The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 06-Nov-2020 | Report No: PIDA30427 Sep 14, 2020 Page 1 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Tajikistan P175168 Additional Financing for P173765 the Tajikistan Emergency COVID-19 Project Parent Project Name Region Estimated Appraisal Date Estimated Board Date Tajikistan Emergency COVID-19 EUROPE AND CENTRAL 11-Jan-2021 11-Mar-2021 Project ASIA Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Ministry of Finance Ministry of Health and Financing Social Protection, State Agency for Social Protection Proposed Development Objective(s) Parent Project Development Objective (PDO) is to prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan. Proposed Development Objective(s) Additional Financing Project Development Objective (PDO) is to prevent, prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan. Components Component 1. Strengthening intensive care capacity Component 2. Multi-sectoral response planning and community preparedness Component 3. Temporary social assistance for vulnerable households Component 4. Project Implementation and Monitoring PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 8.35 Total Financing 8.35 of which IBRD/IDA 8.35 Sep 14, 2020 Page 2 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 8.35 IDA Grant 8.35 Environmental and Social Risk Classification Substantial Other Decision (as needed) B. Introduction and Context Country Context 1. Tajikistan is a low-income IDA country with a large proportion of the population vulnerable to poverty and shocks, despite notable accomplishments in poverty reduction over the past 20 years. Tajikistan is a land-locked country, which borders China, and 93 percent of its terrain is mountainous. It has a population of 9.1 million1. From 2000 through 2015 the country had an average economic growth rate of 7.7 percent annually, yet by 2018 still had the lowest gross domestic product (GDP) per capita in the Europe and Central Asia region at US$3061 (in 2011 purchasing power parity terms). Nonetheless, the country has achieved sustained progress in reducing poverty in the national official poverty rate, from more than 37 percent in 2013 to about 27 percent in 2019. Remittance inflows are a powerful driver of poverty reduction in Tajikistan (in total equivalent to 29 percent of GDP in 2018), and exports are dominated by commodities, especially cotton and aluminum. Official development assistance inflows and in high levels of public investment account for above-average shares of GDP. About 70 percent of the population lives in rural areas according to official projections, and the agricultural sector is by far the largest employer in the country. Rural and remote areas are significantly poorer than urban settings on average, and face highly volatile incomes compounded by strong seasonality – the national poverty rate rises be as much as 8 percentage points during the winter and spring months. 2. The Country Partnership Framework (CPF) and Systematic Country Diagnostic also note the country’s social vulnerabilities and fragility risks, and these are compounded by the country’s geography. Fragility risks include: the legacy of the 1992-97 civil war; persistent poverty pockets in lagging regions; 1 Official data of the State Agency on Statistics under the Government of Tajikistan, 2018. Sep 14, 2020 Page 3 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) income insecurity; under and unemployment and security risks emanating from the 1,400-kilometer border with Afghanistan. More than one in three youth (age 15-24) and almost nine out of ten female youth are not in employment, education or training. In addition, Tajikistan is vulnerable to natural disasters. From 1992 to 2016, disasters in Tajikistan are estimated to have caused economic losses in excess of US$1.8 billion, affecting almost 7 million people. 3. Tajikistan’s economic ties to China, where the COVID-19 outbreak began, make it particularly vulnerable and both World Bank and International Monetary Fund’s projections point towards a steep reduction in GDP growth in 2020. In 2019, China was Tajikistan’s largest trading partner accounting for 4.7 percent of the export market and 18.1 percent of its import market. Further, oil prices fell in the first quarter of 2020 to lows not seen since the Great Recession, greatly reducing expected remittance inflows from Russia and limiting the growth outlook for Tajikistan’s immediate neighbors. This combination of factors stands to cause a decline in consumption expenditure and imports, lowering tariff and VAT revenue and leading to a deterioration in fiscal sustainability. Aluminum, Tajikistan’s primary export commodity at 17 percent of exports, hit a 40-month low of $1,665 per ton in January. New foreign direct investment is also expected to decline. In 2019, the Chinese foreign investments account for nearly half (46 percent) of total foreign investments to Tajikistan, which are equivalent to 3.5 percent of GDP. 4. Remittances from Russia to Tajikistan are expected to sharply decline due to expected travel restrictions, the rapid ruble depreciation in Q1 of 2020, and collapsing oil prices. Tajik migrants living in Russia are the source of more than 90 percent of remittance income in Tajikistan, and the rapidly deteriorating economic prospects in Russia linked to falling oil prices, fears of the Covid-19 outbreak spreading, and exchange rate volatility are severe risks to economic stability in Tajikistan. Changes in the flow of remittances are expected to have a substantial impact on food security, particularly for vulnerable populations. In 2019, more than 10 percent of households reported an inability to buy enough food. More than half of households receiving remittances report using remittance income primarily to support household consumption of food and other necessities. Moreover, the poverty rate among children is structurally higher than among adults, and the country struggles with elevated rates of stunting. Finally, as remittances are highly targeted to the poorest regions and districts of the country, declining income from remittances and the absence of a quick recovery will lead to rising incidence and depth of poverty. 5. Higher inflation and potential labor market impacts are expected to have knock-on effects on vulnerable households and have the potential to increase the prevalence and depth of poverty. Falling remittances, the expected decline in Chinese imports (many of which are intermediate inputs), and a planned electricity tariff increase of 15 percent this year will place upward pressure on prices and reduce domestic output in comparison to expectations. Domestic business reliant on the supply of external raw materials will also face supply constraints. Approximately 300 Chinese-Tajik joint ventures are operational in Tajikistan and it is expected that they too will face disruptions on the flow of goods and people. Although the upward price movement in Tajikistan is likely to first be seen largely in non-food commodities, behavioral responses in the event of the outbreak spreading, and further supply constraints may lead to food price increases. Sectoral and Institutional Context 6. Tajikistan’s health system faces long-standing challenges, exacerbating the immediate vulnerability to a COVID-19 pandemic. The health system is in a period of reform and transition from the Sep 14, 2020 Page 4 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) Semashko system inherited from the former Soviet Union, but progress has been slow. The system is still dominated by economic stringency, overlapping functions of state institutions, fragmentation and management that is highly centralized and heavily hospital-based. Tajikistan’s health care system is tax- financed, with the government being the primary purchaser of health services. Government spending on health as a share of general government spending is low: at 6.6 percent, equating to US$17 per capita, with out-of-pocket spending accounting for two-thirds (64 percent) of combined health expenditure. In 2007, 11 percent of households reported spending at least 10 percent of their income on health, markedly higher than other countries in the region. Fiscal space for health remains constrained due to slowing growth and priority given to infrastructure projects in the government budget. Patterns of public health spending – with the bulk of spending on salaries and inpatient care – suggest that there is considerable scope for improvements in the efficiency of spending. There are marked inequities in the health system, evident in the financing and distribution of services and resources. Quality of care is another major concern, which is affected by the lack of investments in health facilities and technologies; an insufficient budget for, and government bargaining on, pharmaceuticals; poorly trained health care workers; and a lack of medical protocols and systems for quality improvement. This weak health system performance led the World Health Organization (WHO) to assess Tajikistan’s operational readiness for preventing, detecting and responding to a public health emergency as 2 out of 5, among the lowest in the region, and highlights the country’s vulnerability to the COVID-19 pandemic. 7. Recognizing these challenges, the Government of Tajikistan established a Standing Headquarters on Outbreak Prevention and Containment, led by the Deputy Prime Minister and designated the National Public Health Laboratory, which is equipped with adequate diagnostic equipment and staffed by limited WHO-trained technicians, as a reference laboratory for COVID-19 testing. With the support of the WHO, the Ministry of Health and Social Protection (MOHSP) established a working group and finalized the COVID-19 Emergency Response Plan. During the preparation of the parent Project, the World Bank undertook a rapid gap analysis of emergency response and preparedness, in dialogue with major stakeholders. During a rapid response preparation mission, the Bank team held discussions with Government counterparts and development partners to understand challenges in current capacity, resources and clinical care settings. 8. The parent Project, with a total funding envelope of SDR 8.3 million (US$11.3 million equivalent) was prepared as part of the emergency response under the COVID-19 Strategic Preparedness and Response Program using the Multiphase Programmatic Approach. It was approved on April 2, 2020, signed on April 3, 2020, declared effective on April 24, 2020, and has a closing date of December 1, 2021. The Project seeks to support the response of the Government of the Republic of Tajikistan to the COVID-19 pandemic, and the implementation of its Emergency Response Plan, adopted in March 2020. The Project Development Objective (PDO) is to prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan. It includes four Components: (i) Strengthening Intensive Care Capacity; (ii) Multi-sectoral Response Planning and Community Preparedness; (iii) Temporary Social Assistance for Vulnerable Households; and (iv) Project Implementation and Monitoring. 9. Component 1 focuses on strengthening the Government’s capacity to manage severe cases of the COVID-19 infection. More specifically, it provides financing for the procurement and installation of intensive care unit (ICU) equipment, and training of ICU personnel on the use of the equipment. This Component also provides funding for personal protective equipment (PPE) for ICU staff, and essential ICU consumables (medications, syringes, etc.) in 10 hospitals around the country. It also finances small works Sep 14, 2020 Page 5 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) to ensure that the ICUs in the selected hospitals can accommodate the equipment purchased by the Project. 10. Component 2 provides financial support for risk and behavior change communication related to COVID-19. It finances the development and dissemination of risk-reduction messages, and other communication materials. It provides support for the government agencies responsible for risk communication and community engagement, including the Ministry of Health and Social Protection (MOHSP) Press Center and the Republican Center for Healthy Lifestyles. It also supports training for the media on how to effectively communicate with the population regarding COVID-19 related risks, beneficiary feedback, and training of community health volunteers. Finally, it finances expert consultants/advisors for the MOHSP to help in the coordination of the national response to the pandemic. Work under Component 2 is coordinated by the National COVID-19 Coordinator, the Deputy Minister of Health and Social Protection. 11. Component 3 supports a program of nutrition-sensitive emergency cash transfers targeting poor households with children under the age of 3. The program is providing time-limited support to vulnerable households with young children, where food price shocks caused by the COVID-19 pandemic can negatively affect the children’s nutrition status and jeopardize the human capital investments being made by the Government of Tajikistan and the World Bank. The transfers are delivered using the existing Targeted Social Assistance (TSA) system implemented by the State Agency for Social Protection (SASP), in collaboration with the state bank “Amonatbank�, which processes the payments. The Project is also financing accompanying measures to deliver messages on optimal nutrition, appropriate hygiene, and preventive health services to the cash transfers’ beneficiaries. 12. Component 4 provides funds for Project management, including support for the Project Implementation Unit (PIU) located within the MOHSP. 13. Progress towards achieving the PDO and the overall implementation progress are rated Satisfactory. Activities under all Project Components are progressing well and are on schedule. Cumulative disbursements currently stand at 66 percent (US$7.67 million), and there are no overdue audit reports. 14. The original Government request for COVID-19 response support in February 2020 was for US$27.5 million. Through the World Bank’s Fast Track COVID-19 Facility (FTCF), Tajikistan was eligible for US$7.5 million. Additional non-FTCF financing came from advanced commitments from IDA-19, which were capped at US$3.8 million (50 percent of the FTCF allocation). As such, the parent Project was approved in the amount of US$11.3 million, with the intention at the time of original design to eventually propose a US$16.2 million Additional Financing (AF). The proposed AF presents an opportunity to increase the development effectiveness of IDA resources by addressing gaps in both the scale and scope of the parent Project. Scale: Sep 14, 2020 Page 6 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) 15. The resources available under the parent Project allowed for the provision of limited cash assistance to poor households with children under the age of 3 to help protect them from food insecurity and safeguard adequate nutrition. However, the socio-economic impact of the pandemic since March 2020, when the parent Project was designed, has been greater than expected. Data from the Listening to Tajikistan (L2T) monthly household survey show substantially reduced food consumption: the proportion of households reporting reduced food consumption spiked to 41 percent in May 2020 and remained 10 percentage points above 2019 levels through August 2020. The L2T data show overall deterioration in a range of food security indicators, with rising shares of the population who reported going hungry, reducing dietary diversity, and having worries over obtaining enough food. Increasing food insecurity is part of a much deeper decline in living standards, with 40 percent of households reporting work disruption in August 2020. While work disruptions are becoming less pervasive than the period immediately following the outbreak, the rising share of persistent unemployment may become permanent. The share of respondents who halted work and who reported that they were unlikely to resume working rose from 19 percent in May 2020 to 33 percent in August 2020. Finally, the average value of remittances, the key source of income for poorer households, declined by 37 percent between January and May 2020. Consequently, there is a dire need to expand the social assistance program for the most vulnerable populations in Tajikistan. Scope: 16. Consistent with the evidence available in the early stages of the COVID-19 pandemic (November 2019-March 2020), the parent Project focused on supporting the Government’s capacity to provide care for critical cases of COVID-19 – that is, patients requiring care in ICUs. However, subsequently, evidence emerging from countries battling COVID-19 has shown that the success rate of treatment of the most severe cases was quite low, with mortality rates of intubated patients on ventilators at between 60 and 85 percent. This evidence strongly suggests that treating patients before they reach the critical stage (i.e., requiring invasive ventilation) is crucial. Oxygen therapy for severely but not critically ill COVID-19 patients has been advocated as an effective and efficient treatment option. However, access to medical gases, including medical oxygen, remains a challenge in Tajikistan. According to the MOSHP, only a small percentage of the demand can be met by the existing oxygen production capacity. 17. Another critically important change in the state of science since the early stages of the epidemic has been the emergence of new therapies and the potential production of COVID-19 vaccines. Dexamethasone, an anti-inflammatory, has been shown to reduce mortality in critical cases by one-third, and by one-fifth in severe patients receiving respiratory support.2,3 The World Health Organization (WHO) recommends the use of dexamethasone for severe and critical cases of COVID-19. Currently, Tajikistan has only a limited stock of dexamethasone, and lacks sufficient financial resources to procure substantial supplies of it, or other new therapies that can become available. 2WHO. 2020. Corticosteroids for COVID-19. https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020 3The RECOVERY Collaborative Group. 2020. Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa2021436 Sep 14, 2020 Page 7 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) 18. In addition to new therapeutics, a number of promising COVID-19 vaccines are being developed. Seven are already in large-scale phase-3 clinical trials. Recently published results from the trials of the Oxford University/Astra Zeneca and the CanSino vaccines show that both vaccines are safe and produce desired immune responses.4,5 In parallel with vaccine research, the global production capacity is being developed, making it plausible that a COVID-19 vaccine will become commercially available as early as the first quarter of 2021. Though Tajikistan is one of 92 countries eligible to receive donor-financed vaccines under the Gavi COVAX Advanced Market Commitment (COVAX-AMC) mechanism, supply is unlikely to fully meet the country’s needs. Therefore, in order to vaccinate its first priority populations, once a COVID- 19 vaccine that has credible approval for safety and effectiveness is available, the Tajikistan will face a financing gap. 19. Finally, the COVID-19 pandemic has created a significant risk of disruptions in utilization of essential health services due to constraints on both the supply-side (e.g., declining government revenues and health budgets, disruptions in global markets for essential medications and supplies, health workforce challenges due to large numbers of providers becoming sick) and the demand-side (e.g., unwillingness to seek care out of fear of becoming infected with COVID-19, lack of resources to pay for health care due to declining income, mobility restrictions). Such disruptions may have disastrous consequences. An analysis conducted by the Global Financing Facility has shown that, in Tajikistan, disruptions in delivery of essential services similar to those observed under other large epidemics could increase child mortality by 20 percent, wiping out most of the progress that has been made over the past decade. Early evidence from Europe and the United States shows that child vaccination is particularly vulnerable to such disruptions. Indeed, in May 2020, the Government of Tajikistan announced that, because of lower revenues, financing for the routine child immunization program was at risk, with insufficient funds to procure vaccines for calendar year 2021. C. Proposed Development Objective(s) Original PDO Project Development Objective (PDO) is to prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan. Current PDO Project Development Objective (PDO) is to prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan. Key Results 4 Folegatti P, Ewer K, Aley P, Angus B, Becker S, 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. 5 Feng Z., Guan X., Li, Y, Huang J., Jian T. 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. Sep 14, 2020 Page 8 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) 20. The PDO will be monitored through the following PDO-level outcome indicators: • Number of beds in fully equipped and functional intensive care units (ICUs) financed by the Project • Number of oxygen stations procured by the Project • Number of vulnerable households who have received targeted cash assistance financed by the Project D. Project Description 21. The AF will fill two critical gaps of the parent Project described above, namely the small scale of the emergency cash assistance and predominant focus of health-sector investments on critical ICU care. The proposed AF seeks to fill these two gaps. The PDO of the parent Project, “to prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan�, and the Project’s component structure remain unchanged. Component 1: Strengthening Intensive Care Capacity 22. Continuation: The implementation of the activities from the parent Project will continue without any substantive changes. Health facility refurbishments and installation of ICU equipment will be finalized, and preventive maintenance will be carried out during the first year of utilization. Similarly, procurement of consumables will be finalized, and will be distributed to the Project-supported ICUs. Change: New activities proposed under Component 1 respond directly to the key gaps in its initial scope. First, the AF will support strengthening of oxygen supply by financing the establishment of pressure swing adsorption (PSA) oxygen refilling stations in up to 15 hospitals, including those supported by the parent Project. The PSA stations will have capacity to provide oxygen directly to the hospital in which they are installed, as well as re-fill oxygen tanks that can be used in nearby facilities. Oxygen will be used not only in the care of critically ill COVID-19 patients but also those who are less severely ill but still require oxygen therapy, though not necessarily intubation and ICU care. To accompany the oxygen supply investments, the AF will finance procurement of complementary equipment necessary for essential oxygen therapy for patients who do not require ventilation, including vital sign monitors, pulse oximeters, nasal cannulas and catheters, oxygen masks, BiPAP6 and CPAP7 machines, etc. This funding will also include training and maintenance, as well as an initial supply of spare parts and capacity strengthening for the MOHSP to manage the oxygen supply. In addition to improving the care of COVID-19 patients, strengthening of oxygen supply will have an effect on a much broader range of services offered in the supported hospitals and will improve quality of care by filling a critical capacity gap (e.g., general emergency services, emergency obstetrics, inpatient maternal and child care). Second, the AF will finance procurement of medicines for COVID-19 therapy, including dexamethasone and other efficacious therapeutics, as well as an initial supply of COVID-19 vaccines that have credible approval for safety and effectiveness8. It will also 6 Bilevel positive airway pressure. 7 Continuous positive airway pressure. 8 Based on the most recent projection, it is expected that the global supply of the COVID-19 vaccine will only be sufficient to vaccinate about 20 percent of the population of Tajikistan through the end of 2021. This is why, based on the discussions with the Government, the proposed AF are focusing of this first batch of the vaccine. It is envisioned that the initial vaccination program supported by the AF will become a pilot/model for a broader population-based immunization program when additional supply Sep 14, 2020 Page 9 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) provide funding for the development and deployment of the vaccination delivery program (e.g., development of guidelines and protocols, information systems, distribution, training, and additional cold chain equipment, if needed). It is envisioned that the initial vaccination effort will target the key vulnerable groups –health sector personnel, older adults, and people with increased risk of COVID-19- realted mortality. Finally, the AF will provide emergency financing to fill the budget gap for procurement of routine vaccines for measles, mumps and rubella (MMR), as well as PPE for health care staff providing vaccinations. Based on the agreement with the Government, training of ICU staff on COVID-19 management will not be financed under the parent Project and AF, since WHO is already supporting a similar activity. Component 2: Multi-sectoral Response Planning and Community Preparedness 23. Continuation: The parent Project will continue to support surge capacity for the MOHSP, including funding the consultant positions of the Strategic Emergency Response Advisor, the Strategic Communication/Development Partners Liaison Officer, and other consultants supporting the MOHSP. It will also continue providing funds for media training and financial support to the MOHSP Press Center, the national hotline, and the Republican Center for Healthy Lifestyles to conduct communication and sensitization activities around the COVID-19 pandemic. Change: Based on the success of the national COVID-19 hotline, the AF will finance its further strengthening, as well as establishment of regional COVID-19 hotlines, to provide callers with information about COVID-19 (i.e., symptoms, testing options, referrals, etc.) and information about how to access other essential health services during the pandemic. The hotlines will also be used as an additional grievance redress mechanism. The AF will finance staff time, equipment and operational costs of the hotlines, as well as increased capacity of the MOHSP server to accommodate the demand for the COVID- 19 website and its expanding content, and to ensure that the public can access it without interruptions. The development of a national communications and outreach strategy and implementation plan will not be financed, as originally envisaged, under the parent Project, because this activity is supported by UNICEF. Finally, information and messages related to COVID-19 vaccine will be included in the communication activities financed by both the parent Project and the AF. Component 3: Temporary Social Assistance for Vulnerable Households 24. Continuation: The provision of one-off emergency cash transfers to the beneficiaries identified under the parent Project and the delivery of accompanying measures – messages on optimal young child nutrition and stimulation – will continue as scheduled. Change: The AF will expand the one-off emergency cash transfer program to new beneficiary groups, such as households with children under the age of 7, female-headed households with children under the age of 16, and households with children with disabilities. Additional groups, including the poorest households of COVID-19 vaccines becomes available. It is expected that the sources of funding for such expanded immunization will be identified in 20201. Those sources could potentially include IDA financing if they are available and are requested by the Government. Sep 14, 2020 Page 10 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) regardless of whether they have children or not may also be included; the eligibility criteria for those additional groups will be defined in the Project Operations Manual (POM). The additional transfers are expected to have the same value (about USS 50 per household), will use the same delivery mechanism (the TSA9 program administered by the SASP) and follow procedures described in the POM. A small portion of the financing under Component 3 will be used to cover the administrative fees of Amonatbank; to develop and disseminate information regarding the additional cash transfers; to strengthen the TSA program based on the lessons learned from the parent Project, including developing interoperability between the TSA beneficiary database, the civil registry maintained by the Ministry of Justice, and other relevant databases; to increase capacity of the TSA servers; and to finance other capacity strengthening activities. The AF will allow the Government to provide emergency cash payments to a total of approximately 70,000 additional households. Component 4: Project Implementation and Monitoring 25. Continuation: The parent Project will continue to finance the PIU, including staff salaries and operating costs. 26. Change: The AF will finance the operating costs of the PIU, including the extension of the PIU staff contracts for the additional time period covered of the AF (see Table 1 below), as well as the cost of mobilizing short-term consultants with expertise related to oxygen supply and medical equipment. In addition, it was agreed that third-party monitoring by a Civil Society Organization (CSO) or a consortium of CSOs will be carried out to help the MoHSP enhance effectiveness and transparency of Project implementation and elicit public trust and support. The third-party monitoring will be financed through World Bank-executed resources, rather than from the AF budget. Table 1: Additional Financing Current and Proposed Cost by Component (in US$M) Current Additional Revised Component Cost Financing Total Cost Component 1. Strengthening Intensive Care Capacity 6.3 7.0 13.3 Component 2. Multisectoral Response Planning and Community 1.0 0.4 1.4 Preparedness Component 3. Temporary Social Support for Vulnerable Households 3.0 8.5 11.5 Component 4. Project Implementation and Monitoring 1.0 0.3 1.3 Total 11.3 16.2 27.5 9The TSA program, administered by SASP, is the national social-safety net program targeting the poor. Households are eligible to participate in the program based on a proxy means test. The program provides quarterly cash benefits as well as a range of non- monetary benefits, including discounted public utility fees, exemption from co-payments for health services, and others. The emergency cash transfer program financed by the parent Project uses the existing TSA infrastructure to deliver one-off emergency cash transfers to beneficiaries included in the TSA database (that is, meeting the proxy means test criteria) and meeting additional eligibility criteria based on the criteria described in the POM (for the parent Project, those include households with children under the age of 3). The emergency cash transfers are administered through a separate administrative module and are not part of the TSA program. Rather, they constitute a separate program providing a separate payment to a sub-group of TSA recipients. It is worth mentioning that the module was first developed through a collaboration between MOHSP, SASP, UNICEF, and the World Bank to provide emergency cash assistance to victims of natural disasters. However, it has never been deployed until the COVID- 19 pandemic. The one-off emergency cash transfer program financed by the parent Project and the AF is the first to be delivered through the module. Sep 14, 2020 Page 11 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) Institutional arrangements: 27. Given the satisfactory pace and quality of implementation of the parent Project to date, institutional and implementation arrangements will remain unchanged. The activities financed by the AF will be implemented by the PIU under the direction of the MOHSP. The PIU consists of MOHSP technical, fiduciary, administrative staff, and local consultants at the central level who manage implementation of Project activities, including M&E. Implementation of citizen engagement activities will be carried out by the MOHSP public relations team, in collaboration with consultant facilitators and will be funded through Project funds. Full details on operational procedures that guide Project implementation are outlined in the POM, which will be updated to include the AF activities. The financial management responsibilities for the AF will remain with the MOHSP’s PIU. The PIU has the required capacity in implementing World Bank- funded projects, is adequately staffed, and appropriate controls and procedures have been instituted. Results framework: 28. The Results Framework will be modified to reflect the changes in the scale and scope of the parent Project. The modifications will include adjustments to some of the original indicators and the addition of new ones to reflect the new activities proposed under the AF. Project duration: 29. Finally, the AF will extend the Project Closing Date from December 1, 2021 to July 31, 2022 to accommodate the additional activities, especially those related to the installation and maintenance of oxygen supply stations and related equipment. Consistency with the Country Partnership Framework (CPF): 30. The AF is consistent with CPF’s Pillar 1 (Human Capital and Resilience) objectives of improving nutrition, hygiene, and reducing the still high under-five mortality rates. The need to invest in health systems to ensure the productive capabilities of Tajik people is recognized, as is the challenge of overcoming a legacy of limited investment in human capital and social resilience systems. This AF and the parent Project were not included in the CPF; however, they respond to the unprecedented COVID-19 outbreak, which has also increased the importance and prioritization of health protection and treatment in Tajikistan. By building the strength of the health system and its resilience to shocks, it is aligned with the focus of the CPF Objective 2, which focuses on improving health services. The AF, like the parent Project, is also aligned with both global health priorities and IDA priorities on improving pandemic preparedness. . Sep 14, 2020 Page 12 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) Legal Operational Policies Triggered? No Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 Summary of Assessment of Environmental and Social Risks and Impacts . 31. The Environmental risk rating is Substantial, and the Social risk rating is Moderate, resulting in an overall Environmental and Social Framework (ESF) risk rating of Substantial. The major areas of environmental and social risks for the Project are: (a) risks related to rehabilitation of existing health care facilities; (b) risks related to medical waste management and disposal; (c) risks related to spread of COVID- 19 among health care workers; (d) risks related to the spread of COVID-19 among the population at large; (e) challenges related to the emergency cash transfers being offered to vulnerable groups; and (f) the additional risks related to establishment of PSA oxygen refilling stations at selected hospitals. These risks are covered by Environmental and Social Standards (ESS) 1, ESS 2, ESS 3, ESS 4, and ESS 10. 32. The small scale works related to oxygen supply systems installations are expected to take place on the property of existing facilities; therefore, they will be mostly locally-based activities and environmental issues (and impacts thereof) are expected to be temporary, predictable, and easily mitigable. There will be no land acquisition. 33. The more substantial risks are around ensuring contagion vectors are controlled through strict adherence to standard procedures for medical waste management and disposal; the use of appropriate PPE for all health care workers; and working with local governments and communities to ensure that social distancing measures and quarantine regimes are strictly adhered to is also vital for lowering the speed and incidence of infection. 34. The key social issues and mitigation measures taken by the parent Project, and to be followed by the AF, focus on: (a) ensuring a favorable and safe environment, complimented by the WHO training opportunities at the targeted health care facilities to avoid the spread of virus among health workers; (b) assuring proper and quick access to appropriate and timely medical services, adequate hand hygiene and PPE based on the current needs of the target health facilities; (c) anticipating and addressing issues of laborers resulting from the civil works; and (d) expanding the range of the emergency cash transfer recipients to minimize the risk of exclusion. 35. To manage these risks, the MOHSP will update two major instruments of the parent Project, the Environmental and Social Management Framework (ESMF) to include international best practices in planning, installation, and operations of oxygen systems and refill stations, and the Stakeholder Engagement Plan (SEP) to incorporate the proposed AF activities and investments to increase capacity of Sep 14, 2020 Page 13 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) the MOHSP to develop and disseminate COVID-19 risk communication messages and feedback mechanisms. The ESMF and SEP will be updated to a standard acceptable to the World Bank, consulted on, and disclosed both in-country on the MOHSP website and on the World Bank website. E. Implementation Institutional and Implementation Arrangements 36. Given the satisfactory pace and quality of implementation of the parent Project to date, institutional and implementation arrangements will remain unchanged. The activities financed by the AF will be implemented by the PIU under the direction of the MOHSP. The PIU consists of MOHSP technical, fiduciary, administrative staff, and local consultants at the central level who manage implementation of Project activities, including monitoring and evaluation (M&E). Implementation of citizen engagement activities will be carried out by the MOHSP public relations team in collaboration with consultant facilitators and will be funded through Project funds. Full details on operational procedures that guide Project implementation are outlined in the POM, which will be updated to include the AF activities. The financial management responsibilities for the AF will remain with the MOHSP’s PIU. The PIU has the required capacity in implementing World Bank-funded projects, is adequately staffed, and appropriate controls and procedures have been instituted. . CONTACT POINT World Bank Jakub Jan Kakietek Economist, Health Baktybek Zhumadil Senior Operations Officer Borrower/Client/Recipient Ministry of Finance Faiziddin Qahhorzoda Minister of Finance faiziddin@inbox.ru Implementing Agencies Sep 14, 2020 Page 14 of 15 The World Bank Additional Financing for the Tajikistan Emergency COVID-19 Project (P175168) Ministry of Health and Social Protection Saida Umarzoda Deputy Minister of Health sumarzoda@mail.ru State Agency for Social Protection Abdukhakim Kholzoda Director hakim.67@mail.ru FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Jakub Jan Kakietek Task Team Leader(s): Baktybek Zhumadil Approved By Practice Manager/Manager: Country Director: Jan-Peter Olters 25-Jan-2021 Sep 14, 2020 Page 15 of 15