce the national logistics working group and assess dry storage and cold chain capacity. GAVI’s/COVAX’s role Financing amount • Provide vaccines for 20 percent of the total population to be fully vaccinated in Mauritania. Range 15 percent–20 • Provide technical assistance related to the development and the implementation of the percent: [US$9.76 NDVP (Technical Assistance COVAX Readiness and Preparation). million–US$13.02 million] US$371,993 (COVAX TA Ceiling) US$150,000 (Cold Chain Equipment [CCE] Ceiling) African Union (AU)/AVAT Financing amount 352,800 J&J doses have been purchased. • AVAT has facilitated the provision of approximately 352,800 Johnson and Johnson (J&J) Mauritania plans to doses to be financed fully through the first AF. purchase an additional • UNICEF plays the role of procurement agent. 600,000 J&J doses (supported under the second AF). 14. This second AF is being proposed at a crucial juncture in the Government of Mauritania’s response to COVID-19. A critically important change in the state of science since the early stages of the Page 14 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) pandemic has been the emergence of new therapies and the successful development and expansion of production of COVID-19 vaccines (see Annex 1 for status). Published results show that COVID-19 vaccines are safe and produce desired immune responses.7,8 In parallel with vaccine research, global production capacity is being developed to make several COVID-19 vaccines rapidly more available. Given the centrality of limiting the spread of COVID-19 to health and economic recovery, providing access to COVID- 19 vaccines will be critical to accelerate economic and social recovery in Mauritania. A key rationale for the proposed second AF is to provide upfront financing for safe and effective vaccine acquisition and deployment in Mauritania, thus enabling the country to procure safe and effective vaccines at the earliest opportunity, recognizing that there is currently excess demand for vaccines from both high-income and lower-income countries. This second AF will continue to support health system strengthening to provide optimal medical care, maintain essential services, and minimize risks for patients and health personnel, including additional HR to support the COVID-19 response and providing them with the appropriate protective equipment and hygiene materials. F. National Capacity and COVID-19 Vaccination Plan (i) Vaccine Readiness Assessment 15. Mauritania has conducted a vaccine readiness assessment using the integrated Vaccine Introduction Readiness Assessment Tool (VIRAT)/Vaccine Readiness Assessment Framework (VRAF 2.0) tool to identify gaps and options to address them, as well as to estimate the cost of vaccine deployment, with the support of international organizations including the World Bank, WHO, UNICEF, and Global Alliance for Vaccines and Immunizations (GAVI) (See Table 1 below). This assessment considers the Government’s vaccine deployment strategy described below. The uncertainties related to the COVID-19 vaccine market, including testing, approval, availability, and pricing, require flexibility, close monitoring, and strong World Bank supervision during implementation. The readiness assessment will continue to be updated as necessary to continue to inform project design and implementation. 7 Folegatti, P., K. Ewer, P. Aley, B. Angus, S. Becker, et al. 2020. “Safety and Immunogenicity of the ChAdOx1 nCoV -19 Vaccine Against SARS-CoV-2: A Preliminary Report of a Phase 1/2, Single-Blind, Randomized Controlled Trial.” The Lancet 396 (10249): 467–478. 8 Feng, Z., X. Guan, Y. Li, J. Huang, T. Jian, et al. 2020. "Immunogenicity and Safety of a Recombinant Adenovirus Type-5-Vectored COVID-19 Vaccine in Healthy Adults Aged 18 Years or Older: A Randomized, Double-Blind, Placebo-Controlled, Phase 2 Trial.” The Lancet 396 (10249): 479–488. Page 15 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment9 Readiness Readiness of Government Key Gaps to Address Before Domain Deployment Planning and • According to its NDVP, Mauritania aims to • Implementation of a digital coordination vaccinate 63 percent of the country's total vaccination platform will population, which represents the population 16 further assist with the years old and over. Only populations 18 years and planning and coordination. over are eligible for a COVID-19 vaccination The proposed second AF will currently. The target populations have been support the development defined and identified (Table 3): and implementation of this - First stage- 20 percent: The NDVP identifies operational platform. health workers, adults over 45, adults with • The NDVP is being updated co-morbidities, and certain occupational to include the lessons groups as priority groups for immunization. learned from the COVID-19 - Second stage- 24 percent: People aged vaccination campaigns between 25 and 44 years. implemented. This will also - Third stage- 19 percent: All adults between include more of a focus on the ages of 16-24 years. the strategy to vaccinate • The Government is planning to reach the 63 adolescents and the percent national target in CY22; 30 percent target implications of the third dose by end of CY21 and the remaining 33 percent in to increase immunity among CY22. populations already fully • Implementing bodies have been identified and vaccinated. The updated governing body exists and operates. NDVP is expected in January • Geographic prioritization based on 2022. epidemiological data was implemented. • The Government has stipulated mandatory vaccinations for populations that work and use public transportation, those that are traveling across regions, and those accessing schools and universities (18 years and over). Public sector employees have also been mandated to be vaccinated. Budgeting • The costs (vaccine and operational costs) of rolling • The NDVP is being revised out the vaccine in the three rounds to cover the and will include an updated population 16 years and over have been finalized. budget for vaccinations for • A plan for resource mobilization down to the most adolescents as well as decentralized level was adopted. administration of the third dose. The updated NDVP is expected in January 2022. Regulatory • A National COVID-19 Vaccine Committee and six • There is inadequate Technical Working Groups have been formed. operational funding for the 9 A multi-partner effort led by the WHO and UNICEF developed the VIRAT to support countries in developing a roadmap to prepare for vaccine introduction and identify gaps to inform areas for potential support. Building upon the VIRAT, the World Bank developed the VRAF to help countries obtain granular information on gaps and associated costs and program financial resources for deployment of vaccines. To minimize burden and duplication, in November 2020, the VIRAT and VRAF tools were consolidated into one comprehensive framework, called VIRAT-VRAF 2.0. Page 16 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Readiness Readiness of Government Key Gaps to Address Before Domain Deployment • A COVID-19 Vaccine Introduction Plan in routine monitoring of Mauritania has been finalized by the Technical vaccines safety. The first and Committee for Vaccine Introduction and shared second AF will support with the World Bank team. monitoring and supervision • Regulatory measures are in place for vaccine of relevant authorities for approval, procurement, data protection, and vaccine surveillance and liability. Mauritania policy on data protection is safety. guided by law No 20-2017 that lays out the conditions in which any processing of personal data, in any form whatsoever, respects the fundamental rights and freedoms of individuals. Prioritization, • Use of the prioritization roadmap has been • The ToR for the targeting, proposed by the WHO Strategic Advisory Group of pharmacovigilance surveillance Experts on Immunization to vaccinate the entire committees have been population. developed but the • Five target groups were identified as targets for committees are not yet COVID-19 vaccination. operational. This is expected • The first three groups, estimated at 20 percent of to be finalized by January the population, make up the first phase of 2022. vaccination; the second group, estimated at 24 percent of the population, makes up the second phase; and the third group, estimated at 19 percent, covers the population 16 years and over. • A circular of the Minister of Health n°27 of January 11, 2019 determines the composition of the independent National Technical Committee for Pharmacovigilance and the Regional Committees, whose mandate for two years expired in January 2021. • A national manual for the surveillance of Adverse Event Following Immunization (AEFI) was developed and adopted on January 17, 2017. Service delivery • The following different vaccination strategies will • Additional HR need to be be used to reach each target group: health recruited, particularly in rural facilities and dedicated mobile teams. regions, to reinforce existing - Known chronic patients will be vaccinated at gaps, particularly for the EPI. their care and monitoring establishments. The proposed second AF will - Employees at the entrance doors will be finance this activity. vaccinated by dedicated mobile teams. • There are challenges with the - The security forces will be vaccinated in their follow-up of populations who health structures. have received their first dose. - Special populations such as people who are The platform that will be difficult to reach and nomadic and semi- financed by the proposed nomadic populations will be vaccinated by second AF will help to mobile vaccination teams. identify those vaccinated - Refugee populations will be vaccinated in with one-dose or two-dose Page 17 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Readiness Readiness of Government Key Gaps to Address Before Domain Deployment local health posts. regimens and the - Populations over 16 years of age will be populations that need follow- vaccinated at the level of the care up. establishments of their place of residence by • Additional training on fixed or mobile teams. communication is needed for - Personal Protective Equipment (PPE) will be vaccinators. The first and available for the protection of vaccination second AFs will support this personnel. activity. - Health workers will be advised on preventive • Low-carbon and measures for COVID-19 through environmentally friendly Interpersonal Communication sessions during incinerators need to be immunization sessions. procured. This will be - The biomedical waste management plan and supported under the first and the Environmental and Social Management second AFs. Framework (ESMF) have been updated as part of the response preparation project activities. • Vaccination strategies adapted to the context of each geographic or socio-professional group have been established. • Mapping of vaccination sites was finalized. • Surveillance tools (for example, certificates and health registers) needed were updated and disseminated. • Vaccination campaigns have made it possible to reach populations that are difficult to access using mobile and advanced strategies with temporary sites (such as mosques, at the entry or exit of certain communities, government offices, and other public spaces). Training and • Immunization team has been defined (five people • Training guides have been supervision per team, one supervisor for eight teams, and developed but not yet community staff for sensitization and organization disseminated. This is of vaccination sites). expected by the end of December 2021. • Training on the administration of the Pfizer vaccine is not yet complete. This is expected by the end of December 2021. M&E • A register and a vaccination record have been • A digital vaccination platform drawn up. will be developed and • Gap analysis of delivery and storage capacity implemented under the conducted. proposed second AF to • The basic infrastructure for recording and improve M&E. processing data using digital tools is available. Page 18 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Readiness Readiness of Government Key Gaps to Address Before Domain Deployment • Regular monitoring of implementation was put in place as soon as the vaccine was introduced to detect and correct any deviations from recommended practices. A post-introduction evaluation of the entire process will be scheduled at the end of the vaccination campaign. • Manual record books and immunization cards are developed and implemented. • M&E framework and system for handling grievances has been completed. • Data collection tools were updated and published once the Vaccine Delivery and Distribution Manual was finalized. Vaccine, cold There are three types of settings where vaccination • Additional CCE, including chain, logistics, will take place: ultra-cold storage capacity infrastructure • At the national level there are nine public (freezers) need to be reference hospitals. purchased. The proposed • At the intermediate level, there are 17 hospitals in second AF will finance these the regional capitals and some large towns. activities. • At the Moughataa (district) level, there are two types of structures: health posts and health centers. There are 693 health posts which provide certain preventive and curative services and are run by one or two nurses and a midwife and 112 health centers which are run by doctors and provide preventive and curative services as well as observation and hospitalization. • Distribution plan: Nouakchott is the only entry point for vaccines. From here, they are transported to central storage. Vaccines will be transported from central to regional storage by refrigerated trucks, and then transported to the Moughataa level in insulated boxes inside smaller vehicles. Consumable equipment for vaccination usually arrives through the seaport of Nouakchott. • The evaluation of the delivery and storage capacity of the existing cold chain under the Effective Vaccine Management initiative carried out in collaboration with the WHO and UNICEF shows an overall storage capacity of 97,307 L. This storage capacity will increase to 100,093 L through the acquisition of additional units. • Capacity building will ensure that the storage capacity is ready to support the introduction of Page 19 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Readiness Readiness of Government Key Gaps to Address Before Domain Deployment new vaccines by providing 18 electrified health facilities and 75 health posts without cold chain, some of which are in remote areas and difficult to access. • Systems and protocols for tracking distribution are in place. • 570 health facilities have CCE - these are health centers, regional and national hospitals. Safety • The MoH has a national vaccine • Protocols need to be surveillance pharmacovigilance system to monitor and report updated to adapt monitoring AEFIs. A technical committee as well as a national systems for dissemination to committee of independent experts were created operational levels in for that purpose. December 2021. • According to the NDVP, as part of the • There is a need to create a management of waste related to biological risks regulatory framework for and vaccination, the availability of technical compensation for sheets on injection safety will be ensured at all unintended health service points and the following practices will be consequences and to allocate implemented: compensation funds. This is • Exclusive use of auto-disable syringes for being discussed at the MoH injections. level and will not be financed • Each vaccination team will have daily safety boxes by the project at this time. for the syringes and used needles and plastic bags for other types of waste. • The syringes and needles used will be inserted without being recapped in the safety boxes. On average, each safety box should contain 100 syringes with their needles. • Plastic bags will be used to collect empty bottles and cotton. • Full safety boxes will be taken to destruction sites. Demand • The NDVP sets the goal that at least 80 percent of • Stronger communication generation and target population as well as hard-to-reach campaigns are necessary to communication populations agree to be vaccinated and inform 90 convince populations that percent of the entire population about the continue to hesitate to get importance of anti-COVID-19 vaccination and the COVID-19 vaccine. The vaccine strategy. proposed second AF will • The MoH has a COVID-19 call center that answers support increased questions from the public. communication and • The MoH has an immunization communication community mobilization plan that addresses the issue of the introduction activities, including the of new vaccines in a cross-cutting manner, while recruitment of experts in this identifying appropriate methods and strategies area. for the introduction of any vaccine. • Moreover, more emphasis on • An external communication, community community engagement, wall engagement, and accountability plan has been posters, leaflets in all Page 20 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Readiness Readiness of Government Key Gaps to Address Before Domain Deployment developed. national languages, television • Data collection tools updated and placed at and radio spots, the vaccination sites. involvement of authorities and community leaders, and engagement in community festivals and other gatherings. This will be supported under the proposed second AF. (ii) National Deployment and Vaccination Plan (NDVP) 16. The Government of Mauritania has prepared an NDVP, and it was approved and disclosed on February 23, 2021, which draws on the findings of the VRAF/VIRAT 2.0 assessments and gap analysis. Vaccine coverage and purchase plan is a central part of its national vaccination readiness. Mauritania’s vaccine strategy is to cover at least 30 percent of its population in CY21, which would enable them to reach the first phase (20 percent) and parts of the second phase (10 of 24 percent). The remaining target population (33 percent) is planned to be reached in CY22 to achieve the Africa Centers for Disease Control and Prevention’s target of 60 percent coverage. The country has reached a vaccination coverage of 27.0 percent as of December 7, 2021. The proposed second AF aims to cover an additional 14.05 percent of the total population (J&J vaccines through AVAT). In the first AF, the doses needed for the first phase (19.44 percent coverage) were donated by COVAX Advance Market Commitment (AMC) and by several countries via COVAX’s dose-sharing mechanism (see Table 2 below). The country received an additional 8.3 percent of donations (United States of America-USA and United Arab Emirates-UAE) that helped to cover part of the needs of the second phase. These doses, although in the country, have not been fully administered. For the remainder of the second phase and third phase, Mauritania has purchased doses to cover 5.98 percent of the population (J&J via AVAT) and plans to purchase 600,000 additional doses through AVAT (under the second AF), which will allow the coverage of 14.05 percent of the total population. Additional doses will be purchased by the Government and through the first AF to cover an additional 15.23 percent of the total population. Moreover, Mauritania may cover the purchase and deployment of vaccines for minors (between the ages of 12-17 years) when the country has the appropriate doses in the country. The plan for purchase and deployment of WHO-approved adolescent vaccines will be included in the revised NDVP (expected January 2022). Page 21 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Table 2: National Vaccine Coverage and Acquisition Plan As of November 15, 2021 Population targeted World Source of Bank’s Vaccines already arrived financing (Total population: Vaccines Number Estimated VAC Contract in the country (IBRD, IDA, 4.271 million) [1] of doses total (US$, Status of status TF, Govt, needed millions) Price Shipping the Other) % Number Source Name Name Doses (US$/dose) (US$/dose) vaccine PHASE 1: Priority populations and populations 18 years and over Donation doses COVAX AMC 0.81 34,800 COVAX AstraZeneca (AZ) 0.00 0.00 69,600 0.00 Approved delivered AZ 69,600 (COVAX AMC) People’s Donation Republic of 6.2 265,000 China Sinopharm 0.00 0.00 530,000 0.00 Approved doses Sinopharm 530,000 China delivered Donation UAE 2.44 104,000 UAE Sinopharm 0.00 0.00 208,000 0.00 Approved doses Sinopharm 208,000 delivered Donation Government doses 1.94 82,800 Germany AZ 0.00 0.00 165,600 0.00 Approved AZ 165,600 of Germany delivered (COVAX) Donation UN STAFF 0.01 475 UN Staff AZ 0.00 0.00 950 0.00 Approved doses AZ 950 delivered Donation AU/AVAT 0.32 13,500 AU/AVAT AZ 0.00 0.00 27,000 0.00 Approved doses AZ 27,000 delivered Page 22 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Population targeted World Source of Bank’s Vaccines already arrived financing (Total population: Vaccines Number Estimated VAC Contract in the country (IBRD, IDA, 4.271 million) [1] of doses total (US$, Status of status TF, Govt, needed millions) Price Shipping the Other) % Number Source Name Name Doses (US$/dose) (US$/dose) vaccine Donation Government doses 2.5 106,800 USA AZ 0.00 0.00 213,600 0.00 Approved AZ 213,600 of the USA delivered (COVAX) Donation Government doses 1.24 52,800 France AZ 0.00 0.00 105,600 0.00 Approved AZ 105,600 of France delivered (COVAX) Donation Government doses 2.81 120,000 Spain AZ 0.00 0.00 240,000 0.00 Approved AZ 240,000 of Spain delivered (COVAX) Donation Government doses 1.17 50,000 Tunisia AZ 0.00 0.00 100,000 0.00 Approved AZ 100,000 of Tunisia delivered (COVAX) Phase I Total 19.44 830,175 1,660,350 0.00 1,660,350 PHASE 2 and 3: Populations 16 and over IDA Credit - Doses 5.98 255,600 AVAT J&J 7.5 1.03 255,600 1.97 Approved J&J 255,600 AF1 delivered Donation Government doses 7.08 302,400 USA J&J 0.00 0.00 302,400 0.00 Approved J&J 302,400 of the USA delivered (COVAX) Donation UAE 1.22 52,065 UAE Pfizer 0.00 0.00 104,130 0.00 Approved doses Pfizer 104,130 delivered Page 23 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Population targeted World Source of Bank’s Vaccines already arrived financing (Total population: Vaccines Number Estimated VAC Contract in the country (IBRD, IDA, 4.271 million) [1] of doses total (US$, Status of status TF, Govt, needed millions) Price Shipping the Other) % Number Source Name Name Doses (US$/dose) (US$/dose) vaccine Official IDA credit – request has 14.05 600,000 AVAT J&J 7.5 1.03 600,000 4.64 Approved - - AF2 been submitted. Request has not yet been submitted. Government/ May need IDA Credit – 15.23 650,490 COVAX/AVAT Pfizer/Moderna/Other 10.0 2.0 1,300,980 26,019,600.00 Approved - - to purchase AF1 WHO- approved doses for adolescents. PHASE 2 – 3 43.56 1,860,555 2,563,110 32.63 662,130 TOTAL NATIONAL 63.00 2,690,730 4,223,460 32.63 2,322,480 TOTAL Page 24 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Box 2: Liability and Indemnification Issues in Vaccine Acquisition For all countries - Mauritania: • The rapid development of vaccines increases manufacturers’ potential liability for adverse effects following immunization. • Manufacturers want to protect themselves from this risk by including immunity from suit and liability clauses, indemnification provisions, and other limitations of liability clauses in their supply contracts. • Contractual provisions and domestic legal frameworks can all operate to allocate that risk among market participants, but no mechanism will eliminate this risk entirely. For COVAX-financed vaccines for AMC countries: • COVAX has negotiated model indemnification provisions with manufacturers for vaccines purchased and supplied under the COVAX AMC. • In providing vaccines through the COVAX AMC, COVAX requests COVAX AMC participants to have in place an indemnity agreement directly with manufacturers, and the necessary indemnity and liability frameworks for that purpose—either in the form of the COVAX model indemnification arrangements or prior bilateral arrangements with manufacturers. • The COVAX facility will have a no-fault compensation scheme (“NFCS”) for AMC countries as part of its risk mitigation strategy. This will cover vaccines supplied only through the COVAX AMC. • Mauritania will have to consider what it will take to implement these indemnification provisions (including statutory implementation) and how they can avail of the benefits of the no-fault compensation scheme. For vaccines purchased through AVAT: • The Advance Purchase Agreement (“APA”) signed on March 28, 2021 by AVAT, Janssen Pharmaceutica NV (“Janssen”) and the African Export-Import Bank includes indemnification provisions in favor of Janssen for vaccines purchased and supplied under the APA. Participating countries will assume those indemnification obligations upon execution and delivery of a deed of adherence to the APA. • As a condition for the delivery of vaccine doses under the APA, participating countries shall also participate in or establish and adequately fund a National Fund Compensation Scheme (NFCS) in accordance with certain minimum requirements. Participating countries shall either: (i) participate in the NFCS to be established by AVAT, or (ii) establish and maintain their own NFCS. For the avoidance of doubt, AMC countries will not be able to rely on their participation in the COVAX NFCS to meet the conditions under the Janssen APA. • For vaccines purchased through AVAT, Mauritania will have to consider how to implement the indemnification provisions and NFCS requirements under the APA with Janssen. For vaccines purchased outside of COVAX: • Mauritania will need to enter direct indemnification arrangements with manufacturers. Page 25 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) • Mauritania does not currently have legislation in place to provide statutory immunity for manufacturers. Mauritania does not have national NFCS. • Adoption of any such indemnification provisions or compensation scheme would have to be in accordance with Mauritania’s own national strategy and framework. Possible World Bank support to Mauritania, depending on needs, may include: information sharing on (i) statutory frameworks in Organization for Economic Co-operation and Development (OECD) countries and other developing countries; and (ii) overall experience in other countries; provide training and workshops for government officials to familiarize them with the issues. For World Bank- financed contracts, World Bank can provide Hands-on Expanded Implementation Support (HEIS). 17. The Project operational documents (project operational manual) will make clear that the country’s regulatory authority is responsible for its own assessment of the project COVID-19 Vaccines’ safety and efficacy and is solely responsible for the authorization and deployment of the vaccines in the country. II. DESCRIPTION OF ADDITIONAL FINANCING A. Proposed Changes 18. The changes proposed for the second AF entail expanding the scope of activities in the parent project and first AF. As the proposed activities to be funded under the second AF for Mauritania are aligned with the original PDO, the PDO will remain unchanged. 19. The content of the components and the Results Framework of the parent project and first AF are adjusted to reflect the expanded scope and new activities proposed under the second AF. The implementation arrangements will remain the same. The closing date will be extended from April 30, 2023 to December 31, 2024, to provide adequate time for the second AF implementation. (i) Proposed New Activities 20. Vaccine purchasing will be done through Component 1 of the Global COVID-19 MPA. The support for vaccines was anticipated in the initial Global COVID-19 MPA and was added as part of the containment and mitigation measures to prevent the spread of COVID-19 and deaths under Component 1: Emergency COVID-19 Response. Mauritania will use the option of advance purchase through COVAX,10 and depending on vaccine availability, Mauritania will continue to consider three other options to complement its purchases: (a) direct purchases by countries from vaccine manufacturers, either individually or jointly with other countries; (b) purchase of excess stocks from other countries that reserve excess doses; (c) purchase from other pooling mechanisms, such as the AU. The AVAT convened by the AU has negotiated additional coverage, up to 60 percent for its member countries. Given the recent emergence of COVID-19, there is not yet conclusive data available on the duration of immunity that 10COVAX is co-led by GAVI, the Coalition for Epidemic Preparedness Innovations (CEPI), and the WHO. Its aim is to accelerate the development and manufacture of COVID-19 vaccines, and to guarantee fair and equitable access for every country in the world. Page 26 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) vaccines will provide. While some evidence suggests that an enduring response will occur, this will not be known with certainty until clinical trials follow participants for several years. As such, this second AF 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 (that is, tradeoffs between broader population coverage and re-vaccination). As a prudent and contingent measure, a budget for funding has been retained for re-vaccination, if needed, of such a subset of the population. 21. Through Component 1 (parent project: US$4.2 million; AF1: US$14.0 million; AF2: US$16.1 million), the proposed second AF will continue to support the strengthening of the health system to prevent, detect, and treat COVID-19 cases. 22. Subcomponent 1.1: Case Detection, Confirmation, Contact Tracing, Recording, Reporting (parent project: US$1.2 million, AF1: US$0.5 million, AF2: US$2.2 million). This subcomponent will continue to support strengthening of climate-sensitive disease surveillance systems and build testing capacity for early detection and confirmation of COVID-19 cases. This support will also complement activities already funded through the REDISSE III Project (P161163) to strengthen the national laboratory system. In order to support the operationalization of the National Center for Emergency Operations in Public Health for the COVID-19 response and future health emergencies, a provider of technical support from a university or other institution will be contracted. 11 23. Subcomponent 1.2: Health System Strengthening (Parent Project: US$2.2 million; AF1: US$2.5 million, AF2: US$2.3 million). This subcomponent will continue to support health system strengthening to provide optimal medical care, maintain essential community services, minimize risks for patients and health personnel, including training health facility staff and frontline workers on risk mitigation measures and providing them with the appropriate protective equipment and hygiene materials, and purchasing energy-efficient equipment. This subcomponent will specifically finance the following activities to support the COVID-19 response: (i) additional energy-efficient ultra-cold freezers to store COVID-19 vaccines that require storage up to -90 degrees Celsius; (ii) the construction of nine climate-sensitive cold rooms; (iii) procurement of the cold rooms’ energy-efficient transformers and inverters; (iv) oxygen and resuscitation equipment; (v) six fuel-efficient ambulances; (vi) acquisition of 6-8 fuel-efficient trucks and vehicles, including fuel-efficient, refrigerated vehicles; and (vii) capacity building activities to ensure proper maintenance of equipment purchased. 24. Subcomponent 1.3: Communication Preparedness (Parent Project: US$0.8 million; AF1: US$0.7 million; AF2: US$1.8 million). The proposed second AF will continue to support risk communication activities and community engagement to raise awareness, knowledge, and understanding among the general population about the risk and potential impact of the pandemic, as well as the compounded risk of climate change on the population, and to address vaccine hesitancy. This will continue to include a 11 The National Center for Emergency Operations in Public Health was established only a few years ago with support from WHO and the Bill and Melinda Gates Foundation. Additional support is needed for its operationalization such as technical support that will be provided by ICAP/Columbia University and financial resources to support disease surveillance and monitoring, to deploy experts to the field, and coordinate the delivery of supplies and equipment. Page 27 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) broader social engagement and mobilization strategy to address vaccine hesitancy, with tailored content and channels, to target priority groups. There will be a particular focus on addressing vaccine hesitancy among young women and women to dispel rumors and misinformation. Moreover, to support Gender- Based Violence (GBV) survivors, training for healthcare workers and psychosocial support services will be financed to ensure health services are broadly available for this vulnerable group. This subcomponent, which is also supported by UNICEF and other partners, will also support new activities such as: (i) acquisition of audiovisual equipment for the development and recording of messages for the general public; (ii) acquisition of cameras and other communication supplies; and (iii) recruitment of communication professionals. This will enable the country to strengthen its communication and community engagement strategies. 25. Subcomponent 1.4: COVID-19 Vaccine Purchase and Deployment (Parent Project: US$0.00 million; AF1: US$10.03 million; AF2: US$9.80 million). This will include US$5.20 million for vaccine acquisition via AVAT for J&J vaccines and US$4.60 million for vaccine deployment. This subcomponent will continue to finance: (a) procurement, import, storage, and distribution of the COVID-19 vaccines (for example, COVAX, AVAT, and others12); (b) procurement of vaccination supplies13 and PPE, such as surgical masks and face shields for vaccinators; and (c) development of operational/micro-plans and budgets for implementation. The NDVP will include additional measures to deal with any unexpected disruptions to the vaccine supply chain, distribution and storage from climate change impacts, and other unexpected disasters (that is, power outages from flooding and extreme heat). In addition to the activities above, this second AF will also support the recruitment of specialists/personnel for the EPI to provide additional technical assistance and HR at the regional level for vaccine deployment as a new activity. 26. The proposed AF, through Component 2 (parent project: US$1.0 million; AF1: US$1.0 million; AF2: US$3.9 million), will continue to support the implementation actors at central and local levels regarding coordination, financial management (FM), procurement, and the development of project monitoring and the evaluation. To ensure successful implementation of the project, the second AF through Subcomponent 2.1: Implementation Management (parent project: US$0.8 million; AF1:US$0.3 million; AF2:US$0.5 million) will continue to support costs associated with project implementation. This will include the following activities: (i) recruitment of additional personnel to support the management of the project; (ii) acquisition of energy-efficient computer and office equipment; and (iii) procurement of three vehicles for supervision. On project M&E activities, the second proposed AF will continue to finance Subcomponent 2.2: Project M&E (parent project:US$0.2 million; AF1:US$0.2 million; AF2:US$0.5 million) to support the strengthening of existing data and monitoring systems to accommodate COVID- 19 vaccines. 27. Activities under Subcomponent 2.3: COVID-19 Vaccine Planning and Management (parent project: US$0.0 million; AF1: US$0.5 million; AF2:US$2.9 million) will continue to be supported particularly as it relates to pharmacovigilance and the management of AEFIs. Activities that will be 12 In accordance with criteria adopted under the AF given the unprecedented pace of vaccine development, the WBG will accept as threshold for eligible vaccines the approval from three SRAs including Emergency Use Authorization (SRAs from at least two different regions; or vaccines who received approval from WHO EUL and have been produced with a licensing or similar arrangement from a manufacturer of a parent/bioequivalent vaccine that has a prior SRA approval [including Emergency Use Authorization]). 13 Ancillary supply kits that may include needles, syringes, and alcohol prep pads. Page 28 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) supported under this subcomponent are as follows: (i) establishment of a digital vaccination platform for the management of the vaccination process and the management of surveillance and pharmaco-vigilance data and monitoring, which will improve data collection, analysis, reporting, use of data for action and decision making, and provide online access to vaccination cards for the population and (ii) procurement of tablets and other supplies/equipment to reduce record loss, training, and recruitment of personnel to provide technical assistance for the digital vaccination platform being established . 28. The second AF will continue to support the target population groups as summarized in Error! Reference source not found. below, but it is important to note that the country has opened eligibility to populations 18 years and over. Table 3: Priority Groups for Vaccination in Mauritania Ranking of vulnerable groups and inclusion in Population group N umber % of total population phases 1a Health care workers 15,000 0.35 Adults aged 65+ years 137,000 3.2 Registered comorbidities in 1b 64,000 1.5 people aged 18–65 years Adults aged 55–64 1c 173,000 4.05 years Adults aged 45–54 Phase 1 – Essential 1d 283,000 6.62 years Workers and High 1e Teachers 60,000 1.4 Risk Groups Public administration 1f 90,000 2.11 and security personnel Prisoners and workers most at risk (public transport drivers - 1g 32,200 0.75 taxis, buses; hotel and restaurant staff; butchers; and so on) SUB-TOTAL 854,200 20 Adults aged 40–44 2a 196,466 4.6 years Adults aged 35–39 Phase 2 – Adults over 2b 213,550 5 years 25 years old Adults aged 25–34 2c 615,024 14.4 years SUB-TOTAL 1,025,040 24 Phase 3 Adults aged 16–24 Adults over 16 years 3b 811,490 19 years old SUB-TOTAL 811,490 19 Page 29 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Ranking of vulnerable groups and inclusion in Population group N umber % of total population phases TOTAL Phases 1–3 2,690,730 63 (ii) Financing Arrangements 29. The increase in scope as outlined above will be reflected in an increase in indicative component allocation from US$20.2 million to US$40.2 million, with the full amount of the second AF being added under Components 1 and 2 (Table 4 below). An additional US$16.1 million is allocated to Component 1 to reflect the continued COVID-19 case detection, health system strengthening, communication activities as well as vaccine acquisition and deployment, and an additional US$3.9 million is allocated to Component 2 with a focus on supporting the management and implementation of the vaccine deployment, including pharmacovigilance. Table 4: Project Cost and Financing Project Components Parent Parent + AF1 + AF2 AF2 Cost (US$, Trust Funds Co-finance Project Cost (US$, millions) millions) Cost + AF1 (US$, millions) Component 1. Emergency COVID-19 Response 18.2 34.3 16.1 0.0 0.0 Subcomponent 1.1: Case Detection, Confirmation, 1.7 3.9 2.2 0.0 0.0 Contact Tracing, Recording, Reporting Subcomponent 1.2: Health System Strengthening 4.7 7.0 2.3 0.0 0.0 Subcomponent1.3: Communication Preparedness 1.5 3.3 1.8 0.0 0.0 Subcomponent 1.4: COVID-19 Vaccine Purchase and 10.3 20.1 9.8 0.0 0.0 Deployment Component 2. Implementation Management and 2.0 5.9 3.9 0.0 0.0 M&E Subcomponent 2.1: Implementation Management 1.1 1.5 0.5 0.0 0.0 Subcomponent 2.2: Project M&E 0.4 0.9 0.5 0.0 0.0 Subcomponent 2.3: COVID-19 Vaccine Planning and 0.5 3.4 2.9 0.0 0.0 Management Total Costs 20.2 40.2 20.0 0.0 0.0 Page 30 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Table 5: Summary of COVID-19 Vaccine Sourcing and World Bank Financing Source of vaccine financing and population coverage Doses purchased with National plan World Bank World Bank-financed Specific vaccines World Bank Estimated allocation of target Financing COVAX Through and sourcing plans finance World Bank financing (population %) Through Through Other* grant direct (2 doses COVAX AVAT assumed) purchase Purchase: US$5.2 million Deployment: US$12.1 The second AF will million Second AF Phases 2 and 3: - - 14.05% - - purchase doses via 1,200,000 Other: (emergency 43.56% AVAT. COVID-19 health response): US$2.2 million COVAX AMC provided AstraZeneca to Mauritania. COVAX Purchase: US$6.0 through dose- million sharing Deployment: US$4.3 mechanisms million Phase 1: 19.44% 10.47% - - 8.65% First AF 0.32% provided donated 1,708,400 Other: (emergency doses (Germany, COVID-19 health USA, France, Spain, response): US$4.7 Tunisia). AVAT, UN million staff, People’s Republic of China, and UAE provided doses as well. Page 31 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Source of vaccine financing and population coverage Doses purchased with National plan World Bank World Bank-financed Specific vaccines World Bank Estimated allocation of target Financing COVAX Through and sourcing plans finance World Bank financing (population %) Through Through Other* grant direct (2 doses COVAX AVAT assumed) purchase Part of the costs for the doses that will be purchased via COVAX will be covered by the first AF. The Government via Phases 2 and 3: - 15.23% 5.98% - 8.30% the first AF has 43.56% purchased J&J doses through AVAT. Mauritania also received donated doses from the USA (COVAX) and UAE. *Other: Includes coverage financed by the Government, bilaterally, other multilateral development banks, and so on. Page 32 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) (iii) Changes in Institutional Arrangements for NDVP Implementation and Oversight 30. The MoH will remain the implementation agency of the second AF. As in the parent project, the General Secretary (Secrétaire Général) of the MoH will be responsible for overall project coordination. The same fiduciary arrangements will be maintained under the second AF. Project oversight will be provided by the new COVID-19 Steering Committee that was established, which is presided by the Office of the Secretary General under this project. This new Steering Committee will review the progress of the project, ensure coordinated efforts by all stakeholders, and conduct annual reviews of the project. The Directorate General for Public Health (Direction Générale de la Santé) will ensure the technical coordination of the implementation of the second AF. It coordinates the preparation, implementation, and monitoring of COVID-19 vaccines deployment with the support of the EPI and the overall COVID-19 surveillance and response with the support of the National Center for Emergency Operations in Public Health. Through its central departments and regional directorates, the MoH will remain responsible for the implementation of the project. The current project’s Administrative and Financial Manual of Procedures will be updated to include additional measures for procurement. The Vaccine Delivery and Distribution Manual that was developed under the first AF will not need to be updated. 31. The implementation arrangements will be maintained to support the implementation and strengthen coordination considering the lessons learned from implementation of the parent project and the first AF. The second AF will also use existing staff and structures as much as possible for additional tasks that may be required to support the new activities. However, recruitment of an additional Accountant, a Procurement Specialist and an Environmental Specialist are planned under the second AF to provide additional support for the implementation of project activities. (iv) Changes in the disbursement categories 32. The are no changes expected in the disbursement categories. (v) Results Framework 33. To measure overall progress in coverage and deployment of the COVID-19 vaccines, an additional PDO indicator and two intermediate indicators will be added to the project, a PDO indicator and an intermediate indicator will be revised, and end dates of most indicators are being revised to reflect the new closing date: • New PDO indicator: “Target population fully vaccinated (Percentage) (disaggregated by sex)”. This will enable monitoring of the population that is included in the country’s target coverage. The expectation is that the Government will be able to fully vaccinate at least 80 percent of the target population. • Revised PDO indicator: “Population vaccinated, which is included in the priority population targets defined in national plan (disaggregated by sex)” will be revised to “Population in the priority group fully vaccinated (Percentage) (disaggregated by sex)”. This provides clarity to ensure monitoring of the most vulnerable groups. Page 33 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) • Revised Intermediate Indicator: “Functional health management and information system (HMIS) to deploy the COVID-19 vaccine is in place, including identification, registration and follow up with COVID-19 vaccine recipients” will be revised to “Vaccination sites that use the digital vaccination platform for data entry, analysis and reporting (Percentage)”. This indicator is revised to measure the progress of utilization of a digital vaccine platform. • New Intermediate Indicator: “Health care providers trained to recognize early signs of GBV (Number)”. This indicator will track the number of health care providers who are able to recognize the early signs of GBV. • New Intermediate Indicator: “Health centers that provide psychosocial services to GBV survivors (Number)”. This indicator will ensure that psychosocial support services are broadly available to GBV survivors. B. Sustainability 34. There is strong political commitment from Mauritania to mobilize financial resources for the COVID-19 response, including for vaccine purchase and deployment. Having the funds through the proposed second AF for vaccine purchase and deployment will establish an enabling environment for other donors, multilateral development banks, and UN agencies to also support efforts in the country. Investments under the parent project, first AF and second AF are expected to strengthen the health system in the country, ensuring institutional sustainability to deal with infectious diseases. III. KEY RISKS 35. As in the first AF, the overall risk to achieving the PDO will be maintained at High due to the uncertainties with the COVID-19 vaccine procurement and distribution. 36. The large-scale acquisition and deployment of COVID-19 vaccines entails certain significant risks. First, vaccine donations have increased for countries like Mauritania, but many with short expiration dates, which has led in some cases to wastage. Second, a mass vaccination effort stretches capacity, in particular in low-capacity environments such as Mauritania, entailing risks. The proposed World Bank support for Mauritania to develop vaccination acquisition strategies and invest in deployment system capacity specifically aim to mitigate these risks. The remaining risk must be considered against the risk of the country having less timely and effective deployment of vaccines, potentially exacerbating development gaps and eroding past development gains. 37. Political and governance risks are Substantial. There may be political risks related to the commitment and ability of the authorities to ensure appropriate targeting of the project-supported vaccines to reach the target populations and ability to manage public sentiment should there be a gap between vaccine targets and vaccine delivery. These risks will be mitigated through the assurance mechanisms that this second AF will support, such as the establishment of an acceptable policy and plan for prioritized intra-country allocation as well as increase communication and community engagement. For instance, the Government of Mauritania equitably distributed the donated vaccines among all the Page 34 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) regions of Mauritania to ensure equitable access. There are also continued risks related to indemnification. Mauritania plans to have specific indemnification and liability clauses when purchasing vaccines directly from manufacturers. As an AMC country, Mauritania also has access to the regional no- fault compensation scheme for vaccines acquired through COVAX and AVAT. The Government will develop an indemnification plan during project implementation to ensure clear arrangements are included as it relates to indemnification and liability issues. The digital vaccination platform will enable the Government to have access to personal data. To guard against abuse of that data and to ensure data protection, the proposed second AF will incorporate best international practices for dealing with such data. 38. While overall macroeconomic risk in Mauritania remains Substantial given that Mauritania is experiencing severe fiscal pressures and faces the risk of not having sufficient additional fiscal space for the purchase of vaccines at scale and other COVID-related response interventions, the proposed second AF specifically aims to mitigate this risk by providing financing for vaccine purchase and promoting prioritized deployment to eligible groups. Residual macroeconomic risk to the PDO is limited to risks that cannot be readily mitigated (e.g., risks related to significant counterpart financing or other specific macroeconomic risks that may hinder the operation from achieving its intended results). 39. The proposed second AF is designed to address key institutional capacity risks related to vaccine deployment and distribution, but residual risks remain Substantial. Vaccine deployment and distribution capacity are currently inadequate in Mauritania, especially for the anticipated scale and population group coverage for COVID-19 vaccination. This risk will be mitigated by this second AF financing and technical support for immunization system strengthening needs, including conducting capacity assessments in coordination with the WHO, GAVI, UNICEF, and other partners. The residual institutional capacity risk is substantial, considering the inherent risk, and the mitigation via the system strengthening supported under the AF and by partners. 40. Fiduciary residual risks associated with the parent project remain Substantial. The procurement and FM risks initially assessed for the parent project and first AF cover risks associated with the procurement and distribution of vaccines, including fraud and corruption risks. Risks specific to vaccines include: • Procurement: The procurement residual risks remain Substantial. The key procurement risk associated with vaccines relates to: (a) the complexity of the vaccines market given the significant market power enjoyed by vaccine manufacturers; (b) inability of the market to supply adequate quantities of vaccines to meet the demand; (c) the limited market access due to advance orders by developed countries; (d) weak bargaining; and (e) delays in triggering emergency procurement procedures which could delay procurement and contract implementation including payments. The risks under this second AF will be mitigated by providing options to support the country’s needs for direct or advance purchase. • FM: The FM residual risk associated with this second AF is Substantial. The key FM risks relate to: (a) untimely funds flow or lack of liquidity and (b) lack of adequate controls over the transparent, prioritized distribution and application of vaccines, particularly for the most Page 35 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) vulnerable population groups. This second AF will use the same options as in the parent project and first AF to assess and strengthen control systems, facilitate the timely flow of funds, and ensure adequate liquidity to finance project activities. To mitigate these risks, the following actions are envisioned: (i) within one month of the effective date, the customization of the accounting software to include this second AF component; (ii) within one month of the effective date, the revision of the Internal Auditor’s work-program considering this second AF’s internal auditing; and (iii) within six months of the first AF effective date, the revision of the ToR of the external auditor to reflect this second AF external auditing. These FM mitigation measures will ensure (i) the safeguarding of vaccines and (ii) the oversight arrangements for the distribution and deployment of vaccines for the prioritized and targeted populations. • The residual fiduciary risk associated with the AF remains Substantial, which is expected to decrease the current fiduciary risk to the development objective. As in the first AF, the vaccine deployment involves new actors in the project environment and the coordination of these actors will require more time from fiduciary staff. The FM team will support the project team to manage the risk during implementation. 41. The anticipated overall environmental and social risks, as in the parent and first AF project, remain Substantial. The measures to address social and environmental risks in the parent project as well as in the first AF remain relevant, including infection prevention and control improvements in health facilities, such as assessment and mitigation measures for medical waste risk management that will be expanded as inoculation sites expand. While experience indicates that moderate risk ratings can be expected for environment, if medical waste and occupational health and safety (OHS) risks are well managed, current environmental risk rating of the project is however, substantial, taking into consideration the contamination risk to which healthcare workers might be exposed. These risks will be managed through a well-established and operationalized biomedical waste management plan, along with an adequate training program, including OHS training for drivers of new ambulances and trucks. The social risk is anticipated to be at least moderate in Mauritania because there is a broader social risk of inequity in access to vaccines; due to political pressures there may be a risk of providing vaccines to groups that are not prioritized based on need, or vulnerability, or should target groups be misaligned with available vaccines. This includes a possible exclusion of groups based on gender, race, ethnicity, refugee status, or others. Use of military/security forces is not anticipated for the implementation of this AF. In case any activity requests involvement of military/security personnel, the Recipient shall send a written notice to the World Bank communication such a decision and provide information on the activities planned to be carried out. Moreover, the Recipient will have to ensure that the security personnel follow a strict code of conduct and avoid any escalation of situation in accordance with the requirements of Environmental and Social Standards (ESS) 4 and in a manner acceptable to the Association. Government security personnel deployed to provide security or other services as part of implementing activities related to the project shall be managed consistent with the requirements of ESS4 and in a manner acceptable to the Association. Moreover, the Government is ensuring that there is equal access to vaccines for all population groups to allow them to comply. The Government plans to further address this issue in the revision of the NDVP that will be validated in January 2022. Page 36 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) 42. These risks will be mitigated through several measures to ensure vaccine delivery targets the most vulnerable populations, particularly women, the elderly, the poor, refugees, and minorities in accordance with criteria specified in this second AF. First, the World Bank will support Mauritania to develop and adapt an explicit, contextually appropriate, and well-communicated targeting criteria and implementation plan (for example, the national vaccination program and any subsidiary programs), including criteria for access to vaccines. The Government should ensure that this plan is subject to meaningful consultations in accordance with ESS10 (Stakeholder Engagement and Information Disclosure). There should be consensus to continue to aim to target health workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly, people with co- morbidities, and people in high-population density locations such as slums and refugee camps. The World Bank will also continue to provide technical and implementation support to mitigate this risk. 43. All targeting criteria and implementation plans will be reflected in the country’s national vaccination program. Another potential risk is the increased incidence of reprisals and retaliation especially against healthcare workers and researchers. This risk will be mitigated through explicit inclusion in robust stakeholder identification and consultation processes. Further, and linked to the social risks stated above, it is important to have clarity on the risks that may arise related to mandatory vaccinations that have recently been stipulated in the country for use of public transport, access to schools/universities, and those working for the public function. At this time, no major grievances have been found and the Government plans to ensure that all regions comply with increase communication. In addition, the Grievance Redress Mechanisms (GRMs) required under the ESF should be in place and equipped to address community, worked, and/or individual grievances related to such issues. This includes requirements related to having GRMs in place to address labor and working conditions and Sexual Exploitation and Abuse (SEA)/Sexual Harassment (SH). 44. The Other category references the general vaccine-related risks, which is rated as High due to the uncertainties of vaccine acquisition and deployment for populations under 18 years of age that are part of the national target. There is only one vaccine approved by WHO for adolescents (Pfizer) at this time, which is in low supply in the country. The Moderna vaccine is expected to be approved by WHO for use in adolescents in the coming months, which is available for purchase via the COVAX Facility and other mechanisms such as the AVAT. However, the delivery of these doses in-country may take longer than expected. IV. APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis 45. The economic rationale for investment in a COVID-19 vaccine is strong, considering the massive and continuing health and economic losses due to the pandemic. As of December 7, 2021, more than 267.16 million people have been infected and over 5.27 million have died.14 The global economy 14 COVID-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University as of December 7, 2021, available at: https://ourworldindata.org/coronavirus-data Page 37 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) contracted by 4.3 percent in 2020, but forecasts for 2021 show it is expected to bounce back at the fastest post-recession pace in 80 years and expand by 5.6 percent. 46. The successful development, production, and delivery of a vaccine, however, has the best potential to reverse these trends, generating benefits that will far exceed vaccine-related costs. Indeed, a rapid and well-targeted deployment of a COVID-19 vaccine can help reduce the increases in poverty and accelerate economic recovery. Even at levels of imperfect effectiveness, a COVID-19 vaccine that is introduced and deployed effectively to priority populations can assist in significantly reducing mortality and the spread of the coronavirus and accelerating a safe reopening of key sectors that are affected. It can also reverse human capital losses by ensuring schools are reopened. The effective administration of a COVID-19 vaccine will also help avoid the associated healthcare costs for potentially millions of additional cases of infection and associated health-related impoverishment. Global experience with immunization against diseases shows that by avoiding these and other health costs, vaccines are one of the best buys in public health. For the most vulnerable population groups, especially in countries without effective universal health coverage, the potential health-related costs of millions of additional cases of COVID-19 infection in the absence of a vaccine represent a significant or even catastrophic financial impact and risk of impoverishment. The pandemic is also having dire effects on other non-COVID-19 health outcomes. Increased morbidity and mortality due to interruption of essential services associated with COVID-19 containment measures hinder access to care for other health needs of the population, including maternal and childcare services; routine immunization services have been affected, threatening polio eradication and potentially leading to new outbreaks of preventable diseases, with their own related deaths, illnesses, and long-term costs. Simultaneous epidemics are overwhelming public health systems in different countries that had few resources to begin with, and services needed to address the needs of people with chronic health conditions and mental and substance use disorders have also been disrupted. 47. In Mauritania, as a result of the crisis, gross domestic product (GDP) growth has declined sharply from 5.9 percent in 2019 to 3.6 percent in 2020 and only expected at 2.8 percent in 2021, opening a substantial financing gap, increasing debt pressures, and worsening the external position of the country. Despite the crisis, the external and fiscal balances remained resilient in 2020, thanks to increased donor financing, improved terms of trade, and debt service suspension under the G20 Debt Service Suspension Initiative. The economic contraction was associated with an increase in the international poverty rate (US$1.9/day in 2011 purchasing power parity [PPP]) from 5.4 percent in 2019 to 6.3 percent in 2020 — equivalent to an additional 48,000 individuals falling into extreme poverty. The impact of the crisis was mostly felt in urban areas where social distancing measures reduced economic activity in services and affected widespread informal jobs. Knowing that the global economy will not recover fully until people feel they can live, socialize, work, and travel with confidence and given the importance of limiting the spread of COVID-19 to both health and economic recovery, providing access to COVID-19 vaccines will be critical to accelerate economic and social recovery in Mauritania. 48. While the uncertainty around the costs and effectiveness of a COVID-19 vaccine makes it difficult to calculate its cost-effectiveness, the effective launch of a COVID-19 vaccine will have direct benefits in terms of averted costs of treatment and disability, as well as strengthened health systems. Estimated COVID-19 treatment costs from low- and middle-income countries is at US$50 for a non-severe case and US$300 for a severe case. This excludes costs of testing of negative cases, as well as the medical costs associated with delayed or forgone care-seeking, which usually results in higher costs. Further, Page 38 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) investments in vaccine delivery systems generate health and economic benefits beyond just delivering the COVID-19 vaccine. First, investments in last-mile delivery systems to administer the COVID-19 vaccine to remote communities will require strengthening community health systems, which can have spillover effects to effective delivery of other services, helping close the significant urban-rural gap. Second, as the COVID-19 vaccine is introduced and lockdowns and movement restrictions are eased, patients can continue to access care for other conditions. Third, the economic benefits of slowing down the economic downturn are likely to significantly exceed the cost to vaccinate the target population, leaving aside the immediate health benefits. Given both the economic and health system benefits, an effectively deployed COVID-19 vaccine presents significant benefits. B. Financial Management 49. In accordance with the FM Manual for World Bank-Financed Investment Operations that became effective on March 1, 2010and re-issued on September 7, 2021, the proposed FM systems of the second AF have been assessed to determine whether it is acceptable to the World Bank. To this end, the FM aspects of the World Bank-financed Mauritania SPRP (initial and AF) and the INAYA (P156165) have been reviewed. 50. The proposed second AF will build on the existing institutional and fiduciary arrangements under the PCU-INAYA. They are considered acceptable to IDA. These FM arrangements meet the minimum fiduciary requirements under World Bank Policy and Directive for Investment Project Financing (IPF). The PCU-INAYA is familiar with the World Bank FM requirements and is currently managing the parent project and first AF as well as the INAYA Project funded by the World Bank. The FM performance of the PCU-INAYA team was rated Satisfactory following the last implementation support mission and most of the related key recommendations are under implementation. 51. The current FM staffing is adequate; but to support the additional activities under the second AF proposed, additional staff will be required. In particular, an additional accountant will be recruited within one month of effectiveness of the second AF. The existing multi-projects and multi-sites version of PCU-INAYA’s accounting software will be customized within one month of the effective date to integrate the accounts of the proposed second AF. INAYA’s Administrative and Financial Manual of Procedures had been revised to consider the vaccine deployment and new actors involved. It will be adopted before this AF effectiveness, and it is adequate and will be used for this second AF without any additional updates. Furthermore, the COVID-19 Vaccine Delivery and Distribution Manual prepared for the first AF remains acceptable and will be used for this second AF without any further updates. The internal audit function under the ongoing PCU-INAYA-managed projects operates well and the same arrangements will be maintained under the second AF. The current Internal Auditor’s work program will be revised within one month of the effective date to reflect this second AF internal auditing. The unaudited interim financial reports (IFRs) are prepared every quarter and regularly submitted to the World Bank on time (45 days after the end of each quarter). For the second AF, the same IFR arrangement will be used. For activities to be implemented by UN Agencies, each UN Agency will submit Fund Utilization Reports as part of their quarterly progress reports and submit them to the PCU within 30 days after the end of the reporting period. The formats and content of progress reports will be agreed between the World Bank, the Recipient and the UN Agencies. Fund Utilization Reports prepared quarterly by UN Agencies will serve to document Page 39 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) the utilization of the advance and be used in the preparation of the combined IFR to be submitted by the PCU. 52. The audit report of the current PCU-INAYA-managed project for the period ending on December 31, 2020 was submitted on time and was acceptable to IDA, although it was with a modified opinion due mainly to (i) the lack of compliance with national tax collection and (ii) some bookkeeping issues. These reserve points are not considered to be material. The accounts of the second AF will be audited on an annual basis, and the external audit report will be submitted to IDA no later than six months after the end of each calendar year. The ToR of the current external auditor will be revised to reflect the scope of this second AF external auditing. At the time of the preparation of the second AF, there are no overdue audit reports and IFRs under the PCU-INAYA. For the UN implemented activities, the World Bank will rely on WHO and UNICEF external audit arrangements to fulfill the fiduciary requirement. The UN Agencies will ensure that their audited accounts and the External Auditors’ Reports are posted on their websites within ten (10) days of becoming public documents. However, the Recipient will retain the responsibility of ensuring that goods and services acquired are delivered to the intended beneficiaries during implementation. Where and when deemed appropriate, —for example, if a UN Agency progress report show weaknesses or deficiencies— the Recipient may conduct physical inspections of goods and services delivered by the UN Agency. 53. A new designated account will be opened for the second AF disbursement purposes at the Central Bank of Mauritania (Banque Centrale de Mauritanie). The funds will be released to a new Operational Account to be opened in an acceptable commercial bank. Disbursement for the project will follow the existing disbursement arrangements for the parent project and first AF. In the case of the use of one of the UN agencies (WHO, UNICEF, United Nations Office for Project Services, and so on), its engagement will be done pursuant to Standard Form Agreements signed between the Government and the UN agency. UN agencies are used mainly as suppliers. Upon signing of the Standards Form Agreements between the Government and agency, application for withdrawal of proceeds will be prepared by the PCU-INAYA and submitted to IDA. The special World Bank disbursement procedures will be used to establish a Blanket Commitment to allow the amount to be advanced. Funds withdrawn from the IDA credit account will be deposited directly into the UN bank account provided by the agency for the project activities that it will implement. The amount advanced will be documented through the quarterly unaudited IFRs as actual expenditures are incurred by the agency. C. Procurement 54. Procurement under the AF will be carried out in accordance with the World Bank’s Procurement Regulations for IPF Borrowers for Goods, Works, Non-Consulting and Consulting Services, dated November 2020. As with the parent project and first AF, the second AF will be subject to the World Bank’s Anticorruption Guidelines, dated October 15, 2006 revised in January 2011, and as of July 1, 2006. The project will use the Systematic Tracking of Exchanges in Procurement to plan, record, and track procurement transactions. 55. The main procurement planned under the second AF will include: (a) COVID-19 diagnostics tests and PPEs; (b) COVID-19 vaccines, to be procured via the AVAT mechanism and in accordance with criteria Page 40 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) adopted under the second AF; (c) an adequate cold chain capacity to store vaccines; (d) cold boxes; and (e) procurement of ancillary supply kits (that may include needles, syringes, alcohol prep pads, COVID-19 vaccination record cards for each vaccine recipient, PPEs for vaccinators, and CCE. The second AF will also finance technical assistance support from universities or other institutions to support the COVID-19 response. The COVID-19 Project Procurement Strategy for Development (PPSD) has been updated and adopted to take into account the proposed second AF. The PPSD found that all COVID-19 vaccines being purchased will come from the international market, countries with additional doses, and several global mechanisms supporting low- and middle-income countries. 56. For the process of other proposed procurement, the MoH will use competitive methods based on the country’s risk-based thresholds given the market easing and end of emergency period. Also, the facilities granted to parent project/first AF as well as the use of UN structures will be granted to this second AF. 57. As under the parent project and first AF, the procurement risk is rated Substantial. Procurement of COVID-19 vaccines is subject to high level of uncertainties in terms of prices and quantities that will be made available through different purchasing options. The substantial risk will be mitigated through: (i) recruitment of a Procurement Specialist with one month of the effective date; (ii) practical trainings on World Bank’s New Procurement Framework for the MoH staff; (iii) updating the Administrative and Financial Manual of Procedures to include the second AF; and (iv) using HEIS/ World Bank Facilitated Procurement (BFP). Upon the Recipient’s request, the World Bank has agreed to offer HEIS/BFP to support the Recipient’s implementing agency in negotiating contract conditions with manufacturers/suppliers, among other activities. The World Bank’s oversight of procurement will be done through increased implementation support. The World Bank standard prior and post review arrangements apply as specified in the procurement plan. . D. Legal Operational Policies Page 41 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) . Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . E. Environmental and Social 58. As the parent and the first AF, this second AF will have long-term positive environmental impacts, as it should contribute to improve COVID-19 surveillance, monitoring, treatment, and containment. However, adverse environmental and social risks and impacts are anticipated as a result of vaccine provision, conservation, and transmission, as well as result of new acquisitions such as trucks, ambulance and increase in biomedical waste. 59. The project is being implemented under the ESF and is rated Substantial for Environmental risks and Moderate for Social risks. The relevant ESSs are: ESS1 (Assessment and Management of Environmental and Social Risks and Impacts); ESS2 (Labor and Working Conditions); ESS3 (Resource Efficiency and Pollution Prevention and Management; ESS4 (Community Health and Safety); and ESS10 (Stakeholder Engagement and Information Disclosure). 60. Environmental issues are related to: (a) OHS issues related to testing and handling of supplies, transportation and conservation of vaccines, and so on during treatment to a large extent, as well as due to civil works renovations inside functional healthcare facilities to a lesser extent; the OHS issues are also related to the use of new trucks, ambulances and vehicles for supervision, but also related to the availability and supply of PPE for healthcare workers and the logistical challenges in transporting PPE across the country on time; (b) production and management of medical healthcare waste (especially handling highly infectious medical waste such as COVID-19); and (c) community health and safety issues related to the handling, transportation, and disposal of hazardous and infectious healthcare waste, as well as disposing of supplies and medical samples and rehabilitation of health centers. As no civil works other than refurbishing facilities on existing hospital grounds or other government-owned sites are to be undertaken, environmental risks associated with these works are expected to be minor and readily mitigated. 61. The social risk is anticipated to be moderate for the new activities under the proposed second AF, because there is a broader social risk of inequity in access to vaccines within the country, such as political pressures to provide vaccines to groups that are not prioritized based on need or vulnerability. This risk will be mitigated through several measures to ensure vaccine delivery targets the most vulnerable populations in accordance with criteria specified in the second AF. First, the World Bank will support Mauritania to develop and adapt explicit, contextually appropriate, and well-communicated criteria for access to vaccines. There is consensus to continue to target health workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly and people with co-morbidities. The World Bank will also continue to provide technical and implementation support to mitigate this risk. All targeting criteria and implementation plans will be reflected in the country’s national vaccination program. Other potential social risks include the increased incidence of reprisals and retaliation, especially Page 42 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) against healthcare workers and researchers, as well as SEA/SH risk, which has been determined to be substantial for the COVID-19 parent and AF projects together, especially regarding planned rehabilitation activities as well as vaccine deployment-related initiatives. These risks will be mitigated by specific measures to be outlined in an SEA/SH Prevention and Response Action Plan (SEA/SH Action Plan) that is integrated in the ESMF, to be updated by this second AF effectiveness, which will incorporate an accountability and response framework, including codes of conduct outlining prohibited conduct and applicable sanctions, procedural adaptations to the project GRM to ensure safe and confidential management of SEA/SH claims with timely referrals to appropriate survivor care, as well as training and sensitization activities. In addition, the SEA/SH risk will be addressed through robust stakeholder identification and consultation processes, which will take into specific account consultations with women and other vulnerable groups in safe and enabling, sex-segregated environments (including with same-sex facilitators). 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 training during project implementation, as well as for dedicated MoH focal points for environmental and social safeguards. 62. In addition, this second AF will ensure GRMs that were prepared under the parent project and first AF are updated by AF effectiveness to ensure operationalization to address community, worker, and/or individual grievances related to COVID-19 vaccinations. This includes putting in place GRMs to address labor and working conditions as well as SEA/SH. F. Environmental and Social Risk Management Instruments 63. Activities under this second AF, as the first one will fill a critical gap in the scope of the parent project, providing financing for the procurement and deployment of safe and effective COVID-19 vaccines, including vaccine-related communication activity, planning and management, and supply and distribution. To mitigate against environmental risks, the project will update the first AF project’s ESMF, which was updated from the parent project to reflect the proposed new activities, identify additional potential risks and environmental and social impacts, and outline appropriate mitigation measures based largely on adopting WHO guidance, the WBG Environmental Health and Safety (EHS) Guidelines, and other good international industry practices.15 The ESMF will be updated to a standard acceptable to the World Bank, finalized and disclosed on the MoH website and on the World Bank website by project effectiveness and implemented thereafter throughout project implementation. This ESMF will include an Environmental and Social Management Plan Template for minor works associated with the rehabilitation of the health facilities, cold chain needs assessment for vaccine transport, storage, and distribution and associated mitigation measures; Medical Waste Management Plan Template to integrate within the National Medical Waste Management Plan 2017-2021; and updated SEA/SH Action Plan to propose mitigation measures to address SEA/SH risks related to the second AF activities and to prevent potential sexual harassment. The National Medical Waste Management Plan 2017-2021 developed under INAYA Project and revised for the first AF will be used for this second AF as well, taking into consideration Medical 15 In line with WHO Interim Guidance (February 12, 2020) on “Laboratory Biosafety Guidance related to the novel coronavirus (2019-nCov)”, and other guidelines, the parent project development a hospitals’ waste management plan and prepared and ESMF for the project by adding to it WHO standard on COVID-19 response. The plan includes training of staff to be aware of all hazards they might encounter. This provides for the application of international best practices in COVID-19 diagnostic testing and handling the medical supplies, disposing of the generate waste, and road safety. Page 43 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Waste Management Plan Template included in the ESMF. The ESMF will also devote specific attention to data protection concerns and to risks of exclusion/elite capture. Personal data collection and processing will be done in accordance with applicable national law and international guidelines, roles, and responsibilities for the project implementation. Until the ESMF has been approved, the project will strictly follow current WHO guidance and avoid activities such as establishment of isolation units and treatment facilities at scale. 64. Environmental and Social Commitment Plan (ESCP). The Government has prepared an ESCP for this second AF, which includes environmental and social measures to which the Government is committed, including the preparation of environmental and social instruments during project implementation. Mitigation measures for site-specific impacts will be managed through the implementation of required safeguards instruments to be prepared as per the ESCP. Relevant capacity building measures will be included in the ESMF. The PCU has already recruited a social specialist and will be maintained throughout the implementation of the project. The PCU will need to recruit an environmental specialist within three months of the effective date due to the move of the former environmental specialist to the Ministry of Environment. The updated ESCP for the second AF was adopted and disclosed in country on December 20, 2021.16 65. Stakeholder Engagement. The parent project’s Stakeholder Engagement Plan (SEP) was updated for the first AF to reflect requirements related to vaccine activities and include potential new stakeholders, other interested stakeholders, and vulnerable groups and/or persons. The SEP was further revised, finalized and disclosed in the on December 20, 2021.17 The SEP will release routine information on the project’s environmental and social performance, including opportunities for consultation. It will be updated periodically as necessary, via the inclusion of a Risk Communication and Community Engagement (RCCE) strategy, to be prepared under the project in line with WHO provisions, “RCCE readiness and response to the 2019 novel coronavirus (2019-nCoV)” (January 26, 2020). The project will also draw on other resources for carrying out stakeholder engagement in the context of COVID-19, including the World Bank’s “Technical Note: Public Consultations and Stakeholder Engagement in World Bank-Supported Operations when there are Constraints on Conducting Public Meetings” (March 20, 2020). 66. Labor Management Procedures (LMP). The existing LMP under the first AF will be included in the contracts of operators/contractors and will define how the project’s workers will be managed in line with the requirements of national law and ESS2. Due diligence is also necessary to ensure that the Government meets the requirements for child labor, forced labor, and OHS. The LMP include measures to ensure that labor is provided on a voluntary basis and further ensure that the health and safety of workers, especially women, receive adequate attention. As such, these measures will also address the risks related to SEA/SH as well as health and safety in the workplace for project staff. As for the parent and the first AF projects, additional workers who will be recruited under the second AF will have to sign the code of conduct, and they will be trained and sensitized on SEA/SH and GBV issues. 67. OHS. To ensure health and safety of healthcare workers and any other person that can be affected by project activities during all operational phases, healthcare centers/hospitals are required to implement 16 http://www.portailpbf.gov.mr/cside/contents/docs/projet_de_preparation_et_de_reponse_strategique_co_1640026815.pdf 17 http://www.portailpbf.gov.mr/cside/contents/docs/projet_de_preparation_de_reponse_strategique_contr_1640027029.pdf Page 44 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) the health, safety and environmental plan in line with WHO guidance, as well as with World Bank Environment Health and Safety Guidelines, and international good practices. G. Gender Analysis 68. Based on the latest Gender Inequality Index,18 measured using three gender-based inequality dimensions - reproductive health, empowerment, and economic activity - Mauritania is ranked 157th out of 189 countries. This indicates much needs to be done to improve women’s condition in the country. GBV, child marriage (3719 percent), female genital mutation (6720 percent), lack of access to reproductive health and family planning services (30 percent has satisfied contraceptive need), lack of property rights, and lack of laws to protect women from physical and sexual abuses are examples of issues putting women in a disadvantaged position compared to men. According to a recent UN Women report, the adolescent birth rate is 84 per 1,000 population as of 2014 (an increase from 71 per 1,000 population in 2011 21). Furthermore, GBV survivors do not often report or seek help because of the lack of laws, social pressure, and stigma, and inadequate GBV health and legal services for GBV survivors. In Mauritania, survivors of rape could even risk prosecution for engaging in sexual relations outside marriage and many forms of GBV, including female genital mutilation. 69. Some data has shown that Mauritania and neighboring countries have experienced deepened gender inequities due to the social confinement and economic stressors of the pandemic. For instance, women were reported to be more affected because of their dominance in their professions such as being main care givers and restaurant, hotel, and tourism workers. With lockdown measures, many women in abusive relationships have been confined with their aggressors and were unable to escape violent situations. Nearly a third of women in a survey in one of the refugee camps in Mauritania reported that they did not feel comfortable around their spouses during confinement due to lack of freedom and means, restrictions of movement, unemployment, stress, and child management.22 Therefore, this proposed second AF will ensure that healthcare workers have the knowledge and skills to address patients that are GBV victims through capacity building. 70. Moreover, as Mauritania began deploying COVID-19 vaccines, there was initially more of a focus on the priority populations, that in some cases included a larger proportion of men such as the police, military and teachers. Therefore, as of June 1, 2021, women only represented 38.0 percent of the population vaccinated. To address this concern head on, the MoH has engaged women-led cooperatives as well as NGOs to support the vaccine deployment efforts, including communication and community engagement activities. Vaccination campaigns were also implemented closer to where women work and live, which enabled an increase in the number of women being vaccinated. As of December 12, 2021, 49.0 percent of the population vaccinated are women. 18 http://hdr.undp.org/en/countries/profiles/MRT. 19 https://evaw-global-database.unwomen.org/en/countries/africa/mauritania#1. 20 2017 Demographic and Health Surveys (DHS), & Multiple Indicator Cluster Surveys (MICS). 21 https://data.unwomen.org/country/mauritania 22 https://microdata.unhcr.org/index.php/catalog/275/related-materials Page 45 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) 71. Measures to close the gap. This second AF will continue to support prevention and mitigation measures to promote a gender responsive COVID-19 response. First, the AF will ensure that healthcare workers have the knowledge and skills to address patients that are GBV survivors through capacity building. Second, due to the lack of psychosocial support services in healthcare facilities, the second AF will support improved referral pathways and support for GBV survivors in healthcare facilities. This will ensure that psychosocial support services are broadly available. Third, the second AF will also include GBV- related prevention and mitigation messaging into its COVID-19 communication campaigns. Health providers will be trained on getting information and responding to gender-sensitive matters during the COVID-19 pandemic. Fourth, the second AF will continue to support better targeting and tracing of vaccine administration with strengthened M&E capacity. This will include more emphasis on the various strategies that will increase the number of women getting vaccinated such as continuing to engage women-led organizations during vaccine deployment. There will be increased communication and community engagement among younger women to ensure that misinformation about infertility from the COVID-19 vaccines are well managed. This is important as part of the national target of 63 percent includes young women and men between the ages of 16-29 years, which constitutes 19 percent of the population. All data collection and monitoring will be done in a sex-disaggregated way wherever possible. The Government’s social engagement strategy to reduce vaccine hesitancy includes active disinformation management through social listening, review, and follow-up with exposed groups. WHO and UNICEF also plan to conduct a study to understand the vaccine hesitancy among this group and to find solutions. H. Citizen Engagement 72. The involvement of the local population is essential to the success of the project to ensure smooth collaboration between project staff and local communities, and to minimize and mitigate environmental and social risks related to the proposed project activities. In the context of infectious diseases, broad, culturally appropriate, and adapted awareness-raising activities are particularly important to properly sensitize the communities to the risks related to these diseases. As such, the project developed an SEP with the overall objective of defining a program for stakeholder engagement, including public information disclosure and consultation, throughout the entire project cycle. The SEP outlines how the project team will communicate with stakeholders. The project will therefore ensure that continuous, meaningful, and safe consultations on project interventions are conducted throughout the project implementation. Beneficiary feedback will be integrated the project interventions as well as any needed course correction in the implementation. A project-specific GRM will be formulated by the second AF’s effectiveness providing timely, understandable, and accessible procedures that will allow stakeholders to submit complaints and the project to resolve these in timely manner. Moreover, as it relates to COVID-19 vaccine administration, the Government has built their targeting strategy on the WHO’s Fair Allocation Framework, which not only prioritizes older population and populations at risk of being more exposed to COVID-19 such as frontline healthcare workers, but populations with underlying health conditions including those living with disabilities. An indicator was also included in the results framework to track the percentage of complaints to the GRM that are satisfactorily addressed. 73. Grievance redress mechanism (GRM). The parent project and first AF incorporate a comprehensive project-wide GRM, which will enable a broad range of stakeholders to channel concerns, questions, and complaints to the various implementation agencies and COVID-19 Call Centers. The second Page 46 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) AF will continue to support the COVID-19 Call Centers with call-free numbers. These numbers have been publicly disclosed throughout the country in the broadcast and print media. The GRM will be equipped to handle cases of SEA/SH, as rapid guidance on how to respond to these cases will be developed and shared with operators. This will follow a survivor-centered approach. The GRM will continue to be publicized by the MoH and GHS, and other relevant agencies. I. Climate Co-benefits 74. Climate change risks and vulnerabilities. Mauritania has been assessed for climate change and disaster risks and is highly exposed to extreme temperature, extreme precipitation and flooding, and drought. This exposure risk is assessed at this level for both the current and future timescales. Mauritania is one of the most affected countries by drought (3/4 of the country is desert or semi-desert), which has made access to clean water and sanitation a major challenge, leading adults and children to suffer from diarrhea and other diseases linked to poor hygiene. Heat waves have also increased in the region impacting life expectancy, due to the serious implications on the health of the elderly and other vulnerable groups. Moreover, heat waves also have damaging effects on crop production, which impacts nutrition levels of children. Although heat waves and droughts are the main exposures, there are severe flooding events that may lead to increased vector- and water-borne diseases due to standing water. However, the risk on project activities and outcomes is categorized as Moderate due to several adaptation measures. Some mitigation measures have also been integrated and will reduce the impact of the project’s activities on the environment and reduce Greenhouse Gas (GHGs). 75. The second AF intends to address climate change vulnerabilities, enhance climate resilience and adaptation, and mitigate GHG emissions through the following activities: in terms of climate adaptation measures, under Subcomponent 1.1: Case Detection, Confirmation, Contact Tracing, Recording, Reporting (AF2: US$2.2 million), the strengthened case management capabilities and disease surveillance system will enhance the ability of health services to better respond to future climate-related health impacts from extreme weather events. Additional support will be provided to operationalize the National Center for Emergency Operations in Public Health. This will include the integration of weather surveillance to improve the use of information for detecting, investigating, and responding to public health threats. Under Subcomponent 1.2: Health System Strengthening (AF2: US$2.3 million), special attention will be given to healthcare facilities that have unstable electricity supply and weak health infrastructure that may be affected by climate change and climate variability (that is, heat waves, flooding). The widespread loss of power may seriously threaten the COVID-19 vaccine cold chain as vaccine conservation standards will be affected. Therefore, as an adaptation measure, some of the CCEs purchased will be off-grid solar equipment/supplies such as solar-powered fridges and freezers that will provide reliable 24/7 power and efficient cooling and battery-powered coolers (provide up to seven days of cooling during emergencies). Moreover, solar panels will be procured and installed. Low-carbon, energy efficient waste management equipment will be procured to enhance climate resilience to flooding threats faced by the country. This will include properly and safely disposing supplies/products such as syringes, partially used COVID-19 vaccines, unrefrigerated vaccines that are rendered ineffective, expired vaccines, PPE, and other vaccine- related waste in compliant containments. Page 47 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) 76. Under Subcomponent 1.3: Communication Preparedness (AF2: US$1.8 million), financing of community outreach, sensitization, and raising awareness of COVID-19 vaccinations will take place. Important health information on climate-change-related health risks linked to the COVID-19 crisis, such as the increased risks associated with quarantine in extreme heat events and the promotion of healthy behaviors, will be provided. Under Subcomponent 1.4: COVID-19 Vaccine Purchase and Distribution (AF: US$9.8 million), purchase of the COVID-19 vaccines will consume US$5.2 million of the budget. This includes the costs of the vaccines, supplies, safety boxes for disposal of syringes, syringes, international freight, procurement fees to UNICEF, and other deployment-related costs. While no direct climate financing is expected to be assigned at this time to any of these investments, it is expected that some suppliers are taking active steps to ensure climate-resilient considerations are taken into account during the manufacturing, shipment, and distribution stages of the vaccines. The World Bank team, together with UNICEF, the WHO, and GAVI will continue to explore these areas to provide the latest information on any specific climate adaptation and mitigation actions taken about the vaccines. The NDVP will include measures to deal with any unexpected disruptions to the vaccine supply chain, distribution and storage from climate change impacts, and other unexpected disasters (that is, power outages from flooding and extreme heat). 77. In terms of climate mitigation activities, Under Subcomponent 1.2: Health System Strengthening (AF2: US$2.3 million), additional procurement of WHO Performance Quality Safety -certified solar and off-the-grid fridges/freezers, waste management equipment, and other low Global Warming Potential (GWP) below 125 for regions, which will reduce the impact of the project on the country's GHG emissions. This will include the purchase of refrigerators, freezers, and cold rooms. The installation of temperature controls and monitoring systems on the fridges and freezers will monitor any fluctuations and will cut down on excessive use of energy. Energy-efficient transformers and inverters for cold rooms will also be purchased. To ensure sustainable and less energy-intensive infrastructure, climate-resilient and energy- efficient water supply and storage infrastructure will be procured. This will improve water access and water-use efficiency. Improving the insulation of the health facilities and cold rooms against extreme heat with climate-smart technologies such as thermal insulation and solar reflective roofs will improve the energy efficiency of these buildings. Energy-efficient lighting (i.e., LED lights) and light control measures (such as diming and occupancy sensors) will also be procured. Fuel-efficient refrigerated and non- refrigerated vehicles (electric) will also be procured, and route optimization will be considered for vaccine transportation by adjusting routes for vehicles depending on weather and road conditions. This will improve fuel mileage and fuel efficiency of the vehicles. Additional fuel-efficient vehicles will also be purchased under Subcomponent 2.1: Implementation management (AF2: US$0.5 million) that will include the same standards as above. Moreover, energy-efficient computer and office equipment will also be procured under this subcomponent. V. WORLD BANK GRIEVANCE REDRESS 78. Communities and individuals who believe that they are adversely affected by a World Bank supported project may submit complaints to existing project-level grievance redress mechanisms or the World Bank’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the World Bank’s independent Inspection Panel which determines whether Page 48 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) harm occurred, or could occur, as a result of World Bank’s non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress- service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org Page 49 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) VI SUMMARY TABLE OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Disbursements Arrangements ✔ Procurement ✔ Implementing Agency ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ APA Reliance ✔ Other Change(s) ✔ VII DETAILED CHANGE(S) MPA PROGRAM DEVELOPMENT OBJECTIVE Current MPA Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Proposed New MPA Program Development Objective Page 50 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) EXPECTED MPA PROGRAM RESULTS Current Expected MPA Results and their Indicators for the MPA Program Progress towards the achievement of the PDO would be measured by outcome indicators. Individual country- specific projects (or phases) under the MPA Program will identify relevant indicators, including among others: • Country has activated their public health Emergency Operations Centre or a coordination mechanism for COVID-19; • Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents; • Number of acute healthcare facilities with isolation capacity; • Number of suspected cases of COVID-19 reported and investigated per approved protocol; • Number of diagnosed cases treated per approved protocol; • Personal and community non-pharmaceutical interventions adopted by the country (e.g., installation of handwashing facilities, provision of supplies and behavior change campaigns, continuity of water and sanitation service provision in public facilities and households, schools closures, telework and remote meetings, reduce/cancel mass gatherings); • Policies, regulations, guidelines, or other relevant government strategic documents incorporating a multi- sectoral health approach developed/or revised and adopted; • Multi-sectoral operationalmechanism for coordinated response to outbreaks by human, animal and wildlife sectors in place; • Coordinated surveillance systemsin place in the animal health and public health sectors for zoonotic diseases/pathogens identified as joint priorities; and • Mechanisms for responding to infectious and potential zoonotic diseases established and functional; and • Outbreak/pandemic emergency risk communication plan and activities developed and tested Proposed Expected MPA Results and their Indicators for the MPA Program Page 51 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Component 1. Emergency 18.20 Revised Component 1. 34.30 COVID-19 Response Emergency COVID-19 Response Component 2. 2.00 Revised Component 2. 5.90 Implementation Implementation Management and Management and Monitoring and Evaluation Monitoring and Evaluation TOTAL 20.20 40.20 LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline Closing(s) Closing for Withdrawal Applications IDA-D5990 Effective 30-Apr-2022 30-Apr-2023 31-Dec-2024 30-Apr-2025 IDA-D8990 Effective 30-Apr-2023 30-Apr-2023 31-Dec-2024 30-Apr-2025 DISBURSEMENT ARRANGEMENTS Change in Disbursement Arrangements Yes Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2020 140,360.00 140,360.00 2021 4,320,139.40 4,460,499.40 2022 10,000,000.00 14,460,499.40 2023 10,000,000.00 24,460,499.40 2024 8,000,000.00 32,460,499.40 2025 7,739,500.60 40,200,000.00 Page 52 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance ⚫ Substantial ⚫ Substantial Macroeconomic ⚫ Substantial ⚫ Substantial Sector Strategies and Policies ⚫ Moderate ⚫ Moderate Technical Design of Project or Program ⚫ Moderate ⚫ Moderate Institutional Capacity for Implementation and ⚫ Substantial ⚫ Substantial Sustainability Fiduciary ⚫ Substantial ⚫ Substantial Environment and Social ⚫ Substantial ⚫ Substantial Stakeholders ⚫ Moderate ⚫ Moderate Other ⚫ High ⚫ High Overall ⚫ High ⚫ High LEGAL COVENANTS2 LEGAL COVENANTS – Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Sections and Description Schedule 2, Section I.A.3.a: No later than one (1) month after the Effective Date the Recipient, through the Ministry of Health, shall: (a) recruit and thereafter maintain the Project officer and the monitoring and evaluation specialist, both with terms of reference and qualifications acceptable to the Association. Schedule 2, Section I.A.3.b:No later than one (1) month after the Effective the Recipient shall customize the Project’s accounting software to reflect the additional resources provided and activities to be implemented in accordance with this Agreement, under terms and specifications satisfactory to the Association. Schedule 2, Section I.A.3.c:No later than one (1) month after the Effective Date the Recipient shall update the terms of reference of the Project’s internal auditor and social specialist, to include the additional activities under the Project, under terms of reference and modalities satisfactory to the Association. Schedule 2, Section I.A.4: No later than six (6) months after the “Effective Date” as this term is defined in the First Additional Financing Agreement, the Recipient shall revise and adopt updated terms of reference for the Project’s external auditor to include additional resources under the Project, under terms of reference and modalities satisfactory to the Association. Schedule 2, Section I.A.5: No later than three (3) months after the Effective Date, the Recipient shall ensure that an environmental specialist has been recruited, who will be sufficiently available to work on the Project, with terms of reference, qualification and experience acceptable to the Association. Schedule 2, Section I.A.6: No later than three (3) months after the Effective Date, the Recipient shall enter into an agreement or understanding in form and substance acceptable to the Association, with a provider of technical Page 53 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) support for the implementation of its activities under the Project, with terms of reference, qualification and experience acceptable to the Association. Schedule 2, Section I.A.7: No later than one (1) month after the Effective Date, the Recipient shall ensure that a procurement specialist and an additional accountant have been recruited for the Project, on the basis of terms or reference, qualifications and experience acceptable to the Association. Schedule 2, Section I.D: the Recipient shall, by no later than two (2) months after the Effective Date, update the draft Annual Work Plan and Budget, promptly furnish it to the Association for its review and promptly thereafter finalize the draft Annual Work Plan and Budget, taking into account the Association’s comments thereon, not later than three (3) months after the Effective Date. Schedule 2, Section I.F. 1. Without limitations to the provisions of Section E.2 of this Schedule and if during Project implementation, the Recipient decides to use its military or security forces, the Recipient shall: (a) prior to any involvement of its military and/or security forces in the carrying out of Project activities, send a written notice to the Association (in accordance with Section 11.01(b) of the General Conditions) communicating such decision, including the name of the military or security unit; and (b) all activities carried out by said military or security unit under the Project shall be under the control of the Ministry of Health and shall be undertaken exclusively for the purposes related to the Project. Conditions Type Financing source Description Effectiveness IBRD/IDA the Recipient, through the Ministry of Health, has updated the Administrative and Financial Manual of Procedures, in a manner and with contents acceptable to the Association (4.01(b)) Type Financing source Description Effectiveness IBRD/IDA the Recipient, through the Ministry of Health, has updated and disclosed the ESMF and the SEP in a manner and with contents acceptable to the Association (4.01(c)) Page 54 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Mauritania RESULT_NO_PDO Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) Project Development Objective(s) To strengthen the national public health preparedness capacity to prevent, detect and respond to the COVID-19 pandemic in Mauritania Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target To support detection and response efforts in the fight against COVID-19 Suspected cases of COVID-19 reported and investigated per 40.00 100.00 approved protocol (by sex) (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. By sex (Percentage) 0.00 100.00 Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Health facilities with trained staff in Covid-19 infection 85.00 90.00 prevention control per MoH approved protocol (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Page 55 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target Reference and district hospitals with personal protective equipment and infection control products and supplies, without 0.00 80.00 stock-outs in preceding two weeks (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. ICU beds in prioritized ICU units that are fully equipped and 0.00 90.00 operational for COVID-19 response (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Population in the priority group fully vaccinated (Percentage) 0.00 20.00 Rationale: Action: This indicator has been Revised This indicator is being revised for clarity. The target is also being adjusted to focus on the priority group (most vulnerable). By sex (Percentage) 0.00 40.00 Rationale: Action: This indicator has been Revised The description of the indicator is being revised for clarity. Target population fully vaccinated (Percentage) 0.00 80.00 Rationale: Action: This indicator is New This is a new indicator that will enable monitoring of the target population that is fully vaccinated. Page 56 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target By sex (Percentage) 0.00 50.00 Action: This indicator is New PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Emergency COVID-19 Response Border control sites with trained teams and the necessary means of control, isolation and transport to isolation and care sites 0.00 32.00 (Number) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Priority healthcare facilities that received protective equipment and hygiene materials (Percentage) 0.00 100.00 Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Laboratory-confirmed cases of COVID-19 responded to within 48 hours (Percentage) 0.00 100.00 Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Page 57 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Designated laboratories fully equipped with COVID-19 diagnostic equipment, test kits, and reagents per MOH guidelines 0.00 100.00 (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Isolation centers, screening sites and quarantine centers established and equipped with medical supplies and protective 0.00 100.00 equipments in all regions covered by the project (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Community engagement plan developed for increasing demand No Yes creation for the COVID-19 vaccine by the population. (Yes/No) Functional mechanisms to capture community feedback are established (for example, community meetings, hotlines, health No Yes volunteer network, social listening, surveys, and so on). (Yes/No) SOPs or guidelines established for collection and disposal of No Yes medical waste to the relevant stakeholders. (Yes/No) Health care providers trained to recognize early signs of gender- based violence (Number) 0.00 100.00 Rationale: Action: This indicator is New This indicator will track the number of health care providers who are able to recognize the early signs of gender-based violence. Health centers that provide psychosocial services to GBV 0.00 20.00 survivors (Number) Rationale: Action: This indicator is New To ensure that psychosocial support are broadly available to GBV survivors Page 58 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Implementation Management and Monitoring and Evaluation Reference and district hospitals have submitted complete monthly reports on the number of suspected cases identified, 0.00 90.00 tested and contacts traced (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Complaints to the GRM satisfactorily addressed within 15 weeks 0.00 70.00 of initial complaint being recorded (Percentage) Rationale: Action: This indicator has been Revised This indicator's end target date has been revised. Vaccination sites that use the digital vaccination platform for 0.00 50.00 data entry, analysis and reporting (Percentage) Rationale: Action: This indicator has been Revised This indicator is revised to measure the progress of utilization of a digital vaccine platform. Guidelines, documented procedures, and tools for planning and conducting vaccine pharmacovigilance activities are established No Yes and available (Yes/No) COVID-19 vaccine delivery strategies to reach identified target No Yes groups are defined (Yes/No) IO Table SPACE Page 59 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: Number of suspected cases of COVID- 19 cases reported and Suspected cases of COVID-19 reported investigated per approved Collected by the Ministry Monthly HMIS MOH and investigated per approved protocol protocol. of Health (MOH) (by sex) Denominator: Total number of suspected cases of COVID-19 cases reported Numerator: Number of suspected cases of COVID- 19 cases among females reported and investigated per approved protocol. Monthly HMIS Collected by the MOH MOH By sex Denominator: Total number of suspected cases of COVID-19 cases among females reported Numerator: Health facilities with trained staff in Covid- 19 infection prevention Health facilities with trained staff in Project control per MoH approved Semi-annual Data collected by MOH MOH Covid-19 infection prevention control per reports protocols Denominator: MoH approved protocol Total number of health facilities. Reference and district hospitals with Reference and district Quarterly Project Data collected by the MOH Page 60 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) personal protective equipment and hospitals with personal reports/ HMIS MOH infection control products and supplies, protective equipment and without stock-outs in preceding two infection control products weeks and supplies, without stock-outs in preceding two weeks Nominator: Number of ICU beds in prioritized ICU units that are fully equipped and ICU beds in prioritized ICU units that are Project operational for COVID-19 Quarterly Data collected by MOH MOH fully equipped and operational for COVID- reports response 19 response Denominator: Number of ICU beds in prioritized ICU units Numerator : Number of people in the priority Population in the priority group fully Monthly HMIS Data collected by MOH MOH population fully vaccinated vaccinated Denominator : Total population of Mauritania Numerator: Number of females in the priority population that are fully Monthly HMIS Data collected by MOH MOH By sex vaccinated Denominator: Total population in priority group fully vaccinated Numerator: Number of people in the target Monthly HMIS Collected by the MOH MOH Target population fully vaccinated population fully vaccinated Denominator: Total number of people in the Page 61 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) target population fully vaccinated Numerator : Number of females in the target population that are fully vaccinated Monthly HMIS Collected by the MOH MOH By sex Denominator : Total number of the target population fully vaccinated ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Establishment of 32 control sites (airports, ports and land crossing points) with permanent presence of trained teams (three teams Border control sites with trained teams of two people each per site Project Data collected by the and the necessary means of control, Quarterly MOH trained on COVID-19 reports MOH isolation and transport to isolation and prevention, control and care sites contact tracing) with the necessary means of control, isolation and transport to isolation and care sites Priority healthcare facilities that received Numerator: Priority Semi- Project Data collected by MOH MOH protective equipment and hygiene healthcare facilities across annual reports materials the 15 regions that Page 62 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) received protective equipment and hygiene materials Denominator: healthcare facilities identified as priorities for Covid-19 response and covered by the project Numerator: Number of laboratory-confirmed cases of COVID-19 where there was deployment of a rapid response team, contract Semi- Project Data collected by the Laboratory-confirmed cases of COVID-19 tracing was initiated, and MOH annual reports MOH responded to within 48 hours public messaging was disseminated within 48 hours. Denominator: Number of laboratory- confirmed cases of COVID- 19. Number of designated laboratories with COVID-19 Designated laboratories fully equipped Semi- Project diagnostic equipment, test Data collected by MOH MOH with COVID-19 diagnostic equipment, test annual reports kits, and reagents per MOH kits, and reagents per MOH guidelines guidelines Numerator: Number of Isolation centers, screening sites and regions with isolation quarantine centers established and Semi Project centers, screening sites and Data collected by MOH MOH equipped with medical supplies and annual reports quarantine centers protective equipments in all regions established and equipped covered by the project with medical supplies and Page 63 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) protective equipment Denominator: Regions covered by the project Community engagement plan developed Report prepared by the Annual Project Report MOH for increasing demand creation for the project COVID-19 vaccine by the population. Functional mechanisms to capture community feedback are established (for Semi- Project Survey MOH example, community meetings, hotlines, annual Reports health volunteer network, social listening, surveys, and so on). SOPs or guidelines established for Project Annual Monitoring System MOH collection and disposal of medical waste Reports to the relevant stakeholders. Number of health care Monitoring Health care providers trained to recognize providers trained to Monthly Collected by the MOH MOH reports early signs of gender-based violence recognize early signs of gender-based violence Number of health centers Health centers that provide psychosocial Quarterly Report Data collected by MOH MOH that provide psychosocial services to GBV survivors services to GBV survivors Numerator: number of reference and district hospitals who have Reference and district hospitals have submitted complete Project Data collected by the submitted complete monthly reports on monthly reports on the quarterly MOH reports/HMIS MOH the number of suspected cases identified, number of suspected cases tested and contacts traced identified, tested and contacts traced Denominator: total number of reference hospitals (5 in Page 64 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Nouakchott) and district hospitals (26) Numerator: Number of complaints to the GRM addressed in four weeks of Complaints to the GRM satisfactorily Project Data collected by the initial complaint being Quarterly MOH addressed within 15 weeks of initial reports MOH recorded. Denominator: complaint being recorded Number of complaints to the GRM Numerator: Number of vaccination sites that use the digital platform for Vaccination sites that use the digital data entry, analysis and Monthly HMIS Collected by the MOH MOH vaccination platform for data entry, reporting analysis and reporting Denominator: Total number of vaccination sites Guidelines, documented procedures, and tools for planning and conducting vaccine Annual Reports Collected by the MOH MOH pharmacovigilance activities are established and available COVID-19 vaccine delivery strategies to Annual Reports Collected by the MOH MOH reach identified target groups are defined ME IO Table SPACE Page 65 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) Page 66 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS Status of Vaccines Approvals by SRAs and WHO (as of December 20, 2021) Vaccine SRA Emergency Use Approval WHO PQ/EUL23 BNT162b2/COMIRNATY United Kingdom (UK): December 2, 2020 WHO EUL: December 31, Tozinameran (INN) - Canada: December 9, 2020 2020 Pfizer BioNTech USA: December 11, 2020 European Union: December 21, 2020 Switzerland: December 19, 2020 Australia: January 25, 2021 mRNA-1273 - Moderna USA: December 18, 2020 WHO EUL: April 20, 2021 Canada: December 23, 2020 EU: January 6, 2021 UK: January 8, 2021 Switzerland: January 12, 2021 AZD1222 (also known UK: December 30, 2020 WHO EUL: February 15, as ChAdOx1_nCoV19/ EU: January 29, 2021 2021 for vaccines commercialized as Australia: February 16th, 2021 (overseas manufactured by SK Bio COVISHIELD in India) - manufacturing); March 21, 2021 (for local and Serum Institute of AstraZeneca/Oxford manufacturing by CSL – Seqirus) India Canada: February 26, 2021 Ad26.COV2.S - Johnson USA: February 27, 2021 WHO EUL: March 12 2021 & Johnson Canada: March 5, 2021 EU: March 11, 2021 Switzerland: March 22, 2021 SinoPharm/BIBP WHO EUL: May 7, 2021 23 WHO. Status of COVID-19 vaccines with WHO EUL/PQ evaluation process. December 20, 2021 edition. https://extranet.who.int/pqweb/sites/default/files/documents/Status_COVID_VAX_20Dec2021.pdf Page 67 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) ANNEX 2: LATEST COVID-19 SITUATION IN THE COUNTRY 1. The first case of COVID-19 in Mauritania was confirmed on March 14, 2020. It was identified as an imported case from Europe. The initial confirmed COVID-19 cases were few with only 8 cases reported in the first two months and fewer than 100 cases confirmed until May 20, 2020. The introduction of the virus in the country unleashed a period of local transmission in the city of Nouakchott, that is visible in the Epidemiological Weeks 11 to 19. By week 20 the country presented a clear community transmission trend. By week 21 local transmission of the virus was observed throughout the country. 2. Three different peaks have been observed since the beginning of the pandemic. The first peak occurred in June 2020 with over 100 confirmed COVID-19 cases a day. This was followed by a period with few cases reported before the epidemic picked up again in December 2020 with over 200 confirmed COVID-19 cases a day. A third peak can be noted in July 29, 2021 due to the delta variant, registering 401 daily confirmed cases on July 29, 2021 (peak; see Figure 2.1 below). As of December 9, 2021, there were 39,704 confirmed cases and 846 deaths. There is a potential fourth wave developing as confirmed cases are rising in the eastern part of the country. Mauritania is ranked fifth out of 15 in the highest number of cases and third out of 15 in the highest number of deaths due to COVID-19 in West Africa. Figure 2.1: Daily Number of COVID-19 Cases in Mauritania, March 2020–December 2021 3. Upon the receipt of the first batch of Sinopharm vaccines from the People’s Republic of China on March 24, 2021, the Government launched its COVID-19 vaccination program on March 26, 2021. Between March 26 and June 14, 2021, the vaccination strategy was based exclusively on the fixed strategy which consists of offering vaccination sites at health facilities with a functional cold chain. This strategy started in an ascending manner from the top of the health pyramid and gradually spread towards Page 68 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) the base of the pyramid, namely the health centers and health posts. Progress was slow because of logistical difficulties such as low storage capacity in the interior of the country and insufficient means of transportation. To increase the vaccination coverage, the Government included a vaccination campaign strategy that was very successful. As of December 9, 2021, 27.0 percent of the eligible target population (18 years and over) is fully vaccinated. Among those vaccinated, 61.0 percent were men and 38.0 percent were women (June 1, 2021). However, the Government has employed a strategy to increase the number of women getting vaccinated such as the inclusion of women-led cooperatives and non-governmental organizations to support the vaccine deployment efforts. This has increased the number of women getting vaccinated and as of December 12, 2021, 49.0 percent of the population fully vaccinated are women. 4. Moreover, given the limited availability of vaccines, the very short shelf life of some of the vaccines and some vaccine hesitancy, the Government (i) extended the vaccine eligibility to all persons over 18 years of age; (ii) limited the supply of Sinopharm to the second dose for those who have already received the first dose of this vaccine, due to its relatively long expiration date (two years) compared to AstraZeneca; (iii) offered only the AstraZeneca vaccine to the rest of the eligible population until the end of the available stock, in order to avoid wasting doses of this vaccine; (iv) received donations and purchased J&J to rapidly increase the number of fully vaccinated people, particularly for hard to reach regions where patient follow-up is difficult; and (v) organized a national vaccination campaigns to increase coverage among the priority target population. Page 69 of 70 The World Bank Second Additional Financing for the Mauritania COVID-19 Strategic Preparedness and Response Project (SPRP) (P178100) ANNEX 3: SUMMARY OF THE PROJECT COMPONENTS 1. The parent project, Mauritania COVID-19 SPRP (P173837), was developed under the SPRP using the MPA approved by the Board on April 2, 2020, to support the Government’s comprehensive National COVID-19 Response Plan. The World Bank approved a US$12 billion WBG FTCF (“the Facility”) to assist IBRD and IDA countries in addressing the global pandemic and its impacts. Of this amount, US$6 billion came from IBRD/IDA (“the World Bank”) and US$6 billion from the IFC. The IFC subsequently increased its contribution to US$8 billion, bringing the FTCF total to US$14 billion. The first AF for the Mauritania COVID-19 SPRP (P176526) was prepared under the AF of the MPA SPRP of US$12 billion (IBRD/IDA) approved on October 13, 2020 to support the purchase and deployment of vaccines, as well as strengthening the related immunization and healthcare delivery system. The first AF was approved on June 30, 2021. 2. The PDO is to strengthen the national public health preparedness capacity to prevent, detect, and respond to the COVID-19 pandemic in Mauritania. The implementation of the parent project and first AF is strengthening the capacity of the Mauritania Government, and more specifically the MoH to detect and respond to infectious diseases on time. This includes improvements in coordination, surveillance, and response and timely information sharing with the public. It is also supporting the country in its vaccine acquisition and deployment activities. The project includes two components: 3. Component 1: Emergency COVID-19 Response (US$18.2 million). The component provides immediate support to enhance disease detection capacity through well-trained and well-equipped frontline health workers. The component finances the procurement of equipment and supplies for health facilities and laboratories such as diagnostic equipment, test kits, reagents, PPE, and capacity building of port of entry officers, healthcare workers, community-based nurses, and community health workers involved in the COVID-19 response. The component supports the strengthening of climate-sensitive disease surveillance systems and building testing capacity for early detection and confirmation of COVID- 19 cases and the strengthening of the health system to provide optimal medical care, maintain essential community services, and minimize risks for patients and health care personnel. This component also supports vaccine acquisition and deployment. Risk communication activities and community engagement to raise awareness, knowledge, and understanding among the general population about the risk and potential impact of the pandemic as well as the sensitization on the COVID-19 vaccines. 4. Component 2: Implementation Management and M&E (US$2.0 million). The component supports the implementation actors at central and local levels for coordination, FM, procurement, and the development of project monitoring and impact evaluation assessments. The component supports the capacity strengthening of the implementation institution and all the costs associated with project implementation. Page 70 of 70