ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK FOR RWANDA COVID-19 EMERGENCY RESPONSE PROJECT OCTOBER 2020 1 Contents 1. Introduction ...................................................................................................................................... 5 1.1. Background ............................................................................................................................... 5 1.2. Development Objectives ........................................................................................................... 6 1.3. Rationale of the ESMF ............................................................................................................... 6 1.4. Purpose of the ESMF ................................................................................................................. 7 1.5. Scope of the ESMF .................................................................................................................... 7 2. Project Description............................................................................................................................ 8 2.1. Project Components ................................................................................................................. 8 2.2. Eligibility criteria for exclusion of subprojects ........................................................................ 10 2.3. Environmental and Social Screening of Subprojects............................................................... 11 3. Policy, Legal and Regulatory Framework ........................................................................................ 13 3.1. National Environmental Legislation and Regulatory Framework ........................................... 13 3.2. Rwanda EIA process ................................................................................................................ 16 3.3. International Conventions ...................................................................................................... 16 3.4. The World Bank Environment and Social Framework ............................................................ 18 4. Environmental and Social Baseline ................................................................................................. 23 4.1. Ports of Entry ............................................................................................................................... 24 4.2. Priority Communities ................................................................................................................... 25 4.3. Rwanda Healthcare System ......................................................................................................... 26 COVID-19 Associated Waste Management requirements.................................................................. 27 5. Potential Environmental and Social Risks and Mitigation .............................................................. 32 5.1. Planning and design stage....................................................................................................... 32 5.2. Construction stage .................................................................................................................. 34 5.3. Operational Stage ................................................................................................................... 36 5.4. Decommissioning Stage .......................................................................................................... 49 6. Institutional Arrangements, Responsibilities and Capacity Building .................................................. 54 6.1. Institutional arrangements, roles and responsibilities ................................................................ 54 6.2. Capacity building .......................................................................................................................... 56 7. Procedures to Address Environmental and Social Issues ............................................................... 59 7.1. Environmental and Social Screening of Subprojects............................................................... 59 7.2. National EIA requirement ....................................................................................................... 59 2 7.3. Review, Clearance, Public Disclosure and Consultation ......................................................... 61 7.4. Labor Management Procedures ............................................................................................. 62 7.5. Stakeholder Engagement ........................................................................................................ 72 7.6. Stakeholder Engagement Plan ................................................................................................ 76 7.7. Implementation and monitoring of E&S plans and instruments ............................................ 80 I. Annexes, Abbreviations and Acronyms .......................................................................................... 82 II. Screening Template for Potential Environmental and Social Issues............................................... 83 III. Environmental and Social Management Plan (ESMP) Template ................................................ 89 IV. Infection Control and Waste Management Plan (ICWMP) Template....................................... 120 V. Code of Conduct for Contractors and workers hired under the Rwanda COVID-19 ERP ............. 131 VI. Resource List: COVID-19 Guidance ........................................................................................... 140 VII. Chance find procedure.............................................................................................................. 142 VIII. VC Stakeholder Consultation Oct 16 2020 – Chat registration record ..................................... 145 IX. DHSOs/EHOs/C-EHOs Consultation Oct 12-15, 2020 .............................................................. 148 3 FIGURES Figure 1 EIA Procedure in Rwanda according to current legislation of March 2020. ................................ 16 Figure 2 Rwanda COVID-19 Incident Management & Coordination Structure. Source: RBC, March 2020. .................................................................................................................................................................... 23 Figure 3 Rwanda’s main ports of entry Secondary Cities and HCFs (District, Provincial and Referral Hospitals and Health Centers) .................................................................................................................... 25 Figure 4 Flow if medical waste management and responsible officers at the hierarchical HCF levels (MWMP, 2020)............................................................................................................................................ 28 Figure 5 Decommissioning process............................................................................................................. 50 Figure 6 Rwanda COVID-19 ERP Implementation arrangements for the ESF instruments including ESMF and SEP........................................................................................................................................................ 55 Figure 7 Grievance Redress Mechanism for the Rwanda ERP .................................................................... 79 TABLES Table 1 Rwanda COVID-19 eligibility criteria questionnaire for subproject/activity exclusion .................. 11 Table 2 Key policy, legislation and regulations relevant to the Rwanda COVID-19 ERP ............................ 13 Table 3 Summary of International Conventions and applicability to the RWANDA COVID-19 ERP ....... 17 Table 4 Rwanda stats of non-community entries for 2019 by neighboring country and hours of operation (Directorate General of Immigration and Emigration, 2019) ..................................................................... 24 Table 5 Medical Waste quantities generated annually in 35 HCFs............................................................. 27 Table 6 Health care waste treatment and disposal as per level of HCF ..................................................... 29 Table 7 Minimum requirements for safety during the decontamination phase ........................................ 51 Table 8 MoH trainings carried out under the implementation of the EVD Preparedness and Response Plan ............................................................................................................................................................. 56 Table 9 Key competencies of personnel designated to supervision of the implementation of this ESMF for Rwanda COVID-19 ERP .......................................................................................................................... 57 Table 10 Training activities featured in the COVID-19 National Preparedness and Response Plan........... 58 Table 11 Summary of key issues raised by stakeholders ............................................................................ 73 Table 12 Stakeholder engagement plan in compliance with ESS10 using the Rwanda RCCE plan methods .................................................................................................................................................................... 76 4 1. Introduction This Environmental and Social Management Framework (ESMF) assists the Borrower in identifying the type of environmental and social assessment that should be carried out for World Bank-supported Rwanda COVID-19 Emergency Response Project (P173855) and its additional financing (P175252) that involves the construction, expansion, rehabilitation and/or operation of healthcare facilities in response to COVID-19, and in developing the environmental and social (E&S) management plans in accordance with the World Bank’s Environmental and Social Framework (ESF). The World Bank is providing support to Government of Rwanda (GoR) for preparedness planning to provide optimal medical care, maintain essential health services and to minimize risks for patients and health personnel (including training health facilities staff and front-line workers on risk mitigation measures and providing them with the appropriate protective equipment and hygiene materials). As COVID-19 places a substantial burden on inpatient and outpatient health care services, support will be provided for a number of different activities, all aimed at strengthening national health care systems. 1.1. Background The coronavirus pandemic poses serious economic and public health threats to Rwanda. Rwanda was in the middle of an economic boom prior to the COVID-19 pandemic. Economic growth exceeded 10 percent in 2019 driven mostly by large public investments for implementation of the National Strategy of Transformation. Strong growth was expected to continue in 2020. The global pandemic has disrupted international flows of goods and services with significant spillovers to the broader global economy. Exports and tourism are taking a strong hit amid disruption in international trade and travel. Rwanda is already feeling mounting balance of payment and fiscal pressures. This could negatively impact the provision of public health services with respect to COVID-19 response and preparedness capacity as well as adversely affect the provision of other essential health service delivery in Rwanda, as healthcare workers and fiscal resources are redirected to the emergency response. Rwanda is at high risk of transmission of the coronavirus and as of June 2020 had about 750 confirmed cases, as of October 18, 2020 there were 4,974 cases (as per RBC statistics). The risk of community transmission remains substantial given that infected individuals can be asymptomatic and transmit the disease; the country has a high population density; and a sizable proportion of the population in Kigali lives in unplanned settlements. The government of Rwanda has demonstrated high-level leadership and taken swift action to tackle the risks associated with the ongoing pandemic and bend the curb on COVID-19. The effort to contain the potential spread of COVID-19 is led by the Office of the Prime Minister under the National Epidemic Preparedness & Response Committee (NEPRCC), in collaboration with the Ministry of Health, Ministry of Local Government and Ministry of Foreign Affairs. The government put in place a mandatory national lock down policy on March 21, 2020 which was in effect for two weeks and extended for another two weeks. This included border closings and stringent social distancing policies (e.g. closing schools, churches, and bars; postponing conferences, mandating home-based work) and banning motorcycle drivers from carrying passengers. All commercial passenger flights to and from Rwanda were suspended on March 20, 2020, but some have been reinstated since Aug 1 2020. The government has taken several other complementary actions to enhance preparedness. Authorities have conducted a risk assessment which highlighted key risk factors for importation of the coronavirus into the country. The Ministry of Health has expeditiously activated its Emergency Operation Centre and has established a Coronavirus National Taskforce to coordinate the national response. Rwanda has strengthened surveillance at all entry points; placed a high alert among health care workers and strengthened community- 5 based disease surveillance. The government is promoting handwashing best practices with President Kagame taking part in the ‘Safe Hands’ challenge to encourage the public to emulate these behaviors. The country has recently benefited from a grant contribution of testing kits from Jack Ma Foundation that will help in quickly initiating testing with distribution through the Africa CDC which is managing the continental COVID-19 response and stockpiling of critical commodities. Government of Rwanda (GoR) requested financing for this COVID-19 support project because of the high- level political commitment in Rwanda to protect public health, invest early, and avert the high socio- economic costs associated with disease outbreaks and global pandemics. The Project objectives are aligned to the results chain of the COVID-19 Strategic Preparedness and Response Program (SPRP). This project was selected for COVID-19 immediate financing because of the high-level political commitment in Rwanda to protect public health, invest early, and avert the high socio-economic costs associated with disease outbreaks and global pandemics. The objectives and components are fully aligned with the COVID-19 Fast Track Facility guidelines. The project is expected to complement activities to be supported by the government and other development partners. The focus is on supporting the COVID-19 National Preparedness and Response Plan, assisting Rwanda to respond swiftly to confirmed cases. The project is also aligned with the guiding principles for the COVID-19 national plan, such as: (i) recognizing that prevention and control of COVID-19 is a global public good with spillover effects for all countries, requiring strong financial contributions at the national and international level (which aligns well with the WBG coronavirus facility); (ii) underscoring the need to leverage existing institutions, draw on scientific evidence, and adopt innovative digital solutions; and (iii) acknowledging the importance of strengthening overall national disease prevention and emergency response capacity. 1.2. Development Objectives The Project Development Objective (PDO) is to prevent, detect and respond to the threat posed by COVID- 19 and strengthen national systems for public health preparedness in Rwanda. The specific objectives of the project, aligned with the national COVID-19 Plan, are to: (i) strengthen case detection and confirmation and conduct contact tracing; (ii) improve clinical care capacity; (iii) raise public awareness and promote community engagement; and (iv) bolster coordination, planning, logistical support, and reporting. While the focus is on the coronavirus response and preparedness, the activities to be supported are expected to have cross-cutting benefits for addressing other disease outbreaks. PDO level indicators: The PDO will be monitored through the following PDO level outcome indicators: PDO Indicators: • Proportion of suspected cases of COVID-19 reported and investigated based on national guidelines • Number of designated laboratories with COVID-19 diagnostic capacity (equipment, test kits, reagents) • Proportion of targeted healthcare facilities with isolation capacity 1.3. Rationale of the ESMF The Project involves minor civil works to refurbish and/or rehabilitate existing structures and adapt them as COVID-19 isolation units. The refurbishments re-equip isolation units at national and district hospitals established for other infectious diseases to make efficient use and include triaging and treating COVID-19 cases. Project works include installation of medical and laboratory equipment and supplies as well as waste management equipment and supplies. Video conferencing equipment will also be installed for telemedicine. Targeted national and district hospitals for refurbishment activities around the country had not yet been identified and therefore the nature and magnitude of the potential environmental and social impacts could not be known by project appraisal stage. This Environmental and Social Management Framework (ESMF) assesses all issues in broad terms and identifies potential impacts and possible mitigation measures that will 6 guide project component or sub-project screening and in determining whether or not any further assessment is required. E&S screening results determine whether or not there is a need to procure and commission site specific Environment and Social Impact Assessments (ESIAs). These documents are required to guide compliance with the relevant laws and regulations of Rwanda and the World Bank Environment and Social Framework (ESF). 1.4. Purpose of the ESMF The purpose of this ESMF is to guide the RBC Single Project Implementation Unit (SPIU) as the project implementation team and project component activity proponents on the E&S screening and subsequent project component activity assessment during implementation, including component activity-specific plans in the emergency nature of the project. However, it should be noted that COVID-19-related in-country movement restrictions caused the emergency activities to overtake the ESMF preparation. Disbursements of ERP funds have run up to 72% before the ESMF could be approved disclosed although 60% was spent on retroactive financing for the purchase of medical supplies that included masks, gloves and consumable for testing laboratories. Other costs logistics, communication, accommodation and food for Command Post and contact-tracing activities. No activities with identified environmental and social impacts (based on the E&S screening), such as adoption of biomedical waste disposal measures or facility rehabilitation activities were commenced yet. 1.5. Scope of the ESMF The ESMF was prepared in accordance to applicable Rwanda environmental assessment law and regulations and the World Bank ESF. The preparation process involved the following steps: a) Desktop research on the biophysical and social baseline and the state of emergence response for COVID-19 risks within the project coverage; b) Only minimal consultations public authorities and health experts were held, including consultations with Africa CDC, because of the restrictions imposed by the COVID-19 emergency; c) Identification and analysis of potential environmental and social impacts the implementation processes of the ERP will likely trigger and generate; d) Development of screening procedure for negative environmental and social impacts for proposed project sites and project activities; e) Identification of appropriate mitigation measures for the predicted impacts and compilation of a management plan for addressing environmental and social impacts during implementation, operation and maintenance of the project activities and; f) Development of guidance for sub-project level Environmental and Social Management Plans and Infection Control and Waste Management Plans. 7 2. Project Description 2.1. Project Components The project comprises three mutually complementary components that focus on the immediate response (plus a Contingency Emergency Response Component (CERC)), and includes a range of evidence-based interventions: Component 1. Case Detection, Confirmation and Contact Tracing (US$5.9 million, PLUS US$ 942,857 of Additional Financing) This component will support the government to enhance disease surveillance, improve sample collection and ensure rapid laboratory confirmed diagnoses to promptly detect all potential COVID-19 cases and to carry out contact tracing to quickly contain COVID-19. Component 1 focuses on: (i) Screening travelers at 31 Ports of Entry (Kigali International Airport and cross-border areas once the current restrictions are lifted); (ii) Screening priority communities and targeted health facilities; (iii) Diagnosing cases and referring them for treatment as needed; (iv) Carrying out contact tracing to minimize risk of transmission; (v) Conducting risk assessments to identify hot spot areas of transmission, including digital maps that can help visualize transmission; and (vi) Carrying out multispectral simulation exercises for COVID-19 and other disease outbreaks. To this end, the project will fund: (i) Medical supplies and equipment (e.g. thermo-scanners; SARS-CoV-2 test kits; drugs; lab equipment and supplies, personal protective equipment); (ii) Training and capacity building for frontline workers; and (iii) Operating costs for Rapid Response Teams and recruitment of additional personnel. Component 2: Public Health Measures and Clinical Care Capacity (US$8.0 million) This component will fund the reinforcement of public health policies and measures and the establishment of critical clinical care capacity at a network of public sector district hospitals, promoting digital solutions to be explored during implementation. The main public health policies to be enforced include: social distancing measures (e.g. border closings; work-at-home policies; restricting public gatherings); personal hygiene promotion, including handwashing and proper cooking; and risk communication and community engagement (RCCE) in line with WHO guidance and using local channels (e.g. national radio and other IT related tools) to disseminate messages about the risks associated with COVID-19 and applying innovative digital solutions such as mobile apps for sending out messages. A separate Stakeholder Engagement Plan (SEP) that applies RCCE activities has been prepared for this project in compliance with ESS10. With respect to clinical care, the project will support the government to establish isolation facilities at a selected number of national and district hospitals which would be responsible for triaging and treating COVID-19 cases and would benefit from video conferencing equipment to establish telemedicine capacity. The goal is to rehabilitate/adapt existing structures, and leverage isolation units established for other infectious diseases to make efficient use of costly structures. To support providers to triage and provide urgently needed care to sick patients, the project will ensure health personnel are well protected and work in a safe and secure environment. 8 To this end, the project will fund: (i) Production and dissemination of communication materials (including in digital form) and organization of national and local campaigns to raise awareness as well as establishment of data analytics capability to improve targeting and measure effectiveness; (ii) Medical and laboratory equipment and supplies and waste management equipment and supplies and video conferencing equipment for telemedicine; (iii) Minor civil works (mainly refurbishments); and (iv) Operating costs, including recruitment of additional clinical personnel. The following should be noted regarding activities of the Rwanda COVID-19 ERP and its Additional Financing: • National and district hospitals and laboratories (biosafety levels – BSL not yet determined) for refurbishment, and installations/re-equipping have not yet been selected. • Only medical supplies and equipment, personnel recruitment and training will be funded for the yet to be identified screening posts, quarantine and isolation centers, infection treatment centers, intensive care units (ICUs), and assisted living facilities. • The project may involve minor civil refurbishment/rehabilitation works of existing healthcare facilities and the supervision of the special management requirements of COVID-19 associated waste It should be noted some activities including refurbishments for establishing COVID-19 isolation and treatment facilities were financed within the support for the National Ebola Virus Disease (EVD) Preparedness and Response Plan as a CERC component of the Bank supported Stunting Prevention and Reduction Project (SPRP). Additional needs if any, for activities involving minor civil works for refurbishments have not yet been identified. • The project will not involve acquisition of existing public or private facilities such as a stadium or hotels and converting them to temporary hospital, quarantine or isolation centers, or other uses. • The project does not finance procurement of incinerators. • The country’s Medical Waste Management Plan (MWMP) of 2017 was updated with waste management requirements for the Ebola Virus Disease (EVD) in Feb 2020. An Infection Control and Waste Management Plan (ICWMP) is included in this ESMF as an update of the national MWMP with the following COVID-19 requirements: o Reduction of production, enabling segregated collection, storage, transportation and disposal of COVID-19 associate waste including capacity requirements. o Supervision of COVID-19 peculiarities in the existing external waste management including third-party incineration services1. • The project is expected to employ of a minimal workforce for the required refurbishment and equipment installation works. Specialists such as medical equipment engineers, bio-medical technicians as well as skilled workers such as electricians and plumbers as well as painters and fitters are expected to be employed in the project. A set of Labor Management Procedures (LMP) is included in this ESMF in compliance with ESS2. • The project will not involve land acquisition nor restrictions on land use in connection to the required refurbishments/adaptation of existing parts of healthcare facilities to isolation units or waste management facilities. • The project not involve use of security or military forces. 1 Incineration services of healthcare waste in the City of Kigali and its surrounding are provided by a third-party operator, Kalisimbi Depot Pharmaceutics. 9 Component 3. Implementation Management and Monitoring & Evaluation (US$.35 million) The third component will support program coordination, management and monitoring; operational support and logistics; and project management. This will include support for the COVID-19 Incident Management System Coordination Structure; operational reviews to assess implementation progress and adjust operational plans; fiduciary support, including environmental and social safeguards; and provide logistical support. To this end, the project will fund: (i) technical assistance; (ii) vehicles to facilitate supervision; and (iii) operating costs. Component 4: Contingency Emergency Response Component (CERC) (Zero cost) A zero cost CERC component will provide support for future emergency responses. Following an eligible crisis or event, clients may request the Bank to re-allocate project funds to support an additional emergency response. This component would draw from the uncommitted credit resources under the project from other project components to cover emergency response. CERCs can be activated without needing to first restructure the original project, thus supporting rapid implementation. To facilitate a rapid response, formal restructuring is deferred to within three months after the CERC is activated. Once the Component is activated and implementation plan is designed, a section on the CERC is included based on an indicative list of activities related to the likely emergencies that led to the CERC’s inclusion in the project. The project ESMF will be updated with to include a CERC-ESMF sections. The update will describe the potential emergencies and the types of activities likely to be financed and evaluates the potential risks and mitigation measures associated with them. It will also identify likely vulnerable locations and/or groups and includes, where needed, some social assessment to guide emergency responses (e.g. what existing social conflicts could be exacerbated by an emergency situation?). The CERC-ESMF sections of this document will provide a screening process for the potential activities, the institutional arrangements for environmental and social due diligence and monitoring, any needed capacity-building measures, and generic guidance on emergency small-scale civil works. To ensure readiness, the Bank, as part of its institutional capacity assessment for the Original Project’s appraisal, verifies whe ther the implementing agency has the requisite skills and capacity to implement the CERC ESMF and any additional safeguard instruments that might be required for the CERC. The CERC-ESMF sections will indicate which kinds of emergency response actions can proceed with no additional environmental or social assessment, and which ones would require assessment (and at what level) prior to being initiated. It will also identify trade-offs (as relevant), where required short-term responses could create longer-term risks that need to be managed. 2.2. Eligibility criteria for exclusion of subprojects Refurbishments for establishing COVID-19 isolation and treatment facilities have been financed within the support for the National Ebola Virus Disease (EVD) Preparedness and Response Plan, a CERC component of the Bank supported SPRP. The COVID-19 Joint Task Force Coordination (JTFC) may identify additional capacity needs and commission additional civil works for refurbishments in a few HCFs and/or reequipping laboratories as need be, based on the recommendations of its Epidemiology Operations Cell. No healthcare waste management are planned in the ERP. The proposed activities will undergo eligibility criteria for investment or exclusion according to criteria based on the ESCP and presented in questionnaire format in Table 1. The MoH has not yet identified subprojects for each Project component and information is not yet available on geographic coverage, locations and designs for refurbishment/reequipping target healthcare facilities, laboratories and facilities for the disposal of waste. The RBC SPIU will fill-in the Table 1 questionnaire in order to determine eligibility of proposed subprojects for ERP support. If the answer to 10 any one of the questions in Table 1 is ‘Yes’, then the subproject will be redesigned to be acceptable according to relevant ESSs or excluded if redesigning is not possible. If on the contrary the answer is ‘No’ for all the above questions, then the subproject will proceed to Environmental and Social Screening (see Annex II for reference). Table 1 Rwanda COVID-19 eligibility criteria questionnaire for subproject/activity exclusion Subproject eligibility exclusion criteria question Yes No 1. Will the subproject involve laboratory activities that may require BSL3 lab facilities? 2. Will the subproject involve activities that may cause long term, permanent and/or irreversible impacts (e.g. loss of major natural habitat)? 3. Will the subproject involve activities that have high probability of causing serious adverse effects to human health and/or the environment? 4. Will the subproject involve activities that may have adverse social impacts and may give rise to significant social conflict? 5. Will the subproject involve activities which would require Free Prior Informed Consent? 6. Will the project involve activities that may affect lands or rights of indigenous people or other vulnerable minorities? 7. Will the subproject have activities that may involve permanent resettlement or land acquisition or impacts on cultural heritage? 2.3. Environmental and Social Screening of Subprojects The screening process provides a mechanism for ensuring that potential adverse environmental and social impacts of the ERP subprojects are identified, assessed and mitigated as appropriate to comply with the Environmental assessment requirements are outlined in Rwanda’s Law N°48/2018 on Environment and in the World Bank’s Environmental and Social Standards, especially ESS1, ESS2, ESS3, ESS4, ESS6, ESS8, ESS10. Subproject in the context of the Rwanda COVID-19 ERP are project activities procured under a contract. Subproject ES measures therefore apply to HCF where investments have been made. MoH/RBC-SPIU purchases ERP medical supplies and equipment through the Africa Medical Supplies Platform (AMSP). The AMSP is a “not-for-profit� initiative launched by the African Union as an immediate, integrated and practical response to the Covid-19 pandemic. The practice fulfils applicable screening requirements for the purchase of medical supplies and equipment subproject by establishing due diligence for all potential suppliers to guarantee quality equipment and products. The Platform ensures purchase of certified medical equipment such as diagnostic kits, PPE and clinical management devices with increased cost effectiveness and transparency from vetted manufacturers. A screening template is provided in Annex II to be used by the RBC SPIU for identifying the relevant Environmental and Social Standards (ESS) (1-10), establishing an appropriate E&S risk rating for these subprojects and specifying the type of environmental and social assessment required, including specific instruments/plans. The screening template in Annex II includes a note on Considerations and Tools for E&S Screening and Risk Rating on infection control for medical laboratories, quarantine and isolation centers; treatment centers and labor and working conditions. 11 The screening form sets out a list of questions on the screening of E&S risks and impacts, identifies the relevant ESSs for which the PIU fills in Yes or No answers from which conclusions are reached for each subproject proposing an E&S risk rating (High, Substantial, Moderate or Low) with justifications provided and E&S Management Plans/ Instruments proposed. Subproject screening results will be reviewed by the Rwanda Development Board (RDB) which holds a delegated mandate from the Rwanda Environment Management Authority (REMA) and the World Bank. E&S instruments such as ESIA/ESMP, SEP, LMP and/or RAP will be prescribed for subprojects to ensure appropriate mitigation for subprojects whose risk ratings are indicated High, Substantial or Moderate by the screening results. Subprojects whose risk ratings are indicated as Low, ESMPs instead of a full ESIAs will be recommended. E&S instruments are prepared by authorized consultants according to Article 31 of law n°36/2016 of 08/09/2016 establishing Rwanda Association of Professional Environmental Practitioners and determining its organization and functioning. The RBC-SPIU will recruit consultants to prepare the required E&S instruments from ERP funds. However, in-house environmental and social specialists may prepare some instruments such as ESMP or ICWMP using RDB approved templates. RDB will review the E&S instruments to ensure that the necessary mitigation measures are duly incorporated before certification for the subproject in question to proceed. 12 3. Policy, Legal and Regulatory Framework This Chapter discusses the key national legislation and regulatory framework that are directly relevant to the activities to be carried out by the Rwanda COVID-19 ERP. ESSs and the WBG Environment Health and Safety Guidelines (EHS Guidelines) relevant to the project are discussed. The chapter also describes international and regional conventions to which Rwanda is signatory as well as Good International Industry Practice (GIIP), with special attention to the WHO developed guidance documents for addressing COVID- 19. 3.1. National Environmental Legislation and Regulatory Framework Key environmental and other legislation and regulations and their applicability to the Rwanda COVID-19 ERP activities are summarized in Table 2 below. Table 2 Key policy, legislation and regulations relevant to the Rwanda COVID-19 ERP Policy/Law/Regulation Key provisions Applicability to Rwanda COVID-19 ERP National Strategy for NST-1 Transformational NST1 requires that sub-projects apply ESIAs and Transformation (2018- Governance Pillar stipulates its principles of biodiversity and ecosystem management, 2024) Priority area 6 as “Increase citizens’ pollution and waste management provided. These participation, engagement and provisions are in alignment with ESS1, ESS3, ESS4 and partnerships in Development�. ESS10. Environmental and Climate Change are key interventions. National Environment and Rwanda to be a nation that has a Policy requires sub-projects to consider principles that Climate Change Policy clean and healthy environment, complement ESF including: Assessment of (2019) resilient to climate variability and environmental risks and impacts for development change that supports a high quality projects; Mitigation and Adaptation; Information of life for its society. dissemination and community awareness raising in the conservation and protection of the environment. Health Sector Policy (2015) Ensure and promote the health status The policy is given effect by the 2019-2024 Health of the population of Rwanda by Sector Strategic Plan aiming to strengthen country’s providing quality preventative, focus to include decentralization of health services, curative, rehabilitative and development of primary care health system and promotional services. reinforcement of community participation in line with ESS4 and ESS10. National Policy on Guidance to health professionals on The policy is aligned to ESS3, ESS4 and EHS Injection Safety, Prevention Infection Prevention and Control Guidelines that are relevant to the ERP regarding the of Transmission of through injections and other medical enhancement of Infection Prevention and Control (IPC) Nosocomial Infections and procedures and ensures that medical related to safe injection practices and associated waste Healthcare Waste waste is safely managed and management in treatment centers. Management (2009) disposed. 13 Policy/Law/Regulation Key provisions Applicability to Rwanda COVID-19 ERP International health Aim to prevent, protect against, The regulations are aligned with the WHO advisories regulations (2005) control and provide public health and guidance documents that the GoR and WB are response to the international spread abiding by during preparation and implementation of of disease with minimum the ERP. interference to international traffic and trade. Coronavirus Disease 2019 Aims to enhance the capacity to The Plan will among others, create and raise public National Preparedness and prevent, timely detect and awareness for engagement on COVID-19 preparedness Response Plan effectively respond to the COVID- and response activities The plan will apply the Risk 19 outbreak. Communication and Community Engagement (RCCE) developed by the WHO in compliance with ESS10. Law N°48/2018 on Article 3: Precautionary principle - The law applies for all subprojects of the ERP and Environment Activities considered or suspected to complements ESS1. have negative impacts on environment must not be implemented pending results of a scientific assessment ruling out the potentiality of such impacts. Ministerial order N° Provides roles and responsibilities The law will apply to sub-projects in carrying out full or 003/2008 relating to the of all participants in the EIA process partial EIA certification from RDB before any works requirements and procedure and its General Guidelines and start. The law is in alignment with ESS1. for EIA Procedure step-by-step. Law no 66/2018 regulating Stipulates several provisions for These laws will apply to sub-projects that will entail labor in Rwanda employment contract, Occupational employment of workers to ensure their terms and Health and Safety (OHS) and conditions of work as well as health and safety comply general working conditions. and complement ESS2. These laws will also support measures of compliance with ESS4. Any form of The National Gender discrimination, GBV, sexual exploitation and abuse Outlines principal guidelines on Policy, 2010 (SEA) as well as sexual harassment (SH) will be which sectoral policies and prohibited in the ERP. The project will put in place programs will base to integrate mechanisms and strategies to ensure Occupational gender issues in their respective Health and Safety (OHS) and community health and social, cultural, economic and safety requirements in compliance with ESS2, ESS4 political planning and programming and the WBG EHS Guidelines. Law No. 59/2008 of 2008 This Law is aimed at preventing and on Prevention and suppressing the gender- based Punishment of Gender- violence Based Violence Rwanda Green Building Promotes energy and water Refurbishment and/or fitment works in the ERP will Minimum Compliance efficiency, environmental ensure resource efficiency and pollution prevention in System (2019) protection, indoor environmental energy and water saving, efficient lighting, ventilation 14 Policy/Law/Regulation Key provisions Applicability to Rwanda COVID-19 ERP quality to building occupants and and appropriate waste management. The regulation green innovation. Applies to compliments ESS3. buildings public buildings including health facilities. National Building Provides the minimum requirements The ERP will control and regulate refurbishment and/or construction code (2015) to safeguard public health during fitment works, quality of materials, sanitation and safety construction and occupancy. of contractors and workers. The regulation complements ESS2 and the WBG EHS Guidelines. LAW N° 04/2013 relating Provides the public with right to The project will avail information and involve the to access to information information. This law enables the public and project stakeholders in assessing activities, public to access information documents or records related to the project activities. possessed by public organs and The access to information law complements ESS10. some private bodies. It also sets out ERP documents will be disclosed to public in electronic the methods for promoting the and/or print forms as appropriate. These ESF documents publication and sharing of for the ERP will be disclosed on MoH/RBC and WB information. websites. 15 3.2. Rwanda EIA process In Rwanda, the environmental assessment procedure starts with the submission of a project description note to the RDB One Stop Center. RDB officials responsible for EIA then conduct field visits as part of a screening process. RDB then reviews the subproject screening results and prepares (or approves) ToR for a full EIA study or an ESMP as appropriate. The project proponent then submits the EIA report or ESMP which is again reviewed by RDB and an EIA certificate to proceed is issued. If the project is not approved, Project Brief to EIA OSC-RDB EIA Process Field Visit & Screening ToR 14 days EIA Study EIA Report Review Succeed EIA Record of Appeal 20 days Decision Not Approved Approved Non compliance Fail to EMP Environment Project Discontinued Management Plan (EMP) Figure 1 EIA Procedure in Rwanda according to current legislation of March 2020. the proponent is given an opportunity to appeal as shown in Figure 1. 3.3. International Conventions The Environmental Impact Assessment (EIA) process in Rwanda operates within and towards the global concept of sustainable development. The process provides a basis for future international cooperation and conflict resolution concerning environmental impacts at a regional level. Rwanda signed and ratified international environmental and climate change conventions, some of which apply to the Rwanda COVID- 19 ERP as summarized in Table 3 below. The full list of references on COVID-19 guidance is provided in Annex V. 16 Table 3 Summary of International Conventions and applicability to the RWANDA COVID-19 ERP International Treaty / Convention Key provisions Applicability to ERP Stockholm Convention for Aims to protect human health and the The Convention complements Persistent Organic Pollutants environment from persistent organic compliance of the ERP to ESS3 and (2017) pollutants through measures to reduce or ESS4 and the WHO technical eliminate releases from intentional guidance for COVID-19, especially production and use; from unintentional on water, sanitation, hygiene and production; and from stockpiles and wastes. waste management. Basel Convention for hazardous Ensures: generation and transboundary The Convention complements wastes and disposal movement of hazardous wastes and other compliance of the ERP to ESS3, wastes is reduced to minimum; availability ESS4, ESS5 and the WHO technical of adequate disposal facilities, for the guidance for COVID-19, especially environmentally sound management of on water, sanitation, hygiene and hazardous wastes and other wastes; persons waste management. involved in the management of hazardous wastes or other wastes within it take such steps as are necessary to prevent pollution due to hazardous wastes and other wastes arising from such management and, if such pollution occurs, to minimize the consequences thereof for human health and the environment. WHO Laboratory biosafety Aimed at providing interim guidance on The technical guide provides basis for guidance related to coronavirus laboratory biosafety related to the testing of screening E&S Risks associated with disease 2019 (COVID-19) clinical specimens of patients that meet the medical laboratories and for assessing case definition of coronavirus disease 2019 and managing the risks throughout the (COVID-19) ERP in compliance with ESS1, ESS2, ESS3, ESS4 and WBG EHS Guidelines. WHO Infection prevention and Intended for health care workers (HCWs), The technical guide provides basis for control during health care when health care managers, and IPC teams at the screening E&S Risks associated with COVID-19 is suspected facility level, national, provincial and COVID-19 treatment centers and for district levels. assessing and managing the risks throughout the ERP in compliance with ESS1, ESS2 and WBG EHS Guidelines. WHO rights, roles & Provides specific measures to maintain The technical guide is aligned to responsibilities of HCWs, including rights and responsibilities of HCWs and ESS1, ESS2 and WBG EHS key considerations for OSH in their OSH. Guidelines to be complied with COVID-19 Outbreak throughout the ERP. WHO Water, sanitation, hygiene, Intended for water and sanitation The technical guide is aligned to and waste management for the practitioners and providers and health care ESS4, ESS10 and WBG EHS COVID-19 virus providers to ensure good and consistently Guidelines to be complied with applied WASH and waste management throughout the ERP. practices in communities, homes, schools, marketplaces, and health care facilities to help prevent human-to-human transmission of the COVID-19 virus. 17 International Treaty / Convention Key provisions Applicability to ERP WHO Rational use of personal Intended for those involved in distributing The technical guide is aligned to protective equipment (PPE) for and managing PPE and its most appropriate ESS2, ESS4, ESS10 and WBG EHS coronavirus disease (COVID-19) use by public health authorities and Guidelines to be complied with individuals in health care and community throughout the ERP. settings. WHO Oxygen sources and Intended for health facility administrators, The technical guide is aligned to distribution for COVID-19 clinical decision-makers, and procurement ESS1, ESS10 and WBG EHS treatment centers officers, planning officers, biomedical Guidelines to be complied with engineers, infrastructure engineers and throughout the ERP. policy-makers. It describes how to: quantify oxygen demand, to identify oxygen sources that are available, and select appropriate surge sources to best respond to COVID-19 patients’ needs, especially in low-and-middle income countries. WHO Considerations for Aimed to offer guidance to WHO Member The technical guide is aligned to quarantine of individuals in the States on implementing quarantine ESS4, ESS10 to be complied with context of containment for measures for individuals in the context of throughout the ERP. coronavirus disease (COVID-19) COVID-19 outbreak. 3.4. The World Bank Environment and Social Framework The new World Bank Environmental and Social Framework (ESF) adopted in October 2018 set out the commitment to sustainable development through a set of environmental and social standards (ESS) that are designed to support borrower projects. The ESSs set out the requirements for Borrowers relating to the identification and assessment of environmental and social risks and impacts associated with projects supported by the Bank. RISK CLASIFCATION At the time of preparation, the World Bank has categorized the Rwanda COVID-19 ERP with a “Substantial Risk� rating based on the expected potential environmental and social impacts and risks. ENVIRONMENTAL AND SOCIAL STANDARDS The World Bank Environmental and Social Framework (ESF) comprises the following 10 ESSs: 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 ESS5: Land Acquisition, Restrictions on Land Use and Involuntary Resettlement ESS6: Biodiversity Conservation and Sustainable Management of Living Natural Resources ESS7: Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS8: Cultural Heritage ESS9: Financial Intermediaries ESS10: Stakeholder Engagement and Information Disclosure 18 During preparation, based on conducted due diligence process, it was determined that ESS1, ESS2, ESS3, ESS4, ESS6, ESS8 and ESS10 are relevant to the ERP. ESS5 is not relevant to the Project. All eventual construction will be undertaken within existing facilities, no new construction planned under this project and thus at this point ESS5 is not considered relevant. Small scale renovation and rehabilitation within the existing facilities will be undertaken. Temporary closures, reduced access, or disruption will follow principles of voluntary negotiations. ESS7 is not relevant to the Project as there are no Indigenous Peoples/Sub-Saharan Historically Underserved Traditional Local Communities within the proposed project interventions areas, nor is the project taking place in areas on which they rely for natural resources. ESS9 is not relevant as there are no financial intermediaries in the Project. The link below provides the requirements including the 10 Environmental and Social Standards (ESS) that apply to Borrowers and were assessed as relevant to the project during preparation: https://www.worldbank.org/en/projects-operations/environmental-and-social- framework/brief/environmental-and-social-framework-resources ESS1 Assessment and Management of Environmental and Social Risks and Impacts Although this project is expected to have positive outcomes as it aims to improve COVID-19 surveillance, monitoring and containment, there are also potential environmental and social risks associated with the project financed activities. The environment, health and safety risks are due to the dangerous nature of the pathogen (COVID-19) and reagents to be used in project-supported facilities. Infections due to inadequate adherence to occupational health and safety standards can lead to illness and death among healthcare workers. The laboratories which will be used for COVID-19 diagnostic testing can generate biological waste, chemical waste, and other hazardous biproducts. As the facilities to be supported by the project will process COVID-19 that can have the potential to cause serious illness or potentially lethal harm to the laboratory staff and to the community, effective administrative and containment controls should be put in place so minimize these risks. There are also occupational health and safety risks associated with the rehabilitation of medical facilities/minor civil works to be financed by the project. Wastes from the operation and rehabilitation of medical centers could cause considerable environmental and social risks if not properly managed. Environmentally and socially sound healthcare including laboratory operation will require adequate provisions for minimization of occupational health and safety risks, proper management of hazardous waste and sharps, use of appropriate disinfectants, proper quarantine procedure for COVID-19, appropriate chemical and infectious substance handling and transportation procedure, institutional/implementation arrangement for environmental and social risks, etc. In line with WHO Interim Guidance (March 19, 2020) on “Laboratory Biosafety Guidance related to the novel coronavirus (2019-nCoV)�, COVID-19 diagnostic activities and non-propagative diagnostic laboratory work (e.g. sequencing) could be undertaken in BSL2 labs with appropriate care. Any virus propagative work (e.g. virus culture, isolation, or neutralization assays) will need to be undertaken at a containment laboratory with inward directional airflow (BSL-3 level). Such activities, requiring BSL-3 labs are excluded from project financing (which is stated in the ESCP and ESMF). Environmentally and socially sound medical laboratory operation will require adequate provisions for minimization of occupational health and safety risks, proper management and disposal of hazardous waste (including sharps disposal), use of approved disinfectants, proper quarantine procedure for COVID-19, 19 appropriate chemical and infectious substance handling and transportation procedure, institutional/implementation arrangement for environmental and social risks, etc. This ESMF takes into account the relevant GIIP, especially WHO protocols developed for the occupational health and safety of people during the current global pandemic. All subprojects that are classified as high, substantial or moderate risk including medical facilities/isolation and treatment centers that will receive the project financed medicalsupplies and laboratory equipment will prepare site-specific ESMPs with an Infection Control and Waste Management Plan (ICWMP) as its integral part. ESMP with an integrated ICWMP will cover both construction and operation phases/aspects. A template for these plans, and a timeline for developing them, which in all cases will be before any works begin, has been included in the project’s ESMF. This ESMF covers the procedures for the safe handling, storage, and processing of COVID-19 materials including the techniques for preventing, minimizing, and controlling environmental and social impacts during the operation of project supported laboratories. It includes a template for Infection Control and Waste Management Plan and details procedures to be followed in managing E&S risks of healthcare centers rehabilitation activities as well as the implementation arrangements to be established by the RBC for environmental and social risk management; training programs focused on COVID-19 laboratory biosafety, operation of isolation centers and screening posts, as well as compliance monitoring and reporting requirements. WHO COVID-19 biosafety guidelines were reviewed while preparing the ESMF so that all relevant risks and mitigation measures will be covered. In addition to the ESMF, the client has prepared an Environmental and Social Commitment Plan (ESCP) and Stakeholders Engagement Plan (SEP) and allocated the resources necessary for the implementation of the ESCP and the SEP in the proposed timeline. ESS2 Labor and Working Conditions It is expected that most of the direct workers (especially those who are working in the medical facilities) will be civil servants and therefore subject to their existing contracts, with the added protection of getting access to necessary OHS protocols and equipment as detailed under ESS2. Due to the hazardous nature of the work, no children under the age of 18 will be employed on any aspect of the Project. The use of forced labor to carry out any activities is also prohibited. Contracted workers may be involved in rehabilitation of medical centers and their contracts should be in line with the requirements of ESS2 including details of hours of work, rest periods and compensation, as well as access to necessary OHS PPE. All issues of concern for direct and contracted workers are documented in the Labor management procedures (LMP) (Section 7.4 of the document). A grievance mechanism will be made available to all workers to report any issues associated with OHS and / or labor and working conditions. The mechanism includes contact details for submission of grievances, timelines for responses and escalation procedures. Laboratory and/or COVID19 healthcare facilities associated infections may result from inadequate adherence to occupational health and safety standards and can lead to illness and death among laboratory/healthcare workers. To minimize or avoid this risk for workers deployed to assist in a laboratory setting or medical waste disposal, the client developed the LMP in such a way which (i) respond to the specific health and safety issues posed by COVID-19, including those related to waste management risks, and (ii) protect workers’ rights as set out in ESS2. Healthcare facilities/laboratories which will receive project funding will, therefore implement the following that are also part of the LMP section elaborated in 7.4 of this ESMF: • Develop a procedure for entry into health care facilities, including minimizing visitors and undergoing strict checks before entering 20 • Develop a procedure for protection of workers in relation to infection control precautions and include these in the labor management procedures and in contracts • Provide immediate and ongoing training on the procedures to all categories of workers, and post signage in all public spaces mandating hand hygiene and PPE • Develop a basic, responsive grievance mechanism to allow workers to quickly inform management of labor issues, such as a lack of PPE and unreasonable overtime • Ensure adequate supplies of PPE (particularly facemask, gowns, gloves, handwashing soap and sanitizer) are available • Ensure adequate OHS protections in accordance with General EHSGs and industry specific EHSGs and follow evolving international best practice in relation to protection from COVID-19; • Mandate staff to follow the protocol prepared for this Project. • Prohibit the use of forced labor or conscripted labor in the project/construction/health care facilities as per the 2018 Rwanda Labor Law. • Where the component involves possible contact with COVID-19, prohibit children under 18 from being employed due to the hazardous nature of the work (e.g. in health care facilities) Medical staff at the facilities will be trained and be kept up to date on WHO advice (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance) and recommendations on the specifics of COVID-19 by the SPIU. ESS3 Resource Efficiency and Pollution Prevention and Management Hazardous wastes from the COVID 19 supported activities (drugs, clinical supplies, PPE and medical equipment) can have a significant impact on the environment (including soil and groundwater) or human health. These include liquid contaminated waste, sharps, chemicals, and other hazardous materials used in diagnosis and treatment. Each medical facility and isolation center prepared a template for Infection Control and Medical Waste Management Plan (as part of ESMF) to prevent or minimize such adverse impacts following the requirements of the COVID-19 ESMF prepared for the Project, WHO COVID-19 guidance documents, and other good international practices. The ESMF includes procedures for the management of construction wastes that may be generated from the rehabilitation of medical facilities. The ESMF and site- specific instruments (ESMPs) include guidance related to transportation and management of samples and medical goods or expired chemical products. Resources (water, air, etc.) used in quarantine facilities and labs will follow standards and measures in line with Africa CDC and WHO environmental infection control guidelines for medical facilities. ESS4 Community Health and Safety Medical wastes from COVID 19 diagnosis and treatment centers can have a high potential of carrying micro-organisms that can infect the community at large if not properly managed. There is a possibility for the infectious microorganism to be introduced into the environment if not sustainably contained within the clinical practice, supplies’ transportation and laboratory operation or due to accidents/ emergencies e. g. a fire response or natural phenomena. The infection control and waste management plan to be prepared by medical facilities which will receive the project support will describe: • how laboratory activities in COVID-19 testing medical facilities Project activities will be carried out in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (such as WHO guidelines) • measures in place to prevent or minimize the spread of infectious diseases • emergency preparedness measures In addition, the project design itself actively promotes sound community health and safety practices in the management of COVID-19 through training of member countries in WHO guidelines for identification, prevention and control of COVID-19. The project implementation will ensure the avoidance of any form of Sexual Exploitation and Abuse by relying on the WHO Code of Ethics and Professional conduct for all workers in the quarantine facilities as 21 well as the provision of gender-sensitive infrastructure such as segregated toilets and enough light in quarantine and isolation centers. The project will also ensure via the above noted provisions, including stakeholder engagement, that quarantine and isolation centers and screening posts are operated effectively throughout the country, including in remote and border areas, without aggravating potential conflicts between different groups, including host communities and refugees/IDPs. In case quarantine and isolation centers are to be protected by security personnel, it will be ensured that the security personnel follow strict rules of engagement and avoid any escalation of situation, taking into consideration the above noted needs of quarantined persons as well as the potential stress related to it. The project will ensure the security personnel follow strict rules of engagement and avoid any escalation of situation, including possible training/ guidelines. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources No major construction or rehabilitation activities are expected in this project and all works will be conducted within existing facilities. Hence, likely impacts of the project on natural resources and biodiversity are low. However, if medical and chemical wastes are not properly disposed of, they can have impacts on living natural resources. The procedures outlined in the infection control and waste management plan will describe how these impacts will be minimized. ESS8 Cultural Heritage Based on the screening of potential and known locations for rehabilitation and construction works, likely impact of the project on cultural heritage is low. As a precautionary measure the ESMF includes a chance finds procedure (Annex VI). Environmental, Health and Safety (EHS) guidelines from the WBG The World Bank Group has produced the Environmental, Health and Safety (EHS) guidelines to ensure government/borrowers apply industry and international good practices and standards for pollution, waste management, etc. in the construction of civil works. Rwanda COVID-19 ERP will consult and apply these guidelines as relevant in the project development. The EHS guidelines can be accessed by the link following links: i. World Bank Group General EHS Guidelines ii. World Bank Group EHS Guidelines - Health Care Facilities iii. World Bank Group EHS Guidelines - Hazardous Materials Management iv. Interim note from the World Bank on COVID-19 and construction/civil works projects v. World Bank Technical Note on Public Consultations and Stakeholder Engagement in WB- supported operations when there are constraints on conducting public meetings vi. Guidelines on Prevention of GBV/SEA vii. World Bank Good practice note on road safety. The above WBG guidelines apply to sub-projects under Components 1 and 2 of the project (including activities under Additional Financing). 22 4. Environmental and Social Baseline The effort to contain the spread of COVID-19 in Rwanda is led by the Office of the Prime Minister under the National Epidemic Preparedness & Response Committee (NEPRCC), along with the Ministry of Health, Ministry of Local Government and Security Organs. A Coronavirus Disease 19 National Preparedness and Response Plan was expeditiously prepared and operationalized under the direction of the NEPRCC. The plan is fully in line with the World Health Organization (WHO) global guidance and includes all recommended pillars. The Ministry of Health activated its Emergency Operation Centre and established a Coronavirus National Taskforce to coordinate the execution of this plan. The Plan is consistent with the Joint Continental Strategy on COVID-19, as agreed with African Union Ministers of Health in February 2020 under the auspices of the Africa CDC, a flagship institution established by the African Union with a continental mandate for infectious disease surveillance and control. The COVID-19 National Preparedness and Response Plan is comprehensive and costed and covers the full range of interventions to support the coronavirus preparedness and response efforts. The overriding goal is to prioritize prompt case detection, infection control, risk communication and community engagement, point of entry screening, laboratory confirmation, quarantine and isolation for effective case management. The plan’s implementation strategies entail: Leadership and Coordination; Epidemiological Surveillance; Points of Entry; Laboratory; Infection Prevention and Control (IPC); Case Management; Risk Communication and Community Engagement (RCCE); Operational Support and Logistics; and Business Continuity and Disaster Recovery Plan. The implementation strategies for the COVID-19 Preparedness and Response Plan is organized in an Incident Management System Coordination Structure shown in Figure 2 below. National Epidemic Preparedness & Response COVID-19 NATIONAL STEERING COMMITTEE Coordination Committee (NEPRCC) COVID-19 Task Force Coordination (JTFC) Command Post Expert Advisory Team Plans Epidemiology Ops Cell Admin & Logistics Cell Communication Cell Cell Awareness & Case Management Transport Community Surveillance Lab Engagement & Infection Ctrl Equipment & Media Point of Entry Rapid Response Materials Management Screening Team Health Facility & Rumors Infection Infrastructure Management Community Prevention & (Call Centre) Surveillance Control Contact Tracing & Quarantine Isolation and Follow-up Treatment Data Management COVID-19 Incident Management & Coordination Structure Figure 2 Rwanda COVID-19 Incident Management & Coordination Structure. Source: RBC, March 2020. The government put in place a mandatory national lock down on March 21, 2020 which was lifted on May 4, 2020 and thereafter maintained a 5am to 9pm curfew, social distancing, and use of masks while in public as well as variety of travel (restricted inter-provincial travel and motorcycle taxi ban remains in force) and other restrictions to be reviewed in 15 days. Borders remain closed and congregational activities including 23 closing schools, and higher education institutions, churches and conferences remain suspended. Home- based work was recommended for civil service, private sector and other non-essential personnel. All commercial passenger flights to and from Rwanda remain suspended. 4.1. Ports of Entry Rwanda’s Directorate General of Immigration and Emigration statistics2 show that 4,245,917 non-border community (people recognized by immigration services of border-sharing countries) entered Rwanda in 2019 through 17 border posts and the Kigali International Airport (Table 4). The highest inflows were recorded entries into Rwanda were from the Democratic Republic of Rwanda (DRC) at Rusizi (I and II) in Rusizi district, Poids Lourds and Corniche in Rubavu District followed by people entering from Burundi at Bugarama and Ruhwa in Rusizi district and at Gatuna from Uganda. The Kigali International Airport entries show a near median number of 348,018. Entry flows from Tanzania were the lowest by country in 2019. Table 4 shows a summary of statistics of entry flows of people across the 17 borders and through the Kigali International Airport. Figure 3 features a map showing 11 main border posts of the 17 countrywide. It is possible that COVID-19 IPC issues associated with imported cases would be concerned with travelers from non-border communities entering the country possibly from countries other than the immediate neighbor. Much higher entries were however registered from border-community entries with a total of 14,195,085 people. The highest entries of border communities were still from the DRC at Poids Lourds (51%), Rusizi-I (22%), Rusizi-II (11%), Corniche (6%) making a combined entry of 80%. Table 4 Rwanda stats of non-community entries for 2019 by neighboring country and hours of operation (Directorate General of Immigration and Emigration, 2019) RWANDA BORDERS, NEIGHBORING COUNTRY NON-COMMUNITY 2019 ENTRIES AND HOURS OF OPERATION No BORDERS DISTRICT NEIGHBORING Non-community HOURS OF COUNTRY entry flows (2019) OPERATION 1 Kigali Intl Airport Kicukiro Kigali Global 384,018 24hours 2 Nemba (OSBP3) Bugesera Burundi 47,475 04:00am - 10:00pm 3 Akanyaru Bas Nyaruguru Burundi 146 06:00am - 06:00pm 4 Akanyaru Haut Nyaruguru Burundi 109,557 06:00am - 06:00pm 5 Nshili Nyaruguru Burundi 2,154 06:00am - 06:00pm 6 Bugarama Rusizi Burundi 480,429 06:00am - 06:00pm 7 Ruhwa Rusizi Burundi 231,018 06:00am - 06:00pm 8 Rusizi I Rusizi DRC 626,992 06:00am - 10:00pm 9 Rusizi II Rusizi DRC 432,735 06:00am - 06:00pm 10 Corniche (OSBP) Rubavu DRC 524,946 24hours 11 Kabuhanga Rubavu DRC - 06:00am - 06:00pm 12 Poids Lourds (Petite Rubavu DRC 840,857 06:00am - 06:00pm Barriere) 13 Rusumu (OSBP) Kirehe Tanzania 123,117 06:00am - 10:00pm 14 Cyanika Burera Uganda 86,691 5:00am - 8:00pm 15 Gatuna (OSBP) Gicumbi Uganda 223,490 24hours 16 Buziba Nyagatare Uganda 8,383 06:00am - 06:00pm 2 https://www.migration.gov.rw/fileadmin/templates/PDF_files/Non Border_Community_Statistical_data_of_the_ year_2019.pdf accessed: May 9, 2020. 3 One Stop Border Post 24 17 Kagitumba (OSBP) Nyagatare Uganda 123,909 06:00am - 08:00pm 4.2. Priority Communities In 2018 Rwanda implemented the Integrated Disease Surveillance and Response System (IDSR) for risks associated with the Ebola Virus Disease (EVD) focusing on urban communities of 15 priority districts. The 15 districts that were considered most at risk of the EVD outbreak in Rwanda comprised urban communities of Rusizi, Nyamasheke, Karongi, Rutsiro, Rubavu bordering DRC; Nyabihu, Musanze, Burera, Gicumbi Kagitumba Cyanika Gatuna Corniche/ Poids Lourds Nemba Rusumo Rusizi I/II Bugarama Akanyaru Figure 3 Rwanda’s main ports of entry Secondary Cities and HCFs (District, Provincial and Referral Hospitals and Health Centers) and Nyagatare bordering Uganda; Nyanza and Bugesera bordering Burundi; and the City of Kigali area comprised of Gasabo, Kicukiro, and Nyarugenge districts. Rusizi, Rubavu, Musanze, Nyagatare, Muhanga and Huye (Figure 3) are under urban development support as Secondary City growth poles according the country’s urbanization policy. The City of Kigali was considered high risk because of the Kigali international airport and its high population density. This urban community prioritization is also valid for COVID-19 IPC under the ERP intervention. The harm inflicted on especially urban poor and many women heads of households, is likely to be devastating. In informal urban settlements, families occupy cramped informal dwellings, and just barely survive by casual jobs in the city, work that has stopped. It is particularly important to understand whether project impacts may disproportionately fall on disadvantaged or vulnerable individuals or groups, who often do not have a voice to express their concerns or understand the impacts of a project and to ensure that 25 awareness raising and stakeholder engagement with disadvantaged or vulnerable individuals or groups on infectious diseases and medical treatments in particular, be adapted to take into account such groups or individuals particular sensitivities, concerns and cultural sensitivities and to ensure a full understanding of project activities and benefits. 4.3. Rwanda Healthcare System The Rwanda health system consists of twelve national referral hospitals, including the King Faycal Hospital (KFH), University Teaching Hospital of Kigali (CHUK), University Teaching Hospital of Butare (CHUB), Rwanda Military Hospital (RMH) 4 and the Ndera Neuropsychiatric Hospital (HNP). The system also includes thirty-six District Hospitals and 495 Health Centers. Since 2011, the GoR established District Hospitals at the core of health service delivery through the District Health System (DHS) which comprises the district hospital and a network of health centers either public, government assisted, not for profit or private. The country’s health facility distribution by district is displayed the map in Figure 3 above. Medical Waste Management Framework As mentioned in the introduction of this ESMF, a national Medical Waste Management Plan (MWMP) of 2017 was updated with waste management requirements for the Ebola Virus Disease (EVD) in Feb 2020 and publicly disclosed. The national MWMP elaborates measures for the isolation and management of Ebola-contaminated solid medical waste; onsite treatment of Ebola-contaminated solid medical waste; offsite transport of Ebola-contaminated solid medical waste; safe and dignified burials of deceased persons from EVD; management of Ebola-contaminated liquid waste disposal. Although not directly comparable, provisions of this plan have been adapted for COVID-19 associated waste management as Category A infectious substances based on the WHO Guidance on regulations for the transport of infectious substances 2019–2020. Current Medical Waste Practices Several policies are in place to guide medical waste management, including the 2018 National Policy on Environment and Climate Change, the 2009 National Policy on Injection Safety, Prevention of Transmission of Nosocomial Infection and the 2016 Health Care Waste Management that clearly defines how key medical waste has to be managed, transported and disposed. A set of National Healthcare Waste Management Guidelines have been also prepared and applied. The MWMP of 2017 indicates that health care waste management and injection safety training was carried out for HCWs countrywide and national and district hospital equipped with incinerators. Current Good International Industry Practices (GIIP) include provision of Personal Protective Equipment (PPEs), auto- disable syringes and needles, disinfectants and availing post-exposure prophylaxis for victims of accidental occupational exposures (blood and amniotic fluid during labor and delivery). Safe storage of sharp medical waste, separation of waste according to their category at production site, waste transportation and destruction in a safe manner is recognized as extremely vital. According to the assessment conducted by MoH in 35 healthcare facilities in the country in October 2016 (MoH, 2017), a national volume of 1.27 t/day of (solid) medical waste is generated by inpatients and outpatients. Thetotal amount of 60,775,164 kg of waste (solid and liquid) generated per year (was of 2017), made of 74% of non-infectious waste, 24% of liquid waste and 1.3 % of infectious and/or hazardous waste. 4 The Rwanda Military Hospital (RMH) treats 80% civilian and 20% military patients as a national referral hospital open to the public. However, no ERP activities will be delivered by the RMH. 26 Waste Generation Estimation The Rwanda Health Sector Strategic Plan 2012–2018 has among key indicators to increase the number of healthcare facilities with effective medical waste management systems from 55% in 2012 to 88% in 20185. An assessment of waste quantities and types generated by health facilities was conducted in 2016 in 35 health facilities, comprising 3 referral hospitals, 2 provincial hospitals and 31 district hospitals. This assessment, based upon daily waste per inpatient and waste per out-patient has been extrapolated to determine the national volume of medical waste and determine an estimated average of 5.168 kg/day of medical waste generated by inpatients and outpatients. The assessment showed that from the total volume of medical waste produced in one year by health facilities in the country, 74% are non-infectious waste, 24% are liquid waste and 1.3% of infectious and/or hazardous waste (Infectious, sharps, pharmaceutical, radioactive, cytotoxic, chemical). Table 5 Medical Waste quantities generated annually in 35 HCFs (Source: RBC 2019) Characterization of Healthcare Waste MW Description MW Quantity MW (%) (kg/yr) The Medical Waste Management Plan Infectious Wastes 599,994 0.99 (MWMP) of Mar 2017 updated in Feb 2020 Sharps Wastes 96,482 0.16 describes major sources of healthcare waste as No Infectious Wastes 45,076,608 74.17 coming from the following categories of Pharmaceutical Wastes 38,603 0.06 healthcare facilities in the country: hospitals, university hospitals, general hospitals, district Radioactive Wastes 4,620 0.01 hospitals, other healthcare facilities, emergency Genotoxic/ Cytotoxic 47,364 0.08 medical care, services, healthcare centers and Chemical Wastes 23,862 0.04 dispensaries, obstetric and maternity clinics. Nonhazardous general 263,976 0.43 Other health structures generating waste are Wastes outpatient clinics, dialysis centers, long-term Liquid Wastes 14,543,346 23.93 healthcare establishments and hospices, Special Wastes 80,309 0.13 transfusion centers, military medical services6, (Electronic Wastes) prison hospitals or clinics, medical and Total 60,775,164 100 biomedical laboratories, biotechnology laboratories and institutions, medical research centers, mortuary and autopsy canters, animal research and testing, blood banks and blood collection services. COVID-19 Associated Waste Management requirements The WHO interim guidance of April 2020 on Water, sanitation, hygiene, and waste management for the COVID-19 virus advises that there are two main routes of transmission of the COVID-19 virus: respiratory and contact. Respiratory droplets are generated when an infected person coughs or sneezes. Any person who is in close contact with someone who has respiratory symptoms (sneezing, coughing) is at risk of being exposed to potentially infective respiratory droplets. Droplets may also land on surfaces where the virus could remain viable; thus, the immediate environment of an infected individual can serve as a source of transmission (contact transmission). The guidance advises that best practices for safely managing health care waste should be followed, including assigning responsibility and sufficient human and material resources to dispose of such waste safely. All health care waste produced during the care of COVID 19 patients should be collected safely in 5 MoH 2012, Rwanda Third Strategic Plan 2012-2018 6 Some military medical services in Rwanda such as the referral level Rwanda Military Hospital are open to the public and are an integral part of the national healthcare system. However, no specific ERP activity that is designated to the Military for its delivery. 27 designated containers and bags, treated, and then safely disposed of or treated, or both, preferably on-site. If waste is moved off-site, it is critical to understand where and how it will be treated and destroyed. All who handle health care waste must wear appropriate PPE (boots, apron, long-sleeved gown, thick gloves, mask, and goggles or a face shield) and perform hand hygiene after removing it. For more information refer to the WHO guidance, Safe management of wastes from health-care activities. The national MWMP of Feb 2020 makes reference to guidance provided by specialist institutions including CDC, WHO and Médecins Sans Frontières (MSF) EVD infection control guidelines. Annex IV of this ESMF provides a template for the preparation of HCF Infection Control and Waste Management Plan (ICWMP) for the ERP. Waste management implementation arrangements The MoH will be supported to handle its policy and strategy formulation roles and the RBC will be responsible for coordinating the implementation of the project through the SPIU that has managed Flow of Health Care Waste Management in Rwanda previous Bank-funded health projects. At the decentralized level, district authorities will be Central Level responsible for providing oversight, working (EHD) with other stakeholders. At the decentralized level, two committees are in Referral Hospital Provincial Hospital level place at the Health Center and District Hospital level (EHOs) (EHOs) levels for effective Health Care Waste Management: The Infection Prevention Committee and the District Hospital level (EHOs) Sanitation and Hygiene Committee. These committees work closely together and are composed of the Environmental Health Officer, the Laboratory Techncician, Pharmacist and the Health Center HCF administrator nominated by the institution. level (EHOs) Waste management will follow the health care waste treatment and disposal mechanism described in Table 6. Community level Health Post level (CHWs) The healthcare waste management structure is built from the community level up to the referral Figure 4 Flow if medical waste management and responsible level, as shown in Figure 4. However, suspected officers at the hierarchical HCF levels (MWMP, 2020) or confirmed COVID-19 associated waste will be kept isolated from and disposed of separately from other regulated medical waste at HCFs as indicated in Table 6. Waste generated during the care of a suspected or confirmed Ebola patient will be treated onsite through inactivation or incineration as appropriate. Wastewater treatment facilities are appropriately able to administer sewage handling processes that are designed to inactivate infectious agents. However, certain disinfection measures will be taken in the case of human exposure prior to delivery to the wastewater treatment facility. 28 Table 6 Health care waste treatment and disposal as per level of HCF Description CHWs/Health Post Health Center District Hospital Sharps Transfer to HC Transfer to District Hospital Incineration Infectious Transfer to HC Transfer to District Hospital and Incineration/deep burial deep burial Highly infectious Transfer to HC Transfer to District Hospital and Incineration deep burial Incineration, return to source Pharmaceutical Transfer to HC Return to District Hospital or manufacturer Landfills In Rwanda there are no third-party sanitary landfills. All generic solid wastes are centralized in public landfills. Each district operates one public landfill. Incinerators • Currently, operational incinerators for medical wastes are predominantly owned by district and referral hospitals. Each district and each referral hospital operates a well performing incinerator with acceptable minimum standards from which, all medical wastes in the respectable catchment areas are treated. • One third-party incinerator in Kigali is operated by the Kalisimbi Depot Pharmaceutics. • MoH/RBC operates two Covid-19 treatment centers in the country and a number of quarantine facilities hosted in temporarity repurposed hotels for self isolation services. All medical waste generated by the two Covid-19 treatment centers are collected, transported and incinerated or appropriately treated by the Kalisimbi Depot Pharmaceutics specialized in medical wastes treatment. Wastewater Treatment Plants • Currently facilities relevant to Covid-19 are National Reference Laboratory (NRL) and the two treatment centers mentioned above. • Hospitals, the NRL and the two Covid-19 treatment centers have well-performing Wastewater Treatment Plans as required by national regulations that apply to all major public buildings including. Medical Waste Transportation Arrangements Transportation arrangements in City of Kigali: The medical wastes generated by HCFs in the City of Kigali are collected, transported and treated by Kalisimbi Depot Pharmaceutics. This specialized private company is certified and well equipped with appropriate materials and equipment as well as trained medical wastes handlers. Transportation arrangements in district HCFs: The management of medical waste follows the hierarchy of the HCF structure. Each HCF without modern incinerator has a signed contract with the HCF that has an incinerator in its closest proximity to provide the service. Modalities of transportation of medical wastes is stipulated in the contract between the two HCF parties. The contract may include the provision that the client HCF provides its own transport for the medical waste or that the service provider HCF collects the medical wastes and incinerates it as a combined service. The transportation capacity of medical wastes depends on size and road infrastructures and is conducted by using designated waste transportation to the extent feasible. District hospitals collect medical 29 waste from health centers in their respective catchments to incinerators using district specialized waste transportation vehicles. Testing for COVID-197 Currently, the COVID -19 related samples testing is centralized at the National Reference Laboratory (NRL) under the Rwanda Biomedical Center located in Kigali. All samples collected in City of Kigali and across districts are transported to and analyzed at NRL. Frequency depends on identification of suspects and their respective locations. National process for collecting samples 1) Sample collection procedural steps • Ask the patient to sit with his head tilted back • Ask the patient to open his mouth and say "aahh" to elevate the uvula • Lower the patient's tongue using a tongue blade disposable. • Remove the sterile swab from its sheath • Rub the swab on the pharyngeal mucosa avoiding any contact with the surface of the tongue. (N.B. This procedure can induce the gag reflex.) • Remove the swab and tongue depressor • Discard the tongue depressor in a solution of 5% bleach • Open the tube containing the transport medium. • Dip the swab into transport medium and break the upper end. • Close the tube. • Ask the patient again to sit with his head tilted back • Remove another sterile swab from its sheath • Insert the sterile swab into the nostril parallel to the palate and back to the nasopharynx. The swab is inserted following the base of the nostril towards the auditory pit and will need to be inserted at least 5–6 cm in adults to ensure that it reaches the posterior pharynx. (Do NOT use rigid shafted swabs for this sampling method —a flexible shafted swab is essential). • Leave the swab in place for a few seconds • Slowly remove the swab while slightly rotating it • Open the same tube containing the transport medium used before for the oro-pharyngal swab • Put the swab in transport medium and break the upper end. • Close the tube • Label the sample tube (code, initials, date and sex) • Put all (swab transport medium) in the cooler, add ice packs and route at the National Reference Laboratory • If the delivery to the National Reference Laboratory should be deferred to keep the specimen at 4 °C for up to 72 hours. Do not forget to label the time of collection storage at 4 °C • Remove gloves • Wash hands with soap and water 2) Transporting of samples to testing facilities (when samples are collected from districts) • Samples/specimen are transported by RBC/NRL vehicles directly after they are collected (within an hour of collection), 7 Respiratory sample collection, handling, storage and transport 30 • Currently more than 7 vehicles are dedicated to the sample transportation program and collect samples from various districts hospitals/sites and deliver them to the NRL on regular on a regular basis and sample packaging requirements, • RBC drivers have been trained on the requirements of samples transportation, • The Directors of districts hospitals and 3) Specimen Receiver(s) at Reception • Receive and register the specimens according to acceptance and rejection criteria; • Note the date, the time, and NRL specimen code number on the specimen form as well as his/her initials; • Enter specimen information into laboratory log book and or LIS; • Give specimen courier a specimen reception acknowledgement; • Verify the completeness of mandatory information on Lab request forms; • Verify the condition of submitted specimen(s); • Accept or reject specimen noting the specimen condition and reason for refusal, if refused using the specimen rejection criteria; • If the specimen is rejected, inform the courier and the site of origin that specimen is refused and request another specimen from the site; • If the specimen is accepted transfer specimens to the specimen testing area. 4) Laboratory staff in testing area • Re-verify the completeness of forms; • Re-verify the specimen condition; • Accept or reject specimen noting the specimen condition and reason for refusal, if refused; • If the specimen is rejected, inform the specimen receiver and site of origin that specimen is refused and request another specimen from the site; • If specimen is accepted, analyze the specimen, crosscheck the result, validate & register the results and transfer the results at reception for further delivery; • Discard or store specimens for future testing as appropriate. 5) Specimen Disposal at NRL • Dispose of specimens that have been rejected for testing and/or when testing is complete in appropriate waste containers. • Autoclave wastes containers containing specimens at 1210C for 15 minutes before their incineration. • Pack and incinerate waste containers appropriately. 31 5. Potential Environmental and Social Risks and Mitigation This chapter provides a summary of potential impact of ERP activities that may be associated with the specific project phases comprising the planning and design phase, the minor civil works phase of refurbishments, the operations phase of case detection, confirmation and contact tracing and the decommissioning. ESF instruments to mitigate potential impacts associated with ERP activities by phases comprising the project LMP, templates for ESMP and ICWMP have been included in this ESMF. 5.1. Planning and design stage Information on facilities upgrading and/or rehabilitation needs is not yet been finalized and therefore type, location and scale of PoEs, HCFs and hotspot areas of transmission for ERP investments have not yet been identified. The ERP Environmental Specialist will put in place a working arrangement District Hygiene and Sanitation Officers (DHSOs) screening posts, Environmental Health Officers (EHOs) at hospitals and Community Environmental Health Officers (C-EHOs) that will assist the SPIU in implementing the ESMF and integrated instruments according to Figure 6. Inadequate facilities and processes for treatment of waste During the planning stage, the ERP Environmental Specialist under RBC-SPIU supervision will fill-in the ICWMP (Annex IV) to implement at HCFs that will be sites for ERP subproject/activities. The plan takes consideration of onsite and offsite waste management facilities, and waste transportation routes and service providers will be identified. Inadequate facilities and inadequate processes for treatment of waste may cause the spread of infection and environmental pollution. Exposure to work-related hazards Needs for workforce and type of project workers for upgrading and/or rehabilitation works will be identified as a planning activity. Occupational risks are expected of worker exposure to hazardous work such as working at heights or in confined spaces, use of heavy machinery, or use of hazardous materials. Other risks include the likely presence of migrants or seasonal workers; risks of labor influx or gender-based violence; possible increased risks of contracting COVID-19, risk of accidents or emergencies with reference to the sector or locality and inadequate understanding and implementation of occupational health and safety requirements. The project Social Specialist will arrange for the identification of numbers and types of workers, consider accommodation and measures to minimize cross infection and apply other mitigation measures elaborated in the COVID-19 LMP in Section 7.4. of this ESMF. Upgrade/refurbishment/rehabilitation design flaws Upgrade, rehabilitation or refurbishment designs for laboratories, isolation and treatment centers may not meet standards and could cause personnel to be exposed to infectious diseases and occupational health hazards. The HCF staff with support from the SPIU Environmental Specialist will ensure that designs for refurbishment, set up and management of will take into account the advice provided by WHO guidance for Severe Acute Respiratory Infections Treatment Center available at: https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre . Other mitigation measures include the following: • Hand washing facilities should be provided at the entrances to health care facilities in line with WHO Recommendations to Member States to Improve Hygiene Practices. • Isolation rooms should be provided and used at medical facilities for patients with possible or confirmed COVID-19. • Isolation rooms should: o be single rooms with attached bathrooms (or with a dedicated commode); o ideally be under negative pressure (neutral pressure may be used, but positive pressure rooms should be avoided); 32 o be sited away from busy areas or close to vulnerable or high-risk patients, to minimize chances of infection spread; o have dedicated equipment (for example blood pressure machine, peak flow meter and stethoscope; o have signs on doors to control entry to the room, with the door kept closed; and o have an ante-room for staff to put on and take off PPE and to wash/decontaminate before and after providing treatment. Insufficient mortuary capacity Design considerations are necessary during the project planning stage for adequate mortuary arrangements, failure of which might result in insufficient capacity leading to spread of infection in case of a surge in COVID-19 deaths. The HCF staff with support from the SPIU Environmental Specialist will ensure that adequate mortuary arrangements are included in subproject designs with due reference to the WHO Infection Prevention and Control for the safe management of a dead body in the context of COVID-19 available at: https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1- eng.pdf . A summary of Environmental and Social Risks and Mitigation Measures during Planning and Designing Stage is provided in Table 1 in Annex III. The measures may be updated as appropriate under the supervision of the RBC SPIU (PIU) Coordinator. 33 5.2. Construction stage Workers coming from infected areas During the minor civil works for refurbishment or rehabilitation, COVID-19 infection may be spread by workers coming from infected areas, co-workers becoming infected and workers introducing infection into community or general public. To mitigate these risks, the project Social Specialist ensure the application of the COVID-19 Labor Management Plan (LMP) that is elaborated in Section 7.4 LMP mitigation measures include among others the following: • Consider ways to minimize/control movement in and out of construction areas/site. • If workers are accommodated on site require them to minimize contact with people outside the construction area/site or prohibit them from leaving the area/site for the duration of their contract • Implement procedures to confirm workers are fit for work before they start work, paying special to workers with underlying health issues or who may be otherwise at risk • Check and record temperatures of workers and other people entering the construction area/site or require self-reporting prior to or on entering • Provide daily briefings to workers prior to commencing work, focusing on COVID-19 specific considerations including cough etiquette, hand hygiene and distancing measures. • Require workers to self-monitor for possible symptoms (fever, cough) and to report to their supervisor if they have symptoms or are feeling unwell • Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days • Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days Occupational Health and Safety (OHS) risks Improper work procedures during civil works and in the management of healthcare waste management can cause OHS risks on health care providers and supportive staff or persons with disabilities. Mitigation measures will involve adopting and implementing safety guideline or manuals from OHS guideline and WHO technical guideline for COVID-19 Key considerations for occupational safety and health. The Social Specialist will be accountable for the supervision of these measures on behalf of the SPIU and MoH. Traffic hazards Lack of traffic and road safety procedures can lead to traffic accidents caused by moving machinery and equipment. The project Environmental and Social Specialists will monitor that civil works contractors implement measures including segregated location of vehicle traffic, machine operation and walking areas, and controlling vehicle traffic through one-way traffic routes, setting of speed limits and frequent regular training and capacity building to promote safe traffic management culture. Gender Based Violence, Sexual Exploitation and Abuse and Sexual Harassment issues and risks Worker environments can present Gender Based Violence (GBV), Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) risks if deterrent measures are not planned for and practiced. As a mitigation measure, project Social Specialist will arrange the preparation of a GVB/SEA/SH action plan to be implemented by all subproject contractors. Each subproject contractor, permanent or temporary, will sign a Code of Conduct, to promote appropriate behavior, among other requirements. Temporary disruption of healthcare services Since facilities under renovation would not be closed, modifications of buildings in which medical services are provided may entail moving patients or equipment from one area or room to another. This may cause temporary disruption in delivery of health services to patients at facilities under renovation. Temporary rearrangement of service areas can have the undesirable consequence of slowing down emergency services 34 or cause inability among health workers to efficiently offer necessary treatment for visiting patients. Movement of equipment may cause their damage. This impact is short-term but can have long-term and irreversible impacts (such as where human life is lost). Extent of this impact will be mostly local to facilities under renovation although, due to the disturbance, some patients might choose to transfer to alternative healthcare facilities, leading to their congestion. The impact will potentially occur at every facility in this project. Likelihood of the impact occurring is high and significance is therefore predicted to be medium-high. Cultural heritage Refurbishment and/or rehabilitation civil works in the ERP are expected to be minor with low likely impact on cultural heritage. However, as a precautionary measure, Chance-find Procedures (see sample in Annex VI) will be included in civil works contracts requiring contractors to stop construction if cultural heritage phenomena are encountered during refurbishment or rehabilitation activities in order to coordinate with the relevant mandated country authority for the salvaging, restoration or other appropriate action of such cultural heritage. The project Social Specialist will ensure that an appropriate clause is included all civil works contracts. Fire risk and chemical spill and other toxicity accidents Lack of appropriate emergency preparedness and response plans can result in accidents such as fire, chemical spills and other toxic substance releases causing danger to humans and to the environment. The Environmental Specialist will arrange the preparation of an Emergency Response Plan for containment of fire accident and an emergency response plan for containment of chemical spill and toxic substance release during ERP investment activities. The ERPs would be operationalized by respective EHOs or C-EHOs at recipient HCFs of project investments as displayed in Figure 6. Water pollution and temporary loss of utility services Minor civil works related to onsite waste management facilities, including temporary storage, incinerator, sewerage and/or wastewater treatment works can cause water pollution from construction wastes as well as on-site make shift toilets. Civil works and also cause temporary loss of access to services such as water and electricity. The HCF staff with support from the SPIU Environmental Specialist and Supervising engineer will ensure that contractors collect and dispose wastes in designated disposal sites as required by the Local Authority and provide appropriate and approved temporary toilets. A summary of Environmental and Social Risks and Mitigation Measures during the construction (minor civil works) stage is provided in Table 2 in Annex III. The measures may be updated as appropriate under the supervision of the RBC SPIU (PIU) Coordinator. HCF Infection control and waste management plan risks Inadequate or flawed planning for infection control and waste management may result in infection spread due to inadequate hand hygiene and respiratory hygiene during COVID-19 triage, early recognition and source control. The project Environmental Specialist will conduct a screening of each of the participating HCFs and arrange the preparation and implementation of an Infection control and waste management plan (ICWMP) according the template provided in Annex IV of this ESMF. Due reference to the WHO interim guidance for “IPC during health care when COVID-19 is suspected� available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel- coronavirus-(ncov)-infection-is-suspected-20200125. 35 5.3. Operational Stage Risks resulting from operational activities in Component 1 (case detection, confirmation and contact tracing for COVID-19 patients) and Component 2 (public health measures and clinical care capacity improvement) will lead to generation of various categories of medical waste which ranges from general infectious waste, pathological waste, chemical waste (laboratory reagents) and sharps. For the operational phase activities supported by the GoR outside of the project, risks and mitigation measures are presented in this ESMF (Annex III) and ICWMP (Annex IV). The following are the potential impacts associated with implementation of Rwanda COVID-19 Emergency Response Project and its Additional Financing: HCF wastewater and fecal waste Isolation and quarantine facilities are associated with increased volume of wastewater and excreta. Liquid contaminated waste (e.g. pathological sample, blood, feces, urine, other body fluids and contaminated fluid) requires special handling, as it may pose an infectious risk to healthcare workers with contact or handle the waste. There is no evidence to date that the COVID-19 virus has been transmitted via sewerage systems with or without wastewater treatment. Mitigation measures to be implemented: • Inorganic waste should be given to the authorized vendor for free of cost for recycling; • Minimization and safe storage of potential sources of liquid wastes. • Install a sewer system to collect liquid waste from around a facility and carry it below ground to a central location for treatment. • Liquid waste originating from the laboratory should pass through a disinfection process before directing to the general sewer line according to WHO-Laboratory biosafety guidance related to COVID-19 available at https://apps.who.int/iris/handle/10665/332076 . • People with suspected or confirmed COVID-19 disease should be provided with their own flush toilet or latrine. • Where this is not possible, patients sharing the same ward should have access to toilets that are not used by patients in other wards. • Each toilet cubicle should have a door that closes, to separate it from the patient’s room. • Flush toilets should operate properly and have functioning drain traps. • When possible, the toilet should be flushed with the lid down to prevent droplet splatter and aerosol clouds. • If it is not possible to provide separate toilets for COVID-19 patients, then the toilets they share with other non-COVID-19 patients should be cleaned and disinfected at least twice daily by a trained cleaner wearing PPE (impermeable gown, of if not available, an apron, heavy-duty gloves, boots, mask and goggles or a face shield). • Health-care staff should have toilet facilities that are separate from those used by all patients. • A disinfection step may be considered if existing wastewater treatment system is not optimized to remove viruses. • Make sure all containers, drums and tanks that are used for storage are in good condition; • Take all precautionary measures when handling and storing fuels and lubricants, avoiding environmental pollution; Improper medical waste management During their operation, health centers will generate medical waste through several clinical activities including; sample collection from COVID-19 suspected patients, laboratory practices and procedures (performing and handling of specimen and chemicals), blood transfusion procedures and from activities in isolation and quarantine facilities; which need to be disposed of in an appropriate medical waste disposal facility. Improper disposal of medical waste would have environmental and public health impacts: for example, open burning and incineration of medical wastes can result in emission of dioxins, furans and 36 particulate matter, and result in unacceptable cancer risks under medium (two hours per week) or higher usage. Impact mitigation measures provided here below are sourced from the WBG EHS Guidelines for Healthcare Facilities. Other measures provided in Annex III (ESMP) Table 3 and Annex IV (ICWMP). • Health care facilities should establish, operate and maintain a health care waste management system (HWMS) adequate for the scale and type of activities and identified hazards. • Each health facility should prepare (prior to the start of operations under the project) an Infection Control and Waste Management Plan (ICWMP) based on the template provided in Annex IV and in accordance with national regulations. • Waste should be identified and segregated at the point of generation. Non-hazardous waste, such as paper and cardboard, glass, aluminum and plastic, should be collected separately and recycled. Food waste should be segregated and composted. Infectious and / or hazardous wastes should be identified and segregated according to its category using a color-coded system. • Prevention and minimization of the production of waste (integrating systems and practices to avoid the creation of waste into facility design and management and equipment and consumables purchasing). • Reuse or recycling of wastes to the degree feasible, employing: o Source reduction measures such as purchasing restrictions to ensure the selection of methods or supplies that are less wasteful or generate less health care waste; o Recyclable products (use of materials that may be recycled either on- or off-site); o Good management practices rigorously applied to purchase and control of chemicals and pharmaceuticals; and o Segregation of wastes into different categories—for control of quantities and disposal methods. • Seal and replace waste bags and containers when they are approximately three quarters full. Full bags and containers should be replaced immediately. • Identify and label waste bags and containers properly prior to removal. • Transport waste to storage areas on designated trolleys / carts, which should be cleaned and disinfected regularly. • All healthcare waste generated during care of COVID-19 patients should be treated as infectious waste and managed in accordance to WHO guidelines on Water Sanitation, Hygiene and Waste Management for COVID-19. • Instructions on how to handle the infectious waste from isolation and treatment centers should be made available to the waste handlers in all health facilities. • Ensure safety and health of the health care waste handlers through provision of appropriate PPEs, vaccination against Hepatitis B and tetanus as well as provision of post-exposure prophylaxis (PEP). • Waste storage areas should be located within the facility and sized to the quantities of waste generated, with the following design considerations: o Hard, impermeable floor with drainage, and designed for cleaning / disinfection with available water supply; o Secured by locks with restricted access; o Designed for access and regular cleaning by authorized cleaning staff and vehicles; o Protected from sun, and inaccessible to animals / rodents; o Equipped with appropriate lighting and ventilation; o Segregated from food supplies and preparation areas; and o Equipped with supplies of protective clothing, and spare bags / containers. • Unless refrigerated storage is possible, storage times between generation and treatment of waste should not exceed 48 hours during cool season, 24 hours during hot season. 37 • Store mercury separately in sealed and impermeable containers in a secure location. • Store cytotoxic waste separately from other waste in a secure location. • Store radioactive waste in containers to limit dispersion, and secure behind lead shields. • Transport waste destined for off-site facilities according to the guidelines for transport of hazardous wastes / dangerous goods in the General EHS Guidelines. • Transport packaging for infectious waste should include an inner, watertight layer of metal or plastic with a leak-proof seal. Outer packaging should be of adequate strength and capacity for the specific type and volume of waste. • Packaging containers for sharps should be puncture-proof. • Waste should be labeled appropriately, noting the substance class, packaging symbol (e.g. infectious waste, radioactive waste), waste category, mass / volume, place of origin within hospital, and final destination. • Transport vehicles should be dedicated to waste and the vehicle compartments carrying waste sealed. • Facilities receiving hazardous health care waste should have all applicable permits and capacity to handle specific types of health care waste. The SPIU will review the contracts for District hospitals receiving waste from the participating HCFs, including Kalisimbi Depot Pharmaceutics waste processing facility, to include applicable EHS clauses to comply with ESSs, specifically ESS3 and ESS2, including OHS aspects. • Health care waste generated in the management of COVID-19 patient is considered infectious wastes and should be treated in the following methods and technologies sequentially: chemical disinfection, wet thermal treatment, inertization, microwave irradiation, incineration and landfill disposal. • Customized training for the staff handling and management health care wastes contaminated withCOVID-19 should include: o The use of appropriate / full PPEs (N95 respirators, apron, heavy duty gloves, eye protection, boots and long sleeved gown); o Hand hygiene practices; o Waste segregation strategies and clean up procedures; o On-site Handling, Collection, Transport and Storage; o Exposure to COVID-19 infections and diseases transmission; o Exposure to radiation; and o Fire safety measures. Impact as a result of improper procurement of Medical Supplies and Equipment The project shall procure: a. Equipment such as intensive care equipment (intubation, oxygen concentrators, suction machines, respiratory support machines) and dialysis machine and plant. b. Supplies: sample collection and packaging supplies, lab reagents, pharmaceutical supplies, health care waste management/lab PPE among others. Poor quality equipment may exacerbate COVID19 fatality due to failure of operations especially live saving machines like ventilators. On the other hand, due to poor handling of samples collection and packaging supplies, lab reagents, pharmaceutical supplies, health care waste management the use of lab PPE may lead to the spread of infections to the healthcare workers. Mitigation measures • Adhere to the procurement plan for acquisition of all medical supplies and equipment from certified suppliers only. 38 • Carry out due diligence for all potential suppliers to guarantee quality equipment and products. It is noted that MoH/RBC-SPIU practice of purchasing ERP medical supplies and equipment through the Africa Medical Supplies Platform (AMSP) ensures certified medical equipment such as diagnostic kits, PPE and clinical management devices with increased cost effectiveness and transparency from vetted manufacturers fulfils the requirement for due diligence. • WHO interim guidance on rational use of PPE for coronavirus disease 2019 provided further details on the types and quality of PPE that are required for different functions. The ERP frontline healthcare workers shall be provided with medical personal protective equipment (PPE) includes: Medical mask, Gown, Apron, Eye protection (goggles or face shield), Respirator (N95 or FFP2 standard), Boots/closed work shoes. HCF operational hazards General operation of HCFs can involve vulnerability to spread of infection (especially during a pandemic) physical hazards, electrical and explosion hazards, fire, chemical use, ergonomic and radioactive hazards. The ERP will deploy regular MoH and district officials in project activities on existing contractual conditions and does not recruit additional staff. The project provides funds logistical and operational support for personnel. The project Environmental Specialist will work together with the EHOs or C-EHOs at intervention HCFs as in Figure 6 to ensure the establishment of the following mitigation measures to be implemented. These measures are elaborated in Annex III and Annex IV. • Health facilities should establish and apply Standard Precautions including: o Hand Hygiene (HH); o Respiratory hygiene/cough etiquette. o Use of personal protective equipment (PPE); o Handling of patient care equipment, and soiled linen; o Environmental cleaning; o Prevention of needle-stick/sharp injuries; o Appropriate Health Care Waste Management; • Health facilities should establish and apply Transmission based precautions (contact, droplet, and airborne precautions) as well as specific procedures for managing patients in isolation room/unit. • Establishment of Standard precautions and Transmission based precautions in line with National guidelines for IPC in healthcare facilities and take into account guidance from WHO and/or CDC on COVID19 infection control, • Collection of samples, transport of samples and testing of the clinical specimens from patients meeting the suspect case definition should be performed in accordance with WHO interim guidance Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases. • Tests should be performed in appropriately equipped laboratories (specimen handling for molecular testing requires BSL-2 or equivalent facilities) and by staff trained in the relevant technical and safety procedures. • All hospitals and laboratories should prepare waste management procedures in accordance with the national requirements that outline waste segregation procedures, on site handling, collection, transport, treatment and disposal, and training of the staff. • Health facilities shall ensure the provision of safe water, sanitation, and hygienic conditions, which is essential to protecting human health during all infectious disease outbreaks, including the COVID-19 outbreak. Health facilities shall establish and apply good practices line with WHO guidance on water, sanitation and waste management for COVID-19 and National guidelines for Infection Prevention and Control in the healthcare facilities. • Samples that are potentially infectious materials (PIM) need to be handled and stored as described in WHO document Guidance to minimize risks for facilities collecting, handling or storing 39 materials potentially infectious for polioviruses (PIM Guidance).Organize and implement medical surveillance which includes medical service and immunization programs; • Provide health and safety training; • Adopt and implement safety manuals aligned with OSH guideline and WHO laboratory biosafety manual; WHO technical guideline for COVID-19 Key considerations for occupational safety and health • Develop and implement safety standards. Labor issues in HCF operation Worker grievances can develop in general operation of HCFs that may involve among others, PPE availability and/or use; lack of proper procedures or unreasonable overtime; time-sensitivity and/or confidentiality of grievance. To mitigate these labor risks, the HCF will adopt the application of the GRM as features in the COVID-19 Labor Management Plan (LMP) as elaborated in Section 7.4 as well as the WHO resources for COVID-19: occupational health available at: https://www.who.int/news- room/detail/09-03-2020-covid-19-occupational-health Vulnerable and/or special needs groups Lack of considerations in HCF operation for differentiated treatment for vulnerable and/or special needs groups may put the elderly, people preexisting conditions, the very young, people with disabilities at higher risk of contracting COVID-19 virus. The project design must include considerations for differential treatment for special needs groups are incorporated in subproject activities based on results and recommendations from stakeholder engagements according to the project SEP. Inadequate cleaning risks in HCF operation Inadequate cleaning equipment, materials and disinfectant and inadequate training of cleaning staff for COVID-19 requirements may result in infection propagation in HCF operation. The HCF will adopt the following mitigation measures to be implemented: • Provide cleaning staff with adequate cleaning equipment, materials and disinfectant. • Review general cleaning systems, training cleaning staff on appropriate cleaning procedures and appropriate frequency in high use or high-risk areas. • Where cleaners will be required to clean areas that have been or are suspected to have been contaminated with COVID-19, provide appropriate PPE: gowns or aprons, gloves, eye protection (masks, goggles or face screens) and boots or closed work shoes. If appropriate PPE is not available, provide best available alternatives. • Train cleaners in proper hygiene (including handwashing) prior to, during and after conducting cleaning activities; how to safely use PPE (where required); in waste control (including for used PPE and cleaning materials). • Refer to WHO Interim guidance for WASH waste management for the COVID-19 virus available at: https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste-management-for- the-covid-19-virus-interim-guidance. Risks associated with sample collection, packaging and laboratory procedure It is essential that laboratory analysis is carried out to immediately ascertain or rule out a suspected COVID- 19 case. It is expected that COVID-19 samples collected during a suspected outbreak will be transported by Ministry of Health trained staff to a specialized reference laboratory for analysis in accordance with WHO and MoH standard operating procedures. This avoids the potential impact of risks associated with improper collection of samples, transportation of samples, improper laboratory waste disposal in communities or at emergency treatment units. Improper management of laboratory waste (syringes, Gene Expert cartridges etc.) would lead to offsite COVID-19 transmission slowing effective containment of the 40 outbreak. The impact and severity due to unplanned disposal of COVID-19 related laboratory waste would be a negative impact with potentially long-term and irreversible socio-economic impact with high significance. The following mitigation measures shall be implemented. These measures are elaborated in Annex III and Annex IV. Ministry of Health, through SPIU and HCF staff shall: • Ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, an N95 mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a certified N95, an EU standard FFP2, or the equivalent; • Ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures; • Place specimens for transport in leak-proof specimen bags (i.e., secondary containers) that have a separate sealable pocket for the specimen (i.e., a plastic biohazard specimen bag), with the patient’s label on the specimen container (i.e., the primary container), and a clearly written laboratory request form; • Establish a quality control system for packaging, collection and transportation of laboratory samples following the WHO guidelines on laboratory biosafety guidance related to COVID-19; • Ensure the collection of samples, transport and the testing of clinical specimens from patients meeting the suspect case should be performed in accordance with WHO interim guidance on laboratory testing for coronavirus disease 2019; • Utilize incinerator for destroying Gene Expert cartridges at higher than 1,200 °C • Put in place innovative and efficient mechanisms to improve transport of COVID-19 samples to reference laboratories in the shortest time possible and following the safety precautions; • Sample transportation should not expose transporters to risk either during normal handling or in case of an accident. Impact management Continue building the capacity of laboratory staff to meet necessary standards, including: • Ensure proper medical waste management in accordance with existing WHO standard operating procedures (SOPs); • Daily monitoring of laboratory capacity to ensure they are all able to accommodate the number of samples collected; • Organizing sample management (collection, storage, packaging and transport) in accordance with WHO guidelines; • Regularly train the relevant health personnel on COVID-19 diagnosis and sample management. Risks associated with on-site healthcare waste treatment and disposal On-site healthcare waste treatment and disposal involving incineration that may include chemicals containing Volatile Organic Compounds (VOCs) may pause health risks and pollution. The project Environmental Specialist together with EHOs or C-EHOs at ERP beneficiary HCFs will ensure that septic and other systems recommended by WBG EHS guideline and by WHO Interim guidance for WASH waste management for the COVID-19 virus are duly considered in HCF infection control and waste management plans. Appropriate waste drainage systems leading to septic tank or public sewerage facilities or treatment technologies such as activated sludge and sanitary facilities will be used, if available in the local municipality. These measures will be included in the ICWMP according to Annex III and Annex IV. 41 Risks associated with waste transportation, off-site treatment and disposal Waste transportation, off-site treatment and disposal can cause transmission risk of COVID-19 virus. There is a risk associated with traffic and road safety hazard during operational phase due to use of ambulances, transportation of samples to the laboratory and transportation of highly infectious medical waste from facilities with no HCW treatment and disposal facilities. Appropriate facilities and methods as stipulated in the WBG EHS guideline for Health Care Facilities and WHO interim guidance on WASH for the COVID-19 virus will be deployed to collect, and transport wastes, treat and dispose them using appropriate technologies and disposal facilities (incineration as a last alternative). Mitigation measures • The relevant staff should be trained on pre-hospital emergency care, infection prevention and control measures, how to handle samples in transit, healthcare waste and spillage management in case of an accident and provided with the required PPE, • Vehicles used as ambulances or for transporting any hazardous material and medical waste should be road worthy, labelled to indicate its load and its payload secured to minimize risk of accidents and spillage, • The project shall well-equipped ambulances; ensure they are outfitted with audible back-up alarms as well as with effective communication system for emergency service functions and activities • Periodic community awareness on traffic awareness campaign, • Use of competent drivers with defensive driving technics, • MoH and the respective project beneficiaries (health facilities, referral laboratories) shall regularly inspect vehicle safety and maintain them accordingly, and • Ambulance drivers should follow guidance on safe emergency driving, • Vehicles used in transport of samples or healthcare waste should be easy to clean, free of sharp edges and shall be cleaned thoroughly and disinfected after use Improper clinical care, isolation of suspected cases and follow-up of survivors The aim of clinical care for COVID-19 patients will be to provide high quality, safe care and individualized patient-centered care in a bio-secure environment to minimize the risk of spreading this disease to other patients or health workers. Clinical care includes medical, nursing, nutritional, rehabilitation, psychosocial care and early childhood care services, disabled persons, children and women, including pregnant and lactating women. If this undertaking is not planned or carried out with due caution, there is a high risk of transmitting COVID-19 infection to healthcare workers or other people in their families. The onward infection of medical workers or other people due to improper clinical care, isolation of suspected cases and follow-up of survivors would be a negative impact with long-term and irreversible (if death occurred) socio-economic impact will have high significance. 42 Mitigation measures MoH, through the SPIU and HCF staff shall: • Improve biosecurity and harmonize care protocols to avoid risk of infections of medical workers and other people; • Build triage centers in referral hospitals or in health facilities according to the dynamics of COVID- 19 pandemic; • Set up a management system specific to case management structures under the management of MOH (finance, logistics, administration, etc.); and • Restructure the survivors’ follow-up program by fully integrating it into the clinical care. • In case of blood/bodily fluid exposure: 1. Persons including HCWs with percutaneous or muco-cutaneous exposure to blood, body fluids, secretions, or excretions from a patient with suspected or confirmed infectious disease, should immediately and safely stop any current tasks, and leave the patient care area. 2. Safely take off PPE according to the steps in the procedure, in the anteroom. 3. Treat affected exposed area: ▪ wash the affected skin surfaces or the percutaneous injury site with soap and water ▪ Irrigate mucous membranes (e.g. conjunctiva) with copious amounts of water or an eyewash solution, and not with chlorine solutions or other disinfectants. 4. Immediately report the incident to the chief of unit, IPC focal point (following hospital exposure procedure) as soon as the HCF staff exist the isolation room/ unit. 5. Exposed persons should be medically evaluated for: ▪ infectious disease (ID) (of isolated patient) ▪ other potential exposures (e.g., HIV, HCV) if sharp/needle-stick injury. 6. Exposed persons must receive follow-up care, including: ▪ fever monitoring, twice daily period of recording symptoms will depend on the ID ▪ Counselling and psychological support. 7. Immediate consultation with an expert in infectious diseases for any exposed person who develops fever, symptoms after exposure. 8. If fever appears and other symptoms, isolate HCF staff, and follow procedure for ID suspected until a negative diagnosis is confirmed. 9. Workers suspected of having infected should be cared for/isolated, and the same recommendations outlined in this document must be applied until a negative diagnosis is confirmed. 10. Conduct contact tracing and follow-up of family, friends, co-workers and other patients, who may have been exposed to COVID-19 virus through close contact with the infected HCW/ staff Weak infection prevention and control measures Infection prevention and control (IPC) measures and water, sanitation and hygiene (WASH) aim to prevent and control nosocomial (originating in a hospital) and community transmission of COVID-19. The absence of effective IPC and WASH measures would curtail efforts to control COVID-19. This reiterates the importance of precautions such as avoiding handshaking, hand washing with soap and water and Infection prevention and control (IPC) measures and water, sanitation and hygiene (WASH) aim to prevent and control nosocomial (originating in a hospital) and community transmission of COVID-19. The absence of 43 effective IPC and WASH measures would curtail efforts to control COVID-19. This reiterates the importance of precautions such as avoiding handshaking, hand washing with soap and water. Mitigation measures Main activities in the health facilities shall include the following: • Health facilities should establish and apply standard precaution including hand hygiene, respiratory hygiene, use of PPE, handling of patient care equipment and soiled linen, environmental cleaning and prevention of needle stick and sharp injuries. • Health facilities shall ensure provision of safe water, sanitation and hygienic conditions in line with WHO guidance on water, sanitation and waste management for COVID-19 and National guidelines for infection prevention and control of health facilities. • Strengthen training activities of healthcare providers and IPC supervisors on issues related to COVID-1912 (see Annex VI): o ensuring triage, early recognition, and source control (isolating patients with suspected COVID-19); o applying standard precautions for all patients; o implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of COVID-19; o implementing administrative controls; and o using environmental and engineering controls. • Implement the IPC package that includes standard operating procedures (SOPs), tools, and rapid diagnostic tests. • Strengthen the IPC / WASH support system in health facilities based on health facility assessments, training supervision with corrective actions, and the establishment of a quality assurance system in close collaboration with the independent monitoring and evaluation team. • Evaluate and implement WASH infrastructures (improvement of water and sanitation facilities) and services in health facilities. • Provide health facilities with IPC / WASH inputs (detergents) as needed and monitor their use; • Ensure the decontamination of health facilities that have received confirmed COVID-19 cases. • Ensure implementation of the IPC ring approach around each confirmed case of COVID-19. • Promote preventive medicine; no pregnant women, staff older than 65 or staff with underlying health conditions, should be working in isolation areas, provision of psychosocial support to medical staff and team and any health care workers reporting COVID-19 symptoms should stop work immediately Infection prevention and control in affected communities In communities, IPC activities shall be carried out in households and in public places. These include: • Ensuring access to water and sanitation in schools and public places; • Ensuring decontamination of households and public places that have had confirmed COVID-19 cases; • Providing hygiene kits to households, schools and public places; • Strengthening the monitoring and evaluation system; and • Training community leaders in COVID-19 prevention. WHO guidance on key questions and answers concerning water, sanitation and hygiene (WASH) is presented in Annex V. Air pollution Incineration of hospital waste if carried out in inappropriate facilities could result into localized pollution of air with pollutants such as ash, furans and dioxins. Dioxins are known to promote cancers in humans. The Downwash of incinerator emissions has potential to degrade indoor air quality of healthcare buildings or those of nearby offsite buildings. The impact severity associated with this is that the duration of onsite and offsite air pollution would be long-term lasting entire life on incineration units unless the deficient units 44 are either decommissioned or improved. Considering the gravity of potential air pollution on health of patients and nearby communities, this impact will have high significance. Single-chamber, drum and brick incinerators will not be used. If small-scale incinerators are used, best practices (such as WBG EHS Guidelines on HCFs) to minimize operational impacts will be applied. Selected District Hospital incinerators should be regularly inspected and monitored: Healthcare administrators should undertake regular visual inspection of incinerator stack for incidents of downwash and undertake annual monitoring of ambient air quality or a general environmental audit of entire healthcare facility. The project should contribute to training of incinerator operators as it is important for them to be familiar with basic principles and routine practices. For example, homogenization of waste is crucial to ensure efficient and complete combustion during incineration to avoid generation of dioxins for instance when wet waste batches quench flames and lower combustion temperature below levels at which such pollutants are destroyed. Aerosol and organic solvent transmission risk of COVID-19 virus Improper methods of transportation and delivery of specimen (and other infectious material), samples, reagents, pharmaceuticals and medical supplies as well as improper storage and handling may result in aerosol and organic solvent transmission risk of COVID-19 virus. The HCF staff with support from the SPIU Environmental Specialist will ensure that due reference is made to WHO Laboratory biosafety guidance related to COVID-19 for proper handling and storage of infectious materials including specimen and samples. The guide includes use standard laboratory practice to avoid/minimize release of aerosols and organic solvents to atmosphere as well as adequate ventilation in laboratories and treatment areas and use of fume hoods if necessarily for chemical processing. Risks associated with improper use of COVID-19 equipment Improper use of COVID-19 equipment and other assets pause infection spread risk. Exclusive use of disposable supplies for IPC is appropriate in highly infectious situations and therefore require diligent waste management procedures during screening of potential COVID-19 patients and during pre-triage. The project HCF staff with guidance from the SPIU Environmental Specialist will ensure appropriate handling and management of generated waste, assisted by District Sanitation & Hygiene Officer (DSHOs) responsible for E&S compliance at Screening Posts (PoEs) and Centers of Quarantine, by Hospital Environmental Officers (HEOs) at hospital Isolation and Treatments Facilities and by Environmental Health Officers (EHOs) at Screening Posts (PoEs) of Health Centers or other community designated centers. Due reference will be made to the WHO interim guidance for “Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19)� available at: https://www.who.int/publications- detail/rational-use-of-personal-protective-equipment-for-coronavirus-disease-(covid-19)-and- considerations-during-severe-shortages. Risk associated with procurement of Sub-standard PPEs Procurement of poor quality PPE may exacerbate COVID-19 infection transmission to healthcare workers and cleaners in relation to laboratory procedures, interaction with COVID-19 patients and handling of healthcare waste. Mitigation measures 45 • Adhere to the procurement plan for acquisition of all personal protective equipment from certified suppliers only. • Carry out due diligence for all potential suppliers to guarantee quality supply of personal protective equipment and products. • Abide by the WHO interim guidance on rational use of PPE for coronavirus disease 2019 over the types and quality of PPE required for different functions. • The healthcare workers shall be provided with medical personal protective equipment (PPE) includes: Medical mask, Gown, Apron, Eye protection (goggles or face shield), Respirator (N95 or FFP2 standard), Boots/closed work shoes and trained on use. Occupational Safety and Health Risks COVID-19 is highly infectious and the risk of contraction by healthcare workers and the general public is high, if requisite training, sensitization and protective gear are not provided. Medical facilities are a potential source of infectious waste and these could pose unsafe conditions for healthcare staff. Of particular concern are health workers handling infectious waste (including sharps) without adequate protective gear, storage of sharps in containers that are not puncture-proof. While some OSH risks will be new borne by equipment or services introduced after renovation or upgrade of facilities, most other effects are existing (hence cumulative) and would only be exacerbated by increased use of healthcare services as a result of COVID-19 cases. Below is a list of OHS risk sources for healthcare staff: • Biological hazards (blood or other body fluids with potential to cause diseases); • Lack of adequate lighting in workplaces; • Lack of safe access particularly for disabled employees; • Inadequate ventilation in rooms; • Lack of adequate training (or neglect of safety precautions/ guidelines) in use of medical equipment; • Misuse of equipment and materials for functions they are not designed; • Lack of safety signage in specific areas (e.g. X-ray rooms) from radioactive hazards; • Electrical hazard; • Eye hazards such as splashes in laboratories and operating rooms; and • Chemical hazards (acids, alkalis, expired drugs, oxidizing and reactive chemicals); • Likelihood of the impact occurring is high unless control measures are instituted. Although it is a cumulative impact, the risk to human health is significant. Mitigation measures • Ensure the implementation of standard precautions and transmission based precautions in line with national guidelines for IPC in healthcare facilities taking into account guidance from WHO and/or CDC on COVID19 infection control, • Update and implement HCF OHS plan and/or emergency response plan, • Ensure identification of risks (Job Risk Assessment) and instituting proactive measures, • Train the healthcare workers on the potential OSH risks in relation to COVID-19, • Provision of adequate and required personal protective equipment (PPE) to health workers and enforce on use. This includes: single use medical mask, gown, Apron, eye protection, boots or closed shoes. • Provision of a system for disinfection of the multi-use PPE if not available. • Implementation of systemic risk management plan comprising risk prevention, evacuation of accident victims, evaluation and improvement measures. • Ensure availing of Material Safety Data Sheet for all chemical use in the lab to the lab technicians. • The beneficiary facilities (labs and HCF) will prepare sub-project specific ICWMP and this will include update of the health facility OSH plan. 46 Fire risk Without provisions for fire safety, there is a risk of fire outbreak at healthcare facilities (quarantine, isolation, laboratories) with disastrous life and financial impact. Fires can start from ignitable materials in laboratories, cigarette smoking in non-designated places or old electrical connections. Mitigation Measures • Provide fire extinguishers to healthcare facilities during their renovation at strategic positions and ensure servicing is done. • Key healthcare staff shall have basic training in fire control. • Fire emergency telephone numbers should be displayed in communal areas. • Each healthcare facility shall prepare a fire emergency management plan. • Undertake regular fire drills at healthcare facility, to test on emergency response and use the results to improve on the response mechanism. • Specific site Emergency Response Plan should adequately address all potential hazards (not just fire) including but not limited to man-made (spills, accidental releases, loss of energy supply) and flood / storm. Community Health Risk Improper waste disposal can cause public health risks due to environmental pollution: impaired air quality from burning of waste, storm water contamination or when people rummage through raw waste stockpiles. Wastewater may not seem to pose considerable disposal challenge since all existing facilities either has onsite septic systems or sewage lagoons. However, this remains a risk in areas where there is no drainage system. Plume downwash leads to chronic exposure of nearby communities to potent air pollutants including dioxins. Infections sustained when people or children rummage through improperly dumped infectious waste can be life-threatening. Unless mitigation recommendations are implemented, this impact will occur at all healthcare facilities. Likelihood of the impact occurring is high if incinerator stack designs are flawed or proper medical waste management practices are not instituted, and if common practices of open air burning of all waste types continue. Mitigation measures • Targeted procurement of only required pharmaceutical, equipment, and other medical supplies in small quantities; • Ensure regular monitoring of solid, liquid waste management practices and incineration; • Ensure proper management of pharmaceutical waste by engaging a consultant to develop measures and guidelines for each facility in accordance with the national healthcare waste management plan; • To ensure proper sewage management and use of latrines where they there is no sewer; • SPIU under MoH shall develop measures for proper management of expired pharmaceutical drugs and instigate this policy at all health care facilities; • Install appropriate drainage channel within the health facility; • Facility operators should undertake regular assessment of waste generation quantities and categories to facilitate waste management planning, and investigate opportunities for waste minimization on a continuous basis, • Separate residual chemicals from containers and remove to proper disposal containers to reduce generation of contaminated wastewater; • All waste disposal sites should be REMA licensed, secured and out of reach from the scavengers; 47 • Select facilities which have incinerator(s) that are appropriate to handle healthcare waste with specification including air pollution control option; • Ensure the healthcare waste generated in the facilities are disinfected, treated and safely disposed of; and • Community should be sensitized on infection prevention and control measures related to COVID- 19. Emergency Situations It is important to develop procedures and practices for the handling of hazardous materials that allow for quick and efficient responses to accidents that may result in injury or environmental damage. The ERP investment beneficiary HCFs should prepare an Emergency Preparedness and Response Plan that should cover: ➢ Planning Coordination: This should include procedures for: • Informing the public and emergency response agencies • Documenting first aid and emergency medical treatment • Taking emergency response actions • Reviewing and updating the emergency response plan to reflect changes and ensuring that the employees are informed of such changes ➢ Emergency Equipment: The plan should include procedures for using, inspecting, testing, and maintaining emergency response equipment. ➢ Training: Employees should be trained in any relevant procedures ➢ Undertake regular emergency drills (fire, chemical spill) at healthcare facility, to test on emergency response and use the results to improve on the response mechanism. Lack of sustainability When improved healthcare facilities and equipment’s installed are not continually maintained, they quickly degenerate. This could have significant negative medium-term impacts of local spatial extent which are reversible. Mitigation measures • A Facility Maintenance Plan shall be prepared and implemented at each healthcare facility. • HCF shall have timely engagement with MoH to secure a budget to sustain healthcare facilities in a functional state. • Equipment’s available in the health facilities should be serviced and maintained regularly • Stigma The impact severity in the absence or weak psychosocial support systems would impede effective prevention of stigma attached to COVID-19, a negative but short-term and reversible impact, reducing or ceasing with heightened awareness. Mitigation measures • Ensure accurate information on the disease, its spread, symptoms and outcomes is broadly distributed to communities using channels that are accessible. • Handle all people directly affected by the disease with dignity (those in hospitals, quarantine/isolation centers and the dead). • Strengthen psychological support for ETCs (for confirmed, suspected, and discharged cases) and assistance with hygiene kits for all discharged and cured patients. • Support affected households to anticipate management of behavioral problems, which can generate tensions and resistance in the community. 48 Gender-based violence (GBV) and sexual harassment, exploitation and abuse (SEA) There is a risk of GBV and SHEA during operational phase in the management of quarantine/isolation centers. If security personnel are deployed to guard isolation/quarantine centers the risk of abuse of women and girls could be high. There is also a risk of GBV/SHEA among co-workers. Mitigation measures • Ensure isolation and quarantine centers are protected. • Limit admission of outsiders into the centers. • Monitor and report on the behavior of security guards at the centers. • Ensure the people in these facilities understand the GBV/SEA/SH referral pathways. • Ensure the people at the center have access to the toll free hotline. • All workers should sign the code of conduct to hold them accountable (see the LMP). Lack of or inadequate public participation and consultation Public participation is a legal requirement for any development activity. However, given the emergency nature of this project, this process may not be effectively done. Those at the periphery - rural populations, the urban poor and VMGs/HUTLCs may be discriminated against in this process. Mitigation measures • Ensure that measures are put in place to identify and reach the vulnerable community members with project information. Special efforts should be made to reach the deaf and blind with critical information on COVID-19. • Use communication channels that are accessible to marginal populations including use of community radios, translating information in local languages. • Identify and equip local leaders with information for further dissemination in their communities through their local structures including community leadership, churches, mosques, clans, etc. 5.4. Decommissioning Stage This section outlines the implementation of the technical activities for the safe decommissioning of COVID-19 HFCs established with ERP investments, including triage and screening areas, quarantine, isolation and treatment centers with particular reference to the process and the technical aspects, including the physical infrastructure, furnishings, equipment and supplies. The primary responsibility lies with the institutions in charge of the facilities under the supervision of the facility manager and the MoH. The subproject level ESMPs will cover decommissioning related activities for all Project-related works. Decommissioning is intended as the technical process in which COVID-19 healthcare facilities are assessed, dismantled and/or repurposed after a proper decontamination phase aiming to prevent possible exposure to contaminated structures, equipment or material. Areas of COVID-19 care facility can also be decommissioned during the operational phase when they are no longer required and/or their physical status is visibly deteriorated. Such areas should be cordoned off to prevent unauthorized re-entry in order to avoid re-contamination. 49 Decommissioning process The decommissioning process has been divided into four phases as illustrated in Figure 5. It covers only the physical structures and equipment as all the other related factors of the decommissioning process are outside the scope of this guidance. These phases should be strictly followed to ensure that operations are conducted in a safe manner. Dismantling / Reporting Preparation Decontamination Repurposing Figure 5 Decommissioning process Preparation for decommissioning should be undertaken well in advance of the authorization for decontamination to ensure stakeholders’ buy-in. This phase includes the planning of the required pre-and post-decontamination actions as follows: • Health facility/site manager should issue notice of the intention to decommission the site to relevant departments; • Access control should be maintained throughout the whole process to guarantee the smooth running of operations, safety of the staff involved and to manage the perception of the process within the local community; and o Items (e.g., furniture, beds, tents, equipment, and instruments) should only leave the site at the end of the process and with the permission of the site manager to reduce risk of recontamination. • The facility manager should brief the decommissioning team. The briefing should focus on infrastructures in place and method of construction, and identification of a “clean zone� for the reception and temporary storage of disinfected material. • Community engagement should aim to inform, consult, engage and reassure the surrounding community in regards to the decommissioning process. • Infrastructure assessment refers to the visual inspection for signs of decay or breakdown. • Logistical activities are divided into supply, inventory (or list) and storage: o Supply: all items required to perform all the activities included in the process with particular reference to personal protective equipment (PPE), machine and equipment’s, appropriate disinfectants (including chlorine, alcohols, peroxygen, detergents, iodophors, quaternary ammonium and phenolic compounds) are effective against corona viruses if used at the correct concentration for the appropriate contact time as specified in the manufacturer’s recommendations. o Inventory (or list): all equipment should be revised during the preparation phase and agreement made about their future with particular reference to tents, medical equipment, 50 generators, pumping devices and incinerators, based on the regulations and agreements stipulated at the time of opening the facility. o Storage: refers to the identification and briefing of the team in charge of disassembling the tents and temporary infrastructures. This process includes also identification of the site for temporary storage of the material that can be reused. • Risk analysis: refers to the revision of the associated hazards in each phase of the process and related mitigating measures already in place and/or to be established. • Staff requirements: should be based on the size of the facility and timeline considered for the completion of the process. • The team must include a former infection prevention control staff from COVID-19 care facility. This decreases the time spent on retraining staff on the correct implementation of technical areas. • More than one team can operate at the same time under supervision of their respective team lead/supervisor. However, their assigned area should be identified, marked and reviewed during the preparation phase. • Training of the team: should comprise the preparation, activities to be undertaken and potential risks involved, emergency response plans, occupational Safety and Health measures and safe use of cleaning and disinfectant solutions and the different types of PPE for use. Tetanus immunization should be offered to the team, if available. Decontamination The following precautions shall be undertaken: • Monitoring of the sectioned areas during the whole decontamination phase; • Use of tape or rope to demark the area during the operation and identify the disinfected areas if the work is conducted in phases; and • Creation of a dedicated space for the drying of equipment/materials during the cleaning phase. • The IPC officer and/or designee should observe the cleaning and disinfection process as a way to validate that the surfaces have been properly cleaned and disinfected.8 Table 7 highlights the minimum requirements for safety during the decontamination phase. It is classified into three groups: equipment, human resources, personal protective equipment and consumables. Table 7 Minimum requirements for safety during the decontamination phase Human Resources Personal Protective Equipment Consumables Double gloves (non-sterile examination gloves and heavy duty gloves). Demarcation tape Project officer A disposable gown or coverall made of fabric that is tested for resistance to Disposable plastic IPC officer penetration by blood or body fluids or to blood borne pathogens to cover waste bag. clothing and exposed skin. For other Hygienists A disposable waterproof apron worn over the gown or coverall. If consumables. Water and sanitation officer disposable aprons are not available, heavy duty reusable waterproof aprons can be used. If appropriate, cleaning and disinfection is performed. Occupational Safety and A fluid-resistant medical/surgical mask with a structured design that does Health officer not collapse against the mouth (e.g., duckbill, cup shape). Eye protection (either goggles or face shield) in order to have the mucous Laundry staff (optional) membranes of the eyes, mouth and nose completely covered by PPE and Waste handler prevent virus exposure. Waterproof boots (e.g., rubber/gum boots). If boots are not available, health County Public Health workers must wear closed shoes (slip-ons without shoelaces and fully Officer covering the dorsum of the foot and ankles) and overshoes. Security guards 8 World Health Organization. (2020). Cleaning and disinfection of environmental surfaces in the context of COVID-19: interim guidance, 15 May 2020. https://apps.who.int/iris/handle/10665/332096 51 Dismantling / Repurposing The dismantling phase refers to the disassembly of temporary infrastructures and the potential reuse and/or recycling of material or its disposal. It should start only after the validation of the proper cleaning and decontamination of the structures by the IPC officer/designee. Creation of a well demarcated “clean� zone (e.g., fenced with plastic mesh) within the low-risk area where disinfected equipment and materials from the low-risk area can be temporary stored. The size of the area is dependent on the care facility. However, it is generally recommended to consider a large area due to the volume of items to be stored. The process of dismantling can be conducted in different areas of the facility simultaneously. However, for larger facilities, it is recommended to proceed in phases in order to better monitor the safe implementation of the activities. Tents if not damaged (tent must be intact) and not made of absorbable material can be packed in storage for subsequent reuse. Wooden shelters and fencing built using tarpaulin can be dismantled and burnt due to their likely deteriorated condition. Concrete surfaces requiring break up should be left until the end of the process. This will allow for the safe use of the excavator. If break up of concrete is done manually, precautions should be taken to prevent Safety and Health hazards. No equipment or material should be abandoned on site without the approval of the relevant regulatory authorities and affected landholders. In the event that masonry or concrete structures are buried, it is recommended that the responsible agencies provide a site plan to the landowner and also explain to the landowner where the abandoned facilities are located. If buried and decommissioned latrine pits or septic tanks are present, it is recommended to conduct a simple risk assessment including soil type, water table, hydraulic gradient, and time since pit was buried, etc. This will ensure the safety of new installations, including possibly water pipes. Repurposing principle The key technical principles for the repurposing of COVID-19 care facility are: • Location and assigned purpose of the structure; • Quality of the construction and the material used, in particular for temporary structures; • Evaluation of the water system in terms of water quantity, in particular during the dry season, and water quality (especially for microbial containment); and • Quality of the construction and functioning of sanitation facilities. If the permanent structures are to be returned to their original condition, an assessment of the condition of the building should be performed and maintenance activities conducted before the re-opening of the facility. A fresh coat of paint is recommended as a reassuring measure for the community. Reporting A final report of the entire decommissioning process should provide records of all activities, final dispositions of waste and recycled products. This should be submitted within 2 weeks of completing the decommissioning process. It should include: • The completed audit checklist approved by an IPC officer and by the Ministry of Health (MoH) or relevant authority and facility manager; • Listed material and equipment for reuse and donation; • Organization and management of occupational Safety and Health during the decommissioning process; 52 • Site plans, including underground masonry or concrete structures, water points and location of waste disposal areas (burn pits, latrine pits, etc.); • Waste management process; • Photo journal; • Conclusions and recommendations; • Strategy for after action review; The completed audit checklist shall be handed over to the management of the facility hosting the isolation center (e.g. school, etc.). 53 6. Institutional Arrangements, Responsibilities and Capacity Building 6.1. Institutional arrangements, roles and responsibilities The Rwanda COVID-19 ERP will use a structured approach to environmental and social management complying with the ESF requirements, following the mitigation hierarchy of avoidance, minimization and mitigation for negative impacts and enhancement of positive impacts where practically feasible. The proceeding sections describe what needs to be done at each stage of the overall project life cycle of sub- project implementation, monitoring and reporting on progress. The Government of Rwanda is responsible for compliance to the national policies, regulations and the ESF of the World Bank including the 7 ESSs and the ESH Guidelines, as mentioned in this ESMF. Overall supervision for this ESMF will be the responsibility of the MoH. Consultations between the preparation team for ESF instruments and members of the MoH and RBC-SPIU confirmed adequate capacity for the required implementation requirements within the existing human resources and operational structures of the ministry and within environmental health officials in beneficiary district administrations, hospitals and health centers (Figure 6). The designated Environmental Specialist and Social Specialist as well as DHSOs, EHOs and C-EHOs will carry out their respective duties within the ERP within the existing contractual frameworks as civil servants and therefore no remuneration budget is allocated. Logistical support e.g. contact-tracing and IPC activities is provided for within ERP activity budgets. These officials had been among previously trained personnel together with clinical and laboratory staff on IPC for Ebola Virus Disease (EVD) as indicated in Table 8, aspects of which are applicable to COVID-19 IPC requirements. Additional COVID-19 specific capacity building were elaborated in the COVID-19 National Preparedness and Response Plan for targeted human resources as displayed in Table 10. The RBC SPIU as the PUI is mandated with the responsibility for implementing ESF instruments for the Rwanda COVID-19 ERP having designated an Environmental Specialist and a Social Specialist to oversee the implementation of this ESMF assisted by EHOs and C-EHOs for operational requirements. The Environmental Health Specialist is responsible for Infection Prevention and Control (IPC) including environmental decontamination following COVID-19-postive contact-tracing. The ERP Environmental Specialist and Social Specialist are guided by RBC’s Epidemic Surveillance Response (ESR) division and the Health Communication Centre (RHCC) in the implementation of the ESF instruments for ERP through the SPIU (PUI) Coordinator (Figure 2). The Environmental Specialist and Social Specialist will supervise the implementation of the ESMF assisted by District Hygiene and Sanitation Officers (DHSOs) at District Administration level, by Environmental Health Officers (HEOs) at Referral, Provincial and Districts hospital level and by Community Environmental Health Officers (C-EHOs) at Health Centre level according to the following functions: • District Hygiene and Sanitation Officers (DHSOs) at District Administration level (ERP works for Screening Posts, Centers of Quarantine and Contact Tracing); • Hospital Environmental Officers (HEOs) at Referral, Provincial and District hospital levels (ERP works for IPC at Isolation & Treatment Facilities); and • Environmental Health Officers (EHOs) at ERP works for Health Centers. 54 The roles and responsibilities of the environmental management team as shown in Figure 6 are described in the proceeding sections according to the required sequential procedures of compliance to the applicable ESSs and the ESMP. Joint COVID-19 Task Force Coordination (JTFC) MoH/RBC-SPIU PIU Coordinator Command Post KEY ES SS ES: Environmental Specialist SS: Social Specialist EHO: Environmental Health Officer CCH: Coordinator of Community Based Environmental Health Promotion Program C-EHO: Community Environmental Health Officer DHSO: District Hygiene & Sanitation Officer District Administration: (Screening Posts; Centres of DHSO DHSO DHSO DHSO Quarantine; Contact Tracing) Hospitals (all levels): GRM • Supervisors (IPC; Isolation & Treatment EHO EHO EHO EHO • Health Facility Specialist • Contractors Facilities) • Health & Safety Committees • Consultants Health Centres & CEHO CEHO CEHO CEHO Community Surveillance Figure 6 Rwanda COVID-19 ERP Implementation arrangements for the ESF instruments including ESMF and SEP 55 6.2. Capacity building 6.2.1. Existing Capacity The MoH had recently trained various target groups including personnel responsible for implementing the Ebola Virus Disease (EVD) Preparedness and Response Plan that is applicable to the requirements of COVID-19, although it is noted that the latter is much more infectious. The trained officials included health workers at all levels, waste handlers at health facilities, local communities and personnel from private sector operators. Training activities were generally oriented towards the quality of healthcare services and prevention of infections. A summary of target groups trained is showed in Table 8 below. Table 8 MoH trainings carried out under the implementation of the EVD Preparedness and Response Plan Target Group EVD Training Topic District Directors of Health; • General awareness on EVD District Hygiene & Sanitation Officers (DHSOs); • EVD preparedness and prevention Environmental Health Officers (EHO); • Infection Prevention and Control and WASH District Hospital and HCF staff • EVD medical waste management Laboratory Technicians • EVD testing Medical Doctors • EVD clinical management Nutritionists • Nutritional support for EVD patients Hospital Psychologists • Psycho-social Support CHWs in charge of Prevention and Health Promotion • Community Based Environmental Promotion Program and Health Care Waste Management Point of Entries Staff • EVD surveillance EVD Rapid Response Team (Central and District • Regular intensive SIMEX (Simulation Exercises) Level Staff) As indicated in the previous sections, supervision for the implementation this ESMF and other ESF instruments will be led by the RBC-SPIU (PIU) comprising the Environmental Specialist and the Social Specialist all of whom have received trainings including IPC and WASH. The officers have therefore significant levels of IPC, WASH and other competencies relevant to COVID-19 required to supervise and monitor district, hospital and HCF environmental health colleagues in the ensuring the implementation of mitigation measures for potential environmental and social impacts of the COVID-19 ERP activities. However, dedicated training is required for COVID-19 specific IPC and other competencies. The Environmental and Social Commitment Plan (ESCP) outlines the following capacity support in training for the Rwanda COVID-19 ERP, in topics including among others: • COVID-19 Infection Prevention and Control (IPC) recommendations • Laboratory biosafety guidance related to the COVID-19 • Specimen collection and shipment • Standard precautions for COVID-19 patients • Security management plan • Risk communication and community engagement • Grievance redress mechanisms • WHO and Africa CDC guidelines on quarantine including case management The training recommended by the ESCP will provide the competencies required by the ESF team to implement compliance instruments of the ERP. The EHOs and C-EHOs at ERP investment beneficiary HCFs will under the guidance of the ERP Environmental Specialist and Social Specialist will train subproject contractors on basic IPC practices and SOPs and supervise their compliance. Table 9 provides a summary of competencies required by the implementation of the project ESF instruments. 56 Table 9 Key competencies of personnel designated to supervision of the implementation of this ESMF for Rwanda COVID-19 ERP Designated staff for ESMF implementation Key competencies needed by ESMF supervision staff MoH Environmental Health Desk: ▪ Environmental, social and economic impacts of the COVID- • Environmental Health Specialist 19; • Environmental Health Officer ▪ Relevant environmental legislation and World Bank ESF • Coordinator of Community-Based compliance requirements; Environmental Health Promotion ▪ Role of various players in implementation and monitoring Programme of the ESMF and SEP; ▪ Conducting or supervising the screening process; ▪ Monitoring implementation of the ESMP and Environmental Guidelines for Contractors by the civil works contractor; ▪ Monitoring implementation of the COVID-19 Waste Management Plans; ▪ Preparing ESMF interim and final evaluation reports; ▪ Environmental and social clauses in work contracts if needed ▪ Code of conduct for workers District level staff: ▪ Environmental, social and economic impacts of the COVID- • District; Sanitation and Hygiene Officers 19; (DSHOs); ▪ Importance of environmental management and COVID-19 • Community Environmental Health Officer at Waste Management, Referral, Provincial and District Hospitals ▪ Understanding roles of various players in implementation and monitoring of the ESMP; ▪ Conducting public consultations during the environmental and social screening process; ▪ Supervising adherence to contractor Codes of Conduct for workers ▪ Supervising implementation of mitigation measures specified in contractor’s contract ▪ Supervising implementation of COVID-19 Medical Waste Management activities; ▪ Preparing interim reports Health Care Facility staff: ▪ Understanding community group roles in achieving • Environmental Health Officers environmental sustainability; ▪ Linkages between environmental and social impacts and health; ▪ Supervising adherence to contractor Codes of Conduct for workers for works at HCFs ▪ Supervising implementation of mitigation measures specified in contractor’s contract for works at HCFs 6.2.2. Planned capacity building in the National Preparedness and Response Plan The COVID-19 National Preparedness and Response Plan provides for the following capacity building in training topic that are aligned to the ESCP listed above including the following: • Identification and training of spokespersons for vulnerable populations and to conduct comprehensive simulation exercises (SIMEX) • Train National Reference Laboratory (NRL) staff on COVID-19 assays (conducted by external partners) 57 • Train and mentor laboratory personnel on COVID-19 sample collection, triple packaging, shipping and waste management • Train frontline healthcare workers on sample collection for screening and surveillance • Train and mentor Rapid Response Teams (RRT) teams on COVID-19 surveillance, IPC and Case Management • Train health care workers on Case Management • Train health promotion officers at sub-national levels A detailed training plan by activity, cost, responsible RBC unit and timeframe as extracted from the National Preparedness and Response Plan is featured in Table 10. Table 10 Training activities featured in the COVID-19 National Preparedness and Response Plan Training activity Cost (USD) Responsible Timeframe Conduct full scale SIMEX 1,917 RBC/ESR Mar-20 Conduct capacity assessment and risk analysis including mapping of 18,168 RBC/ESR Mar-20 vulnerable populations Conduct trainings on COVID-19 surveillance in HF setting (Case ID, 46,885 RBC/ESR Mar-Aug 20 reporting, IPC, triage and contact tracing Training District Hospital staff by Surveillance Lead and RRT Clinician 1,587 RBC/ESR Mar-Aug 20 (in each hospital) Training of Private HFs on COVID-19 surveillance, IPC and Case 61,878 RBC/ESR Mar-Aug 20 Management Training on COVID-19 Surveillance at PoEs 17,181 RBC/ESR Mar-Aug 20 Train of contact tracers on COVID-19 contact tracing 8,760 RBC/ESR Mar-Aug 20 Training for 5 NRL staff on COVID-19 assays by external Partners - RBC/NRL Mar-Aug 20 (provided in kind) Training of District Hospitals on specimen collection, sample collection, 4,949 RBC/NRL Mar-Apr 20 triple packaging and transport Conduct training of RRTs on COVID-19 surveillance, IPC and Case 178,729 RBC/ESR Apr-Jun 20 Management Training HCWs on Case Management - RBC/ESR - Train RCCE teams at central level on COVID-19 762 RBC/RHCC Mar-Aug 20 Train RCCE teams at District level on COVID-19 10,920 RBC/RHCC Mar-Aug 20 Train journalists on COVID-19 pre and during outbreak 2,730 RBC/RHCC Mar-Aug 20 Build Capacity of District leadership HCW and CHW PoEs staff to 83,324 RBC/ESR TBD strengthen surveillance of COVID-19 Build capacity of District leadership CHWs to strengthen surveillance of 524,339 RBC/ESR TBD COVID-19 Refresher training and drills to medical and ambulance teams 65,947 RBC/ESR TBD Total (USD) 1,028,076 The ERP Environmental Specialist and the Social Specialist will participate in national level training and facilitate relevant trainings for District Hygiene and Sanitation Officers (DHSOs), Hospital Environmental Health Officers (HEOs), Community Environmental Health Officers (C-EHOs) as scheduled in Table 10. The RBC-SPIU will confirm that the training took place as scheduled and fill capacity gaps if any are identified. 58 7. Procedures to Address Environmental and Social Issues The following sections will describe the environmental and social management procedures that RBC-SPIU (PIU) will use to comply with the ESF and the ESCP. Exclusion criteria for potential subprojects The ESCP stipulates exclusion of potential projects according to the following criteria as ineligible for ERP financing: • Laboratory activities that may require BSL3 lab facilities • Activities that may cause long term, permanent and/or irreversible (e.g. loss of major natural habitat) impacts • Activities that have high probability of causing serious adverse effects to human health and/or the environment • Activities that may adverse social impacts and may give rise to significant social conflict • Activities which would require Free Prior Informed Consent. • Activities that may affect lands or rights of indigenous people or other vulnerable minorities, • Activities that may involve permanent resettlement or land acquisition, impacts on cultural heritage These criteria have been formulated into a questionnaire (Table 1) under the Project Description chapter earlier in this ESMF, for use by the RBC SPIU in deciding eligibility or exclusion of potential subprojects for ERP funding. The Environmental Specialist and Social Specialist will assist the SPIU in using the Table 1 instrument to decide eligibility of potential ERP subprojects. 7.1. Environmental and Social Screening of Subprojects Environmental and Social Screening Process outlined below complies with: • The Rwanda environmental assessment requirements, as outlined in Law N°48/2018 on Environment and the EIA and Audit guidelines • The World Bank’s Environmental and Social Standards, especially ESS1, ESS2, ESS3, ESS4, ESS5, ESS6, ESS8, ESS10. The screening process provides a mechanism for ensuring that potential adverse environmental, social and OHS impacts of Rwanda COVID-19 ERP sub-projects are identified, assessed and mitigated as appropriate, through an environmental and social screening process to comply with national EIA requirements and the WB ESS1. A screening template is provided in Annex II to be used by the RBC SPIU (as the PIU) for identifying the relevant Environmental and Social Standards (ESS), establishing an appropriate E&S risk rating for these subprojects and specifying the type of environmental and social assessment required, including specific instruments/plans. The screening template in Annex II includes a note on Considerations and Tools for E&S Screening and Risk Rating on infection control for medical laboratories, quarantine and isolation centers; treatment centers and labor and working conditions. The screening form sets out a list of questions on the screening of E&S risks and impacts, identifies the relevant ESSs for which the SPIU fills in Yes or No answers from which conclusions are reached for each subproject proposing an E&S risk rating (High, Substantial, Moderate or Low) with justifications provided and E&S Management Plans/ Instruments proposed. 7.2. National EIA requirement Subproject screening results will be reviewed by the Rwanda Development Board (RDB) which holds a delegated mandate from the Rwanda Environment Management Authority (REMA) and the World Bank. 59 E&S instruments such as ESIA, SEP, LMP will be prescribed for subprojects to ensure appropriate mitigation for subprojects whose risk ratings are indicated High, Substantial or Moderate by the screening results. Subprojects whose risk ratings are indicated as Low, ESMPs instead of full ESIAs will be recommended. The RBC SPIU Coordinator will submit screening results prepared or arranged jointly by the Environmental Specialist and Social Specialist to WB for review. Following approval by the latter, RBC on behalf of MoH will subsequently submit results to RDB for review and approval of ToR for subsequent preparation of subproject ESMP or ESIA. LMP, ICWMP as found appropriate. The required instruments will be prepared by duly certified consultants on behalf of RBC-SPIU. RDB will review the E&S instruments including ESMPs and ICWMPs to ensure that the necessary mitigation measures duly incorporated before certification for the subproject in question to proceed. In addition each beneficiary health facility or laboratory with identified potential waste management impacts will be required to prepare its own ICWMP using the guidance provided in Annex IV. EHOs and C-EHO will under the supervision of the ERP Environmental Specialist and Social Specialist, implement the relevant EFS instruments within their respective existing employment arrangements and within existing operational means of the ERP investment beneficiary HCF. Assigning of Environmental and Social risk classification Assignment of appropriate environmental and social risk classification to a particular activity will be based on information provided in the environmental and social screening form Annex II that the MoH Environment and social specialist will have administered. According to WB ESF projects are classified as high risk, substantial risk, moderate risk and low risk project with respect to the environmental and social sensitivity of the project. Contrary to the ESRS findings, most activities under Component 1 and 2 will entail the procurement of COVID-19 medical supplies and laboratory equipment as well as logistical and operational support for Command Posts with Low Risk and therefore not requiring full, Environmental and Social Impact Assessment. As mentioned in the introductory sections earlier in this ESMF, the RBC-SPIU purchases ERP medical supplies and equipment through the Africa CDC affiliated Africa Medical Supplies Platform (AMSP) ensuring certified medical supplies and equipment with increased cost effectiveness and transparency from vetted manufacturers. However, should the subproject be categorized as high or substantial risk e.g. involving minor civil works requiring an ESIA, it will comply with ESS1 Subproject E&S assessment and instrument preparation Preparation of subproject environmental and social management instruments (ESMPs/ESIAs) and/or ICWMP will be carried out for the respective types of subprojects as follows:. • The ERP Environmental Specialist and Social Specialist will prepare or supervise consultancy services for the preparation of ToR to select environmental and social consultancy services for preparing the necessary subproject environmental documents (ESMPs, ESIAs) as prescribed by RDB based on screening results of the subproject. It should be noted that the RBC-SPIU has already prepared a LMP as Section 7.4 of this ESMF and a separate SEP for implementation in ERP subprojects. • The RBC SPIU Coordinators will submit ToR for ESMP of ESIA to WB for review and following the latter’s approval to RDB for input/comments and approval. • The RBC SPIU Coordinator will contract out consultancy services for the preparation of draft subproject ESMP, ESIA and carry out public consultations with stakeholders, people that may be affected and local authorities and incorporate results into final subproject ESMP, ESIA. • EHOs or C-EHOs as applicable to the ERP investment beneficiary HCF will prepare an ICWMP based on the template provided in Annex IV of this ESMF. ICWMPs are approved by the RBC SPIU Coordinator with support from the SPIU E&S specialists, with subsequent clearance from 60 the WB. However, some ERP investment beneficiary HCFs may not have adequate EHO/C-EHO capacity to prepare the ESMP and/or ICWMP, in which case funds will be allocated from the Component 2 budget (capacity building activity) by the RBC-SPIU (PUI) to hire a consultant to provide technical support. • The ESMPs, ESIAs and ICWMPs will be monitored and checked by the RBC SPIU for and on behalf of MoH and reviewed by WB. ESHS requirements for minor civil work contracts and other Project contracts The Rwanda COVID-19 ERP will comply with ESS2 and ESS4 and the Environmental, Social Health and Safety Guidelines (ESHS) and the Occupational Health and Safety (OHS) of the World Bank and Labor regulations of Rwanda as elaborated in Annex II and Annex IV. A Code of Conduct for Contractors and workers hired under the Rwanda COVID-19 ERP in provided in Annex V for inclusion in respective ESMPs and contracts of ERP subprojects. 7.3. Review, Clearance, Public Disclosure and Consultation The following procedure will be followed in publicly disclosing this ESMF and other safeguards documents prepared for the implementation of the Rwanda COVID-19 ERP: • The RBC SPIU (PIU) Coordinator will submit draft ESMPs or ESIAs to RDB as appropriate for review and certification. The World Bank will review and approve most of the safeguards instruments produced by the project, especially those identified to have Substantial, Moderate (and High, if any identified) risk activities. • Following approval of the safeguards document(s), the RBC SPIU Coordinator will also carry out the necessary arrangements for Disclosure and Consultations taking into account ESS10 and ensure harmonization with the Rwanda COVID-19 ERP Stakeholder Engagement Plan (SEP). • The RBC SPIU Coordinator will follow up and obtain required licenses/ permits that comply with the approved ESMF for the necessary Rwanda COVID-19 ERP subproject activities. • RBC as the implementation agency will have to create a webpage for the project in its institutional website and publish all ESF documents and reports as defined in this ESMF. • WB will disclose the approved safeguards documents on the project webpage already created and that will be permanently accessible for all during all project implementation and after closure. https://projects.worldbank.org/en/projects-operations/project-detail/P165017?lang=fr • WB receives and takes note of consultation reports. 61 7.4. Labor Management Procedures Overview of labor use on the project The Rwanda COVID-19 ERP will fund medical supplies and equipment, training and capacity building for frontline workers; and operating costs for Rapid Response Teams and recruitment of additional personnel in Component 1. Communication and awareness raising and improving targeting and measure effectiveness; medical and laboratory equipment and supplies and waste management equipment and supplies and video conferencing equipment for telemedicine as well as minor civil works (mainly refurbishments will be the focus of Component 2. Implementation management and M&E and CERC are the focus of Components 3 and 4 respectively. Although not yet been determined, requirements for minor civil works for refurbishments of laboratories and for isolation facilities are not expected to demand large numbers of labor. It is expected that semi- skilled workers will be required in small numbers for refurbishment civil works and smaller numbers of skilled workers for installations of specialized equipment. Exact number of project workers, their characteristics, timing of their requirements and contracting modalities will be established following the identification of target screening posts and HFS as well as refurbishment needs. Health Care Workers and Civil Servants Consultations between the preparation team for ESF instruments and members of the MoH and RBC-SPIU confirmed the Rwanda COVID-19 will be implemented using the existing human resources and operational structures of the ministry and within the existing healthcare and other collaborating sector officials in beneficiary district administrations, hospitals and health centers (Figure 4). The MoH Environmental Health Desk is mandated with the responsibility for implementing ESF instruments for the Rwanda COVID-19 ERP under the supervision of the RBC SPIU as the PIU. Under existing employment or contractual arrangements, HCWs will carry out a range of activities including assessing, triaging and treating COVID-19 patients and workers; establishing public health reporting procedures of suspect and confirmed cases; providing or reinforcing accurate infection prevention and control and public health information, including for concerned workers. Other civil servants collaborating in the ICP effort of the ERP will provide the needed services under their existing employment or contractual arrangements. Frontline Service Providers Activities conducted by frontline service providers will include people providing services such as food supply, delivery and preparation; waste disposal; pharmacies; security services; and public transport workers. The military will not be used to support or carry out the ERP activities. ESS2 recognizes that all personnel involved in the project remain subject to the terms and conditions of their existing public sector employment agreement or arrangement. Nevertheless, their health and safety needs are considered and the measures adopted by the project for addressing occupational health and safety issues, including those specifically related to COVID-19, will apply to them. Waste Management Workers: An Infection Control and Waste Management Plan (ICWMP) will be prepared and implemented for the project according to the templates provided in Annex II and Annex IV of this ESMF under the supervision of the project Environmental Specialist. Waste management worker modalities and arrangements and 62 compliance to ESS2 will be addressed in the project ICWMP. Waste management workers for the ERP will be covered by mitigation measures as provided for in this LMP and ICWMP in compliance with ESS2. Updating ERP labor information The project Social Specialist will update this LMP with elaborations of: Number of Project Workers; Characteristics of project e.g. local workers, civil servants, national or international migrants, female workers, workers between the minimum age and 18; Timing of Labor Requirements in terms of numbers, locations, types of jobs and skills required; and Contracted Workers anticipated or known contracting structure for the project, with numbers and types of contractors/subcontractors and the likely number of project workers to be employed or engaged by each contractor/subcontractor. If it is likely that project workers will be engaged through brokers, intermediaries or agents, this fact should be noted together with an estimate of how many workers are expected to be recruited in this way. Assessment of key potential labor risks ERP Key Labor Risks The Rwanda COVID-19 ERP will not involve establishment of large greenfield medical facility for quarantine and treatment of COVID-19 patients. Migrant workers or workers from adjoining provinces or regions or from abroad, or local workers returning from abroad will therefore not be needed in the minor civil works for refurbishment of rehabilitation of laboratories and/or isolation facilities. Hospitality business establishments are being deployed for quarantine services while a selection of hospitals are designated as treatment facilities. Hiring of migrant workers in for the ERP is therefore not expected. Doing hazardous work Needs for workforce and type of project workers for upgrading and/or rehabilitation works will be identified as a planning activity by the project Specialist. Although ERP activities are not expected to require large numbers, measures against physical risk associated with hazardous work must be put in place according to ESS2 requirements. A social risk is expected of worker exposure to hazardous work such as working at heights or in confined spaces, use of heavy machinery, or use of hazardous materials. Other risks include the likely presence of migrants or seasonal workers; risks of labor influx or gender-based violence; possible accidents or emergencies with reference to the sector or locality and inadequate understanding and implementation of occupational health and safety requirements. Workers coming from infected areas During the minor civil works for refurbishment or rehabilitation, COVID-19 infection may be spread by workers coming from infected areas, co-workers becoming infected and workers introducing infection into community or general public. To mitigate these risks, the project Social Specialist ensure the application of the COVID-19 mitigation measures including the following: • Consider ways to minimize/control movement in and out of construction areas/site. • If workers are accommodated on site require them to minimize contact with people outside the construction area/site or prohibit them from leaving the area/site for the duration of their contract • Implement procedures to confirm workers are fit for work before they start work, paying special to workers with underlying health issues or who may be otherwise at risk • Check and record temperatures of workers and other people entering the construction area/site or require self-reporting prior to or on entering • Provide daily briefings to workers prior to commencing work, focusing on COVID-19 specific considerations including cough etiquette, hand hygiene and distancing measures. 63 • Require workers to self-monitor for possible symptoms (fever, cough) and to report to their supervisor if they have symptoms or are feeling unwell • Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days • Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days Occupational Health and Safety (OHS) risks Improper work procedures during civil works and in the management of healthcare waste management can cause OHS risks on health care providers and supportive staff or persons with disabilities. Mitigation measures entail adopting and implementing safety guideline or manuals from OSH guideline and WHO technical guideline for COVID-19 Key considerations for occupational safety and health. OHS measures have been additionally been elaborated in Annexes II, III and IV. The Social Specialist will be accountable for the supervision of these measures on behalf of the PIU and MoH. HCF operational hazards General operation of HCFs can involve vulnerability to physical hazards, electrical and explosion hazards, fire, chemical use, ergonomic and radioactive hazards, this includes risks related to waste management and incineration-related occupational injuries, such as: sharps-inflicted injuries, toxic exposure to mercury or dioxins, during the handling or incineration of health care wastes, and thermal injuries occurring in conjunction with the operation of medical waste incinerators. The HCF staff with support from the SPIU Environmental Specialist will ensure the following mitigation measures are implemented: • Provide appropriate PPE to the construction personnel for handling construction materials; • Implement engineering control systems like primary and secondary barriers; • Organize and implement medical surveillance which includes medical service and immunization programs; • Provide health and safety training; • Adopt and implement safety manuals aligned with OSH guideline and WHO laboratory biosafety manual; WHO technical guideline for COVID-19 Key considerations for occupational safety and health • Develop and implement safety standards. OHS measures have been additionally been elaborated in Annexes II, III and IV. Labor issues in HCF operation Worker grievances can develop in general operation of HCFs that may involve among others, PPE availability and/or use; lack of proper procedures or unreasonable overtime; time-sensitivity and/or confidentiality of grievance. To mitigate these labor risks, the project Social Specialist ensure the application of the GRM as featured in Figure 6 as well as the WHO resources for COVID-19: occupational health available at: https://www.who.int/news-room/detail/09-03-2020-covid-19-occupational-health. Brief overview of labor legislation: terms and conditions Worker Terms and Conditions provisions of the labor law Law N° 66/2018 of 30/08/2018 regulating labor in Rwanda9 makes general provisions and fundamental rights under Chapter I that include conducive working environment for the employee, minimum age for admission into employment and prohibited forms of work for the child, prohibition of forced labor, 9 https://mifotra.gov.rw/fileadmin/news_import/New_Labour_Law_2018.pdf 64 prohibition of sexual harassment, protection against discrimination and rights to freedom of opinion and association. Article 7 Prohibition of forced labor under this Chapter stipulates exceptions for prescribed labor under circumstances such as work imposed in case of the state of siege, emergency or disasters. Chapter II of the labor law makes provisions on employment contract and subcontract arrangements for citizens and foreign workers and covers occupational accident and disease. The labor law provides for general working conditions, making stipulations on rights and obligations of the employer and the employee, working hours, rest hours and leave under Chapter III. Provisions under this chapter include working terms and conditions regarding pregnancy of women workers, maternity leave, and breastfeeding period. Provisions are also made for persons with disabilities under this chapter of the labor law. Salary and minimum wage provisions are made under Chapter IV of the labor law. Chapter V makes provisions on occupational health and safety (OHS) with stipulations on mandatory workplace OHS committees, first aid, firefighting and imminent danger, preventing and fighting occupational accidents and diseases, and declaration of accidents, disease or death. OHS committees will Other include Chapter VI that provides for association of employees and association of employers and Chapter VII for collective agreements and rules of procedure of enterprise. Chapter VIII provides for labor disputes settlement including individual and collective modalities. Chapter IX provides for the right to strike and lockout, Chapter X for labor organs including the Labor Inspectorate, Chapter XI for declaration made by an enterprise, Chapter XII for Offences and their penalties and related sanctions, of specific significance is Article 119 that stipulates offences and penalties relating to occupational health and safety. Chapter XIII provides for miscellaneous, transitional and final provisions. The labor law is given effect by a suite of the following regulatory orders: • Ministerial Order Nº 001/19.20 du 17/03/2020 relating to labor inspection • Ministerial Order N° 002/19.20 of 17/03/2020 establishing the list of gross misconduct • Ministerial Order N° 003/19.20 of 17/03/2020 relating to employees’ representatives • Ministerial Order Nº 004/19.20 of 17/03/2020 determining essential services that should not be interrupted during strike or lock-out • Ministerial Order N° 005/19.20 of 17/03/2020 determining modalities for the implementation of working hours a week in the private sector • Ministerial Order Nº 006/19.20 of 17/03/2020 determining modalities for training of employees • Ministerial Order Nº 007/19.20 of 17/03/2020 determining core elements of a written employment contract • Ministerial Order N° 009/19.20 of 17/03/2020 determining funeral expenses and death allowances for an employee The provisions of the labor law discussed above will apply to the ERP temporary unskilled and skilled workers that will be employed in the minor civil works for the refurbishment and/or rehabilitation of selected parts of existing HCFs for the establishment of isolation facilities and for enhancing laboratories. The provisions will also apply to frontline support personnel. HCWs and other civil servants will participate in the implementation of the ERP within the frameworks of their existing employment arrangements established in compliance of the labor law. Brief Overview of Labor Legislation: Occupational Health and Safety National Standards and Guidelines The Ministry of Health developed National Guidelines on Healthcare Waste Management in 2016 aiming to guide health service providers in the management of waste generated from health care activities and ultimately mitigate risks of exposure and transmission of infectious diseases to service providers, patients and the community being served. Moreover, the Ministry prepared two sets of guidelines in 2014: (i) 65 guidelines for the prevention and management of Viral Hemorrhagic Fever in health care settings which include injection safety and waste management recommendations; and (ii) guidelines on sorting, transportation, treatment and final disposal of medical waste from site of generation to site of disposal. These guidelines aim at improving injection safety and healthcare waste management in the country and categorize wastes into infectious sharp waste, infectious non-sharp waste and non-infectious waste. National Standards Operating Procedures on Healthcare Waste Management were instituted in 2016, aiming to give effect to the abovementioned guidelines. This SOPs define the chain of responsibilities for healthcare waste management and the best practices to apply along the chain. The guidelines and SOPs were incorporated in the in the national Medical Waste Management Plan (MWMP) that was updated for the Ebola Virus Disease (EVD) in Feb 2020. This ESMF requires the Rwanda COVID-19 ERP to prepare and implement an Infection Control and Waste Management Plan (ICWMP) according to Annex VI with consideration of existing waste management national instruments already in place. The ICWMP will be applicable to HCW involved in ERP activities including PoE screening, quarantining, triaging and isolation/treatment. The SOPs and ICWMP are also applicable to frontline support services including waste management workers of the ERP. OHS provisions of the national labor law as applicable to COVID-19 Chapter V of Rwanda’s labor law stipulates the following OHS provisions: Article 77: General health and safety conditions in the workplace: An employer must ensure the health, safety and welfare in the workplace for employees working in his/her enterprise and for all persons who frequent the enterprise. An employee is not required to pay any cost in connection with measures aimed at ensuring occupational health and safety. This provision is applicable to temporary workers and frontline support personnel. Article 78: Occupational Health and Safety Committee: An enterprise establishes an OHS Committee. An Order of the Minister in charge of labour determines general occupational health and safety conditions. HCWs and Civil Servants involved in the implementation of the ERP will serve in the existing employment frameworks and would therefore be operating under such a committee. The minor civil works for refurbishment and/or rehabilitation for isolation facility establishment and enhancement of laboratories will require relatively small workforce numbers for relatively short durations. The same applies to frontline support personnel. OHS committees will therefore not be viable. Contractors will be required to prepare and implement OHS protocol in compliance with the Rwandan labor law and ESS2. Article 79: Personal protective equipment: An employer provides every person entering an area in an enterprise where he/she is likely to be exposed to the risk of injury or harm from contamination, with suitable protective equipment and instructions for their use and verify that they are used. The contractor for the subproject ERP minor civil works will abide by this provision under the supervision of the project Environmental Specialist and assisted by the designated HCF project officers according to Figure 4. Article 80: First aid, fire-fighting and imminent danger: An employer takes the necessary measures for first aid, fire-fighting, preventing and fighting imminent danger that can occur in his/her enterprise. The contractor for the subproject ERP minor civil works will abide by this provision under the supervision of the project Environmental Specialist and assisted by the designated HCF project officers according to Figure 4. Article 81: Preventing and fighting occupational accidents and diseases In order to prevent and fight occupational accidents and diseases, an employer does the following: 1. assess risks of occupational accidents and diseases; 2. develop occupational safety and health policy and monitor its implementation; 3. prevent risks of occupational accidents and diseases; 4. reduce in the best possible way risks of occupational accidents and diseases; 66 5. fight occupational accidents and diseases; and 6. adapt modalities of preserving occupational health and security of employees with new technology. The contractor for the subproject ERP minor civil works will abide by this provision under the supervision of the project Environmental Specialist and assisted by the designated HCF project officers according to Figure 4. Article 82: Declaration of occupational accidents, disease or death: An employer declares to the management of the social security body in Rwanda and to the Inspectorate of Labour where the enterprise is located, occupational accident, disease or death in accordance with relevant Laws. In case the employer fails to declare occupational accident, disease or death, the victim of an accident or of the disease is entitled to do it. It can also be done by the beneficiary of the victim of accident or disease or of the deceased or by the competent authority within a period provided for by relevant Laws. The contractor for the subproject ERP civil works will abide by this provision under the supervision of the project Social Specialist and assisted by the designated HCF project officers according to Figure 4. Reference will also be made to applicable international conventions, and directives for addressing health and safety issues relevant to COVID-19, such as: • ILO Occupational Safety and Health Convention, 1981 (No. 155) • ILO Occupational Health Services Convention, 1985 (No. 161) • ILO Safety and Health in Construction Convention, 1988 (No. 167) • WHO International Health Regulations, 2005 • WHO Emergency Response Framework, 2017 • EU OSH Framework Directive (Directive 89/391) Responsible Staff The Social Specialist will supervise the implementation of the LMP, with the project Environmental Specialist at central level and by District Hygiene & Sanitation Officers (DHSOs) at District Administration level, by Hospital Environmental Officers (HEOs) at Referral, Provincial and Districts hospital level and by Environmental Health Officers (EHOs) at Health Centre level according to the following functions: • District Hygiene & Sanitation Officers (DHSOs) at District Administration level (ERP works for Screening Posts, Centers of Quarantine and Contact Tracing); • Hospital Environmental Officers (HEOs) at Referral, Provincial and District hospital levels (ERP works for IPC at Isolation & Treatment Facilities); and • Environmental Health Officers (EHOs) at ERP works for Health Centers. The roles and responsibilities of the environmental management team as shown in Figure 4 are described in the proceeding sections according to the required sequential procedures of compliance to the applicable ESSs and the ESMP. Policies and Procedures for Mitigation Measures Doing hazardous work Needs for workforce and type of project workers for upgrading and/or rehabilitation works will be identified as a planning activity by the project Social Specialist. Although ERP activities are not expected to require large numbers, however, measures against physical risk associated with hazardous work must be put in place according to requirements the requirements of the Rwandan labor law and ESS2. The project Social Specialist will ensure that contractors implement physical safety measures including signage, prevention of hazardous substance spills and exposure to humans. Workers coming from infected areas 67 The project Social Specialist will ensure that the measures listed below are applied to mitigate risks associated with workers coming from COVID-19 infection areas. OHS measures have been additionally been elaborated in Annexes II, III and IV. • Consider ways to minimize/control movement in and out of construction areas/site. • If workers are accommodated on site require them to minimize contact with people outside the construction area/site or prohibit them from leaving the area/site for the duration of their contract • Implement procedures to confirm workers are fit for work before they start work, paying special to workers with underlying health issues or who may be otherwise at risk • Check and record temperatures of workers and other people entering the construction area/site or require self-reporting prior to or on entering • Provide daily briefings to workers prior to commencing work, focusing on COVID-19 specific considerations including cough etiquette, hand hygiene and distancing measures. • Require workers to self-monitor for possible symptoms (fever, cough) and to report to their supervisor if they have symptoms or are feeling unwell • Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days • Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days Occupational Health and Safety (OHS) risks Mitigation measures will be put in place against improper OHS practices including adopting and implementing safety guideline or manuals from OSH guideline and WHO technical guideline for COVID- 19 Key considerations for occupational safety and health. The Social Specialist will be accountable for the supervision of these measures on behalf of the PIU and MoH. HCF operational hazards The project HCF staff with support from the SPIU Environmental Specialist will ensure the following mitigation measures are implemented against operational hazards in project HCFs: • Provide appropriate PPE to the construction personnel for handling construction materials; • Implement engineering control systems like primary and secondary barriers; • Organize and implement medical surveillance which includes medical service and immunization programs; • Provide health and safety training; • Adopt and implement safety manuals aligned with OSH guideline and WHO laboratory biosafety manual; WHO technical guideline for COVID-19 Key considerations for occupational safety and health • Develop and implement safety standards. Labor issues in HCF operation The project Social Specialist ensure the application of the GRM as a mitigation measure against labor issues associated with HCF operation as featured in Figure 6 as well as the WHO resources for COVID-19: occupational health available at: https://www.who.int/news-room/detail/09-03-2020-covid-19-occupational-health. 68 Specific procedures have been adopted in the National COVID-19 Preparedness and Response Plan that include a capacity building program that includes hygiene and social distancing, as well as what should be done if workers become sick as described in capacity building section of this ESMF. The following guidance materials should be used as additional reference in implementing the LMP: • For health workers rights, roles and responsibilities, including on OHS, consult WHO COVID-19 interim guidance • For guidance on infection prevention and control (IPC) strategies for use when COVID-19 is suspected, consult WHO IPC interim guidance • For rational use of PPE, consult WHO interim guidance on use of PPE for COVID-19 • For workplace-related advice, consult WHO guidance getting your workplace ready for COVID- 19 • For guidance on water, sanitation and health care waste relevant to viruses, including COVID-19, consult WHO interim guidance • For projects requiring management of medical waste, consult guidance issued by WHO Safe management of wastes from health-care activities As the Rwanda COVID-19 ERP involves some civil works, contractors should develop specific procedures or plans so that adequate precautions are in place to prevent or minimize an outbreak of COVID-19, and that it is clear what should be done if a worker gets sick. Details of issues to consider are set out in Section 5 of the World Bank’s Interim Note: COVID-19 Considerations in Construction/Civil Works Projects and include: • Assessing the characteristics of the workforce, including those with underlying health issues or who may be otherwise at risk • Confirming workers are fit for work, to include temperature testing and refusing entry to sick workers • Considering ways to minimize entry/exit to site or the workplace, and limiting contact between workers and the community/general public • Training workers on hygiene and other preventative measures, and implementing a communication strategy for regular updates on COVID-19 related issues and the status of affected workers • Treatment of workers who are or should be self-isolating and/or are displaying symptoms • Assessing risks to continuity of supplies of medicine, water, fuel, food and PPE, taking into account international, national and local supply chains • Reduction, storage and disposal of medical waste • Adjustments to work practices, to reduce the number of workers and increase social distancing • Expanding health facilities on-site compared to usual levels, developing relationships with local health care facilities and organize for the treatment of sick workers • Building worker accommodations further apart, or having one worker accommodation in a more isolated area, which may be easily converted to quarantine and treatment facilities, if needed • Establishing a procedure to follow if a worker becomes sick (following WHO guidelines) • Implementing a communication strategy with the community, community leaders and local government in relation to COVID-19 issues on the site. The Rwanda COVID-19 ERP will support HCFs and therefore plans or procedures will be in place to address the following issues: • Obtaining adequate supplies of medical PPE, including gowns, aprons, curtains; medical masks and respirators (N95 or FFP2); gloves (medical, and heavy duty for cleaners); eye protection (goggles or face screens); hand washing soap and sanitizer; and effective cleaning equipment. Where relevant PPE cannot be obtained, the plan should consider viable alternatives, such as cloth masks, alcohol-based cleansers, hot water for cleaning and extra handwashing facilities, until such time as the supplies are available 69 • Training medical staff on the latest WHO advice and recommendations on the specifics of COVID- 19 • Conducting enhanced cleaning arrangements, including thorough cleaning (using adequate disinfectant) of catering facilities/canteens/food/drink facilities, latrines/toilets/showers, common areas, including door handles, floors and all surfaces that are touched regularly • Training and providing cleaning staff with adequate PPE when cleaning consultation rooms and facilities used to treat infected patients The project Stakeholder Engagement Plan (SEP) includes the implementation of COVID-19 communication imperatives to support regular communication, accessible updates and clear messaging to health workers, regarding the spread of COVID-19 in nearby locations, the latest facts and statistics, and applicable procedures. Age of Employment Article 5 under Chapter I of Law N° 66/2018 of 30/08/2018 regulating labor in Rwanda stipulates that the minimum age for admission to employment is 16 years. Article 6 further stipulates that it is prohibited to subject a child below the age of 18 years to any of the following forms of work: 1. forms of work which are physically harmful to the child; 2. work underground, under water, at dangerous heights or in confined spaces; 3. work with dangerous machinery, equipment and tools, or which involves the manual handling or transport of heavy loads; and 4. work in an environment which exposes the child to temperatures, noise levels or vibrations damaging to his/her health; work for long hours or during the night or work performed in confined spaces. The article stipulates that an Order of the Minister in charge of labor determines the nature of prohibited forms of work for a child. The Rwanda COVID-19 ERP will abide by these provisions and will not employ children under the age of 18 years. Terms and Conditions Chapter III of Law N° 66/2018 of 30/08/2018 regulating labor in Rwanda provides for general working conditions, making stipulations on rights and obligations of the employer and the employee, working hours, rest hours and leave. Article 43 and 44 stipulate that maximum working hours are 45 hours a week and 24 hours a week respectively. The article provides that the weekly rest hours are not counted among the weekly working hours. The daily timetable for work hours and break for an employee is determined by the employer. The daily rest granted by the employer to the employee is not counted as work hours. The article however further stipulates that an employee can work extra hours upon the agreement with his/her employer. Although Article 7 of Chapter III prohibits of forced labor, exceptions stipulated under circumstances of work imposed in case of the state of siege, emergency or disasters. However, imposed work emanating from such circumstances as requiring HCWs to work longer hours than normal because of the COVID-19 emergency is unlikely as daily infection rates remain in single or low double digits while daily recoveries are increasing. As of November 22, 2020 RBC reported that Rwanda had a total of 5,665 confirmed COVID-19 cases, 5,164 recovered cases, 454 active cases and 47 death. Cumulative tests were reported at 607,283 on this date. Grievance Mechanism The Rwanda COVID-19 ERP Grievance Redress Mechanism (GRM) is aimed assisting to resolve among other, worker complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Specifically, it provides a transparent and credible process for fair, effective and lasting outcomes. 70 It also builds trust and cooperation as an integral component of broader community consultation that facilitates corrective actions. Grievances will be handled at the District Level by the Officer in charge of Social Affairs and on the national level by MoH and RBC, including via dedicated hotline to be established. The ERP Social Specialist will prepare a grievances register that will be maintained by Contractors at ERP activity sites. Contractors will record grievances and forward the information to the designated facilitation officer for GRM at the ERP beneficiary HCF and to the District Social Affairs officer for appropriate action. The GRM facilitation function is the responsibility ERP-designated officers as indicated in Figure 4. Contractor Management The Rwanda COVID-19 ERP Contractors management will be the responsibility of the RBC SPIU as the PIU. The RBC SPIU Coordinator will ensure that the following measures required of Contractors are implemented: • As part of the bidding/tendering process, specific requirements for certain types of contractors, and specific selection criteria (e.g. for medical waste management, certifications, previous experience) • Provision of medical insurance covering treatment for COVID-19, sick pay for workers who either contract the virus or are required to self-isolate due to close contact with infected workers and payment in the event of death • Specific procedures relating to the workplace and the conduct of the work (e.g. creating at least 1.8 meters of 6 feet between workers by staging/staggering work, limiting the number of workers present) • Specific procedures and measures dealing with specific risks. For example, for health care contractors: infection prevention and control (IPC) strategies, health workers exposure risk assessment and management, developing an emergency response plan, per WHO Guidelines • Appointing a COVID-19 focal point with responsibility for monitoring and reporting on COVID- 19 issues, and liaising with other relevant parties • Including contractual provisions and procedures for managing and monitoring the performance of contractors, in light of changes in circumstances prompted by COVID-19 Community Workers Community workers will not be involved in the Rwanda COVID-10 ERP activities. Primary Supply Workers No significant risk of child or forced labor or serious safety issues in relation to primary suppliers have been identified or expected in the Rwanda COVID-10 ERP activities. 71 7.5. Stakeholder Engagement MoH on behalf of GoR as the borrower will meet the requirement of the World Bank ESS10: Stakeholder Engagement and Information Disclosure. Due to the emergency situation, and the need to address issues related to COVID19, no dedicated consultations beyond public authorities and health experts, including Africa CDC, have been conducted so far. However, the project has prepared a SEP and publicly disclosed it to ensure early, continuous and inclusive stakeholder engagement (including vulnerable/disadvantaged groups). The overall objective of the SEP is to define a program for stakeholder engagement, including public information disclosure and consultation, throughout the entire project cycle. The SEP outlines the ways in which the project team will communicate with stakeholders and includes a mechanism by which people can raise concerns, provide feedback, or make complaints about project and any activities related to the project. The involvement of the local population is essential to the success of the project in order 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 infectious diseases. The Bank recently provided a Technical Note titled “Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints of conducting public meetings� with respect to the outbreak and spread of COVID-19. The Note makes due reference to the WHO technical guidance in dealing with COVID-19, including: (i) Risk Communication and Community Engagement (RCCE) Action Plan Guidance Preparedness and Response; (ii) Risk Communication and Community engagement (RCCE) readiness and response; (iii) COVID-19 risk communication package for healthcare facilities; (iv) Getting your workplace ready for COVID-19; and (v) a guide to preventing and addressing social stigma associated with COVID-19. All these documents are available on the WHO website through the following link: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance. The Government of Rwanda through the Ministry of Health launched an extendable six month COVID-19 National Preparedness and Response Plan under the oversight of the National Epidemic Preparedness and Response Committee led by the Office of the Prime Minister. One of main objectives of the plan is to “Create and raise public awareness for engagement on COVID-19 preparedness and response activities�. The Rwanda Health Communication Centre (RHCC), a unit of the RBC/MoH mandated with the coordination of health promotion interventions, handling media and public relations wit hin the country’s health sector is full deployed in the implementation of Rwanda’s RCCE. The RHCC disseminates COVID- 19 relevant messages through national radio, megaphone broadcasts, TV, mobile phone SMS and social media platforms and obtains feedback as appropriate. Stakeholder Consultations for project preparation Consultations on this ESMF have suffered extended delays due to COVID-19 related in-country movement restrictions and selective lockdowns in outbreak districts and neighborhoods. This has led to the disbursement of ERP funds to the tune of 72% before the ESMF could be disclosed. However, it should be noted that 60% of the disbursements have been used for retroactive financing. A senior level virtual consultation with stakeholders in district administration of the health sector was conducted on this ESMF on Oct 16, 2020 using a video conference facility hosted by the Ministry of Local Government (MINALOC). Participants included District Executive Secretaries, Directors General of District Hospitals, District Directors of Health, District Hygiene and Sanitation Officers and Hospital Environmental Health Officers. The consultation session was facilitated by the MoH/RBC-SPIU Coordinator and the designated ERP Social Specialist. The ERP environmental Specialist and members of the MoH Environmental Health Desk participated in the consultation. 72 Over 90 officials participated in the virtual consultation session, although registered in the VC system (Annex VII). Earlier in the week consultation sessions on this ESMF were slotted in the Environmental Safeguards training programme from Oct 12 to Oct 15, 2020 for District Hygiene and Sanitation Officers (DHSOs) and District Hospital Environmental Health Officers (EHO) and Health Centre Community Environmental Health Officers (C-EHOs) for 4 districts. 33 officers from Nyabihu and Ngororero districts were consulted on the ESMF on Oct 12, and 31 officers from Rubavu and Rutsiro districts consulted on Oct 14, 2020 (Annex VIII). A summary of key issues raised are provided in Table 11. Table 11 Summary of key issues raised by stakeholders Comments and Issues raised Stakeholder Reply from ESF Team &/or PIU Designation • Handwashing facilities are inadequate Director of Health - • PIU Coordinator: MoH found Bugesera District that there internal water supply challenges in some HCFs. These • There is need for assessment of water Director of Health - HCFs have been identified and will distribution within HCFs Gasabo District; be assisted to resolve the problem. • Presentation did not feature people with Director of Health - • ESF team: People disabilities are disabilities among the stakeholders Bugesera District included as key stakeholders of the ERP and referenced in this ESMF among vulnerable groups. • Current practice of home-based care is DG Gisenyi Hospital • PIU Coordinator: A capacity straining HCW capacity. HCW capacity needs assessment was done and challenges expected increase when borders results used in the COVID-19 open (e.g. 50,000 people crossing daily at National Preparedness and Rubavu-Goma border). Response Plan. • Has there been any HR capacity needs • PIU Coordinator: There is no assessment for C-19 response? budget for recruitment of • Is project considering recruiting additional additional HCWs. Most of the ERP non-civil service staff? budget is being used for logistical • EHOs & C-EHOs over-stretched, not able to EHOs/C-EHOs support for case-management and follow appropriate schedule, resorting to most Nyabihu/Ngororero medical supplies. urgent • How is the budget managed to mitigate Director of Health – • PIU Coordinator: ERP budget is implementation challenges? Rulindo District managed by RBC-SPIU according GoR guidelines for financial accountability and efficiency of delivery • The country is moving into the C-19 Director of Health - • ESF Team: This ESMF provides eradication phase. Is the ERP considering Gasabo District guidance on decommissioning of rehabilitation of facilities e.g. isolation and ERP facilities as the final stage of quarantine centers? project activities. • Some decontamination activities caused Director of Health - • ESF Team: Damage attributable damage of people’s properties. Will the ERP Gasabo District; to the project will be compensated. compensate them? EHOs/C-EHOs ERP Grievance Redress Nyabihu/Ngororero Mechanism is intended to address problems that may emerge from project activities fairly and efficiently. Aggrieved parties should be facilitated to register 73 Comments and Issues raised Stakeholder Reply from ESF Team &/or PIU Designation these and other grievances in the GRM register using the “Incident Reporting Form� of the nearest HCF. GRM Incident Reporting Forms� are maintained by DHSOs, EHOs and C-EHOs how forward registered grievances to HCF Health & Safety Committee for resolution. • Transportation of medical waste to district EHOs/C-EHOs • ESF Team: Noted for the hospitals for incineration is adhoc and staff Musanze/Rutsiro; attention of RBC-SPIU (PIU) rely on improvisation Nyabihu/Ngororero • Incineration expensive (Rwf1,600/kg at EHOs/C-EHOs Gisenyi Hospital); considered low priority in Nyabihu/Ngororero current situation of low budget • Incinerators maintenance costly (e.g. Gisenyi Hospital cost Rwf18m (USD18.6m) • No weighing scales and colour-coded waste EHOs/C-EHOs bags not available for medical waste Nyabihu/Ngororero characterization • Component 4 indicates zero cost. Is this RBC/IHDPC • ESF Team: Component for is correct? CERC and indeed zero cost to the ERP. • Will the ERP consider purchasing Director of Health – • ESF Team: ERP will not incinerators for hospitals? Gasabo District purchase incinerators for hospitals. However, the project • ERP should make consideration of hospitals EHO - Mibilizi DH can contribute to the training and without modern incinerators capacity building of operators of the existing facilities to maximize their safe operation and support future planning, prioritization of the waste management within these district facilities. • ERP should make considerations for waste Director of Waste • ESF Team: Noted for the management in COVID-19 homebased Management Kicukiro attention of RBC-SPIU (PIU) care/treatment District Key Outcomes of the initial stakeholder consultations The initial stakeholder consultations provided critical information to key stakeholders in the health sectors. Important questions and comments mainly emanated from grievances emerging from property damage caused by decontamination activities associated with contact-tracing for IPC of COVID-19 such as use chlorine and other chemicals on equipment surfaces. Stakeholders were informed of the GRM that in place for grievance resolution associated with ERP activities. Stakeholders were also concerned with medical waste management challenges faced by HCFs and wondered whether or not the ERP would address them, especially towards the need for incinerators. A critical aspect of waste management raised related to waste management of the current homecare for COVID-19 patients. This aspect should be addressed by RBC. Another critical issue raised by stakeholders was the overstretched situation of HCWs. The PUI was able to explain that the countries were generally 74 under stress and that the RBC would try to make do with the resources that were available and that no resources were available in the ERP or from elsewhere for recruit more staff. It was noted that some participants experienced poor connectivity during the VC consultation proceedings. It would be useful to assess connectivity challenges in an effort to enhance and improve participation. 75 7.6. Stakeholder Engagement Plan Stakeholder engagement will be carried out using the recommended methods provided in the Rwanda RCCE plan, the project Stakeholder Engagement Plan disclosed on April 1, 202010 and in the guidance provided in the Bank’s Technical Note as summarized in Table 12 below: Table 12 Stakeholder engagement plan in compliance with ESS10 using the Rwanda RCCE plan methods Stakeholder Group Engagement Methods GoR Ministries, Institutions and Agencies: Email and text messages • MoH/RBC; Africa CDC and WHO; Formal Video Conference meetings • MoE; REMA; RDB; RHA; • Immigration & Emigration (border control) /Civil Electronic Factsheets with text message feedback Aviation Authority/Airports Company of contact details Rwanda/Airlines; One-On-One phone conversations • MINECOFIN/Customs; • MINEMA; MINALOC/LODA; MINICOM; • MININFRA/RTDA/Public Transport/ Road Transport Industry (cooperatives) Project Affected Persons (Contact risk): Radio and TV Public Service Announcements; social • COVID19 infected people medial announcements; text messaging; Virtual Focus • People under COVID19 quarantine Group Discussions; • Relatives of COVID19 infected people One-On-One phone conversations • Relatives of people under COVID19 quarantine • Travelers and inhabitants of areas where cases have Electronic Factsheets with text message feedback been identified contact details • Public Health Workers Focus Group Discussions with minimum number of • Private Health Workers mobilized by MoH/RBC for participants according to national social-distancing COVID-19 IPC activities advisory/guidelines • Medical waste collection and disposal workers • Airline and border control staff • Other international transport business personnel Project Affected Persons (High risk areas): Focus Group Discussions with minimum number of • ERP workers at renovation/refurbishment sites for participants according to national social-distancing isolation and treatment centers, laboratories, advisory/guidelines quarantine centers and screening posts Virtual Focus Group Discussions with local influencers • Neighboring communities to laboratories, quarantine and local network reps centers, and screening posts Electronic billboard posters with text feedback contact details Disadvantaged/ Vulnerable Individuals or Groups: Focus Group Discussions with minimum number of • Elderly participants according to national social-distancing • Illiterate people advisory/guidelines • People with disabilities Virtual Focus Group Discussions with local influencers • Refugees and local network reps • Female-headed households • Child headed households 10 Rwanda ERP Stakeholder Engagement Plan (P173855): http://documents.worldbank.org/curated/en/465331585778137487/Stakeholder-Engagement-Plan-SEP-Rwanda- COVID-19-Emergency-Response-Project-P173855 76 Stakeholder Group Engagement Methods • Poor households One-On-One phone conversations Other Affected Groups: Radio and TV talk shows with a phone-in feedback • Traditional media facility • Participants of social media Electronic billboard posters with text feedback contact • Private Sector Federation details • Religious institutions • Schools Electronic Factsheets with text message feedback • Higher Education Institutions contact details • Other national and international health organizations Short video broadcasts with text message feedback • Politicians contact details • Other NGOs • Businesses with international links Virtual Focus Group Discussions • The public at large One-On-One phone conversations Overall supervision for stakeholder engagement will be the responsibility of the MoH. Consultations between the preparation team for ESF instruments and members of the MoH and RBC-SPIU confirmed adequate capacity for the required implementation requirements within the existing human resources and operational structures of the ministry and within environmental health officials in beneficiary district administrations, hospitals and HCFs (Figure 4). As mentioned earlier in this ESMF, the MOH/RBC-SPIU (PUI) is mandated with the responsibility for implementing ESF instruments including the SEP for the Rwanda COVID-19 ERP. The designated ERP Social Specialist within the PUI will arrange and carry out SEP activities assisted by District Hygiene and Sanitation Officers (DHSOs) at District Administration level, by Environmental Health Officers (EHOs) at Referral, Provincial and Districts hospital level and by Community Environmental Health Officers (C-EHOs) at Health Centre level. The Level, method and activity of engagement to be applied will be guided by the Stakeholder Engagement Plan shown in Table 12 under the supervision of the RBC-SPIU (PUI). The ERP Social Specialist will be responsible for the documentation of the stakeholder engagement activities under this ERP and will be responsible for quarterly reporting on the SEP. Stakeholder engagement activities may be iterative through the project’s lifecycle based on comments received that may identify new important stakeholders. Grievance Redress Mechanism (GRM) The SEP features a Grievance Redress Mechanism (GRM) that applies to all activities of the Rwanda COVID-19 ERP. The GRM is aimed assisting to resolve complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Specifically, it provides a transparent and credible process for fair, effective and lasting outcomes. It also builds trust and cooperation as an integral component of broader community consultation that facilitates corrective actions. Specifically, the GRM: • Provides affected people with avenues for making a complaint or resolving any dispute that may arise during the course of the implementation of projects; • Ensures that appropriate and mutually acceptable redress actions are identified and implemented to the satisfaction of complainants; and • Avoids the need to resort to judicial proceedings. Grievances are handled at HCFs by established and operational Health and Safety Committees under the supervision of the MoH Health Facility Specialist at national level. The Health Facility Specialist monitors the work of Health and Safety Committees through regular reviews of grievance registers adopted from the MoH “Incident Reporting Form�. The Health and Safety Committees implement the GRM with the facilitation the ERP Social Specialist. The Social Specialist ensures that Contractors maintain a grievance 77 register (Incident Reporting Form)� at ERP activity sites. Contractors are required to record any grievance in the grievance register/incident form and forward the information to the Health and Safety Committee at the HCF where there are ERP activities through DSHOs, HEO or EHO as described in Figure 2. The structure of the Health and Safety Committee mandated by MoH to implement the Rwanda COVID-19 ERP is described below. Health and Safety Committee Structure: 11 • Chairperson: Head of Pharmacy • Focal Person: Biomedical Technician • Committee Secretary: o District Hygiene & Sanitation Officers (DHSOs) at District Administration level also responsible for ERP works for Screening Posts, Centers of Quarantine and Contact Tracing; or o Hospital Environmental Officers (HEOs) at Referral, Provincial and District hospital level also responsible for ERP works on IPC at Isolation & Treatment Facilities or o Environmental Health Officers (EHOs) also responsible for ERP works at Health Center level. • Committee Members o Head of Physiotherapy o Procurement o Medical Doctor o Lab Technician Health and safety committee responsibilities: • Establish budget for hazardous materials and waste management • Orientation for new personnel for proper use and storage of hazardous materials • Develop procedures for handling hazardous materials • Conduct a monthly environmental safety round in HCF as well as reporting and analyzing the findings for decision making • To integrate safety monitoring and response activities into the patient safety program The GRM as displayed in Figure 7 will be applied for the implementation of the ERP. The ERP-GRM will be implemented at the HCFs by Health and Safety Committees with provisions for incident/case escalation to District Level and at national level (MoH-RBC/Ombudsman/National Court System) as shown in Figure 7. The ERP Social Specialist will ensure that grievances registers are maintained by Contractors at ERP activity sites. Contractors will register grievances and forward the information to the Health and Safety Committee secretary to evoke the GRM. The GRM will include the following steps as illustrated in Figure 7 below: Step 0: Grievance discussed with the respective health facility Step 1: Grievance raised with the District Social Affairs Office or IOSC in case of GVB Step 2: Appeal to the Provincial Department of Social Affairs Office Step 3: Appeal to the Rwanda Office of the Ombudsman and/or the Ministry of Health/RBC. Once all possible redress has been proposed and if the complainant is still not satisfied then they should be advised of their right to legal recourse. However, in case of incidents of Gender Base Violence (GVB), there is need for timely access to quality, multi-sectoral services and involves confidentiality and informed consent of the survivor. Should they occur, GVB complaints will be directed to the Isange One Stop Center (IOSC) by DSHOs, HEOs or EHOs 11 Health and Safety Committee membership my vary according to the category HCF and staff functions 78 as GRM facilitators. The IOSC is a specialized free-of-charge referral center where survivors of GVB can find comprehensive services such as: medical care; psychosocial support; police and legal support, and collection of legal evidence. IOSC works closely with police stations, sector, cell and village leaders in surrounding areas, community police, hospitals and health centers. ERP Social Specialist will ensure that bidding and subsequent contract documents for the project ERP clearly define GBV/SEA/SH requirements, including the requirement for a Code of Conduct (CoC). During works, separate facilities for women and men with GBV-free zone signage will be retained in place. The Social Specialist will continue to provide information to all contractors with contact details the IOSC. In Aggrieved Grievance Step 0 Health Facility Step 1 District Social Affairs Appeal Party registration (24hrs) Office (1-2days) GBV complaint Appeal GVB Task Force/ Isange One-Stop Center (1-12hrs) Step 2 Grievance Resolution Provincial Social Affairs Office (1- 2days) National Court System MoH-RBC Step 3 Appeal Ombudsman Appeal Figure 7 Grievance Redress Mechanism for the Rwanda ERP the instance of the COVID 19 emergency, existing grievance procedures should be used to encourage reporting of co-workers if they show outward symptoms, such as ongoing and severe coughing with fever, and do not voluntarily submit to testing. Recent consultations with the RBC-SPIU (PIU) indicated that no grievances have so far been registered within the ERP. This is understandable as most of the ERP activities have entailed logistical support for Command Post activities and acquisition of medical supplies. 79 7.7. Implementation and monitoring of E&S plans and instruments Environmental and Social Specialists within the RBC SPIU (PUI) will ensure that prevention and mitigation measures for ESHS and OHS as prescribed in ESMPs or ESIAs as appropriate for particular subprojects and supervise contractor compliance. Adverse environmental impacts are expected to be low from ERP minor civil works carried out in refurbishments for POEs, screening and isolation facilities as well as operational IPC and WASH activities. Supervision and Monitoring Contractor supervision and monitoring • The Contractor will implement all mitigation measures detailed in the Contractor-ESMPs. • Contractor performance for ESHS and OHS compliance will be monitored by the RBC SPIU Coordinator through reports compiled jointly by Environmental Specialist and Social Specialist. • WB will conduct random checking. Daily monitoring • District Hygiene & Sanitation Officers (DHSOs) at District Administration level will supervise ERP works for Screening Posts at PoEs, Centers of Quarantine and Contact Tracing. DHSOs will prepare and submit monthly reports to the RBC-SPIU through the Environmental Specialist and Social Specialist. • Environmental Health Officers (EHOs) at Referral, Provincial and District hospitals benefiting from ERP investments will conduct daily supervision of minor civil works for refurbishment, fittings and installations for establishment and/or re-equipping isolation and treatment facilities as well as IPC activities in the operational and decommissioning phases. • Environmental Health Officers (EHOs) will conduct daily supervision of ERP works for Screening Post at Health Centers and surveillance at community level and prepare and submit monthly reports to the RBC-SPIU through the Environmental Specialist and Social Specialist. • Monitoring indicators will include compliance with PPE usage standards, standard precautions and transmission based precautions in line with national, WB and WHO guidelines, presence of standard documentation (incl. Material Safety Data Sheets), review of grievance logs and incident reporting logs. • In case a non-compliance is noted, an Environmental Health Officer (or Community EHO) after taking action in accordance with the site-specific ESMP and ICWMP, is expected to include relevant information about this non-compliance in their report to the District Administration. Any significant ESHS (including OHS or community health) incidents must be reported to the SPIU and the WB within 48 hours of occurrence. • Overall, routine Environmental and Social performance reports will be submitted to the World Bank for review. Daily monitoring will take into consideration requirements prescribed in the Labor Management Procedures (LMP) including grievance resolution using the ERP GRM the following: ERP level Reporting The contractors will prepare their compliance reports with respect to the ESMP, which document the implementation of environmental mitigation and protection measures (together with prescribed monitoring activities carried out during the reporting period) and submit them to RBC SPIU Coordinator. The overall project compliance is reviewed by the MoH and by the WB, the latter may carry out the periodic supervision 80 missions. Comprehensive monitoring parameters and details on reporting arrangements, including operational phase supervision recommendations, will be described in subproject ESMP (Annex III). 81 I. Annexes, Abbreviations and Acronyms AFB Acid-Fast Bacilli AMR Antimicrobial Resistance BMBL Biosafety in Micro Biological and Biomedical Laboratories BMW Bio Medical Waste Management BSC Biological Safety Cabinets BSL Biosafety Level CDC Centre for Disease Control and Prevention COVID-19 Coronavirus Disease 2019 EOC Emergency Operating Centre ESF Environmental and Social Framework ESS Environmental and Social Standard ESIA Environmental and Social Impact Assessment ESHS Environmental, Social, Health and Safety EHS Environmental, Health and Safety ERP Emergency Response Plan ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan GBV Gender Based Violence HCF Healthcare Facility HCW Healthcare Waste HEPA High Efficiency Particulate Air filter HIV Human Immunodeficiency Virus HWMS Healthcare Waste Management System HVAC Heating, Ventilation and Air Conditioning ICWMP Infection Control and Waste Management Plan IPC Infection and Prevention Control LMP Labor Management Procedure OHS Occupational Health and Safety POE Point of Entry PPE Personal Protective Equipment PPSD Project Procurement Strategy for Development RAP Resettlement Action Plan RBC The Rwanda Biomedical Center RPF Resettlement Policy Framework SEA Sexual Exploitation and Abuse SEP Stakeholder Engagement Plan SOP Standard Operating Procedures TA Technical Assistance TB Tuberculosis WB World Bank WHO World Health Organization WWTP Wastewater Treatment Plant 82 II. Screening Template for Potential Environmental and Social Issues This form is to be used by the Single Project Implementation Unit (SPIU) to screen for the potential environmental and social risks and impacts of a proposed subproject. Subprojects in the context of the Rwanda COVID-19 ERP are project activities procured under a contract. Subproject ES measures therefore apply to HCF where investments have been made. It will help the PIU in identifying the relevant Environmental and Social Standards (ESS), establishing an appropriate E&S risk rating for these subprojects and specifying the type of environmental and social assessment required, including specific instruments/plans. Use of this form will allow the PIU to form an initial view of the potential risks and impacts of a subproject. It is not a substitute for project-specific E&S assessments or specific mitigation plans. A note on Considerations and Tools for E&S Screening and Risk Rating is included in this Annex to assist the process. Subproject Name Subproject Location Subproject Proponent Estimated Investment Start/Completion Date Subproject eligibility exclusion criteria question Yes No 1. Will the subproject involve laboratory activities that may require BSL3 lab facilities? 2. Will the subproject involve activities that may cause long term, permanent and/or irreversible impacts (e.g. loss of major natural habitat)? 3. Will the subproject involve activities that have high probability of causing serious adverse effects to human health and/or the environment? 4. Will the subproject involve activities that may have adverse social impacts and may give rise to significant social conflict? 83 Subproject eligibility exclusion criteria question Yes No 5. Will the subproject involve activities which would require Free Prior Informed Consent? 6. Will the project involve activities that may affect lands or rights of indigenous people or other vulnerable minorities? 7. Will the subproject have activities that may involve permanent resettlement or land acquisition or impacts on cultural heritage? If any of the above questions are answered as “Yes�, the proposed subproject is not eligible for financing under this ERP. Questions Answer ESS relevance Due diligence / Actions Yes no Does the subproject involve civil works ESS1, ESS2, ESIA/ESMP, including new construction, expansion, ESS3 SEP upgrading or rehabilitation of healthcare facilities and/or waste management facilities? Will the subproject have adding that this includes the operational aspects of a subproject HF, or lab Is the subproject (both construction and ESS3, ESS2, ESIA/ESMP, operational phases) associated with any external ESS4 SEP waste management facilities such as a sanitary landfill, incinerator, or wastewater treatment plant for healthcare waste disposal? Is there a sound regulatory framework and ESS1, ESS3, ESIA/ESMP, institutional capacity in place for healthcare ESS2 SEP facility infection control and healthcare waste management? Does the subproject (both construction and ESS3 ESMP operational phases) have an adequate system in place (capacity, processes and management) to address waste from target Healthcare Facilities (liquid (wastewater) and solid; non-hazardous, hazardous and medical)? 84 Does the subproject involve recruitment of ESS2 LMP, SEP workers including direct, contracted, primary supply, and/or community workers? Does the subproject (both construction and ESS2 LMP operational phases) have appropriate OHS procedures in place, and an adequate supply of PPE (where necessary)? Does the subproject have a GRM in place, to which all workers have access, designed to respond quickly and effectively? ESS3 ESIA/ESMP, Does the subproject involve transboundary SEP transportation (including Potentially infected specimens may be transported from healthcare facilities to testing laboratories, and transboundary) of specimen, samples, infectious and hazardous materials? Does the subproject potentially affect ESS4 ESIA/ESMP, community health and safety? SEP Does the subproject (both construction and ESS4 ESIA/ESMP, operational phases) involve use of security or SEP military personnel during construction and/or operation of healthcare facilities and related activities? Is the subproject located within or in the vicinity ESS6 ESIA/ESMP, of any ecologically sensitive areas? SEP Is the subproject located within or in the vicinity ESS8 ESIA/ESMP, of any known cultural heritage sites? SEP Does the project area present considerable ESS1 ESIA/ESMP, Gender-Based Violence (GBV) and Sexual SEP Exploitation and Abuse (SEA) risk? Is there any territorial dispute between two or OP7.60 Projects Governments more countries in the subproject and its in Disputed concerned agree ancillary aspects and related activities? Areas 85 Will the subproject and related activities involve OP7.50 Projects Notification the use or potential pollution of, or be located in on International international waterways12? Waterways (or exceptions) Conclusions: 1. Proposed project is eligible for financing under the project criteria …………………………………………………………………………………………………….. 2. Proposed Environmental and Social Risk Ratings (High, Substantial, Moderate or Low) based on the World Bank Environmental and Social Directive for Investment Project Financing of Jan 28, 2020. Available at: https://ppfdocuments.azureedge.net/698faa01-d052-4eb3-a195- 055e06f7f3fd.pdf. Provide Justifications …………………………………………………………………………………………………….. 3. Proposed E&S Management Plans/ Instruments among ESMP; ESIA or Technical Assistance. …………………………………………………………………………………………………….. INFECTION CONTROL: CONSIDERATIONS AND TOOLS TO ASSIST IN E&S SCREENING AND RISK RATING: In the context of global COVID-19 outbreak, many countries have adopted a containment strategy that includes extensive testing, quarantine, isolation and treatment either in a medical facility or at home. A COVID-19 response project may include the following activities: • construction of and/or operational support to medical laboratories, quarantine and isolation centers at multiple locations and in different forms, and infection treatment centers in existing healthcare facilities • procurement and delivery of medical supplies, equipment and materials, such as reagents, chemicals, and Personal Protective Equipment (PPEs) • transportation of potentially infected specimens from healthcare facilities to testing laboratories • construction, expansion or enhancing healthcare waste and wastewater facilities • training of medical workers and volunteers • community engagement and communication 12 International waterways include any river, canal, lake or similar body of water that forms a boundary between, or any river or surface water that flows through two or more states. 86 1. Screening E&S Risks of Medical laboratories Many COVID-19 projects include capacity building and operational support to existing medical laboratories. It is important that such laboratories have in place procedures relevant to appropriate biosafety practices. WHO advises that non-propagative diagnostic work can be conducted in a Biosafety Level 2 (BSL-2) laboratory, while propagative work should be conducted at a BSL-3 laboratory. Patient specimens should be transported as Category B “infectious substance� (UN3373), while viral cultures or isolates should be transported as Category A “Infectious substance, affecting humans� (UN2814). The process for assessing the biosafety level of a medical laboratory (including management of the laboratory operations and the transportation of specimens) should consider both biosafety and general safety risks. OHS of workers in the laboratory and potential community exposure to the virus should be considered. The following documents provide further guidance on screening of the E&S risks associated with a medical laboratory. They also provide information for assessing and managing the risks. • WHO; Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios • WHO Covid-19 Technical Guidance: Laboratory testing for 2019-nCoV in humans: • WHO Laboratory Biosafety Manual, 3rd edition • USCDC, EPA, DOT, et al; Managing Solid Waste Contaminated with a Category A Infectious Substance (August 2019) 2. Screening E&S Risks of Quarantine and Isolation Centers According to WHO: • Quarantine is the restriction of activities of or the separation of persons who are not ill but who may have been exposed to an infectious agent or disease, with the objective of monitoring their symptoms and ensuring the early detection of cases • Isolation is the separation of ill or infected persons from others to prevent the spread of infection or contamination. Many COVID-19 projects include construction, renovation and equipping of quarantine and isolation centers at Point of Entry (POE), in urban and in remote areas. There may also be circumstances where tents are used for quarantine or isolation. Public or private facilities such as a stadium or hotel may also be acquired for this purpose. In screening for E&S risks associated with quarantine and isolation, the following may be considered: • contextual risks such as conflicts and presence or influx of refugees • construction and decommissioning related risks • ascertain that land or asset acquisition is not required for ERP activities • ascertaining that security personnel or military forces are not used in ERP activities • availability of minimum requirements of food, fuel, water, hygiene • whether infection prevention and control, and monitoring of quarantined persons can be carried out effectively • whether adequate systems are in place for waste and wastewater management The following documents provide further guidance regarding quarantine of persons. • WHO; Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19) • WHO; Key considerations for repatriation and quarantine of travelers in relation to the outbreak of novel coronavirus 2019-nCoV 87 • WHO; Preparedness, prevention and control of coronavirus disease (COVID-19) for refugees and migrants in non-camp settings 3. SCREENING E&S RISKS OF TREATMENT CENTERS WHO has published a manual that provides recommendations, technical guidance, standards and minimum requirements for setting up and operating severe acute respiratory infection (SARI) treatment centers in low- and middle-income countries and limited-resource settings, including the standards needed to repurpose an existing building into a SARI treatment center, and specifically for acute respiratory infections that have the potential for rapid spread and may cause epidemics or pandemics. • WHO Severe Acute Respiratory Infections Treatment Centre • WHO Covid-19 Technical Guidance: Infection prevention and control / WASH • WBG EHS Guidelines for Healthcare Facilities 4. SCREENING E&S RISKS RELATING TO LABOR AND WORKING CONDITIONS A COVID-19 project may include different types of workers. In addition to regular medical workers and laboratory workers who would normally be classified as direct workers, the project may include contracted workers to carry out construction and community workers (such as community health volunteers) to provide clinical support, contact tracing, and data collection, etc. The size of the workforce engaged could be considerable. Risks for such a workforce will range from occupational health and safety to types of contracts and terms and conditions of employment. Further details relevant to labor and working conditions for COVID-19 projects are discussed in the LMP template for COVID-19. Certification Reviewed and approved by ERP Environment Specialist ERP Social Specialist Name: Name: Date Signature Date Signature 88 COVID-19 Response ESMF – ESMP III. Environmental and Social Management Plan (ESMP) Template Introduction An Environmental and Social Management Plan (ESMP) for a proposed subproject is setting out how the environmental and social risks and impacts will be managed through the project lifecycle. This ESMP template includes several matrices identifying key risks and setting out suggested E&S mitigation measures. The HCF will develop ESMPs jointly with SPIU for each of the ERP-financed activities with identified E&S risks. These matrices can be used to assist in identifying risks and possible mitigations. The ESMP should also include other key elements relevant to delivery of the subproject, such as institutional arrangements, plans for capacity building and training plan, and background information. The Borrower may incorporate relevant sections of the ESMF into the ESMP, with necessary updates. The matrices illustrate the importance of considering lifecycle management of E&S risks, including during the different phases of the project identified in the ESMF: planning and design, construction, operations and decommissioning. The issues and risks identified in the matrix are based on current COVID-19 responses and experience of other Bank financed healthcare sector projects. The Borrower should review and add to them during the environmental and social assessment of a subproject. The WBG EHS Guidelines, WHO technical guidance documents and other GIIPs set out in detail many mitigation measures and good practices, and can be used by the Borrower to develop the ESMP. Proper stakeholder engagement should be conducted in determining the mitigation measures, including close involvement of medical and healthcare waste management professionals. The Infection Control and Waste Management Plan forms part of the ESMP. The ESMP should identify other specific E&S management tools/instruments, such as the Stakeholder Engagement Plan (SEP), labor management procedures (LMP), and/or Medical Waste Management Plan. During implementation of each site-specific ESMP, in case a non-compliance is noted, an Environmental Health Officer (or Community EHO), after taking action in accordance with the ESMP and ICWMP, must include relevant information about this non-compliance in their report to the District Administration. Any significant ESHS (including OHS or community health) incidents must be reported to the SPIU and the WB within 48 hours of occurrence. Overall, routine Environmental and Social performance reports will be submitted to the World Bank for review. 89 COVID-19 Response ESMF – ESMP Table 1 - Environmental and Social Risks and Mitigation Measures during Planning and Designing Stage Key Activities Potential E&S Proposed Mitigation Measures Responsibilities Budget Risks and Impacts Identify onsite and offsite Inadequate facilities and inadequate Prepare a subproject specific ICWMP according to Environmental 0 waste management facilities, processes for treatment of waste Annex IV template, Specialist and waste transportation routes and service providers HCF staff Identify needs for workforce ➢ Doing hazardous work such as ➢ Identify numbers and types of workers Social Specialist 0 and type of project workers for working at heights or in Consider accommodation and measures to upgrading and/or rehabilitation confined spaces, use of heavy minimize cross infection: If possible, sites shall HCF staff machinery, or use of hazardous be on the outskirts of cities to avoid unnecessary materials interaction with the public when delivering ➢ Likely presence of migrants or services to and from the facilities however, seasonal workers since the government is using existing sites, ➢ Risks of labor influx or gender- security measures should be enhanced around based violence the quarantine areas ➢ Possible accidents or ➢ People living in the environs of a emergencies, with reference to quarantine/isolation centers and health facilities the sector or locality shall be given accurate information on the Inadequate understanding and pandemic and receive updates on COVID-19. implementation of occupational ➢ See COVID-19 LMP in Section 7.4 to identify health and safety requirements possible mitigation measures HCF design – general - Structural safety risk; - Functional layout and engineering control for nosocomial infection Design of upgrading and/or Upgrade/refurbishment/rehabilitation ➢ The design for refurbishment, set up and Environmental 0 rehabilitation of facilities for design flaws for laboratories, management of laboratories, isolation and Specialist in laboratory tests, triage, isolation and treatment centers may treatment centers will take into account the consultation with isolation or quarantine not meet standards and could cause advice provided by WHO guidance for Severe Head of Division, personnel to be exposed to infectious Acute Respiratory Infections Treatment Center. ESR13 diseases and occupational health ➢ All the new construction designs shall consider hazards. the concept of universal access that allows for unimpeded access for all people of different ages and abilities. This shall include provision of the ramps, elevators and toilets for the disabled. ➢ Hand washing facilities should be provided at the entrances to health care facilities in line with 13 Epidemic Surveillance Response of the Rwanda Biomedical Centre 90 COVID-19 Response ESMF – ESMP WHO Recommendations to Member States to Improve Hygiene Practices. ➢ Isolation rooms should be provided and used at medical facilities for patients with possible or confirmed COVID-19. ➢ Isolation rooms should: ➢ be single rooms with attached bathrooms (or with a dedicated commode); ➢ ideally be under negative pressure (neutral pressure may be used, but positive pressure rooms should be avoided) ➢ be sited away from busy areas or close to vulnerable or high-risk patients, to minimize chances of infection spread; ➢ have dedicated equipment (for example blood pressure machine, peak flow meter and stethoscope ➢ have signs on doors to control entry to the room, with the door kept closed; have an ante-room for staff to put on and take off PPE and to wash/decontaminate before and after providing treatment. Design to consider mortuary Insufficient capacity ➢ Include adequate mortuary arrangements in the HCF staff arrangements Spread of infection design ➢ See WHO Infection Prevention and Control for the safe management of a dead body in the context of COVID-19) Nosocomial Infection Control There is a significant risk of • Building designs of the renovated health facilities SPIU contracting COVID-19 within a shall be in line with the national building code and hospital facility if its design has not the standard health care setting building designs. HCF staff taken this risk into consideration. Health services (public and private • Traffic flow shall be considered to minimize facilities) are expected to exposure of high risk patients and facilitate patient conceptually meet the quality transport. standards of ISO 9000 and ISO • Adequate spatial separation of patients is key, the 14000 series although this is not the patients care areas shall be stratified by risk of the case in most health facilities in the patient population for acquisition of infections. The developing countries. Thus the four main degrees of risk to be considered include; renovation plans and designs that Low risk areas e.g. administrative sections, shall be prepared for the isolation moderate risks e.g. regular patient units, high risk /quarantine units in the health areas e.g. isolation units, intensive care units, very facilities should be reviewed and high risk e.g. operating rooms. approved by an infection control 91 COVID-19 Response ESMF – ESMP personnel/public health to ensure the • Adequate number and type of isolation rooms shall required measures are adequately be provided with a minimum of least 1 meter space incorporated in the designs. separation between patients to reduce on transmission of infections as well as allow ease in access of health care workers to attend to patients. The facility design shall also be easily accessible by the elderly as well as the persons with disability. • Health facilities shall have appropriate access to hand washing facilities with running water and hand hygiene supplies provided. Hand hygiene is extremely important in prevention against COVID- 19. • Choice of construction materials for covering the internal surfaces (floors/walls) shall be easy to clean and resistant to hot water, detergents and disinfectants. The walls floors and ceiling surfaces as well as furniture and equipment used for patient care shall be smooth, made of non-porous material, easy to clean and do not provide suitable environment for pathogen survival. • Appropriate ventilation for isolation rooms and special patient care areas such as operating theatres and the transplant units) shall be acquired. Adequate ventilation systems require proper designs and maintenance to minimize risk of contamination and may help reduce spread of pathogens. • Water supply to the health facility shall be reliable and to the required standards to limit risk of infections. This can be achieved through treatment of water taken from the public network to ensure that the physical, chemical and bacteriological characteristics of water used in the health care institutions meet the local regulations, (WHO, 2002), Water Law N°62/2008. • Lighting system of the health care facility shall be sufficient to ensure safe working conditions and security. 92 COVID-19 Response ESMF – ESMP • Provision of adequate and accessible toilets taking into consideration the gender aspect including separate facilities for confirmed and suspected cases of COVID -19; and • Provide separate spaces of children and young people to ensure their safety while in the health facilities. • Provision of the right cleaning and disinfection chemicals and equipment. • In operating theatres and rooms for isolating particularly vulnerable patients (e.g. severely immune-compromised patients) they may require positive air pressure conditions, where clean air is drawn into the room, thus avoiding contaminated air entering from other parts of the health care setting, • It would be critical to have separate rooms for people requiring special care and vulnerable people such as persons with disabilities and older persons. • Provision of the right receptacles for waste handling and containment including considerations on waste transfer to provide for minimal disruptions and avoidance of contamination of clean areas during waste collection and on site transportation. ➢ Provisions relating to putting in place other standard precautions must be ensured in order to assure cutting transmission of such nosocomial infections. 93 COVID-19 Response ESMF – ESMP Table 2 - Environmental and Social Risks and Mitigation Measures during Construction Stage Activities Potential E&S Risks and Proposed Mitigation Measures Responsibilities Budget Impacts Nosocomial Infection - There is a significant risk of • Building designs of the renovated health SPIU Control contracting COVID-19 facilities shall be in line with the national within a hospital facility if building code and the standard health care HCF staff its design has not taken this setting building designs. risk into consideration. Health services (public and • Traffic flow shall be considered to minimize private facilities) are exposure of high risk patients and facilitate expected to conceptually patient transport. meet the quality standards • Adequate spatial separation of patients is of ISO 9000 and ISO 14000 key, the patients care areas shall be stratified series although this is not by risk of the patient population for the case in most health acquisition of infections. The four main facilities in the developing degrees of risk to be considered include; countries. Thus the Low risk areas e.g. administrative sections, renovation plans and moderate risks e.g. regular patient units, high designs that shall be risk areas e.g. isolation units, intensive care prepared for the isolation units, very high risk e.g. operating rooms. /quarantine units in the health facilities should be • Adequate number and type of isolation reviewed and approved by rooms shall be provided with a minimum of an infection control least 1 meter space separation between personnel/public health to patients to reduce on transmission of ensure the required infections as well as allow ease in access of measures are adequately health care workers to attend to patients. The incorporated in the designs. facility design shall also be easily accessible by the elderly as well as the persons with disability. • Health facilities shall have appropriate access to hand washing facilities with running water and hand hygiene supplies provided. Hand hygiene is extremely important in prevention against COVID-19. • Choice of construction materials for covering the internal surfaces (floors/walls) shall be easy to clean and resistant to hot water, detergents and disinfectants. The walls floors and ceiling surfaces as well as furniture and equipment used for patient care 94 COVID-19 Response ESMF – ESMP shall be smooth, made of non-porous material, easy to clean and do not provide suitable environment for pathogen survival. • Appropriate ventilation for isolation rooms and special patient care areas such as operating theatres and the transplant units) shall be acquired. Adequate ventilation systems require proper designs and maintenance to minimize risk of contamination and may help reduce spread of pathogens. • Water supply to the health facility shall be reliable and to the required standards to limit risk of infections. This can be achieved through treatment of water taken from the public network to ensure that the physical, chemical and bacteriological characteristics of water used in the health care institutions meet the local regulations, (WHO, 2002), Water Law N°62/2008. • Lighting system of the health care facility shall be sufficient to ensure safe working conditions and security. • Provision of adequate and accessible toilets taking into consideration the gender aspect including separate facilities for confirmed and suspected cases of COVID -19; and • Provide separate spaces of children and young people to ensure their safety while in the health facilities. • Provision of the right cleaning and disinfection chemicals and equipment. • In operating theatres and rooms for isolating particularly vulnerable patients (e.g. severely immune-compromised patients) they may require positive air pressure conditions, where clean air is drawn into the room, thus avoiding contaminated air entering from other parts of the health care setting, 95 COVID-19 Response ESMF – ESMP • It would be critical to have separate rooms for people requiring special care and vulnerable people such as persons with disabilities and older persons. • Provision of the right receptacles for waste handling and containment including considerations on waste transfer to provide for minimal disruptions and avoidance of contamination of clean areas during waste collection and on site transportation. Provisions relating to putting in place other standard precautions must be ensured in order to assure cutting transmission of such nosocomial infections. Minor civil works activities - OHS risks on health care • Adopting and implementing safety 0 – Occupational Health and providers and supportive guideline or manuals from OHS Environmental and Safety (OHS) staff due to improper work guideline14 and WHO technical guideline Social Specialist procedures, healthcare for COVID-19 Key considerations for waste management occupational safety and health15. HCF staff • The contractor shall prepare a OSH plan for the construction works, and should include Supervising consultant input from HCF personnel on potential health and safety risks associated with the HCF • Restricting access to active renovation sites, including establishment of security perimeter. • Use institutional and administrative controls with a focus of high risk areas including: o Screening off or fencing the site, and o Provision of adequate signage and communication of risks to workers, patients and the health community. • The HCF staff, key service providers and the public should be notified of the works through appropriate publicly accessible 14 https://www.ifc.org/wps/wcm/connect/topics_ext_content/ifc_external_corporate_site/sustainability-at-ifc/policies-standards/ehs-guidelines 15 https://www.who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-of-health-workers-including-key-considerations-for- occupational-safety-and-health 96 COVID-19 Response ESMF – ESMP sites such as the main entrance to the health facility. • Barricading the work areas to prevent entry of health staff and patients in the work sites. • Place adequate signboards to divert staff and passengers away from the work sites. • Use of screens/nets to avoid flying debris, ensure good housekeeping in the construction sites. • All workers should be adequately trained on the use of PPEs which they should wear at all times while at the worksite. • Contractor shall provide onsite toilet and washing water for workers. • The water storage tank shall be covered and properly managed to minimize mosquitoes breeding. • Traffic safety plan shall be established for each site by the contractor. • Safety perimeters shall be established around the hazardous areas (around overall construction site, at heights, around wet surfaces, excavated areas, etc.). • Each site must maintain logs of injuries and fatalities. • Each site must establish a grievance redress mechanism to allow workers to raise safety issues and propose improvements on site. • A Safety and Health officer shall be designated at each site by the contractor. Minor civil works – traffic - Traffic accidents due to • The contractor and the respective Environmental 0 and road safety moving machinery and management of the health facilities shall Specialist equipment develop traffic management plan, including Contractor segregating location of vehicle traffic, Supervising Engineer machine operation and walking areas, and controlling vehicle traffic through one-way traffic routes and setting of speed limits. • This can be achieved through use of one-way traffic routes, establishment of speed limits and onsite trained flag personnel wearing high visibility vests to direct traffic. 97 COVID-19 Response ESMF – ESMP • Contractor shall avoid the hospital peak hours for transport of the construction materials. • Warning signs shall be provided at the access roads to warn road users of heavy vehicles during transportation of construction material and equipment. • Contractor shall emphasize safety aspects among project drivers especially speed limits to the health facilities. • Contractors shall regularly inspect vehicle safety and employ trained drivers to minimize the accidents. • Trucks shall be covered with tarpaulin and have tailgates during haulage of construction materials and access roads sprayed with water to reduce on dust levels. • Deploy flagmen at strategic areas during peak hours. • Ambulance drivers should follow guidance on safe emergency driving • Provide regular training to all workers on site to ensure familiarity with traffic safety measures Minor civil works – use of - GBV/SEA/SH issues Prepare a GVB/SEA/SH Action Plan for Social Specialist 0 external workforce Contractor implementation Contractor • Require each worker on site to sign a Code Supervising Engineer of Conduct Disruption of healthcare and For HCFs under renovation • Plan pre-construction activities shall be SPIU other services which will not be closed, may done early to identify suitable rooms or cause temporary disruption in adjoining buildings into which patients or HFC staff delivery of health services to service areas can be relocated with minimal patients at facilities under inconvenience, especially to patients under renovation. intensive care. • Advance relocation information shall be - Temporary loss of access to shared with the affected patients for their utility services such as water planning and mental preparedness. and electricity • Contractors shall work closely and harmoniously with healthcare facility administrators to find practical ways to minimize social cost of temporary disruption of services. 98 COVID-19 Response ESMF – ESMP • A grievance mechanism to address complaints from community shall be in place and awareness promoted. • Cultural heritage - Cultural heritage • Chance-finds procedure (see Annex VI) Social Specialist 0 Contractor Emergency preparedness ➢ Fire ➢Emergency response plan for Environmental 0 and response - Chemical spill and other containment of fire accident Specialist toxicity accidents ➢ Emergency response plan for HCF Staff containment of chemical spill Contractor • Training of HCF staff and contractors on the ERP application and relevant information, such as emergency contract information, evacuation routes, etc.) Community exposure to - Construction work • Restricting access to active renovation Environmental and 0 work related hazards undertaken in the same sites, including screening off the building Social Specialists buildings having patients being renovated or fencing the entire site HCF Staff has potential to cause to limit public access that is appropriate to Contractor injuries to patients or health the site; workers • Only authorized users should be allowed to enter project sites • Use institutional and administrative controls with a focus of high risk areas including: ✓ Provision of adequate signage and communication of risks to workers, patients and the health community; • The public shall be notified of the works through appropriate publicly accessible sites such as the main entrance to the health facility; • Contractors shall ensure measures on Safety and Health are enhanced such as; barricading the work areas to prevent entry of health staff and patients in the work sites, ensure safe access to the health facility if the building will be open to public; • The contractor shall place adequate signboards to divert staff and passengers away from the work sites; 99 COVID-19 Response ESMF – ESMP • Use of screens/nets to avoid flying debris, ensure good housekeeping in the construction sites; • All workers shall be adequately trained on the use of PPEs which they should wear at all times while at the worksite; • All visitor shall wear basic PPE; • Construction workers shall be aware of the sensitive nature of workplace they are operating in and advised to limit verbal noise; and • Contractor shall work closely with the administrators of health facilities to find practical ways to minimize temporal services disruption at the hospitals Minor civil works related to ➢ Improper storage of solid ➢ Collect and dispose wastes in designated Environmental 0 onsite waste management and hazardous waste disposal sites as required by the Local Specialist facilities, including resulting in soil pollution Authority temporary storage, and risks ➢ At the commencement of construction, HCF Staff incinerator (for district - Water pollution from ensure the site has established Contractor HCFs), sewerage / construction wastes as well arrangements for hazardous waste wastewater treatment works as on-site make shift toilets transportation and disposal (including medical waste) ➢ Provide appropriate and approved temporary toilets • Preparation of prior to commencement of activities ICWMP based on the template provided in Annex IV. Community exposure to HCF staff 0 Presence of migrant workers and • Appropriate timely information be health issues SPIU the local community may lead to provided at all levels on risks of infection infection with COVID-19 and between community members and increased risk of over workers. communicable diseases, • Raise awareness on appropriate behavior including HIV/AIDS including prevention of infectious diseases ➢ and sexual harassment, exploitation and abuse. • Carry out HIV/AIDS awareness and control campaigns in the project targeting workers. • Have VCT services on site and encourage workers to undergo testing. 100 COVID-19 Response ESMF – ESMP • Provision of protective devices such as condoms. • Contractor code of conduct to promote appropriate behavior and ensure compliance with COVID 19 prevention measures ➢ In cases of COVID-19 at the construction sites, guidelines have been provided in this ESMF Annex III: Infection, Prevention and Control Protocol on minimization of exposure, training of staff and precautions and management of access and spread Procurement of medical ➢ Poor quality equipment may SPIU Included in the supplies and equipment exacerbate COVID19 • Adhere to the procurement plan for HCF Staff project budget fatality due to failure of acquisition of all medical supplies and Environmental operations especially live equipment from certified suppliers only. Specialist saving machines like • Carry out due diligence for all potential ventilators. On the other suppliers to guarantee quality equipment hand, due to poor handling and products. of samples collection and • WHO interim guidance on rational use of packaging supplies, lab PPE for COVID-19 provided further reagents, pharmaceutical details on the types and quality of PPE that supplies, health care waste are required for different functions. management the use of lab ➢ The healthcare workers shall be provided PPE may lead to the spread with medical personal protective of infections to the equipment (PPE) includes: Medical healthcare workers mask, Gown, Apron, Eye protection (goggles or face shield), Respirator (N95 or FFP2 standard), Boots/closed work shoes. 101 COVID-19 Response ESMF – ESMP Table 3 - Environmental and Social Risks and Mitigation Measures during Operational Stage Potential E&S Risks and Impacts Proposed Mitigation Measures Responsibilities Budget Improper medical waste management: HCF staff - sample collection from COVID-19 Each health facility should prepare (prior to the start of operations suspected patients, under the project) an Infection Control and Waste Management Plan - laboratory practices and procedures (ICWMP) based on the template provided in Annex IV and in (performing and handling of accordance with national regulations. specimen and chemicals), - from activities in isolation and quarantine facilities; which need to be disposed of in an appropriate medical waste disposal facility. Improper disposal of medical waste would have environmental and public health impacts: for example, open burning and incineration of medical wastes can result in emission of dioxins, furans and particulate matter, and result in unacceptable cancer risks under medium (two hours per week) or higher usage Improper procurement of Medical HCF staff Supplies and Equipment, including • Adhere to the procurement plan for acquisition of all medical intensive care equipment and supplies supplies and equipment from certified suppliers only. • Carry out due diligence for all potential suppliers to guarantee quality equipment and products. • WHO interim guidance on rational use of PPE for coronavirus disease 2019 provided further details on the types and quality of PPE that are required for different functions. The healthcare workers shall be provided with medical personal protective equipment (PPE) includes: Medical mask, Gown, Apron, Eye protection (goggles or face shield), Respirator (N95 or FFP2 standard), Boots/closed work shoes. HCF wastewater and fecal waste: • Inorganic waste should be given to the authorized vendor for HCF and District staff Isolation and quarantine facilities are free of cost for recycling; associated with increased volume of • Segregation, minimization and safe storage of potential wastewater and excreta. Liquid sources of liquid wastes. contaminated waste (e.g. pathological • Install a sewer system to collect liquid waste from around a sample, blood, feces, urine, other body facility and carry it below ground to a central location for fluids and contaminated fluid) requires treatment. special handling, as it may pose an infectious risk to healthcare workers with 102 COVID-19 Response ESMF – ESMP contact or handle the waste. There is no • Liquid waste originating from the laboratory should pass evidence to date that the COVID-19 virus through a disinfection process before directing to the general has been transmitted via sewerage sewer line. systems with or without wastewater • People with suspected or confirmed COVID-19 disease treatment. should be provided with their own flush toilet or latrine. • Where this is not possible, patients sharing the same ward should have access to toilets that are not used by patients in other wards. • Each toilet cubicle should have a door that closes, to separate it from the patient’s room. • Flush toilets should operate properly and have functioning drain traps. • When possible, the toilet should be flushed with the lid down to prevent droplet splatter and aerosol clouds. • If it is not possible to provide separate toilets for COVID-19 patients, then the toilets they share with other non-COVID- 19 patients should be cleaned and disinfected at least twice daily by a trained cleaner wearing PPE (impermeable gown, of if not available, an apron, heavy-duty gloves, boots, mask and goggles or a face shield). • Health-care staff should have toilet facilities that are separate from those used by all patients. • A disinfection step may be considered if existing wastewater treatment system is not optimized to remove viruses. • Make sure all containers, drums and tanks that are used for storage are in good condition; • Take all precautionary measures when handling and storing fuels and lubricants, avoiding environmental pollution; HCF general operational hazards: General • Health facilities should establish and apply Standard HCF staff with support operation of HCFs can involve Precautions including: from SPIU vulnerability to spread of infection o Hand Hygiene (HH); (especially during a pandemic) physical o Respiratory hygiene/cough etiquette. hazards, electrical and explosion hazards, o Use of personal protective equipment (PPE); fire, chemical use, ergonomic and o Handling of patient care equipment, and soiled radioactive hazards. linen; o Environmental cleaning; o Prevention of needle-stick/sharp injuries; o Appropriate Health Care Waste Management; • Health facilities should establish and apply Transmission based precautions (contact, droplet, and airborne 103 COVID-19 Response ESMF – ESMP precautions) as well as specific procedures for managing patients in isolation room/unit. • Establishment of Standard precautions and Transmission based precautions in line with National guidelines for IPC in healthcare facilities and take into account guidance from WHO and/or CDC on COVID19 infection control, • Collection of samples, transport of samples and testing of the clinical specimens from patients meeting the suspect case definition should be performed in accordance with WHO interim guidance Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases. • Tests should be performed in appropriately equipped laboratories (specimen handling for molecular testing requires BSL-2 or equivalent facilities) and by staff trained in the relevant technical and safety procedures. • All hospitals and laboratories should prepare waste management procedures in accordance with the national requirements that outline waste segregation procedures, on site handling, collection, transport, treatment and disposal, and training of the staff. • Health facilities shall ensure the provision of safe water, sanitation, and hygienic conditions, which is essential to protecting human health during all infectious disease outbreaks, including the COVID-19 outbreak. Health facilities shall establish and apply good practices line with WHO guidance on water, sanitation and waste management for COVID-19 and National guidelines for Infection Prevention and Control in the healthcare facilities. • Samples that are potentially infectious materials (PIM) need to be handled and stored as described in WHO document Guidance to minimize risks for facilities collecting, handling or storing materials potentially infectious for polioviruses (PIM Guidance).Organize and implement medical surveillance which includes medical service and immunization programs; • Provide health and safety training; • Adopt and implement safety manuals aligned with OSH guideline and WHO laboratory biosafety manual; WHO technical guideline for COVID-19 Key considerations for occupational safety and health • Develop and implement safety standards. 104 COVID-19 Response ESMF – ESMP • Provide cleaning staff with adequate cleaning equipment, materials and disinfectant. • Review general cleaning systems, training cleaning staff on appropriate cleaning procedures and appropriate frequency in high use or high-risk areas. • Where cleaners will be required to clean areas that have been or are suspected to have been contaminated with COVID-19, provide appropriate PPE: gowns or aprons, gloves, eye protection (masks, goggles or face screens) and boots or closed work shoes. If appropriate PPE is not available, provide best available alternatives. • Train cleaners in proper hygiene (including handwashing) prior to, during and after conducting cleaning activities; how to safely use PPE (where required); in waste control (including for used PPE and cleaning materials). Labor Issues, including management or HCF will adopt the application of the GRM as features in the HCF staff worker grievances, such as PPE COVID-19 Labor Management Plan (LMP) as elaborated in Section availability and/or use; lack of proper 7.4 as well as the WHO resources for COVID-19: occupational procedures or unreasonable overtime; health available at: https://www.who.int/news-room/detail/09-03- time-sensitivity and/or confidentiality of 2020-covid-19-occupational-health grievance. Vulnerable and/or special needs groups: The project design must include considerations for differential SPIU with HCF staff Lack of considerations in HCF operation treatment for special needs groups are incorporated in subproject for differentiated treatment for vulnerable activities based on results and recommendations from stakeholder and/or special needs groups may put the engagements according to the project SEP. elderly, people preexisting conditions, the very young, people with disabilities at higher risk of contracting COVID-19 virus. Inadequate cleaning of HCFs • Provide cleaning staff with adequate cleaning equipment, HCF staff with MoH materials and MoH approved disinfectant. support • Review general cleaning systems, training cleaning staff on appropriate cleaning procedures and appropriate frequency in high use or high-risk areas. • Where cleaners will be required to clean areas that have been or are suspected to have been contaminated with COVID- 19, provide appropriate PPE: gowns or aprons, gloves, eye protection (masks, goggles or face screens) and boots or 105 COVID-19 Response ESMF – ESMP closed work shoes. If appropriate PPE is not available, provide best available alternatives. • Train cleaners in proper hygiene (including handwashing) prior to, during and after conducting cleaning activities; how to safely use PPE (where required); in waste control (including for used PPE and cleaning materials). Refer to WHO Interim guidance for WASH waste management for the COVID-19 virus available at: https://www.who.int/publications-detail/water-sanitation- hygiene-and-waste-management-for-the-covid-19-virus- interim-guidance. Improper collection of samples, • Ensure that HCWs who collect specimens use appropriate HCF staff, District transportation of samples, improper PPE (i.e., eye protection, an N95 mask, a long-sleeved gown, authorities, MoH laboratory waste disposal in communities gloves). If the specimen is collected with an aerosol- or at emergency treatment units generating procedure, personnel should wear a particulate respirator at least as protective as a certified N95, an EU standard FFP2, or the equivalent; • Ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures; • Place specimens for transport in leak-proof specimen bags (i.e., secondary containers) that have a separate sealable pocket for the specimen (i.e., a plastic biohazard specimen bag), with the patient’s label on the specimen container (i.e., the primary container), and a clearly written laboratory request form; • Establish a quality control system for packaging, collection and transportation of laboratory samples following the WHO guidelines on laboratory biosafety guidance related to COVID-19; • Ensure the collection of samples, transport and the testing of clinical specimens from patients meeting the suspect case should be performed in accordance with WHO interim guidance on laboratory testing for coronavirus disease 2019; • Utilize incinerator for destroying Gene Expert cartridges at higher than 1,200 °C • Put in place innovative and efficient mechanisms to improve transport of COVID-19 samples to reference laboratories in the shortest time possible and following the safety precautions; • Sample transportation should not expose transporters to risk either during normal handling or in case of an accident. 106 COVID-19 Response ESMF – ESMP Risks associated with on-site healthcare For selected HCFs, and based on technical and financial feasibility: HCF staff, SPIU waste treatment and disposal: • Each HCF should develop an ICWMP according to Annex (environmental On-site healthcare waste treatment and IV. specialist) disposal involving incineration that may • Septic and other systems recommended by WBG EHS include chemicals containing Volatile guideline and by WHO Interim guidance for WASH waste Organic Compounds (VOCs) may pause management for the COVID-19 virus are duly considered health risks and pollution in HCF infection control and waste management plans. • Appropriate waste drainage systems leading to septic tank or public sewerage facilities or treatment technologies such as activated sludge and sanitary facilities will be used, if available in the local municipality. Risks associated with waste • The relevant staff should be trained on pre-hospital HCF staff, District transportation, off-site treatment and emergency care, infection prevention and control measures, disposal. Waste transportation, off-site how to handle samples in transit, healthcare waste and treatment and disposal can cause spillage management in case of an accident and provided transmission risk of COVID-19 virus. with the required PPE, There is a risk associated with traffic and • Vehicles used as ambulances or for transporting any road safety hazard during operational hazardous material and medical waste should be road phase due to use of ambulances, worthy, labelled to indicate its load and its payload secured transportation of samples to the laboratory to minimize risk of accidents and spillage, and transportation of highly infectious • The project shall well-equipped ambulances; ensure they are medical waste from facilities with no outfitted with audible back-up alarms as well as with HCW treatment and disposal facilities. effective communication system for emergency service functions and activities • Periodic community awareness on traffic awareness campaign, • Use of competent drivers with defensive driving technics, • MoH and the respective project beneficiaries (health facilities, referral laboratories) shall regularly inspect vehicle safety and maintain them accordingly, and • Ambulance drivers should follow guidance on safe emergency driving, • Vehicles used in transport of samples or healthcare waste should be easy to clean, free of sharp edges and shall be cleaned thoroughly and disinfected after use 107 COVID-19 Response ESMF – ESMP Improper clinical care, isolation of • Improve biosecurity and harmonize care protocols to avoid HCF staff, MOH suspected cases and follow-up of risk of infections of medical workers and other people; survivors • Build triage centers in referral hospitals or in health facilities The onward infection of medical workers according to the dynamics of COVID-19 pandemic; or other people due to improper clinical • Set up a management system specific to case management care, isolation of suspected cases and structures under the management of MOH (finance, follow-up of survivors would be a logistics, administration, etc.); and negative impact with long-term and • Restructure the survivors’ follow-up program by fully irreversible (if death occurred) socio- integrating it into the clinical care. economic impact will have high • In case of blood/bodily fluid exposure: significance o Persons including HCWs with percutaneous or muco- cutaneous exposure to blood, body fluids, secretions, or excretions from a patient with suspected or confirmed infectious disease, should immediately and safely stop any current tasks, and leave the patient care area. o Safely take off PPE according to the steps in the procedure, in the anteroom. o Treat affected exposed area: ▪ wash the affected skin surfaces or the percutaneous injury site with soap and water ▪ Irrigate mucous membranes (e.g. conjunctiva) with copious amounts of water or an eyewash solution, and not with chlorine solutions or other disinfectants. o Immediately report the incident to the chief of unit, IPC focal point (following hospital exposure procedure) as soon as the HCF staff exist the isolation room/ unit. o Exposed persons should be medically evaluated for: • infectious disease (ID) (of isolated patient) • other potential exposures (e.g., HIV, HCV) if sharp/needle-stick injury. o Exposed persons must receive follow-up care, including: ▪ fever monitoring, twice daily period of recording symptoms will depend on the ID ▪ Counselling and psychological support. o Immediate consultation with an expert in infectious diseases for any exposed person who develops fever, symptoms after exposure. o If fever appears and other symptoms, isolate HCF staff, and follow procedure for ID suspected until a negative diagnosis is confirmed. o Workers suspected of having infected should be cared for/isolated, and the same recommendations outlined in 108 COVID-19 Response ESMF – ESMP this document must be applied until a negative diagnosis is confirmed. o Conduct contact tracing and follow-up of family, friends, co-workers and other patients, who may have been exposed to COVID-19 virus through close contact with the infected HCW/ staff Air pollution: Incineration of hospital Selected District Hospital incinerators should be regularly inspected SPIU, District Hospitals, waste if carried out in inappropriate and monitored: Healthcare administrators should undertake regular Kalisimbi Depot facilities could result into localized visual inspection of incinerator stack for incidents of downwash and Pharmaceutics pollution of air with pollutants such as undertake annual monitoring of ambient air quality or a general ash, furans and dioxins. The Downwash environmental audit of entire healthcare facility. of incinerator emissions has potential to The project should contribute to training of incinerator operators as it degrade indoor air quality of healthcare is important for them to be familiar with basic principles and routine buildings or those of nearby offsite practices. For example, homogenization of waste is crucial to ensure buildings. The impact severity associated efficient and complete combustion during incineration to avoid with this is that the duration of onsite and generation of dioxins for instance when wet waste batches quench offsite air pollution would be long-term flames and lower combustion temperature below levels at which such lasting entire life on incineration units pollutants are destroyed. unless the deficient units are either decommissioned or improved. 109 COVID-19 Response ESMF – ESMP Aerosol and organic solvent transmission SPIU, HCF staff The HCF staff (with support from the SPIU) will ensure that due risk of COVID-19 virus: reference is made to WHO Laboratory biosafety guidance related to Improper methods of transportation and COVID-19 for proper handling and storage of infectious materials delivery of specimen (and other infectious including specimen and samples. The guide includes use standard material), samples, reagents, laboratory practice to avoid/minimize release of aerosols and organic pharmaceuticals and medical supplies as solvents to atmosphere as well as adequate ventilation in laboratories well as improper storage and handling and treatment areas and use of fume hoods if necessarily for chemical may result in aerosol and organic solvent processing. transmission risk of COVID-19 virus. Risks associated with improper use of HCF staff with support Exclusive use of disposable supplies for IPC is appropriate in highly COVID-19 equipment from SPIU infectious situations and therefore require diligent waste management procedures during screening of potential COVID-19 patients and during pre-triage. The HCF staff with support from the Environmental Specialist will ensure appropriate handling and management of generated waste, assisted by District Sanitation & Hygiene Officer (DSHOs) responsible for E&S compliance at Screening Posts (PoEs) and Centers of Quarantine, by Hospital Environmental Officers (HEOs) at hospital Isolation and Treatments Facilities and by Environmental Health Officers (EHOs) at Screening Posts (PoEs) of Health Centers or other community designated centers. Due reference will be made to the WHO interim guidance for “Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19)� available at: https://www.who.int/publications-detail/rational-use-of-personal- protective-equipment-for-coronavirus-disease-(covid-19)-and- considerations-during-severe-shortages. HCF staff Procurement of poor quality PPE may • Adhere to the procurement plan for acquisition of all exacerbate COVID-19 infection personal protective equipment from certified suppliers only. transmission to healthcare workers and • Carry out due diligence for all potential suppliers to cleaners in relation to laboratory guarantee quality supply of personal protective equipment procedures, interaction with COVID-19 and products. patients and handling of healthcare waste. • Abide by the WHO interim guidance on rational use of PPE for coronavirus disease 2019 over the types and quality of PPE required for different functions. • The healthcare workers shall be provided with medical personal protective equipment (PPE) includes: Medical mask, Gown, Apron, Eye protection (goggles or face shield), 110 COVID-19 Response ESMF – ESMP Respirator (N95 or FFP2 standard), Boots/closed work shoes and trained on use. HCF staff Occupational Safety and Health Risks: • Ensure the implementation of standard precautions and transmission based precautions in line with national • Biological hazards (blood or guidelines for IPC in healthcare facilities taking into account other body fluids with potential to guidance from WHO and/or CDC on COVID19 infection cause diseases); control, • Lack of adequate lighting in • Update and implement HCF OHS plan and/or emergency workplaces; response plan, • Lack of safe access particularly • Ensure identification of risks (Job Risk Assessment) and for disabled employees; instituting proactive measures, • Inadequate ventilation in rooms; • Train the healthcare workers on the potential OSH risks in • Lack of adequate training (or relation to COVID-19, neglect of safety precautions/ • Provision of adequate and required personal protective guidelines) in use of medical equipment (PPE) to health workers and enforce on use. This equipment; includes: single use medical mask, gown, Apron, eye • Misuse of equipment and protection, boots or closed shoes. materials for functions they are • Provision of a system for disinfection of the multi-use PPE not designed; if not available. • Lack of safety signage in specific • Implementation of systemic risk management plan areas (e.g. X-ray rooms) from comprising risk prevention, evacuation of accident victims, radioactive hazards; evaluation and improvement measures. • Electrical hazard; • Ensure availing of Material Safety Data Sheet for all • Eye hazards such as splashes in chemical use in the lab to the lab technicians. laboratories and operating rooms; • The beneficiary facilities (labs and HCF) will prepare sub- and project specific ICWMP and this will include update of the • Chemical hazards (acids, alkalis, health facility OSH plan. expired drugs, oxidizing and reactive chemicals); • Likelihood of the impact occurring is high unless control measures are instituted. Although it is a cumulative impact, the risk to human health is significant. HCF staff, District Fire risk: Without provisions for fire • Provide fire extinguishers to healthcare facilities during their safety, there is a risk of fire outbreak at renovation at strategic positions and ensure servicing is done. healthcare facilities (quarantine, isolation, • Key healthcare staff shall have basic training in fire control. laboratories) with disastrous life and • Fire emergency telephone numbers should be displayed in financial impact. Fires can start from communal areas. 111 COVID-19 Response ESMF – ESMP ignitable materials in laboratories, • Each healthcare facility shall prepare a fire emergency cigarette smoking in non-designated places management plan. or old electrical connections • Undertake regular fire drills at healthcare facility, to test on emergency response and use the results to improve on the response mechanism. • Specific site Emergency Response Plan should adequately address all potential hazards (not just fire) including but not limited to man-made (spills, accidental releases, loss of energy supply) and flood / storm. • Health facilities should establish and apply standard District, SPIU, HCF staff Weak infection prevention measures: precaution including hand hygiene, respiratory hygiene, use The absence of effective IPC and WASH of PPE, handling of patient care equipment and soiled linen, measures would curtail efforts to control environmental cleaning and prevention of needle stick and COVID-19. This reiterates the importance sharp injuries. of precautions such as avoiding handshaking, hand washing with soap and • Health facilities shall ensure provision of safe water, water and use of alcohol-based sanitizers. sanitation and hygienic conditions in line with WHO In addition, burial of COVID-19 victims guidance on water, sanitation and waste management for should be left to specialized healthcare COVID-19 and National guidelines for infection prevention teams. The impact severity in case of the and control of health facilities. absence or weak COVID-19 infection • Strengthen training activities of healthcare providers and prevention and control measures would IPC supervisors on issues related to COVID-1912 (see lead to uncontrolled spread of COVID-19, Annex VI): o ensuring triage, early recognition, and source a negative long-term and irreversible (if control (isolating patients with suspected COVID-19); o death occurred) socio-economic impact applying standard precautions for all patients; o with high significance. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of COVID-19; o implementing administrative controls; and o using environmental and engineering controls. • Implement the IPC package that includes standard operating procedures (SOPs), tools, and rapid diagnostic tests. • Strengthen the IPC / WASH support system in health facilities based on health facility assessments, training supervision with corrective actions, and the establishment of a quality assurance system in close collaboration with the independent monitoring and evaluation team. • Evaluate and implement WASH infrastructures (improvement of water and sanitation facilities) and services in health facilities. • Provide health facilities with IPC / WASH inputs (detergents) as needed and monitor their use; 112 COVID-19 Response ESMF – ESMP • Ensure the decontamination of health facilities that have received confirmed COVID-19 cases. • Ensure implementation of the IPC ring approach around each confirmed case of COVID-19. • Promote preventive medicine; no pregnant women, staff older than 65 or staff with underlying health conditions, should be working in isolation areas, provision of psychosocial support to medical staff and team and any health care workers reporting COVID-19 symptoms should stop work immediately. • Targeted procurement of only required pharmaceutical, SPIU, District, HCF staff Community health risks: impaired air equipment, and other medical supplies in small quantities; quality from burning of waste, storm water contamination or when people rummage • Ensure regular monitoring of solid, liquid waste through raw waste stockpiles. Wastewater management practices and incineration; may not seem to pose considerable • Ensure proper management of pharmaceutical waste by disposal challenge since all existing engaging a consultant to develop measures and guidelines facilities either has onsite septic systems or for each facility in accordance with the national healthcare sewage lagoons. However, this remains a waste management plan; risk in areas where there is no drainage • To ensure proper sewage management and use of latrines system. where they there is no sewer; • SPIU under MoH shall develop measures for proper Plume downwash leads to chronic management of expired pharmaceutical drugs and instigate exposure of nearby communities to potent this policy at all health care facilities; air pollutants including dioxins. Infections • Install appropriate drainage channel within the health sustained when people or children facility; rummage through improperly dumped • Facility operators should undertake regular assessment of infectious waste can be life-threatening. waste generation quantities and categories to facilitate waste management planning, and investigate opportunities for waste minimization on a continuous basis, • Separate residual chemicals from containers and remove to proper disposal containers to reduce generation of contaminated wastewater; • All waste disposal sites should be REMA licensed, secured and out of reach from the scavengers; • Select facilities with incinerator(s) that are appropriate to handle healthcare waste with specification including air pollution control option; • Ensure the healthcare waste generated in the facilities are disinfected, treated and safely disposed of; and • Community should be sensitized on infection prevention and control measures related to COVID-19. 113 COVID-19 Response ESMF – ESMP • Ensuring access to water and sanitation in schools and public Community Infection Prevention and places; Control • Ensuring decontamination of households and public places that have had confirmed COVID-19 cases; • Providing hygiene kits to households, schools and public places; • Strengthening the monitoring and evaluation system; and • Training community leaders in COVID-19 prevention WHO guidance on key questions and answers concerning water, sanitation and hygiene (WASH) is presented in Annex V. HCF should prepare an Emergency Preparedness and Response Plan HCF staff Handling emergency situations that should cover: ➢ Planning Coordination: This should include procedures for: • Informing the public and emergency response agencies • Documenting first aid and emergency medical treatment • Taking emergency response actions • Reviewing and updating the emergency response plan to reflect changes and ensuring that the employees are informed of such changes ➢ Emergency Equipment: The plan should include procedures for using, inspecting, testing, and maintaining emergency response equipment. ➢ Training: Employees should be trained in any relevant procedures ➢ Undertake regular emergency drills (fire, chemical spill) at healthcare facility, to test on emergency response and use the results to improve on the response mechanism • A Facility Maintenance Plan shall be prepared and HCF staff, SPIU Lack of sustainability implemented at each healthcare facility. • HCF shall have timely engagement with MoH to secure a budget to sustain healthcare facilities in a functional state. • Equipment’s available in the health facilities should be serviced and maintained regularly • Ensure accurate information on the disease, its spread, HCF staff, SPIU (social Stigma: impact severity in the absence or symptoms and outcomes is broadly distributed to specialist) weak psychosocial support systems would communities using channels that are accessible. impede effective prevention of stigma attached to COVID-19, a negative but • Handle all people directly affected by the disease with dignity (those in hospitals, quarantine/isolation centers and the dead). 114 COVID-19 Response ESMF – ESMP short-term and reversible impact, reducing • Strengthen psychological support for ETCs (for confirmed, or ceasing with heightened awareness suspected, and discharged cases) and assistance with hygiene kits for all discharged and cured patients. • Support affected households to anticipate management of behavioral problems, which can generate tensions and resistance in the community. Gender-based violence (GBV) and • Ensure isolation and quarantine centers are secured. HCF staff, District, SPIU sexual harassment, exploitation and • Limit admission of outsiders into the centers. (social specialist) abuse (SEA) • Monitor and report on the behavior of security guards at the There is a risk of GBV and SHEA during centers. operational phase in the management of • Ensure the people in these facilities understand the quarantine/isolation centers. If security GBV/SEA/SH referral pathways. personnel are deployed to guard • Ensure the people at the center have access to the toll free isolation/quarantine centers the risk of hotline. abuse of women and girls could be high. • All workers should sign the code of conduct to hold them There is also a risk of GBV/SHEA among accountable (see the LMP). co-workers. Inadequate public consultation and • Ensure that measures are put in place to identify and reach SPIU, HCF staff, District participation: the vulnerable community members with project information. Special efforts should be made to reach the Given the emergency nature of this deaf and blind with critical information on COVID-19. project, this process may not be • Use communication channels that are accessible to effectively done. Those at the periphery - marginal populations including use of community radios, rural populations, the urban poor and translating information in local languages. VMGs/HUTLCs may be discriminated • Identify and equip local leaders with information for against in this process. further dissemination in their communities through their local structures including community leadership, churches, mosques, clans, etc. 115 COVID-19 Response ESMF – ESMP Table 4 - Environmental and Social Risks and Mitigation Measures during Decommissioning of the subproject construction activities financed by the project 116 COVID-19 Response ESMF – ESMP Key Activities Potential E&S Risks and Proposed Mitigation Measures Responsibilities Timeline Budget Impacts Key Activities Potential E&S Risks and Proposed Mitigation Measures Responsibilities Impacts Decommissioning of interim HCF Soil Erosion Re-vegetating areas promptly MoH, HCF, District Air Quality Selectively removing potential hazardous air MoH, HCF, District pollutants, such as asbestos, from existing infrastructure prior to demolition, Dust suppression techniques should be implemented, such as applying water or non- toxic chemicals to minimize dust from vehicle movements, and PPE, such as dusk masks, should be used where dust levels are excessive. Solid Waste (scrap wood and Segregate waste at sources, HCF, District, MoH metals, and small concrete spills, Safely dispose and incinerate all office, kitchen, wastes) objects/equipment made of porous/ absorbable material (e.g. linen), Surfaces that are intact and can withstand rigorous cleaning may undergo cleaning and disinfection, Waste should be stored securely while awaiting transport to point of disposal to prevent scavenging, and Use REMA Licensed waste handler to haul away solid wastes, Hazardous solid waste includes Segregate waste at sources, HCF, District, MoH contaminated soils, oily rags, used Sharp objects and equipment that have been oil filters and infection wastes. in contact with blood or body fluids should be placed inside puncture resistant waste containers, Waste should be stored securely while awaiting transport to point of disposal to prevent scavenging, and Use REMA Licensed waste handler to haul away solid wastes, 117 COVID-19 Response ESMF – ESMP Waste water Discharges Segregation of waste water streams to HCF, District, MoH ensure compatibility with selected treatment option (e.g. septic system which can only accept domestic sewage); Meet the pretreatment and monitoring requirements of the sewer treatment system before discharges. OHS Risks Red zone cleaners should wear FULL PPE HCF, District, MoH according to WHO recommendations, All environmental surfaces (including furniture, walls, doors, etc.) or objects should be cleaned with water and a detergent and then disinfected using a 0.5% chlorine solution, Fence off to avoid unpermitted access Disinfect the working area Workers should wear appropriate PPE, which includes protective outerwear, heavy- duty gloves, boots, goggles or a face shield, and a mask; Perform hand hygiene frequently; Avoid touching their eyes, nose or mouth with unwashed hands, and Practice social distancing while working. Waste water infection Spills or waste including blood, other body HCF, District, MoH fluids, secretions or excretions should be removed, and cleaned and decontaminated, Excreta Materials A permanent septic tank or latrine that has HCF, District, MoH been used for COVID-19 facility and is less than 2/3 full should be cleaned and decontaminated with 0.5% chlorine. The pit of the septic tank should be treated with lime. 118 COVID-19 Response ESMF – ESMP Decommissioning of medical Creation of a well demarcated “clean� zone HCF, District, MoH equipment Disinfect the medical equipment Carry out process of dismantling in different areas of the facility simultaneously, No equipment or material should be abandoned on site without the approval of the relevant regulatory authorities and any affected people. Seek approval of clean site from the District, RDB and REMA. 119 COVID-19 Response ESMF – ICWMP IV. Infection Control and Waste Management Plan (ICWMP) Template 1. Introduction 1.1 Describe the project context and components 1.2 Describe the targeted healthcare facility (HCF): - Type: E.g. general hospital, clinics, inpatient/outpatient facility, medical laboratory, quarantine or isolation centers; - Special type of HCF in response to COVID-19: E.g. existing assets may be acquired to hold yet-to- confirm cases for medical observation or isolation; - Functions and requirement for the level infection control, e.g. biosafety levels; - Location and associated facilities, including access, water supply, power supply; - Capacity: beds 1.3 Describe the design requirements of the HCF, which may include specifications for general design and safety, separation of wards, heating, ventilation and air conditioning (HVAC), autoclave, and waste management facilities. 2. Infection Control and Waste Management 2.1 Overview of infection control and waste management in the HCF - Type, source and volume of healthcare waste (HCW) generated in the HCF, including solid, liquid and air emissions (if significant) - Classify and quantify the HCW (infectious waste, pathological waste, sharps, liquid and non- hazardous) following WBG EHS Guidelines for Healthcare Facilities and pertaining GIIP. - Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non-hazardous may be considered hazardous. It’s likely the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak. Special attention should be given to the identification, classification and quantification of the healthcare wastes. - Describe the healthcare waste management system in the HCF, including material delivery, waste generation, handling, disinfection and sterilization, collection, storage, transport, and disposal and treatment works - Provide a flow chart of waste streams in the HCF if available - Describe applicable performance levels and/or standards - Describe institutional arrangement, roles and responsibilities in the HCF for infection control and waste management 2.2 Management Measures - Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations. - Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of hazardous medical goods. 120 COVID-19 Response ESMF – ICWMP - Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. - Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. - Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours. - Onsite waste treatment and disposal (e.g. an incinerator): Many HCFs have their own waste incineration facilities installed onsite. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended. - Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well- performed incinerator onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government or the private sector are probably needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. - Wastewater treatment: HCF wastewater is related to hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged. In cases where municipal sewage system is not in place, HCF should build and properly operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There’re also cases where HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted. 3. Emergency Preparedness and Response Emergency incidents occurring in a HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, communities, the HCF’s operation and the environment. Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed. The key elements of an ERP are defined in ESS 4 Community Health and Safety (para. 21). 4. Institutional Arrangement and Capacity Building 121 COVID-19 Response ESMF – ICWMP A clearly defined institutional arrangement, roles and responsibilities should be included. A training plan with recurring training programs should be developed. The following aspects are recommended: - Define roles and responsibilities along each link of the chain along the cradle-to-crave infection control and waste management process; - Ensure adequate and qualified staff are in place, including those in charge of infection control and biosafety and waste management facility operation. - Stress the chief of a HCF takes overall responsibility for infection control and waste management; - Involve all relevant departments in a HCF, and build an intra-departmental team to manage, coordinate and regularly review issues and performance; - Establish an information management system to track and record the waste streams in HCF; and - Capacity building and training should involve medical workers, waste management workers and cleaners. Third-party waste management service providers should be provided with relevant training as well. 5. Monitoring and Reporting Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams. HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. The HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow. As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing systems should be in place. Externally, reporting should be conducted per government and World Bank requirements. 122 COVID-19 Response ESMF – ICWMP Table ICWMP Activities Potential E&S Issues and Proposed Mitigation Measures Responsibilities Budget Risks [TO BE COMPLETED BASED ON SPECIFIC [TO BE FILLED [ADD RISKS AS ARRANGEMENTS AS AGREED WITH THE OUT WITH NECESSARY] MOH AND SPIU] SPECIFIC ARRANGEMENTS FROM HCF, DISTRICT, MOH, etc.] General HCF operation – General wastes Use of waste receptacles that encourage segregation Environment to hold waste on site before its collection, Use of durable, long-lasting materials that will not need to be replaced often, Deploy MOH contracted waste handler to dispose of hazardous waste and have waste destruction certificate and waste transfer notes. Designate temporal waste / garbage holding areas at site. General waste in the case of handling COVID-19 patients should be treated as infectious waste - Waste water All infectious effluents should be discharged into the public sewer system or soak pits only after being pre-treated according to WHO standards / EMCA (Water Quality Regulations, 2006.) - Air emissions (dioxins, -Controlled procurement process to ensure quality furans, arsenic, lead, and efficient incinerators, cadmium, chromium, -Prohibit open burning of medical waste on site, mercury, etc. - Siting of the incinerators should be away from the Risks by direct exposure health facilities wards , residential areas and farms (inhalation) or in-direct -Ensure the incinerators used in the health facilities exposure (deposited in soil, are fitted with scrubbers to reduce on release of water, plants, etc. pollutants to be in compliance with EMCA (Air Quality regulations) 2014. Incinerator chimney installed should be of the recommended height as stipulated in the Waste Management regulations Improved operation, process monitoring and emission controls will be necessary to meet 123 COVID-19 Response ESMF – ICWMP standards for dioxins, furans and particulate matter release to the environment. General HCF operation - Physical hazards; All workers should be provided with appropriate OHS issues - Chemical use; PPE against exposure to hazards, - Ergonomic hazard; Training for all staff should be given on safe work practices /OHS and guidelines and ensure that they adhere to it, The medical facilities and equipment should be regularly maintained to correct any electrical faults, Strategic display on OHS Policy and regular review of the policy by the manager, Proper maintenance of PPE, including cleaning when dirty and replacement when damaged or worn out, Proper use of PPE should be part of the recurrent training programs for employees, Emergency eye-wash and shower facilities should be equipped with audible and visible alarms to summon aid whenever the eye-wash or shower is activated by the worker and without intervention by the worker, Ensure adequate provision of safety systems which should cover fire, electrical emergencies with First- aid areas or rooms suitably equipped and readily accessible should be available, Provision of first aid kits and first aiders trained the relevant personnel on first aid, and Materials safety data sheet for all chemicals used especially at the lab should be hanged on notice boards. Electrical and explosive All electrical repair activities should be done by hazards; competent electrician, Ensure the Biomedical department in the health facility has a qualified electrician to address the electrical faults, Prepare and implement Emergency response plan- Emergency Contacts, Periodic maintenance of electrical equipment, and 124 COVID-19 Response ESMF – ICWMP Consider safe storage of supplies and undertake precaution with respect to explosives. Fire Prepare and implement Fire emergency response plan Training of fire marshals in the facilities, Early identification of risks (Job Risk Assessment) and instituting proactive measures to avoid. Provide fire extinguishers to healthcare facilities during their renovation Ensure servicing and inspection of the firefighting equipment Fire emergency telephone numbers should be displaced in communal areas. Undertake fire drills at healthcare facility, at a minimum once quarterly. Radioactive hazard. All radioactive materials should be handled safely to prevent harm to people and environment. HCF operators should develop a comprehensive plan to control radiation exposure in consultation with the affected workforce, Radioactive waste should be stored in containers that prevent dispersion behind lead shielding. Waste that is stored during radioactive decay should be labelled with the type of radionuclide, the date and details of the required storage conditions, Radioactive hazard plan should be refined and revised as soon as practicable on the basis of assessments of actual radiation exposure conditions, and radiation control measures should be designed and implemented accordingly, and Places of work involving occupational exposure to ionizing radiation should be provided with requisite protection (PPE) in accordance with recognized international safety standards and guidelines16. 16 International Basic Safety Standard for protection against Ionizing Radiation and for the Safety of Radiation Sources and its three interrelated Safety Guides 125 COVID-19 Response ESMF – ICWMP Waste minimization, reuse - Potential increased -Procure medical supplies & equipment from and recycling generation of waste accredited suppliers preferably in small quantities, Risk in spread of COVID- -Waste generated from care of COVID-19 patient 19 should not be re-used HCF operation - Infection Possible risks of infection Provide appropriate PPE against exposure to control and waste infectious pathogens, hazardous chemicals in management plan accordance with recognized international safety Delivery and storage of - Infection to lab attendants standards and guidelines. specimen, samples, Expiry of medical supplies Orientation for all staff would be given on safe reagents, pharmaceuticals and pharmaceuticals work practices and guidelines and ensure that they and medical supplies adhere to it. Storage and handling of Infection to lab attendants Provide relevant vaccine program for all health specimen, samples, workers and supportive staffs reagents, and infectious materials Adopt or utilize WHO, CDC & NIH guidelines, standards, practice and procedures especially WHO Laboratory biosafety guidance related to coronavirus disease 2019 (COVID-19). Initial processing of all specimens should take place in a validated biological safety cabinet (BSC) or primary containment device. All technical procedures should be performed in a way that minimizes the generation of aerosols and droplets. Use of appropriate disinfectants with proven activity against enveloped viruses should be used (for example, hypochlorite [bleach], alcohol, hydrogen peroxide, quaternary ammonium compounds, and phenolic compounds). Waste segregation, Increased generation of Segregation of wastes into different categories—for packaging, color coding infectious waste due to control of quantities and disposal methods and labeling poor segregation practices Waste containers should be of the same colour as the bags and fitted with lids. Onsite collection and - Infection to the waste Ensure proper waste management practices as transport handlers recommended by the WBG EHS guidelines, WHO - Non segregation of waste Safe waste management guidelines for improvement waste management and Health care - Increased generation of waste management plan 2016-2021. infectious waste due to contamination The collection of waste would be made at least once in 24 hours, and it would be done in such a way to 126 COVID-19 Response ESMF – ICWMP minimize nuisance of smell and dust during collection and all the waste collected must be carried away from the storage site to an approved disposal point. Provide appropriate waste bins for the different types of waste generated in the laboratory to allow segregation and collection at the point of generation. Waste storage - Littering of waste Segregation of wastes into different categories for Contamination of control of quantities and disposal methods. surfaces Provision of color coded waste bins with lid, Provision of appropriate PPEs for waste handlers and incinerator operators Decontamination of surfaces Onsite waste treatment and - Pollution to environment Adopt the suggested design for the waste treatment disposal discharges of contaminated facility, if an incinerator, see section 1. Incineration waste water Waste segregation at point of origin to reduce on Emissions from the waste generated, incinerator Ensure operator of incineration unit is adequately trained to ensure efficient operation. Provide the required PPE to operators and waste handlers Periodic maintenance of the incinerator through cleaning of combustion chamber and de-clogging the air flows Routine inspection of furnace and air pollution system by the regulatory authority Have a well-established audit and reporting system on waste treatment operations Waste transportation to - Littering of wastes Offsite transportation of waste should comply with and disposal in offsite - Disposal in non-permitted the national regulations EMCA (Waste treatment and disposal waste sites Management Regulations), 2006 facilities Use of NEMA licensed Waste transporters, - Keeping record of waste transfer notes as well as waste destruction certificates at the point of disposal facility. Use the appropriate vehicle type for transportation of HCW off site 127 COVID-19 Response ESMF – ICWMP Staff should be aware of emergency procedures for dealing with accidents and incidents of spillage during transportation on public roads Due diligence should be undertaken for all the waste treated off site to ensure waste is transported through the required routes (non-busy route) and safely treated and disposed HCF operation – trans - Importation of substandard Procure medical supplies & equipment from boundary movement of medical supplies and accredited supplier specimen, samples, equipment Proper handling of equipment use, and methods of reagents, medical - Illegal importation storage from cradle to crave, equipment, and infectious - Classes of dangerous goods Cross-boundary transport of specimens of the virus materials without clear G responsible for COVID-19 should follow the United - Improper handling and Nations model regulations, Technical instructions stowage for the safe transport of dangerous goods by air (Doc 9284) of the International Civil Aviation Organization. Emergency events - Spillage, Fire & others Emergency response plan(s) for specific - emergencies, -Regular drills would constantly follow on various possible incidences. This will test the response of the involved stakeholders. Such drills will keep them alert and they will become more responsive to in the case of incidences. -Train relevant staff on response in risk management and emergency procedures in-case of accidents and spillages. - Failure of solid waste and All HCFs should prepare waste management wastewater treatment procedures in accordance with the national facilities; requirements that outline waste segregation procedures, on site handling, collection, transport, treatment and disposal, and training of the staff. - Accidental releases of Train relevant staff on response in risk management infectious or hazardous and emergency procedures in-case of accidental substances to the releases of infectious or hazardous substances, and environment; Provision of receptacles for timely response of accidental releases. - Occupational exposure to Ensure the provision of safe water, sanitation, and infectious; hygienic conditions, which is essential to protecting 128 COVID-19 Response ESMF – ICWMP human health during all infectious disease outbreaks, Health facilities shall establish and apply good practices line with WHO guidance on water, sanitation and waste management for COVID-19 and National guidelines for Infection Prevention and Control in the healthcare facilities. - Exposure to radiation; Refer to earlier section above on radiation - Medical equipment failure; Provide requisite training during equipment - installation. Carry out regular supervision, ensure only trained authorized personnel operate equipment, The manual containing information on how the medical facilities and equipment should be safely handled should be made available to the relevant staff, and Equipment’s should be sanitized and disinfected before use to minimize risks of infections. Operation of acquired - Nonuse of the equipment Ensure equipment purchased is of the required assets for holding potential due to lack of technical standard and specifications, COVID-19 patients know how Ensure good control measures in purchase of - Risk of misuse of the medical equipment, equipment Equipment’s should be disinfected before use to - Poor maintenance leading minimize risk of infections to breakdown Provide requisite training during equipment installation, The equipment’s manual should be made available to the medical workers for safe routine procedures Prepare maintenance plan for all equipment Blood Collection Storage - Unsuitable for transfusion Blood units found to be unsuitable for transfusion and delivery should be promptly removed from the blood stock, Place the blood units in a steel container with a lid or in an autoclavable polythene bag as the bags may burst while being autoclaved and cause blood to spray out, Autoclave the blood bags under a pressure 2 bar (200 kPa) at a temperature of 121°C for a minimum of 20 minutes, 129 COVID-19 Response ESMF – ICWMP Treated blood units can be disposed of by burying in a secured landfill - Injuries from sharps Disinfect infectious liquid waste (e.g. blood - Risk of infectious waste samples used for testing, infectious effluent from test procedures) by chemical treatment using at least - Exposure to harmful toxins 1% sodium hypochlorite solution. like dioxin and furans Only after 30 minutes or more of exposure to the disinfectant, may the inactivated liquid waste be discharged into drains/ sewers for safe dispersal. Handling of dead bodies in - Risk of spread of the Use full PPEs (disposable gown with long sleeves, the case of COVID-19 disease water proof apron, disposable gloves, surgical mask, eye protection, rubber gloves and boots, surgical masks to safely handle; No washing, spraying/ embalming the dead body; Register contact(s) at the HCF, Notify the HCF Director / Medical Superintendent Follow up on health status of the staff 130 COVID-19 Response ESMF – ICWMP V. Code of Conduct for Contractors and workers hired under the Rwanda COVID-19 ERP General Code of Conduct for Rwanda COVID-19 ERP to be inserted in the ESMP and/or Tender documents and Contract The Rwanda COVID-19 ERP will comply with ESS2 and ESS4 and the Environmental, Social Health and Safety Guidelines of the WB (ESHS) and the Occupational Health and Safety (OHS) and Labor regulations of Rwanda. The following is a general Code of conduct to be inserted in the contract of contractors for ERP minor civil works or other contracted activities. 1. Company Code of Conduct for Implementing ESHS and OHS Standards, Preventing Gender Based Violence and Violence against Children -------------------------------------- (company name) is committed to ensuring that the project is implemented in such a way which minimizes any negative impacts on the local environment, communities, and its workers. This shall be done by respecting the environmental, social, health and safety (ESHS) standards, and ensuring appropriate occupational health and safety (OHS) standards are met. The company is also committed to creating and maintaining an environment in which gender- based violence (GBV) and violence against children (VAC) have no place, and where they shall not be tolerated by any employee, associate, or representative of the company. Therefore, in order to ensure that all those engaged in the project are aware of this commitment, the company commits to the following core principles and minimum standards of behavior that shall apply to all company employees, associates, and representatives including sub-contractors, without exception: General 1. The company, and therefore all employees, associates, and representatives, commits to complying with all relevant national laws, rules and regulations and the World Bank Environmental and Social Standards which can read in the internet in this website: a. https://www.worldbank.org/en/projects-operations/environmental-and-social- framework 2. The contractor is responsible to comply with the requirements defined in ESMP which are integral part of the contract. 3. The company commits to full implementing its ‘Contractors Environmental and Social Management Plan’ (C-ESMP) which will be prepared based on the ESIA/ESMP prepared by the government for the works. 4. The company commits to treating women, children (persons under the age of 18), and men with respect regardless of race, colour, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. Acts of GBV and VAC are in violation of this commitment. 5. The company shall ensure that interactions with local community members are done with respect and non-discrimination. 6. Demeaning, threatening, harassing, abusive, culturally inappropriate, or sexually provocative language and behaviour are prohibited among all company employees, associates, and its representatives. 7. Respect to reasonable work instructions (including regarding environmental and social norms) 8. Protect and ensure proper use of property (for example, to prohibit theft, carelessness or waste) 9. Prohibit illegal activities by their workers such as: polluting the soil, rivers, wetlands, hunting, poaching wildlife, settigup fires, spilling diesel, oils in the soil, cutting trees without permit. 131 COVID-19 Response ESMF – ICWMP Health and Safety 10. The company shall ensure to hire professional in occupational health and safety to implement the ESMP. 11. The company shall ensure that the project’s occupational health and safety (OHS) management plan is effectively implemented, including wearing prescribed personal protective equipment, preventing avoidable accidents and reporting accidents of all type within less of 24 hours or conditions or practices in the project sites that pose a safety hazard or threaten the environment and the people. 12. The company will: a. Prohibit the use of alcohol during work activities. b. The company shall prohibit the use of illegal substances, at all times. 13. The company shall ensure that adequate eating, changing and sanitation facilities are available on site and at any worker accommodations provided by the contractor. 14. The company will obey labour, contracting and health and safety regulation in case of accidents, death and incapacity of workers (skilled or no skilled) and pay the compensation required by law. Gender Based Violence and Violence against Children 15. Acts of GBV or VAC constitute gross misconduct and are therefore grounds for sanctions, which may include penalties and/or termination of employment. All forms of GBV and VAC, including grooming are unacceptable, regardless of whether they take place on the work site, the work site surroundings, at worker’s camps or at worker’s homes. 16. In addition to company sanctions, legal prosecution of those who commit acts of GBV or VAC shall be pursued if appropriate. 17. Sexual contact or activity with children under 18—including through digital media—is prohibited. Mistaken belief regarding the age of a child is not a defence. Consent from the child is also not a defence or excuse. 18. Sexual Harassment—for instance, making unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct, of a sexual nature, including subtle acts of such behavior, is prohibited. For example: Looking somebody up and down; kissing, howling or smacking sounds; hanging around somebody; whistling and catcalls; giving personal gifts; making comments about somebody’s sex life; etc. is prohibited. 19. Sexual favours —for instance, making promises or favourable treatment dependent on sexual acts—or other forms of humiliating, degrading or exploitative behaviour are prohibited. 20. Unless there is full consent 17 by all parties involved in the sexual act, sexual interactions between the company’s employees (at any level) and members of the communities surrounding the work-place are prohibited. This includes relationships involving the withholding/promise of actual provision of benefit (monetary or non-monetary) to community members in exchange for sex—such sexual activity is considered “non-consensual� within the scope of this Code. 21. All employees, including volunteers and sub-contractors are highly encouraged to report suspected or actual acts of GBV and/or VAC by a fellow worker, whether in the same company or not. Reports must be made in accordance with GBV and VAC Allegation Procedures. 22. Managers are required to report suspected or actual acts of GBV and/or VAC as they have a responsibility to uphold company commitments and hold their direct reports responsible. 17 Consent is defined as the informed choice underlying an individual’s free and voluntary intention, acceptance or agreement to do something. No consent can be found when such acceptance or agreement is obtained through the use of threats, force or other forms of coercion, abduction, fraud, deception, or misrepresentation. In accordance with the United Nations Convention on the Rights of the Child, the World Bank considers that consent cannot be given by children under the age of 18, even in the event that national legislation of the country into which the Code of Conduct is introduced has a lower age. Mistaken belief regarding the age of the child and consent from the child is not a defense. 132 COVID-19 Response ESMF – ICWMP Implementation To ensure that the above principles are implemented effectively the company commits to ensuring that: 23. All managers sign the ‘Manager’s Code of Conduct’ detailing their responsibilities for implementing the company’s commitments and enforcing the responsibilities in the ‘Individual Code of Conduct’. 24. All employees sign the project’s ‘Individual Code of Conduct’ confirming their a greement to comply with ESHS and OHS standards, and not to engage in activities resulting in GBV or VAC. 25. Displaying the Company and Individual Codes of Conduct prominently and in clear view at workers’ camps, offices, and in in public areas of the work-place. Examples of areas include waiting, rest and lobby areas of sites, canteen areas, health clinics. 26. Ensure that posted and distributed copies of the Company and Individual Codes of Conduct are translated into the appropriate language of use in the work site areas as well as for any international staff in their native language. 27. An appropriate person is nominated as the company’s ‘Focal Point’ for addressing GBV and VAC issues, including representing the company on the GBV and VAC Compliance Team which is comprised of representatives from the client, contractor(s), the supervision consultant, and local service provider(s). 28. Ensuring that an effective GBV and VAC Action Plan is developed in consultation with the Compliance Team which includes as a minimum: a. GBV and VAC Allegation Procedure to report GBV and VAC issues through the project Grievance Redress Mechanism (GRM); b. Accountability Measures to protect confidentiality of all involved; and, c. Response Protocol applicable to GBV and VAC survivors and perpetrators. 29. That the company effectively implements the GBV and VAC Action Plan, providing feedback to the Compliance Team for improvements and updates as appropriate. 30. All employees attend an induction training course prior to commencing work on site to ensure they are familiar with the company’s commitments to ESHS and OHS standards, and the project’s GBV and VAC Codes of Conduct. 31. All employees attend a mandatory training course once a month for the duration of the contract starting from the first induction training prior to commencement of work to reinforce the understanding of the project’s ESHS and OHS standards and the GBV and VAC Code of Conduct. I do hereby acknowledge that I have read the foregoing Company Code of Conduct, and on behalf of the company agree to comply with the standards contained therein. I understand my role and responsibilities to support the project’s OHS and ESHS standards, and to prevent and respond to GBV and VAC. I understand that any action inconsistent with this Company Code of Conduct or failure to take action mandated by this Company Code of Conduct may result in disciplinary action. Company name: _________________________ Signature: _________________________ 133 COVID-19 Response ESMF – ICWMP 2. Manager’s Code of Conduct Manager’s Code of Conduct Implementing ESHS and OHS Standards and Preventing Gender Based Violence and Violence against Children Managers at all levels have a responsibility to uphold the company’s commitment to implementing the ESHS and OHS standards, and preventing and addressing GBV and VAC. This means that managers have an acute responsibility to create and maintain an environment that respects these standards and prevents GBV and VAC. Managers need to support and promote the implementation of the Company Code of Conduct. To this end, managers must adhere this Manager’s Code of Conduct and also sign the Individual Code of Conduct. This commits them to supporting the implementation of the C-ESMP and the OHS Management Plan and developing systems that facilitate the implementation of the GBV and VAC Action Plan. They need to maintain a safe workplace, as well as a GBV-free and VAC-free environment at the workplace and in the local community. These responsibilities include but are not limited to: Implementation 1. To ensure maximum effectiveness of the Company and Individual Codes of Conduct: a. Prominently displaying the Company and Individual Codes of Conduct in clear view at workers’ camps, offices, and in in public areas of the work-place. Examples of areas include waiting, rest and lobby areas of sites, canteen areas, health clinics. b. Ensuring all posted and distributed copies of the Company and Individual Codes of Conduct are translated into the appropriate language of use in the work site areas as well as for any international staff in their native language. 2. Verbally and in writing explain the Company and Individual Codes of Conduct to all staff. 3. Ensure that: a. All direct reportees sign the ‘Individual Code of Conduct’, including acknowledgment that they have read and agree with the Code of Conduct. b. Staff lists and signed copies of the Individual Code of Conduct are provided to the OHS Manager, the Compliance Team, and the client. c. Participate in training and ensure that staff also participate as outlined below. d. Put in place a mechanism for staff to: i. report concerns on ESHS or OHS compliance; and, ii. confidentially report GBV or VAC incidents to the Grievance Redress Mechanism (GRM) e. Staff are encouraged to report suspected or actual ESHS, OHS, GBV or VAC issues, emphasizing the staff’s responsibility to the Company and the country hosting their employment, and emphasizing the respect for confidentiality. 4. In compliance with applicable laws and to the best of your abilities, prevent perpetrators of sexual exploitation and abuse from being hired, re-hired or deployed. Use background and criminal reference checks for all employees. 5. Ensure that when engaging in partnership, sub-contractor or similar agreements, these agreements: a. Incorporate the ESHS, OHS, GBV and VAC Codes of Conduct as an attachment. b. Include the appropriate language requiring such contracting entities and individuals, and their employees and volunteers, to comply with the Individual Codes of Conduct. c. expressly state that the failure of those entities or individuals, as appropriate, to ensure compliance with the ESHS and OHS standards, take preventive measures against GBV and VAC, to investigate allegations thereof, or to take corrective actions when GBV or VAC has occurred, shall constitute grounds for sanctions and penalties in accordance with the Individual Codes of Conduct. 134 COVID-19 Response ESMF – ICWMP 6. Provide support and resources to the Compliance Team to create and disseminate internal sensitization initiatives through the awareness-raising strategy under the GBV and VAC Action Plan. 7. Ensure that any GBV or VAC issue warranting police action is reported to the client and the World Bank immediately. 8. Ensure that any major ESHS or OHS incidents are reported to the client and the supervision engineer immediately. Training 9. The managers are responsible to: a. Ensure that the OHS Management Plan is implemented, with suitable training required for all staff, including sub-contractors and suppliers; and, b. Ensure that staff have a suitable understanding of the C-ESMP and are trained as appropriate to implement the C-ESMP requirements. 10. All managers are required to attend an induction manager training course prior to commencing work on site to ensure that they are familiar with their roles and responsibilities in upholding the GBV and VAC elements of these Codes of Conduct. This training shall be separate from the induction training course required of all employees and shall provide managers with the necessary understanding and technical support needed to begin to develop the GBV and VAC Action Plan for addressing GBV and VAC issues. 11. Managers are required to attend and assist with the project facilitated monthly training courses for all employees. Managers shall be required to introduce the trainings and announce the self- evaluations, including collecting satisfaction surveys to evaluate training experiences and provide advice on improving the effectiveness of training. 12. Ensure that time is provided during work hours and that staff prior to commencing work on site attend the mandatory project facilitated induction training on: a. OHS and ESHS; and, b. GBV and VAC required of all employees. 13. During civil works, ensure that staff attend ongoing OHS and ESHS training, as well as the monthly mandatory refresher training course required of all employees to combat increased risk of GBV and VAC. Response 14. Managers shall be required to take appropriate actions to address any ESHS or OHS incidents. 15. With regard to GBV and VAC: a. Provide input to the GBV and VAC Allegation Procedures and Response Protocol developed by the Compliance Team as part of the final cleared GBV and VAC Action Plan. b. Once adopted by the Company, managers shall uphold the Accountability Measures set forth in the GBV and VAC Action Plan to maintain the confidentiality of all employees who report or (allegedly) perpetrate incidences of GBV and VAC (unless a breach of confidentiality is required to protect persons or property from serious harm or where required by law). c. If a manager develops concerns or suspicions regarding any form of GBV or VAC by one of his/her direct reportees, or by an employee working for another contractor on the same work site, s/he is required to report the case using the GRM. d. Once a sanction has been determined, the relevant manager(s) is/are expected to be personally responsible for ensuring that the measure is effectively enforced, within a maximum timeframe of 14 days from the date on which the decision to sanction was made 135 COVID-19 Response ESMF – ICWMP e. If a Manager has a conflict of interest due to personal or familial relationships with the survivor and/or perpetrator, he/she must notify the respective company and the Compliance Team. The Company shall be required to appoint another manager without a conflict of interest to respond to complaints. 16. Managers failing to address ESHS or OHS incidents or failing to report or comply with the GBV and VAC provisions may be subject to disciplinary measures, to be determined and enacted by the company’s CEO, Managing Director or equivalent highest-ranking manager. Those measures may include: f. Informal warning. g. Formal warning. h. Additional Training. i. Loss of up to one week's salary. j. Suspension of employment (without payment of salary), for a minimum period of 1 month up to a maximum of 6 months. k. Termination of employment. 17. Ultimately, failure to effectively respond to ESHS, OHS GBV and VAC cases on the work site by the company’s managers or CEO may provide grounds for legal actions by authorities. I do hereby acknowledge that I have read the foregoing Manager’s Code of Conduct, do agree to comply with the standards contained therein and understand my roles and responsibilities to prevent and respond to ESHS, OHS GBV and VAC requirements. I understand that any action inconsistent with this Manager’s Code of Conduct or failure to take action mandated by this Manager’s Code of Conduct may result in disciplinary action. Signature: _________________________ Printed Name: _________________________ Title: _________________________ 136 COVID-19 Response ESMF – ICWMP 3. Code of Conduct to be signed by individual workers (skilled and unskilled, casual or non- casual) for Preventing Gender Based Violence (GBV) and Violence against Children (VAC) I, ______________________________, acknowledge that adhering to environmental, social health and safety (ESHS) standards, following the project’s occupational health and safety (OHS) requirements, and preventing gender-based violence (GBV) and violence against children (VAC) is important. All forms of GBV or VAC are unacceptable, be it on the work site, the work site surroundings, at worker’s camps, or the surrounding communities. The company considers that failure to follow ESHS and OHS standards, or to partake in GBV or VAC activities, constitute acts of gross misconduct and are therefore grounds for sanctions, penalties or potential termination of employment. Prosecution of those who commit GBV or VAC may be pursued if appropriate. I agree that while working on the project I will: • Attend and actively partake in training courses related to ESHS, OHS, HIV/AIDS, GBV and VAC as requested by my employer. • Shall wear my personal protective equipment (PPE), in the correct prescribed manner, at all times when at the work site or engaged in project related activities. • Take all practical steps to implement the contractor’s environmental and social management plan (CESMP). • Implement the OHS Management Plan. • Adhere to a zero-alcohol policy during work activities, and refrain from the use of illegal substances at all times. • Consent to a police background check. • Treat women, children (persons under the age of 18), and men with respect regardless of race, color, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. • Not use language or behavior towards women, children or men that is inappropriate, harassing, abusive, sexually provocative, demeaning or culturally inappropriate. • Not participate in sexual contact or activity with children—including grooming or contact through digital media. Mistaken belief regarding the age of a child is not a defense. Consent from the child is also not a defense or excuse. • Not engage in sexual harassment—for instance, making unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct, of a sexual nature, including subtle acts of such behavior. Ex. Looking somebody up and down; kissing, howling or smacking sounds; hanging around somebody; whistling and catcalls; giving personal gifts; making comments about somebody’s sex life; etc. • Not engage in sexual favors—for instance, making promises or favorable treatment dependent on sexual acts—or other forms of humiliating, degrading or exploitative behavior. • Unless there is the full consent18 by all parties involved, I shall not have sexual interactions with members of the surrounding communities. This includes relationships involving the withholding or promise of actual provision of benefit (monetary or non-monetary) to 18Consent is defined as the informed choice underlying an individual’s free and voluntary intention, acceptance or agreement to do some thing. No consent can be found when such acceptance or agreement is obtained through the use of threats, force or other forms of coercion, abduction, fraud, deception, or misrepresentation. In accordance with the United Nations Convention on the Rights of the Child, the World Bank considers that consent cannot be given by children under the age of 18, even in the event that national legislation of the country into which the Code of Conduct is introduced has a lower age. Mistaken belief regarding the age of the child and consent from the child is not a defense. 137 COVID-19 Response ESMF – ICWMP community members in exchange for sex—such sexual activity is considered “non- consensual� within the scope of this Code. • Consider reporting through the GRM (Grievance Redress Mechanism) or to my manager any suspected or actual GBV or VAC by a fellow worker, whether employed by my employer or not, or any breaches of this Code of Conduct. With regard to children under the age of 18: • Wherever possible, ensure that another adult is present when working in the proximity of children. • Not invite unaccompanied children unrelated to my family into my home, unless they are at immediate risk of injury or in physical danger. • Not sleep close to unsupervised children unless absolutely necessary, in which case I must obtain my supervisor's permission, and ensure that another adult is present if possible. • Use any computers, mobile phones, or video and digital cameras appropriately, and never to exploit or harass children or to access child pornography through any medium (see also “Use of children's images for work related purposes� below). • Refrain from physical punishment or discipline of children. • Refrain from hiring children for domestic or other labor which is inappropriate given their age or developmental stage, which interferes with their time available for education and recreational activities, or which places them at significant risk of injury. • Comply with all relevant local legislation, including labor laws in relation to child labor. Use of children's images for work related purposes When photographing or filming a child for work related purposes, I must: • Before photographing or filming a child, assess and endeavor to comply with local traditions or restrictions for reproducing personal images. • Before photographing or filming a child, obtain informed consent from the child and a parent or guardian of the child. As part of this I must explain how the photograph or film shall be used. • Ensure photographs, films, videos and DVDs present children in a dignified and respectful manner and not in a vulnerable or submissive manner. Children should be adequately clothed and not in poses that could be seen as sexually suggestive. • Ensure images are honest representations of the context and the facts. • Ensure file labels do not reveal identifying information about a child when sending images electronically. Sanctions I understand that if I breach this Individual Code of Conduct, my employer shall take disciplinary action which could include: • Informal warning. • Formal warning. • Additional Training. • Loss of up to one week’s salary. • Suspension of employment (without payment of salary), for a minimum period of 1 month up to a maximum of 6 months. • Termination of employment. • Report to the police if wanted. 138 COVID-19 Response ESMF – ICWMP I understand that it is my responsibility to ensure that the environmental, social, health and safety standards are met. That I shall adhere to the occupational health and safety management plan. That I shall avoid actions or behaviors that could be construed as GBV or VAC. Any such actions shall be a breach this Individual Code of Conduct. I do hereby acknowledge that I have read the foregoing Individual Code of Conduct, do agree to comply with the standards contained therein and understand my roles and responsibilities to prevent and respond to ESHS, OHS, GBV and VAC issues. I understand that any action inconsistent with this Individual Code of Conduct or failure to take action mandated by this Individual Code of Conduct may result in disciplinary action and may affect my ongoing employment. Signature: _________________________ Printed Name: _________________________ Title: _________________________ Date: _________________________ Contractor____________________ Supervisor____________________ Date______________________ 139 COVID-19 Response ESMF – ICWMP VI. Resource List: COVID-19 Guidance Given the COVID-19 situation is rapidly evolving, a version of this resource list will be regularly updated and made available on the World Bank COVID-19 operations intranet page (http://covidoperations/). WHO Guidance Advice for the public • WHO advice for the public, including on social distancing, respiratory hygiene, self-quarantine, and seeking medical advice, can be consulted on this WHO website: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public Technical guidance • Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, issued on March 19, 2020 • Recommendations to Member States to Improve Hygiene Practices, issued on April 1, 2020 • Severe Acute Respiratory Infections Treatment Center, issued on March 28, 2020 • Infection prevention and control at health care facilities (with a focus on settings with limited resources), issued in 2018 • Laboratory biosafety guidance related to coronavirus disease 2019 (COVID-19), issued on March 18, 2020 • Laboratory Biosafety Manual, 3rd edition, issued in 2014 • Laboratory testing for COVID-19, including specimen collection and shipment, issued on March 19, 2020 • Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios, issued on March 21, 2020 • Infection Prevention and Control for the safe management of a dead body in the context of COVID-19, issued on March 24, 2020 • Key considerations for repatriation and quarantine of travelers in relation to the outbreak COVID-19, issued on February 11, 2020 • Preparedness, prevention and control of COVID-19 for refugees and migrants in non-camp settings, issued on April 17, 2020 • Water, sanitation, hygiene, and waste management for the COVID-19 virus: interim guidance, issued on April 23, 2020 • Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health, issued on March 18, 2020 • Oxygen sources and distribution for COVID-19 treatment centers, issued on April 4, 2020 • Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response, issued on March 16, 2020 • Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19), issued on March 19, 2020 • Operational considerations for case management of COVID-19 in health facility and community, issued on March 19, 2020 • Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19), issued on February 27, 2020 • Getting your workplace ready for COVID-19, issued on March 19, 2020 • Safe management of wastes from health-care activities, issued in 2014 140 COVID-19 Response ESMF – ICWMP • Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak, issued on March 19, 2020 • Disability Considerations during the COVID-19 outbreak, issued on March 26, 2020 WORLD BANK GROUP GUIDANCE • Technical Note: Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints on conducting public meetings, issued on March 20, 2020 • Technical Note: Use of Military Forces to Assist in COVID-19 Operations, issued on March 25, 2020 • ESF/Safeguards Interim Note: COVID-19 Considerations in Construction/Civil Works Projects, issued on April 7, 2020 • Technical Note on SEA/H for HNP COVID Response Operations, issued in March 2020 • Interim Advice for IFC Clients on Preventing and Managing Health Risks of COVID-19 in the Workplace, issued on April 6, 2020 • Interim Advice for IFC Clients on Supporting Workers in the Context of COVID-19, issued on April 6, 2020 • IFC Tip Sheet for Company Leadership on Crisis Response: Facing the COVID-19 Pandemic, issued on April 6, 2020 • WBG EHS Guidelines for Healthcare Facilities, issued on April 30, 2007 ILO GUIDANCE • ILO Standards and COVID-19 FAQ, issued on March 23, 2020 (provides a compilation of answers to most frequently asked questions related to international labor standards and COVID-19) MFI GUIDANCE • ADB Managing Infectious Medical Waste during the COVID-19 Pandemic • IDB Invest Guidance for Infrastructure Projects on COVID-19: A Rapid Risk Profile and Decision Framework • KfW DEG COVID-19 Guidance for employers, issued on March 31, 2020 • CDC Group COVID-19 Guidance for Employers, issued on March 23, 2020 141 COVID-19 Response ESMF – ICWMP VII. Chance find procedure 1. Purpose of the chance find procedure The chance find procedure is a project-specific procedure that outlines actions required if previously unknown heritage resources, particularly archaeological resources, are encountered during project design, construction or operation. A Chance Find Procedure, as described in World Bank ESS 8, is a process that prevents chance finds from being disturbed until an assessment by a competent specialist is made and actions consistent with the requirements are implemented. 2. Responsibility The SPIU responsible for implantation of ERP is responsible for siting and designing the project to avoid significant damage to cultural heritage. When the proposed location of a project is in areas where cultural heritage is expected to be found, either during construction or operations, the client will implement chance find procedures established through the Environmental and Social Assessment. The client will not disturb any chance finds further until an Assessment by a competent specialist is made and actions consistent with the requirements of this Performance Standard are identified. 3. Scope of the chance find procedure This procedure will be applicable to all activities conducted by the personnel, including contractors at the sub-project level that have the potential to uncover a heritage item/site. The procedure details the actions to be taken when a previously unidentified and potential heritage item/site is found during construction activities. Procedure outlines the roles and responsibilities and the response times required from both project staff, and any relevant heritage authority. 4. Induction/Training All personnel, especially those working on earth movements and excavations, are to be inducted on the identification of potential heritage items/sites and the relevant actions for them with regards to this procedure during the Project induction and regular toolbox talks. 5. Chance find procedure If any person/worker under COVID-19 ERP discovers a physical cultural resource, such as (but not limited to) archaeological sites, historical sites, remains and objects, or a cemetery and/or individual graves during excavation or construction, the following steps shall be taken: 1) Stop all works in the vicinity of the find, until a solution is found for the preservation of these artefacts, or advice from the relevant authorities is obtained especially the Institute of National Museums of Rwanda (INMR); 2) Immediately notify the foreman. The foreman will then notify the Site engineer and the Environment Officer of the contractor; 3) Record details in Incident Report and take photos of the find; 4) Delineate the discovered site or area; secure the site to prevent any damage or loss of removable objects. In cases of removable antiquities or sensitive remains, a night guard shall be arranged until the responsible local authorities take over; 142 COVID-19 Response ESMF – ICWMP 5) Preliminary evaluation of the findings by archaeologists. The archaeologist must make a rapid assessment of the site or find to determine its importance. Based on this assessment the appropriate strategy can be implemented. The significance and importance of the findings should be assessed according to the various criteria relevant to cultural heritage such as aesthetic, historic, scientific or research, social and economic values of the find; 6) Sites of minor significance (such as isolated or unclear features, and isolated finds) should be recorded immediately by the archaeologist, thus causing a minimum disruption to the work schedule of the Contractor. The results of all archaeological work must be reported to the INMR, once completed. 7) In case of significant find the INMR, will be informed immediately and in writing within 7 days from the find, 8) The onsite archaeologist provides INMR with photos, other information as relevant for identification and assessment of the significance of heritage items. 9) The INMR will investigate the fact and provide response in writing. 10) Decisions on how to handle the finding shall be taken by the responsible authorities which is INMR . This could include changes in the layout (such as when finding an irremovable remain of cultural or archaeological importance) conservation, preservation, restoration and salvage; 11) Construction works could resume only after permission is granted from the responsible authorities. 12) In case no response received, this will be considered as authorization to proceed with suspended construction works. One of the main requirements of the procedure is record keeping. All finds must be registered. Photolog, copies of communication with decision making authorities, conclusions and recommendations/guidance, implementation reports are kept. 6. Additional information Management options for archaeological site • Site avoidance. If the boundaries of the site have been delineated attempt must be made to redesign the proposed development to avoid the site. (The fastest and most cost-effective management option); • Mitigation. If it is not feasible to avoid the site through redesign, it will be necessary to sample it using data collection program prior to its loss. This could include surface collection and/or excavation. (The most expensive and time-consuming management option.) • Site Protection. It may be possible to protect the site through the installation of barriers during the time of the development and/or possibly for a longer term. This could include the erection of high visibility fencing around the site or covering the site area with a geotextile and then capping it with fill. The exact prescription would be site- specific. 7. Management of replicable and non-replicable heritage Different approaches for the finds apply to replicable and non-replicable heritage. Replicable heritage Where tangible cultural heritage that is replicable (Replicable cultural heritage is defined as tangible forms of cultural heritage that can themselves be moved to another location or that can be replaced by a similar structure or natural features to which the cultural values can be transferred by appropriate measures. Archaeological or historical sites may be considered replicable where the particular eras and 143 COVID-19 Response ESMF – ICWMP cultural values they represent are well represented by other sites and/or structures and not critical is encountered, mitigation measures will be applied. The mitigation hierarchy is as follows: i. Avoidance; ii. Minimization of adverse impacts and implementation of restoration measures, in situ; iii. Restoration of the functionality of the cultural heritage, in a different location; Permanent removal of historical and archaeological artefacts and structures; iv. Compensation of loss - where minimization of adverse impacts and restoration not feasible. Non-replicable heritage Most cultural heritage is best protected by in situ preservation, since removal is likely to result in irreparable damage or even destruction of the cultural heritage. Nonreplicable cultural heritage (Nonreplicable cultural heritage may relate to the social, economic, cultural, environmental, and climatic conditions of past peoples, their evolving ecologies, adaptive strategies, and early forms of environmental management, where the (i) cultural heritage is unique or relatively unique for the period it represents, or (ii) cultural heritage is unique or relatively unique in linking several periods in the same site. Examples of non-replicable cultural heritage may include an ancient city or temple, or a site unique in the period that it represents.) must not be removed unless all of the following conditions are met: i. There are no technically or financially feasible alternatives to removal; ii. The overall benefits of the project conclusively outweigh the anticipated cultural heritage loss from removal; and Any removal of cultural heritage must be conducted using the best available technique advised by relevant authority and supervised by archaeologist. Human Remains Management Options The handling of human remains believed to be archaeological in nature requires communication according to the same procedure described above. There are two possible courses of action: i. Avoid. The development project is redesigned to completely avoid the found remains. An assessment should be made as to whether the remains may be affected by residual or accumulative impacts associated with the development, and properly addressed by a comprehensive management plan. ii. Exhume. Exhumation of the remains in a manner considered appropriate by decision makers. This will involve the predetermination of a site suitable for the reburial of the remains. Certain ceremonies or procedures may need to be followed before development activities can recommence in the area of the discovery. Emergency Contacts Institute of National Museums of Rwanda (INMR) Adresse: KN 90 St2, Kigali Téléphone : 0730 741 09 Email: info@museum.gov.rw ` Website: www.museum.gov.rw 144 COVID-19 Response ESMF – ICWMP VIII. VC Stakeholder Consultation Oct 16 2020 – Chat registration record Kanyamarere Leonard from Munini DH from user to everyone: 10:13 AM Dr DUFATANYE Erhard,Clinical director MUNINI DH from Mujawayezu Odette to everyone: 10:37 AM Amajwi ntabwo yumvikana from Rutarindwa Alphonse to everyone: 10:46 AM gasabo abitabiriye: from RUSIMBUKAYEJO to everyone: 10:46 AM amajwi ameze nabi pe from Mwumvaneza MUTAGOMA to everyone: 10:47 AM Component 4, handitswe ko ari cost zero. from Mwumvaneza MUTAGOMA to everyone: 10:47 AM Is it possible? from Rutarindwa Alphonse to everyone: 10:48 AM Dir. of health .environmental health officer( district) . hygiene &sanitation officer (District).Epidemiological surveillance officer (DH). from anzakizwanayo to everyone: 10:48 AM Ruhango abitabiriye: Francoise NZAKIZWANAYO;EHO Ruhango provincial hospital. NKURIKIYIMANA Edmond ,DAF Ruhango provincial hospital. from Ntakirutimana Zacharie to everyone: 10:48 AM Ese muri waste management uyu mushinga uzaha ibitaro incinerator from Rutarindwa Alphonse to everyone: 10:49 AM Gasabo :Dir. of health .environmental health officer( district) . hygiene &sanitation officer (District).Epidemiological surveillance officer (DH). from Dr Issa Ngabonziza to everyone: 10:49 AM Dr Issa Ngabonziza DG Gatunda DH from Rutagengwa William to everyone: 10:50 AM Bugesera: Dr William Rutagengwa DG Nyamata Hospital from user to everyone: 10:12 AM Kanyamarere Leonard from Munini DH from user to everyone: 10:13 AM Dr DUFATANYE Erhard,Clinical director MUNINI DH from Mujawayezu Odette to everyone: 10:37 AM Amajwi ntabwo yumvikana from Rutarindwa Alphonse to everyone: 10:46 AM gasabo abitabiriye: from RUSIMBUKAYEJO to everyone: 10:46 AM amajwi ameze nabi pe from Mwumvaneza MUTAGOMA to everyone: 10:47 AM Component 4, handitswe ko ari cost zero. from Mwumvaneza MUTAGOMA to everyone: 10:47 AM Is it possible? from Rutarindwa Alphonse to everyone: 10:48 AM Dir. of health .environmental health officer( district) . hygiene &sanitation officer (District).Epidemiological surveillance officer (DH). from anzakizwanayo to everyone: 10:48 AM Ruhango abitabiriye: Francoise NZAKIZWANAYO;EHO Ruhango provincial hospital. NKURIKIYIMANA Edmond ,DAF Ruhango provincial hospital. 145 COVID-19 Response ESMF – ICWMP from Ntakirutimana Zacharie to everyone: 10:48 AM Ese muri waste management uyu mushinga uzaha ibitaro incinerator from Rutarindwa Alphonse to everyone: 10:49 AM Gasabo :Dir. of health .environmental health officer( district) . hygiene &sanitation officer (District).Epidemiological surveillance officer (DH). from Dr Issa Ngabonziza to everyone: 10:49 AM Dr Issa Ngabonziza DG Gatunda DH from Rutagengwa William to everyone: 10:50 AM Bugesera: Dr William Rutagengwa DG Nyamata Hospital from Director Health Unit to everyone: 10:50 AM NDAYISABYE Viateur, Director of Health Unit/ Bugesera District. from Niringiyimana Eugene to everyone: 10:50 AM Dr Eugene NIRINGIYIMANA - DG Hopital Murunda / Rutsiro District from UWIZEYE PROTOGENE to everyone: 10:50 AM UWIZEYE PROTOGENE ENVIRONMENTAL HEALTH OFFICER KIBILIZI DH GISAGARA DISTRICT from Rutarindwa Alphonse to everyone: 10:50 AM Gasabo amazina yabitabiriye: from irankunda Innocent to everyone: 10:51 AM Irankunda Innocent,EHO of Butaro,Burera district. from user to everyone: 10:51 AM Karemera Athanase Dir of Health Nyaruguru from John Bosco NDUWAMUNGU to everyone: 10:52 AM nitwa Bosco shinzwe Isuku Kicukiro ku Karere mwazatekereza no kuri waste zizava muri community ijyanye na Covid 19 mubya home based care from Rutarindwa Alphonse to everyone: 10:52 AM Gasabo amazina yabitabiriye:ALPHONSE RUTARINDWA.Umwngirije Oswald. Dr.karemera M.Clairere. Tuyizere Vivine from RUSIMBUKAYEJO to everyone: 10:54 AM MUHANGA DISTRICT Attendance:RUSIMBUKAYEJO J.Baptiste ,KAYITESI Antoinette,KAYONGA Donathi,UMUTONIWASE KAMANA Sosthene from Ntakirutimana Zacharie to everyone: 10:54 AM Nitwa Ntakirutimana Zacharie EHO Mibilizi DH mwatekereza no kubitaro bidafite modern incinerator muri waste management from user to everyone: 10:57 AM Presentantion muziduhe from RUSIMBUKAYEJO to everyone: 10:57 AM Thanks. ari izo presentations turazikeneye from user to everyone: 10:57 AM erhardufatanye@gmail.com from Mbayire Vedaste to everyone: 10:57 AM mbavedi@gmail.com from Adrien KUBWIMANA to everyone: 10:57 AM kubwadrien@gmail.com from irankunda Innocent to everyone: 10:58 AM irinnocent2@gmail.com from user to everyone: 10:58 AM kanyamixleo@yahoo.fr from RUSIMBUKAYEJO to everyone: 10:58 AM my email:kayitesiantoine12@gmail.com from John Bosco NDUWAMUNGU to everyone: 10:58 AM 146 COVID-19 Response ESMF – ICWMP Kicukiro email:jbosco.nduwamungu@kicukiro.gov.rw, nduwabosco@gmail.com from Dr Placide NSHIZIRUNGU to everyone: 10:58 AM Nanjye muze kunyoherereza izo PPT presentations kuri pnshizirungu@gmail.com from kabera to everyone: 10:59 AM Nyanza District: from kabera to everyone: 10:59 AM Kabera clement diector of health from kabera to everyone: 10:59 AM Ndayisabye Daniel Saho from UWAMARIYA Jeannette to everyone: 11:01 AM my email: uwamariyajanet@yahoo.com from Dr NZARAMBA Theoneste to everyone: 11:01 AM Dr nzaramba Theoneste,DG of mibilizi DH, email; nzarambat@gmail.com from alphage2000 to everyone: 11:02 AM alphage2000@yahoo.fr from alphage2000 to everyone: 11:02 AM Nyamasheke District team: from alphage2000 to everyone: 11:03 AM Hagengimana Alfred director of health, Nyirabambanza Clementine Hygiene and sanitation officer (Nyamasheke District) 147 COVID-19 Response ESMF – ICWMP IX. DHSOs/EHOs/C-EHOs Consultation Oct 12-15, 2020 Names of Officer HCF Function 1 Mfitumugisha Emmanuel Mudende HC Community Environmental Health Officer 2 Twizerimana Audace Biruyi HC Community Environmental Health Officer 3 Nikuze Justine Kinunu HC Community Environmental Health Officer 4 Mukamana Gervasie Murunda HC Community Environmental Health Officer 5 Uwingabiye Chrlotte Cyimbiri HC Community Environmental Health Officer 6 Ufitinema Emertha Karumbi HC Community Environmental Health Officer 7 Musabyimana Xaverne Kabona HC Community Environmental Health Officer 8 Nizeyimana Bahizi Emmanuel Mukura HC Community Environmental Health Officer 9 Sinibagiwe Adrien Kivumu HC Community Environmental Health Officer 10 Mukaneretse Alphonsine Musasa HC Community Environmental Health Officer 11 Nsengiyumva Gregoire Nyabirasi HC Community Environmental Health Officer 12 Sebazungu Jonathan Bitenga HC Community Environmental Health Officer 13 Uwamahoro Eugene Sigenyi DH Environmental Health Officer 14 Rudahusha Dieu Donnee Nyakiriba HC Community Environmental Health Officer 15 Nyirasafari Gaudence Kigufi HC Community Environmental Health Officer 16 Kayitare Jean Paul Gacuba HC Community Environmental Health Officer 17 Ntacyarutimana Thomas Busigari HC Community Environmental Health Officer 18 Karinganire JMV Bugeshi HC Community Environmental Health Officer 19 Uwayisabye Veneranda Murara hc Community Environmental Health Officer 20 Kabatesi Christine Karambo HC Community Environmental Health Officer 21 Masengesho Irenee Nyundo HC Community Environmental Health Officer 22 Harindintwari F Xavier Congonil HC Community Environmental Health Officer 23 Bagiyumugambi Joseph Mushubati HC Community Environmental Health Officer 24 Nkinzehiki Emmanuel Kibingo HC Community Environmental Health Officer 25 Mugarura Gabriel Kabari CH Community Environmental Health Officer 26 Nsekerabanzi Jackson Busasamana HC Community Environmental Health Officer 27 Kariwabo Felicien Passy Gisenyi HC Community Environmental Health Officer 28 Bizimungu Alain Byahi HC Environmental Health Officer 29 Sibomana Jean de Dieu Rutsiro HC Community Environmental Health Officer 30 Mutabazi Francois Kinihira HC Environmental Health Officer 31 Kwineza Esperance Kayove HC Community Environmental Health Officer 148 COVID-19 Response ESMF – ICWMP 149 COVID-19 Response ESMF – ICWMP Photo Gallery Consultation/training of DHSOs, EHOs and C-EHOs 12-15 Oct 2020 150