The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 27-May-2021 | Report No: PIDA31628 May 26, 2021 Page 1 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Zambia P176400 Additional Financing for P174185 the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project Parent Project Name Region Estimated Appraisal Date Estimated Board Date Zambia COVID-19 Emergency AFRICA EAST 02-Jun-2021 25-Jun-2021 Response and Health Systems Preparedness Project Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Republic of Zambia Zambia National Public Financing Health Institute (ZNPHI) Proposed Development Objective(s) Parent The project development objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 in Zambia and strengthen national public health systems for preparedness. Components Emergency Public Health Response to COVID-19 Resilient Health Service Delivery Project Management, Operational Research, and Governance and Accountability PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 24.00 Total Financing 24.00 of which IBRD/IDA 14.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing May 26, 2021 Page 2 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) International Development Association (IDA) 14.00 IDA Credit 14.00 Non-World Bank Group Financing Trust Funds 10.00 Global Financing Facility 10.00 Environmental and Social Risk Classification Substantial B. Introduction and Context Country Context 1. This Project Information Document outlines the proposal for an Additional Financing (AF) to the Zambia COVID- 19 Emergency Response and Health Systems Preparedness Project (P174185). The AF will support the cost of expanding activities of the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project 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 vaccine AF to the SPRP approved on October 13, 20201. The primary objectives of the AF are: (a) to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccine deployment in Zambia through vaccination system strengthening, and (b) to further strengthen preparedness and response activities under the parent project. In addition to US$25 million under the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project, the AF will provide a US$14 million credit from the International Development Association (IDA) and a US$10 million grant from the Global Financing Facility for Women, Children and Adolescents (GFF). 2. The need for additional resources to expand the COVID-19 response was formally conveyed by the Government of Zambia in February and March 2021. The Government requested US$14 million IDA and US$10 million GFF AF on February 1, 2021 and March 16, 2021, respectively, to purchase and deploy COVID-19 vaccines that meet the World Bank’s vaccine approval criteria (VAC). This includes strengthening the cold chain network and vaccine transportation infrastructure, and risk communication on vaccine introduction. In addition, the GFF grant will finance maintenance of essential reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH-N) services to avert increasing morbidity and mortality resulting from their disruption, which can have a severe impact on broader health outcomes. The GFF grant will not finance purchase of vaccines. The proposed AF will form part of an expanded health response to the pandemic, which is being supported by development partners (DPs) under the coordination of the Government of Zambia. The AF will provide essential resources to enable the expansion of a sustained and comprehensive pandemic response that will include vaccination and continuity of essential RMNCAH-N services in the country. 1The World Bank approved a US$12 billion 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 health care delivery system. May 26, 2021 Page 3 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) 3. COVID-19 has exacerbated Zambia’s pre-existing health burden and macroeconomic vulnerabilities. While Zambia has implemented an effective nationwide response since the first case of COVID-19 was recorded on March 18, 2020, two waves of widespread infections have taken place. The first wave of COVID-19 cases in Zambia peaked in July 2020 which was followed by a second wave of infections between December 2020 and March 2021. The number of confirmed COVID-19 cases and deaths in the second wave surpassed the levels in November 2020 by about 408 and 209 percent, respectively. As of May 26, 2021, the cumulative number of COVID-19 confirmed cases and deaths were 93,627 and 1,273, respectively. The South African COVID-19 variant (501Y.V2) characterized by high transmissibility, geographical spread, disease severity (requiring hospitalization and oxygen therapy), and death was at the center of the second wave. Towards the end of February 2021, the number of cases started to decline, and the second wave of infections has abated. However, a much higher surge in infections and deaths is likely in Zambia due to the upcoming presidential, parliamentary and local government elections in August 2021; and Zambia’s central location in Southern Africa which serves as a transit and destination point for traders, migrants, immigrants, and asylum seekers. Furthermore, given the low capacity in pandemic preparedness and response, and widespread disregard of public health measures to combat the COVID-19 in Zambia, the risk of increased escalation of the disease is very high. In addition, a highly contagious Indian variant B.1.617 was identified in a traveler from Indian to Zambia about mid-May 2021. 4. The pandemic has led to a decline in the utilization of essential health services, particularly RMNCAH-N services. This can be attributed to focus on the COVID-19 as compared to other essential services, reduced financing for essential health services (especially for drugs and routine vaccines for child immunization), and low demand for health services. Results from routine in-country data show substantial and persistent reductions in the utilization of essential health services between March and September 2020 ranging from 4 percent to 15 percent. This includes a decline in outpatient consultations, family planning visits, institutional deliveries, first postnatal care visits, and first dose vaccination of children against measles.2 Continued focus on COVID-19 is also likely to skew service provision towards the urban areas and deepen pre-existing geographical inequities in service provision. Henceforth, strengthening the health system to sustain the provision of essential RMNCAH-N services during the COVID-19 pandemic is critical to slowing the transmission of the disease and accelerating economic and social recovery in Zambia. These essential services include, inter alia, care for small and sick newborns, monitoring, maintenance of routine immunization, strengthened human resource capacity, and improved infection and prevention control. Sectoral and Institutional Context 5. Zambia has prepared and costed a national vaccination and deployment plan (NVDP). The NVDP was adopted by the inter-agency committee for RMNCAH-N3 on March 26, 2021 and has been approved by the Gavi/COVAX regional review committee. The NVDP defines the immunization strategy and identifies human resource needs for each of the five planned immunization phases. The NVDP further identifies additional key areas which need strengthening to optimize vaccine delivery and use. This includes personal protective equipment (PPE), medical and other supplies, waste management, community engagement and advocacy, vaccine safety surveillance, data quality, and infrastructure enhancements. It also contextualizes WHO’s guidelines on the allocation and prioritization of populations for COVID-19 vaccination. In this regard, about 46 percent of the population has been targeted for vaccination by the end of 2022 2 World Bank Development Research Group and the Global Financing Facility. 2020. Preliminary estimates from an analysis of routine data to monitor essential health services in times of COVID-19 3 Membership of the inter-agency committee for RMNCAH-N is drawn from the Ministry of Health, Ministry of Finance and other government ministries, development partners, representatives of civil societies, and the private sector. May 26, 2021 Page 4 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) depending on the availability of resources and manufacturers’ production capacity. Twenty-five percent of the population is expected to be vaccinated during phase 1 (by end-2021) with support from COVAX and the World Bank. Among others, the priority groups are essential health care workers and support staff, personnel maintaining core societal functions, persons at risk of severe illness population and death, and populations in congregate settings. 6. Zambia has leveraged existing Expanded Program on Immunization (EPI) structures with adjustments and enhancements for COVID-19 vaccination. This includes preparation of micro-plans, materials, and procedures for various levels of the healthcare delivery system; guidelines and process for regulation and approval of vaccines in the country; drafting vaccine deployment strategies across the vaccine implementation chain (prioritization, distribution, surveillance, and digital health innovations); and estimating resources required to ensure equitable vaccine distribution. The vaccine delivery options include using existing vaccination structures (health facilities and outreach centers) through the EPI and specialized clinics for those with co-morbidities. However, the adequacy of human resources to support deployment of vaccines throughout the five tiers of the NVDP remains a concern. Additional staff will need to be recruited, trained, and engaged at the national and subnational levels for the deployment of COVID-19 vaccines. Furthermore, considering the uncertainties related to the COVID-19 vaccine market, effectiveness of the strategies for the deployment of COVID-19 vaccines will continually be assessed and revised as necessary to achieve effective implementation. 7. The country is putting in place an institutional framework for the safe and effective deployment of vaccines and capacity to strengthen the provision of essential health services. This includes: (i) ensuring voluntary and informed vaccination practices; (ii) regulatory standards for vaccine quality; (iii) guidelines for acceptable minimum standards for vaccine management, including climate-friendly cold chain infrastructure; and (iv) policies to ensure robust governance, accountability, pharmacovigilance, and citizen engagement mechanisms. The project operational documents will make it 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. To sustain the provision of essential health services, a RMNCAH-N Investment Case is currently being prepared. The draft document includes strategies on maternal and newborn intrapartum service quality; emergency obstetric care and safe surgery; integration of immunization with other preventive, curative and rehabilitative services; and prevention and treatment of cases associated with gender- based violence. C. Proposed Development Objective(s) Original PDO The project development objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 in Zambia and strengthen national public health systems for preparedness. Current PDO The project development objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 in Zambia and strengthen national public health systems for preparedness. Key Results (i) Percentage of identified close contacts of confirmed COVID-19 cases investigated based on national guidelines (by gender). (ii) Number of designated laboratories with SARS-CoV-2 diagnostic capacity (Number). (iii) Percentage of population vaccinated, which is included in the priority population targets defined in national plan (by gender). May 26, 2021 Page 5 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) (iv) Number of designated health facilities with COVID-19 case management capacity. D. Project Description 8. The AF will provide upfront financing to help the government 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 a successful deployment and to prepare for future pandemics. The support will include: Procurement of vaccines to vaccinate 5 percent of Zambia’s population; Deployment costs of World Bank financed vaccines plus deployment costs associated with vaccinating 20 percent of the population using vaccines from COVAX Advance Market Commitment(AMC) and other COVID-19 vaccines meeting the World Bank VAC that will be made available during the life of the project; Improved diagnostics in genomic sequencing and surveillance; and Expanded activities of the COVID-19 response which are essential to protect lives. The GFF grant co-financing will further leverage the opportunity to strengthen COVID-19 related systems for deployment of vaccines, including strengthening health systems to address disruption of essential reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) services, but will not support COVID-19 vaccine purchase. The World Bank financing for the COVID-19 vaccines and their deployment will follow the World Bank’s VAC. Vaccines will be provided by the Government of Zambia free of cost. 9. The proposed changes include: 1) Components and cost: (i) Sub-component 1.1 has been split into two namely, Sub-component 1.1(a) COVID-19 Surveillance, Case Investigation and Rapid Response Capacity, and Sub-component 1.1(b) Vaccine Introduction. o The following activities have been dropped under Sub-component 1.1: (a) establishment of operation of the central and provincial Public Health Emergency Operation Centers (PHEOC) (b) support to the PHEOC including strengthening the call response center; (c) Disease surveillance activities as part of IDSR through: (i) the development/updating of surveillance protocols; (ii) establishment of Influenza-Like Illnesses and Severe Acute Respiratory Infections (ILI/SARI) sentinel sites; (iii) capacity building in surveillance, including the training of community volunteers in event-based surveillance in high-risk districts, and training of staff in the IMS, epidemic preparedness and response; and (iv) disease surveillance information systems, including data audit; (d) assessment of the implementation of International Health Regulations including related operational costs for all activities to release US$2.3 million to support scale up of proposed priority case management interventions that have been informed by lessons learned during implementation of Zambia’s COVID-19 response second wave and reallocation of these resources to component 2 under case management. The dropped activities will be funded under the ACDCP (P167916). o The following activities will continue to be supported under the parent project: (i) coordination of COVID-19 response at national and subnational levels; (ii) COVID-19 risk assessments to identify high-risk areas, events and population groups; (iii) rapid response teams to conduct contact tracing for COVID-19 and emergency response vehicles; and (iv) establishment/rehabilitation of quarantine facilities for suspected COVID-19 cases; (ii) Specific changes under each component include: a. Component 1 o Procurement of COVID-19 vaccine. o Strengthening of systems for vaccine deployment, including distribution and administration of the COVID-19 vaccine. o Enhanced capacity for genomic sequencing and surveillance. May 26, 2021 Page 6 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) o Expanded risk communication and community engagement to overcome vaccine/brand hesitancy and maintain demand for essential services. b. Component 2: o Reallocation of funds from Component 1 to expand oxygen production and strengthen delivery systems for medical oxygen therapy; and expansion of isolation health facilities/wards. o Expansion of IPC including strengthening WASH in healthcare facilities and health care waste management. o Expansion of activities to strengthen capacity to ensure continuity of essential health services. c. Component 3 o Establishment and operational costs of a sub-PIU in the MOH for implementation of vaccine introduction. o Enhancing digital health solutions such as the DHIS2 COVID-19 vaccine delivery tool kit including expansion of Logistimo functionality up to the vaccination sites. o Enhancing platforms for third party monitoring. 2) Results framework: The results framework is being revised to add new indicators for the proposed AF and dropping or modifying original indicators to capture new activities. 3) Institutional and implementation arrangements: These will be adjusted to reflect the shift in the Implementing agency and changes to the project implementation arrangements and oversight structures. 4) Disbursement Arrangements. Creation of an operational account in MOH to finance operation costs for vaccine deployment and maintenance of essential RMNCAH-N services 5) Closing date: The closing date of the parent project will be extended by one year from December 31, 2022 to December 31, 2023. The extension is necessitated by: (i) consideration of the implementation timeline of the NVDP which proposes to vaccinate 21 percent of the rest of the population (18 years and older) under Phase 2, given the uncertainties related to the availability of vaccines globally and their efficacy against new variants of the virus, and (ii) to allow for implementation of activities to be supported by the additional US$10 million GFF grant 1. Component 1: Emergency Public Health Response to COVID-19. US$23.85 million equivalent: US$18.98 million IDA (US$5.98 million parent project; US$11.50 million AF); US$ 4.87 million GFF (US$2.07 million GFF parent project; US$ 2.80 million Additional Grant). (i) Sub-component 1.1(a): COVID-19 Surveillance, Case Investigation, and Rapid Response Capacity. US$2.20 million equivalent: US$1.80 million IDA (parent project after reallocation US$1.00 million; AF Allocation; US$1.00 million AF); US$ 0.2 million additional GFF. The AF under this sub-component will finance: Expansion of emergency response activities including: (i) Enhancing COVID-19 hotlines, sensitive to the unique needs of vulnerable and marginalized populations as well as gendered roles and responsibilities, and social norms in a multicultural society; (ii) SMS to provide callers with information about COVID-19 vaccination, referrals, and information about how to access other essential health services during the pandemic, including serving as an additional channel for grievance redress; (iii) Supporting short term staff requirements, equipment, operational costs for hotlines and call centers, and PPE for health care staff providing vaccinations; (iv) Related operational costs for supervision and coordination, given the need for extensive coordination between national and local May 26, 2021 Page 7 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) authorities and the multidisciplinary participation required in the implementation of the vaccination strategy; and (v) Operating costs for mobilizing additional short-term consultants who will support vaccine deployment. (ii) Subcomponent 1.1(b): Vaccine Introduction. US$13.50 million equivalent: US$11.50 million AF, US$ 2.0 million additional GFF. The AF under this sub-component will finance: (1) Procurement of COVID-19 vaccines for 5 percent of the total population including vaccination supplies and other ancillary products. The Subcomponent 1.1(b)(1) will only be financed by IDA. (2) Deployment of COVID-19 vaccines funded by both the World Bank and the COVAX AMC and other vaccines that meet the World Bank VAC criteria including: (i) Procurement of climate-friendly cold chain equipment such as cold boxes, climate friendly fridges, assorted spares for cold chain equipment and strengthening of the cold chain network; (ii) Maintenance of existing cold chain equipment; (iii) Procurement of 15 ton containerized fuel-efficient or alternative fuel trucks, vehicles and motorcycles, as well as low-emission transportation such as bicycles and marine transport for transportation of vaccines; (iv) Training in vaccine management and deployment, cold chain management, and climate disaster management at national and subnational levels; (v) Printing, dissemination and distribution of stock control cards, guidelines, protocols, and SOPs for the COVID-19 vaccine. (3) Support to infrastructural security enhancements for the COVID-19 vaccine during storage, in transit and at vaccination sites: (i) Installation of CCTV systems at points of entry and national storage warehousing; (ii) Expansion of Logistimo up to the district level; (iii) Installation of GPS trackers in vaccine transportation vehicles including strengthening communication systems in transit; (iv) Security doors and installing burglar bars on windows and CCTV for storage facilities at provincial and district levels; (v) Bridging transport gaps for the last mile vaccine distribution system; and (vi) Training of drivers on transportation of COVID vaccines including related security issues. (4) Support the design and deployment of digital health platforms including implementation of the DHIS2 COVID-19 vaccine delivery tool kit. This will support digitalization of vaccine introduction throughout the service delivery supply chain to: (i) Register vaccine population target groups, track immunization, and reporting to avoid elite capture; (ii) Digitalize stock control cards for vaccines and linking to the Logistimo system; (iii) Digitalize pharmacovigilance as well as post vaccination surveillance of any AEFI; (iv) Vaccination certification; and (v) The GRZ’s long-term investment in digitalization of information systems and telemedicine. (iii) Sub-component 1.2: Laboratory Capacity and Specimen Transport. US$3.83 million equivalent: US$2.78 million IDA (US$2.48 million parent project; US$ 0.30 million AF); US$1.05 million GFF parent project). The AF will finance: (i) Genomic sequencing and phylogenetic analysis for SARS-CoV- 2 to understand the changing disease trajectory; (ii) Enhanced laboratory capacity for genome testing in three selected laboratories, including procurement of reagents; (iii) Training of laboratory technicians in genomic sequencing; and (iv) Specimen transportation and related operational costs. (iv) Sub-component 1.4: Risk Communication and Community Engagement. US$2.65 million equivalent: US$1.03 million IDA (US$0.83 million parent project IDA, US$0.20 million AF); US$1.62 million GFF (US$1.02 million parent project GFF; US$0.60 million additional GFF). The AF under this subcomponent will finance: (i) Printing, dissemination, and implementation of the communication strategy and related operational cost; (ii) SBCC to facilitate uptake of the COVID-19 vaccine, address vaccine hesitancy, enhance preparedness for vaccination against other climate-related diseases, and May 26, 2021 Page 8 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) implement sub-national awareness of COVID-19 vaccine campaigns. SBCC will also take into account vaccines related misinformation (e.g. misconceptions about vaccines causing fertility problems, stigmatization of workers administering vaccines, immunization information for pregnant women, focusing on the acceptance of the vaccine among women), and implement sub-national awareness of COVID-19 vaccine campaigns; (iii) Development and implementation of SBCC messages and materials for RMNCAH-N services; (iv) Putting in place comprehensive risk registers and mitigation measures to address identified risks during implementation of the NVDP; and (v) Procurement of suitable PPE for frontline health workers in the community and community volunteers conducting house-to-house visits under the project. 2. Component 2: Resilient Health Service Delivery. US$21.15 million equivalent. (US$11.72 million IDA {US$9.22 parent project, US$2.3 million reallocation, US$0.2 million AF IDA}; US$9.43million {US$2.93 million GFF parent project; US$6.50 million additional GFF}). (a) Sub-component 2.1: Case Management US$9.49 million equivalent: US$6.91 million IDA (US$4.61 million parent project; US$2.3 million reallocation); US$2.58 million (US$0.58 million GFF parent project; US$2.0 million additional GFF). The GFF additional grant and reallocation of US$2.3 million from sub-component 1.1 to this sub-component will finance: (i) Expansion of the oxygen production capacity and delivery system, and ensuring enough oxygen concentrators, cylinders, and other related accessories for management of critically ill patients; (ii) Expansion of isolation facilities and wards that are well equipped, with functional oxygen delivery systems including procurement of PPEs and other medical supplies; (iii) Recruitment of short-term skilled human resources for health to fill the gap in emergency and isolation facilities and intensive care units (ICUs) including provision of hazard allowance for male and female health workers in these facilities and ICUs; (iv) Production of blood and blood components (red cells, platelets, fresh frozen plasma, cryoprecipitate) as part of support for a sustainable blood supply system. (b) Sub-component 2.2. Infection Prevention and Control. US$5.08 million equivalent: US$2.97 million IDA (Parent IDA US$2.77 million, US$0.2 million AF IDA); US$2.11 million GFF (US$0.61 million GFF parent project; US$1.50 million additional GFF). The AF will finance: (i) Expansion of IPC in all health facilities, including but not limited to those where COVID-19-related services are delivered; (ii) Access to safe water and sanitation and setting up of functional hand hygiene in health facilities and for all health care workers at all points of care; (iii) Safe management of general health care waste; and (iv) Management and disposal of health care waste from the COVID-19 vaccination program. (c) Sub-component 2.3: Strengthening Capacity for Essential Services Continuity. US$6.58 million equivalent: (US$1.84 million IDA; US$1.74 million GFF parent project); US$3.0 million additional GFF. The additional grant will support expansion of activities to ensure continuity of essential health services and strengthen health system resilience in the face of diverse stresses, including the COVID- 19 pandemic. This work will also support emerging priorities in the RMNCAH-N Investment case under preparation. It is anticipated that further resource mobilization among all stakeholders supporting these efforts will be required. Expanded activities will include: (i) Improving maternal and newborn intrapartum service quality, through establishment of provincial-level specialized intrapartum care units and newborn special care units; (ii) Contributing to the strengthening of emergency obstetric care and safe surgery, including procurement of equipment and training of anesthetists in targeted provinces; (iii) Building on the work completed under a Bank Executed Trust Fund (BETF) as part of the GFF-facilitated Service Delivery Learning Program; (i) Implement SOPs for safe delivery of essential May 26, 2021 Page 9 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) services in the COVID-19 context and the revised RMNCAH-N monitoring and evaluation (M&E) framework; (v) Piloting digitalization of civil registration and vital statistics (CRVS) (birth and death) indicators at provincial and district hospital level; (vi) Building capacity of health providers to use innovative technologies and approaches including competency-based pre- and in-service training, as well as digital health tools for supportive supervision; (vii) Strengthening integration of immunization with other preventive, curative and rehabilitative services, such as those for family planning, non- communicable diseases, HIV, and TB; and (viii) Strengthening prevention and treatment of Gender- Based Violence (GBV) and addressing gender gaps in service delivery. 3. Component 3: Project Management, Monitoring and Evaluation, Operational Research, and Governance and Accountability. US$4.00 million equivalent. US$3.3 million IDA (US$2.5 parent project IDA; US$0.8 million AF); US$ 0.7 million Additional GFF grant. a. Sub-component 3.1: Project Management, M&E and Operational Research. US$2.60 million equivalent: (US$2.0 million parent project IDA; US$0.6 million additional GFF). The AF under this sub-component will finance: (i) Establishment of a sub-Project Implementation Unit (S-PIU) in the MOH department of Public Health with relevant PIU staff to support the implementation of the COVID-19 vaccine introduction as well as continuity of essential services; (ii) Polling and rapid surveys to monitor population and health worker perception of vaccine and vaccine brands. Sub-component 3.2: Strengthening Governance and Accountability in the Implementation of the National COVID-19 Response Plan. US$1.4 million equivalent: US$1.3 million IDA (US$0.5 million parent project; US$0.8 million AF); US$0.1 million additional GFF. The AF will support third party monitoring for vaccine deployment to ensure equal access to the COVID-19 vaccine and the DHIS2 vaccine delivery tool kit roll out. . 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 . The activities associated with the Additional Financing will complement the positive impacts of the parent project by facilitating COVID-19 containment, reducing COVID-19 related hospital admissions, and procuring and deploying vaccines. The environmental, community and occupational health and safety impacts and risks associated with this AF project are from the generation of additional COVID-19 related healthcare waste, healthcare workers involved in handling and administering vaccines, those working in the healthcare waste stream, logistical workers involved in the cold storage chain and loss or spoiled vaccines due to mismanagement, refrigeration equipment breakdown, theft and poor vaccine handling and transportation practices. The wider risks to the community are from handling, transport and disposal of vaccine May 26, 2021 Page 10 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) associated healthcare waste. At this stage, the AF does not plan to increase the capacity of healthcare infrastructure to accommodate vaccine centers or require additional refrigerated storage. Improved health care waste management under the parent project should reduce the risks to workers and the communities. However, close monitoring of the implementation of these improvements is required if legal compliance and effective risk management is to be realized. Adequate training and equipping of healthcare workers is required to control risks from exposure to COVID-19, ensure testing and handling of supplies, and improve healthcare waste management. Environmental risks and impacts within the cold chain storage are likely to be from emissions of CFCs and HFCs from poorly maintained or obsolete refrigeration equipment and from vaccine wastage because of the unavailability of climate control vehicles, technical failures in temperature and coolant, human error, road infrastructure and accessibility health care facilities and rural areas, vaccine accountability and tracking of deliveries and shipments, etc. The MOH intends to use existing vaccine supply chains from the port of entry to the vaccination centers. The MOH is well practiced in vaccination roll out programs and, therefore, many of the identified risks could be adequately addressed using existing processes and procedures. In any event, the ESMF will be updated to ensure a full coverage of mitigation measures to address all of the identified risks. Social risks associated with the AF include elite capture due to the limited number of COVID-19 vaccine doses to be procured, and the exclusion of vulnerable groups such as persons living with disabilities, the elderly, those with co- morbidities and refugees from accessing vaccines. The risk of exclusion is attributed to vulnerable groups being in the low income bracket with limited financial capacity to access health services; distance to health facilities due to remoteness particularly rural areas that are characterized by poor road infrastructure which may affect transportation of vaccines; and lacking accurate information on roll out of vaccinations and not having a full appreciation of the eligibility criteria for vaccines. The risk of community resistance to vaccination may potentially affect the successful implementation of the planned intervention. Existing social norms, religious beliefs, previous adverse or unwanted reactions to vaccination and misinformation could be detrimental for the project and may result in fear and lack of trust in the process among target populations. Community and health and safety maybe compromised due to improper handling, transportation and disposal of vaccine associated healthcare waste. Risk of military use is low as the roll out of vaccines will be managed by trained health personnel within MOH. GBV/SEA/SH measures under the parent will apply. No civil works are envisaged on the project. May 26, 2021 Page 11 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) E. Implementation Institutional and Implementation Arrangements The implementation arrangements for the AF are adjusted to reflect the shift in the implementing agency from MOH to the Zambia National Public Health Institute (ZNPHI) following the enactment of the ZNPHI Act No. 19 of 2020. The Director of ZNPHI will be responsible for the coordination, implementation and management of the parent project and the AF. The coordination and implementation arrangements of both parent project and AF will remain integrated under the PIU of the Africa CDC Regional Investment Financing Project (ACDCP; P167916) within ZNPHI. Under the AF, a sub project implementation Unit (S-PIU) will be established to coordinate and manage the COVID-19 vaccine introduction and maintenance of the delivery of essential RMNCAH-N services within the Department of Public Health. The Permanent Secretary for Administration and the Permanent Secretary for Technical Services will be responsible for managing project activities under the S-PIU, in line with their respective administrative mandates. The S-PIU will be led by a designated Immunization Expert who will report to the Director, Public Health on technical aspects of vaccine introduction and to the Project Manager for the parent and AF project on project operational related matters. Other designated project members will include: a Cold Chain and Logistics Officer, Monitoring and Evaluation Officer, Accountant, and RMNCAH-N Specialist. Country Steering Committee (CSC). The overall mandate of the CSC to provide oversight for all World Bank supported projects in pandemic preparedness and response will remain the same under the AF. Zambia’s Incident Management System (IMS), a standard practice for responding to outbreaks or public health emergencies, has been expanded to include the COVID-19 vaccination program. The ICC for RMNCAH-N will provide overall technical guidance on COVID-19 vaccine introduction and implementation. The committee will be responsible for resource mobilization and coordinating partner financing; reviewing and endorsing proposals for vaccination; supporting the roll-out of COVID-19 vaccines, evaluation and monitoring of the vaccination program. The EPI Committee has been expanded to include non-traditional immunization stakeholders for the COVID-19 vaccine introduction. The EPI Committee is responsible for coordinating the vaccine deployment readiness and capacity assessments, planning, prioritization, targeting and coordinating the overall COVID-19 immunization response. The committee is also responsible for ensuring development, costing, monitoring implementation, and evaluation of the NVDP. The Zambia Immunization Technical Advisory Group. This is an existing committee comprising relevant expertise to provide evidence-based recommendations and policy guidance related to COVID-19 vaccine deployment and immunization generally in Zambia. . CONTACT POINT World Bank May 26, 2021 Page 12 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) Musonda Rosemary Sunkutu Senior PHN Specialist John Bosco Makumba Senior Operations Officer Borrower/Client/Recipient Republic of Zambia Mukuli Chikuba Permanent Secretary -Economic Management and Finance Mukuli.Chikuba@grz.gov.zm Implementing Agencies Zambia National Public Health Institute (ZNPHI) 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 Musonda Rosemary Sunkutu Task Team Leader(s): John Bosco Makumba Approved By Practice Manager/Manager: Country Director: Sahr John Kpundeh 28-May-2021 May 26, 2021 Page 13 of 14 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) May 26, 2021 Page 14 of 14