The World Bank AF Djibouti COVID-19 Response (P174675) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 27-Oct-2020 | Report No: PIDA30719 Oct 27, 2020 Page 1 of 7 The World Bank AF Djibouti COVID-19 Response (P174675) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Djibouti P174675 AF Djibouti COVID-19 P173807 Response Parent Project Name Region Estimated Appraisal Date Estimated Board Date Djibouti COVID-19 Response MIDDLE EAST AND NORTH 28-Oct-2020 11-Nov-2020 AFRICA Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project The Republic of Djibouti Ministry of Health Financing Proposed Development Objective(s) Parent To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Components Emergency COVID-19 Response Strengthening Overall Healthcare Services and Clinical Capacity for Emergency COVID-19 Response Implementation Management and Monitoring and Evaluation Contingent Emergency Response Component Contingency (5%) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 0.94 Total Financing 0.94 of which IBRD/IDA 0.00 Financing Gap 0.00 DETAILS -NewFinEnh1 Non-World Bank Group Financing Trust Funds 0.94 Oct 27, 2020 Page 2 of 7 The World Bank AF Djibouti COVID-19 Response (P174675) Pandemic Emergency Financing Facility 0.94 Environmental and Social Risk Classification Substantial Other Decision (as needed) B. Introduction and Context Country Context 1. Djibouti is a lower middle-income country with a mostly urban population of about 1 million that has experienced an average annual real Gross Domestic Product (GDP) increase of 4.4% in per capita terms in the last two decades. Despite the strong economic growth, health service delivery has been challenged by the substantial size of vulnerable populations. Close to 21% of the population live in extreme poverty (EDAM 2017). The densely populated district of Balballa in Djibouti city alone accounts for 32% of the poor in the country, while extreme poverty averages 45% in remote areas of the country. The large influx of refugees and the protracted humanitarian crisis in the region have further strained an already fragile health system in Djibouti. Sectoral and Institutional Context 2. Although health outcomes in Djibouti have improved in recent years, the acute stress of COVID-19 complicates chronic health challenges like shortages of qualified health care workers, drugs, and equipment, disparities in access to healthcare services, and low quality of care. To address the chronic needs, the Government of Djibouti (GoD) has recently launched the National Health Development Plan for 2020-2024 that focuses on four strategic priorities: (i) expanding quality care in all regions; (ii) reducing regional disparities; (iii) strengthening health financing and the Health Management Information System (HMIS); and (iv) reducing the prevalence of diseases. After WHO declared COVID-19 as a Public Health Emergency of International Concern (PHEIC) on January 30, 2020, the government immediately prepared the Djibouti COVID-19 Preparedness and Response Plan with support from WHO and close involvement of development partners (DPs). 3. The COVID-19 situation in Djibouti is dynamic. As of October 26, 2020, there were 5,536 cumulative cases, and a case fatality rate of 1.1% (Figure 1). Currently, there are about a few to 30 new (incident) cases per day (an incidence in early September of 0.12 new cases per 10,000 population), which is an improvement from late May and early June when daily new cases numbered around 100-200. The GoD reports a decrease in local transmission of cases since the summer months, with the weekly positivity rate peaking in May at 22% and falling to 0.18% in mid-September. However, the seemingly low COVID-19 incidence must be interpreted with great caution because the overall test positivity rate in Djibouti is high at 7%, likely indicative that current testing (about 84,000 tests per million population) is insufficient to detect all cases. Furthermore, falling test positivity or incidence rates could reflect a recent decrease in testing; absent testing trend data in Djibouti Oct 27, 2020 Page 3 of 7 The World Bank AF Djibouti COVID-19 Response (P174675) (e.g. number of tests conducted per calendar day), it remains unclear that local transmission is indeed falling. These indicators are critical inputs to the most pressing COVID-19 decisions, including both physical distancing policies and COVID-19 health care preparedness and response planning. 4. The majority of COVID-19 confirmed cases are channeled to hospitals for isolation and/or supportive care, particularly to Hôpital Arta, Bouffard, and Al-Rahma. Over 700 hospital beds are available to COVID-19 patients among these three hospitals (out of a total of 2,000 beds available nationwide). 50 resuscitation beds are available, and 27 respirators are functioning nationwide. Inferring from requests made by the GoD, there remains ongoing need for key supplies, such as drugs, supplies (including testing supplies, PPE, and critical care supplies like respirators, defibrillators, or hemodialysis machines). C. Proposed Development Objective(s) Original PDO To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Current PDO To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Key Results 5. The two PDO indicators of the parent project will remain: • Number of suspected cases of COVID-19 reported and investigated based on national guidelines • Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents 6. With regards to the first PDO indicator, the end target which was not determined during the preparation of the project due to lack of data is introduced through the Additional Financing (AF) which includes support for testing capabilities as all suspected cases are tested as per Ministry of Health (MoH) guidelines. Also, two new citizen engagement indicators, “percentage of health and non-health workers expressing satisfaction with training on case definition, management, infection prevention and control� and “percentage of grievances that are addressed and responded to within a timeline that has been specified and publicly communicated by the project� are proposed as intermediate results indicators. D. Project Description 7. The proposed AF will build on the parent project’s design and scale up the World Bank’s support to the government’s efforts to respond to the COVID-19 crisis. Specifically, the proposed AF will finance the procurement of key medical equipment, laboratories test kits, and medical supplies. 8. Component 1: Emergency COVID-19 Response (US$2.4 million IDA credit and US$378,857.14 PEF AF). The overall design and scope of the component remain the same; the aim is to slow down and limit the spread of COVID-19 in the country and beyond its borders by providing immediate support to enhance case detection, Oct 27, 2020 Page 4 of 7 The World Bank AF Djibouti COVID-19 Response (P174675) confirmation, recording and reporting, as well as contact tracing and risk assessment and mitigation. Under this component, the proposed AF will finance the procurement of additional supplies, PPE and laboratory test kits. 9. Component 2: Strengthening Overall Healthcare Services and Clinical Capacity for Emergency COVID-19 Response (US$1.85 million IDA credit and US$564,000 PEF AF). The overall design and scope of this component remain the same; it supports the strengthening of selected health facilities and establishment and equipping of quarantine and treatment centers to be able to provide the best care possible for people who become ill. The PEF AF finances the procurement of a computed tomography (CT) scanner to improve the clinical management of complications of COVID-19 confirmed cases. More importantly, CT scanner is a general-purpose and widely used tool that can support the cost-effective clinical management of innumerable other conditions. In Djibouti, there is only one functioning CT scanner in the Pelletier Hospital in Djibouti city. The additional CT will be placed in the Balbala hospital, located in a neighborhood in the capital where many of the vulnerable live, with a catchment population of 500,000. 10. Components 3 and 4 remain the same, and the AF funds will not go to these components. . Legal Operational Policies Triggered? No Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 Summary of Assessment of Environmental and Social Risks and Impacts . 11. Though aiming at positive outcomes in term of COVID-19 prevention, treatment and surveillance, the activities under the additional financing could lead to adverse impacts, such as infectious waste generation, health and safety of workers and communities - in particular with regards to COVID-19 exposure, the exclusion of vulnerable and disadvantaged groups and individuals to project benefits, and the generic environmental and social impacts associated with minor civil works. In line with the requirements of the Environmental and Social Commitment Plan (ESCP), the MoH prepared the Environmental and Social Management Framework (ESMF), the Labor Management Procedures (LMP) and the Stakeholder Engagement Plan (SEP) that covers the activities of the Parent Project and the Additional Financing. All the ESF instruments were approved by the Bank and have been disclosed on its website as well as in-country. The ESMF follows national directives, plans and protocols enhanced by the relevant WHO and other lead agencies’ technical guidance on COVID- 19. The instrument includes a generic Infection Control and Waste Management Plan (ICWMP), to guide the development of specific ICWMPs for each beneficiary structure including the procurement of three incinerators. It proposes a checklist to monitor the distribution of the materials, procedures for the safe handling, storage, and processing of COVID-19 materials. The ESMF outlines mechanisms to monitor compliance with environmental and social mitigation measures, and generic environmental and social clauses Oct 27, 2020 Page 5 of 7 The World Bank AF Djibouti COVID-19 Response (P174675) to be included in civil works bidding and contract documents. As for the other ESF instruments, the LMP describes the types of workers, the risks associated with the project, and proposes procedures, protocols and mitigation measures. Finally, the SEP has established a structured approach to stakeholder engagement and public outreach that is based upon meaningful consultations and disclosure of appropriate information, considering the specific challenges associated with COVID-19. E. Implementation Institutional and Implementation Arrangements 12. The COVID-19 Technical Committee handles the day-to-day implementation of project activities and reports to the Minister of Health on the status of the epidemic. The Technical Committee, established on January 28, 2020, is headed by the Secretary General of the MoH and includes representatives of the National Public Health Institute, hospitals, and other MoH departments. The Secretary General serves as the project coordinator with support from the National Nutrition and Food Coordination Authority (OCNNA) with existing fiduciary and M&E staff (working on two ongoing IDA projects - COVID-19 Response Project and Toward Zero Stunting project) as well as the MoH Department of Health Information (DHI). . CONTACT POINT World Bank Fatima El Kadiri El Yamani Health Specialist Borrower/Client/Recipient The Republic of Djibouti Ilyas Moussa Dawaleh Minister of Economy and Finances, in Charge of Industry smibrathu@mefip.gov.dj Implementing Agencies Ministry of Health Mohamed Warsama Dirieh Minister of Health chehem@msn.com Oct 27, 2020 Page 6 of 7 The World Bank AF Djibouti COVID-19 Response (P174675) FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Task Team Leader(s): Fatima El Kadiri El Yamani Approved By Practice Manager/Manager: Country Director: Janette Uhlmann 29-Oct-2020 Oct 27, 2020 Page 7 of 7