The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 09/08/2021 | Report No: ESRSAFA232 Sep 08, 2021 Page 1 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Chad AFRICA WEST Republic of Chad Ministère de la Santé Publique Project ID Project Name P176385 Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project Parent Project ID (if any) Parent Project Name P173894 Chad COVID-19 Strategic Preparedness and Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 8/9/2021 9/30/2021 Population Financing Public Disclosure Proposed Development Objective To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Chad. Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The objective of both the parent project and this AF is to prevent, detect and respond to the threat posed by COVID- 19 and strengthen national systems for public health preparedness in Chad. The parent project has 3 components: (1) Sep 08, 2021 Page 2 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) Emergency COVID-19 Preparedness and Response, (2) Community Engagement and Social and Behavior Change Communication, and (3) Implementation Management, Monitoring and Evaluation, and Coordination. The changes proposed for the AF entail expanding the scope of activities in the parent project, the Chad Covid-19 Strategic Preparedness and Response Project (P173894) and adjusting its overall design. The overall design will be adjusted to increase its scope and cost that will be required to finance (i) vaccine and drug purchase; (ii) upgrading the cold chain for the vaccines; (iii) strengthening service delivery to ensure effective vaccine deployment; and (iv) monitoring, tracking of vaccines use and recording of any adverse reactions to vaccination. Additional financing is also required for sustained communications, which is essential to sustain throughout the vaccine roll-out. The proposed AF will not entail changes to the project’s structure, but additional activities (and funds) will be added to each project component of the parent project. Under Component 1, an additional subcomponent will be added to capture interventions linked to the purchase of vaccines and related consumables, as well as their distribution. This new subcomponent will also include technical assistance to the strategic planning of the COVID-19 vaccination campaign and support for pharmacovigilance. These activities represent 92.5 percent of the additional funds (US$ 18.5 million). Component 2 will be expanded to include communication campaigns linked to vaccine hesitancy costed at US$1.1 million. Finally, the proposed AF includes activities linked to the M&E of vaccine deployment under Component 3 for which US$400,000 have been allocated. While the project will help strengthen the national capacity to respond to the COVID-19 emergency, the distribution of equipment and supplies and the training of staff will prioritize the seven provinces identified by the WHO as high- risk provinces. These provinces are those were there are points of entry to the country and include: N’Djamena, Lake Public Disclosure Chad, Mayo Kebbi East, Mayo Kebbi West, Logone Oriental, Moyen-Chari and Ouaddai. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] This Additional Financing (AF) will be implemented country-wide in Chad as its parent project. The purpose of the proposed AF is to provide upfront financing to help the government purchase and deploy COVID-19 vaccines that meet Bank’s vaccine approval criteria (VAC) and strengthen relevant health systems that are necessary for a successful deployment and to prepare for the future. This AF will build upon the support already being provided to the government through the COVID strategic preparedness and response (P173894 – parent project) which aims to support the country in COVID-19 preparedness, monitoring, surveillance and response and finances technical assistance, policy advice and increased availability and quality of health services; and the REDISSE IV project (P167817) which focuses on: (i) strengthening national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in the Participating Countries; and (ii) in the event of an Eligible Crisis or Emergency, providing immediate and effective response to said Eligible Crisis or Emergency. The three projects will be implemented in parallel. As for the parent project, the specific subproject locations have not yet been identified but are likely to also include refugee and IDP camps in the eastern region of the country. No major civil works will be financed as the limited rehabilitation that will be financed will take place in existing health facilities. The project is not expected to affect natural habitats or cultural sites or require any land acquisition or economic displacement. D. 2. Borrower’s Institutional Capacity The Additional Financing (AF) will be implemented by the Ministry of Health using the existing Project Coordinating Unit (PCU) for the World Bank-funded COVID strategic preparedness and response (P173894) and Regional Disease Sep 08, 2021 Page 3 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) Surveillance Systems Enhancement (REDISSE IV, P167817). The PCU has experience in coordinating and managing Bank financed projects. However, one of the challenges that the unit has faced has been the delay in the development of the relevant environmental and social instruments due to national procurement process. The PCU recruited an environmental specialist and a social risk management specialist as per engagement stated in the parent project ESCP who demonstrated so far great capacities in environmental and social monitoring. Both specialists indeed played an instrumental role in coordinating and participating in the elaboration and finalization of Environmental and Social instruments for the three projects (COVID parent and AF projects and REDISSE IV). Bank environmental and social staff provided training to the Client to build capacity in the World Bank’s Environmental and Social Framework (ESF). This has so far been carried out remotely through videoconference sessions due to the pandemic and recently due to the political events in Chad. Topics covered include: (i) assessment and technical reinforcement of the Complaints Management Mechanism as well as the Complaints Management Mechanism Action Plan during the life of the project, (ii) mapping of GBV service providers; (iii) SEA and Occupational Health and Safety and (iv) Introduction to the approach and mechanisms of citizen engagement in World Bank funded operations. Further training will continue to be provided to the PCU to complete the capacity building process. The environmental and social performance of the parent project is Moderately Unsatisfactory due to the long delay in the preparation of the safeguard instruments for both REDISSE IV and the COVID-19 projects. Indeed, the ESCP of the parent project (P173894) stated that ESMF needed to be finalized and disclosed 30 days after the effectiveness. Project effectiveness was declared on April 30th, 2020. Due to various delays in projects implementation and because of long national procurement procedures, the PIU decided to prepare REDISSE and COVID safeguards instruments at the same time and under the same contract. The Covid-19 public health emergency led to further delays in signing the Public Disclosure contract with the consulting firm selected to prepare the E&S instruments. The contract was finally signed in December 2020. Safeguards instruments are critical and prerequisite to start activities on the ground. The PCU has prepared an Environmental & Social Management Framework (ESMF), updated Waste Management Plan (WMP), Labor Management Procedures (LMP), Stakeholder Engagement Plan (SEP) and Environmental and Social Commitment Plan (ESCP). II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial Like the parent project, the environmental risk rating is substantial due to the fact that the AF activities will include testing and treatment of infected persons, handling of medical waste by medical professionals and local community health and safety. The AF activities will generate medical health care waste, which can affect the health of local communities and Chad’s population if not well managed. Working with patients and materials infected with COVID19 can potentially expose health workers and medical staff to contamination, hence presenting health and safety issues. The AF will provide medical supplies for health facilities in charge of the disease management; personal protective equipment (PPE) for health personnel involved in patient case management; procurement of goods and their distribution across health facilities within Chad. Potential environmental risks and impacts include those related to the handling, storage, processing and disposal of COVID19-infected materials; operation of laboratories and medical facilities; inadequate storage and transportation of COVID-19 vaccines; and upgrading the Sep 08, 2021 Page 4 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) cold chain. To mitigate these risks and impacts, the Client has prepared an ESMF covering REDISSE 4 ((REDISSE IV, P167817), COVID parent project (P173894) and COVID additional financing (P176385) as well as updated the Medical Waste Management Plan (MWMP) which was prepared under the new Health System Performance Strengthening Project (P172504). Social Risk Rating Substantial The social risk is anticipated to be substantial because there is a broader social risk of inequity in terms of access to vaccines, such as political pressure to provide vaccines to groups that are not prioritized due to specific need or vulnerability, or misalignment of target groups with available vaccines. This includes possible exclusion of groups based on gender, ethnicity, refugee status, or religion. Another potential risk is the increased incidence of reprisals and retaliation especially against healthcare workers and researchers, particularly within an evolving socio-political context. This risk will be mitigated through explicit inclusion in robust stakeholder identification and consultation processes. Further, and linked to the social risks stated above, it is important to have clarity on the risks that may arise related to any mandatory aspect of the national program and whether and how this mandatory element relates to cultural, social and traditional community practices and values. Such risks need to be considered in light of the mitigation hierarchy and balanced against the health-related requirements of any mandatory vaccination program. These risks will be mitigated through several measures to ensure vaccine delivery targets the most vulnerable populations, particularly women, elderly, poor, refugees, internally displaced and minorities in accordance with criteria specified in this AF. First, the Bank and other partners will support Chad to develop and adapt an explicit, contextually appropriate, and well-communicated targeting criteria and implementation plan (e.g., the national deployment and vaccination program and any subsidiary programs) including criteria for access to vaccines. The Government will ensure that this plan be subject to timely and meaningful consultations in accordance Public Disclosure with ESS 10. There is consensus to first target health workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly, people with co-morbidities, and people in high-population density location such as slums and refugee, and internally displaced camps. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: This standard is relevant. The various risks identified include: (i) environmental and community health related risks related to the inadequate storage, transportation and disposal of infectious medical waste as the incinerators in the district hospitals are for the most part not very operational and require rehabilitation. Similarly, the artisanal burners in the health centers need to be improved; (ii) occupational health and safety issues related to the availability and supply of personal protective equipment (PPE) for healthcare workers and and the logistical challenges for transporting and storage of vaccine by cold storage and refrigerated trucks across the country in a timely manner; (iii) generation of hazardous wastes related to the cold chain upgrading, (iv) community health and safety risks given close social contact and limited sanitary and hygiene services (clean water, soap, disinfectants) and isolation/quarantine capabilities at health facilities across the country; (v) possible risks around social exclusion in terms of access to health facilities and services, especially for the poorest and most marginalized who have a limited ability to pay, and for the elderly or those with underlying medical conditions who would be most at risk in the event Sep 08, 2021 Page 5 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) of a pandemic; (vi) risks for those receiving treatment for COVID-19 symptoms, including discrimination and GBV/SEA risks for patients in quarantine; (vii) socio-political risks specifically related to insecurity especially in the North and Center regions of the country; and (viii) low trust in the government which could lead to the rejection of public health interventions and information. In addition, specific attention will also be given to the storage and preservation conditions of vaccines which may be further affected by climate change and climate variability (eg heat waves, floods). Widespread energy loss can seriously threaten the cold chain of COVID-19 vaccines as vaccine storage standards will be affected. Storage capacities were analyzed using the WHO Logistic Planning Tool, taking into account all EPI vaccines, including COVID-19. The central vaccine depot has four positive cold chain refrigerators, one positive cold chain fridge and eight freezers, with a total cold chain storage capacity of 44,666 liters. In addition, there are four sub-national storage facilities with cold chain capacity, one in N'Djamena (6,556 liter storage capacity), one in Abeche (6,751 liter storage capacity), one in Moundou (9,050 liter storage capacity), and one in Sarh (9,050 liter storage capacity). An assessment conducted in the context of the development of the National Vaccine Deployment Plan revealed that there are no positive cold chain needs (2-8°C), but more than 13,000 liter (roughly 33 freezers) storage capacity of negative cold chain (-20°C) is needed, as well as 2,390 liters (-80°C) of negative cold chain equipment. These estimates are based on the assumption that vaccines will be distributed in lots of doses to cover not more than 5 percent of the population. During parent project supervision mission, it has been agreed that the distribution plan for goods and equipment (and the associated infrastructure development plan) is approved and implemented only after the finalization, adoption and disclosure on the client's and World Bank’s website of all safeguards instruments (ESMF, MWMP, LMP, Public Disclosure SEP). No “hard” activities have started yet on the ground prior to the finalization of safeguards instruments and only procured equipment – which is now in N’Djamena. The distribution plan (and the associated infrastructure development plan) will be approved and implemented only after the finalization, adoption and disclosure on the client's and World Bank’s website of all safeguards instruments. However, as per parent project ESCP, soft activities such as training activities for lab technicians and doctors have been implemented and communication campaigns (on risk based communication for prevention) have been organized in several provinces (Ennedi East, Mandoul, Mayo- Kebi, Logone, Kanem, Lake, Borkou, Guera, Batha, Sila, Tandjile, Tibesti,Ouaddaï, Hadjer Lamis, Moyen Chari and Ndjamena). The PCU has prepared an ESMF covering REDISSE 4 (P167817), COVID parent project (P173894) and COVID additional financing (P176385) as well as updated the Medical Waste Management Plan (MWMP). The ESMF provides clear guidance regarding the treatment of medical waste, guidelines for community engagement and the preparation of subproject ESMPs. The ESMF also incorporates international protocols for community health and safety during a pandemic and measures to address SEA/SH. The PCU updated the ESCP for AF which will include concrete actions intended to ensure compliance with the ESF as well as a timeline and roles and responsibilities. The ESMF and updated MWMP have been validated, approved and disclosed in the country on 4, August 2021 and 10, August 2021 respectively and on the Bank’s website on 5, August 2021 and 12 August 2021 respectively. The previous SEP disclosed on April 10, 2020, has been updated as recommended in the ESCP and redisclosed in-country on 10, August 2021 and on the Bank’s website on 12, August 2021. ESS10 Stakeholder Engagement and Information Disclosure Sep 08, 2021 Page 6 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) The parent project Stakeholder Engagement Plan (SEP) has been updated to ensure inclusive stakeholder engagement. The SEP expands on other traditional grievance redress platforms that are open to beneficiaries to bring their complaints to the attention of the government authorities. These includes e-mail communication through the government website and community health forums where local community members voice out their concerns, and these get actioned by the health managers for those affected health facilities. The SEP also provides more details on how the GM will be implemented and monitored to close the feedback loop throughout the life of the project. Local level GM committee will be set up to receive complaints as per the GM action plan developed for the parent project. Citizen engagement will be done by way of outreach and consultation; an introduction to citizen engagement was given to the PIU and further training and guidance will be provided so the PIU can start these activities . The Communication sub-committee of the National coordination committee will launch an awareness raising campaign through the mass and social media. Citizens will be informed of the project objectives and informed of the vaccination dates and places. They will also be told how they can complaint about the project. Citizen’s survey will be done at least once a year, and face to face meetings will be organized with some community members of both sexes to gauge the level of satisfaction with the project and gather any information about SEA/SH to explain the specific procedures in place to address gender-based violence, with confidentiality provisions contained in the GRM. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions This standard is relevant. Many activities that would be financed by the AF will be conducted by health care and Public Disclosure laboratory workers that will be at risk for COVID 19 infection due to their front-line engagement with patients and handling of patient samples and medical waste. OHS measures as outlined in the WHO guidelines and captured in the ESMF and in the Labor Management Procedures (LMP). These include procedures for monitoring and managing entry into health care facilities; procedures for protection of workers and infection control precautions; provision of immediate and ongoing training regarding the precautionary procedures for all categories of workers and clear and accessible signage in all public spaces mandating basic sanitation, hand hygiene and the mandatory use of personal protective equipment (PPE); ensuring adequate supplies of PPE (particularly face masks, gowns, gloves, handwashing soap and sanitizer); and generally ensuring adequate OHS protections in accordance with the general and industry specific EHSGs and consistent with the evolving international best practice in relation to COVID-19 protection. In addition, the presence of a male workforce could lead to the risk of sexual harassment, rape and unwanted pregnancies, domestic violence, early/forced marriage, trafficking, and forced prostitution among the beneficiary populations of the sub-projects. The PCU will ensure that the evolving COVID-19 guidance by WHO is being incorporated into these policies and procedures as it emerges. LMP have been validated, approved and disclosed in the country on 10, August 2021 and on the Bank’s website on 12, August 2021. They provide guidance regarding the OHS policies and procedures that will be used to protect health care workers, project staff and other workers hired by the PCU. The LMP also include a worker-specific Grievance Mechanism (GM) that will allow health care workers in particular to raise concerns regarding the lack of enforcement of policies and procedures or other grievances that may arise in the context of their work. Under additional financing some training on the LMP will be set up for all workers, including the workers’ GRM. ESS3 Resource Efficiency and Pollution Prevention and Management Sep 08, 2021 Page 7 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) This standard is relevant for the additional financing. Pollution prevention and management, specifically medical waste management is a particularly important activity under the Project. Medical waste, including chemicals, contaminated PPE and equipment, and lab testing kits from healthcare facilities will need to be safely stored, transported and disposed. Specific attention will also need to be paid to proper storage, transport and disposal of hazardous waste during the upgrade of cold chain. Waste management in general is a huge challenge in Chad due to limited authorized disposal sites, and contaminated medical waste is of special concern. Wastes generated from labs, vaccination campaings, screening posts and treatment facilities to be supported by the COVID-19 readiness and response includes liquid contaminated waste (e.g. blood, other body fluids and contaminated fluid) and infected materials (water used; lab solutions and reagents, syringes, bed sheets, majority of waste from labs and isolation centers, etc.) that require special handling and awareness, as they may pose an infectious risk to healthcare workers in contact with the waste. Medical waste in Chad is mainly managed through incineration – the problem being the number and standard quality of such incinerators. Informal disposal may in addition lead to contamination of soil and groundwater, but more importantly, to further spreading of the virus to nearby communities. The PCU updated the Medical Waste Management plan - which was prepared, validated and disclosed both on national and World Bank websites under the new Health System Performance Strengthening Project (P172504) - which integrates WHO COVID-19 guidance and other international good practices in order to prevent or minimize contamination from inadequate waste management and disposal. ESS4 Community Health and Safety This standard is relevant. Community health and safety risks identified as part of the parent project are the same for Public Disclosure the additional financing. These include: (i) environmental and community health related risks related to the inadequate storage, transportation and disposal of infectious medical waste; (ii) community health and safety risks given close social contact and limited sanitary and hygiene services (clean water, soap, disinfectants) and isolation/quarantine capabilities at health facilities across the country; (iv) possible risks around social exclusion related to access to health facilities and services, especially for the poorest and most marginalized who have a limited ability to pay, and for the elderly or those with underlying medical conditions who would be most at risk in the event of a pandemic; (v) risks for those receiving treatment for COVID-19 symptoms, including discrimination and GBV/SEA risks for patients in quarantine; (vi) socio-political risks specifically related to insecurity especially in the North and Center regions of the country; and (vii) low trust in the government which could lead to the rejection of public health interventions and information and violence against those providing services. In addition, Borrower’s capacity to (i) establish, maintain, and monitor cold chain temperature for COVID Vaccines, and (ii) monitor and handle adverse events following immunization is very challenging. To address these risks, the PCU has prepared an ESMF to provide clear guidance specifically regarding the treatment of infectious disease and other medical waste. With regard to the risks of sexual exploitation and abuse (SEA) and sexual harassment (SH), the project has assessed the risks of GBV/SEA/HS (gender-based violence, sexual exploitation and abuse and sexual harassment) as part of the social assessment and this is reflected in the main safeguard instruments, contractual obligations and other key documents regulating the project's implementation as well as an SEA/HS prevention and response action plan, which includes a framework of responsibilities and response. As part of this plan, the PCU will identify and assess the actors involved in ISA/HS prevention and response in the project implementation area. While the project will be implemented in several areas that are facing very high insecurity, it is not anticipated that security personnel will be required to protect project sites or activities. However, continuous security risk assessment and management will be critical to the achievement of the project’s development outcomes. Sep 08, 2021 Page 8 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement The project is not expected to have any impacts related to land acquisition, restrictions on land use and involuntary resettlement. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources This standard is not currently relevant as no construction or major rehabilitation activities are expected under this additional financing. All anticipated works will be conducted within existing facilities. The risks and impacts on natural resources, biodiversity and natural habitats are not foreseen as laboratories and health centers are located in urban areas and medical waste is handled directly insitu within these health facilities. In addition, all medical wastes will be disposed as per the BMWMP. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities This standard is not relevant in the project context as there are no known Indigenous peoples in the project area. ESS8 Cultural Heritage This standard is not currently relevant. There are no major construction activities anticipated and any physical works will be limited to rehabilitation or upgrading of existing facilities. However, as cultural heritage might be encountered Public Disclosure during rehabilitation, the ESMF includes measures for “Chance Finds” of archaeological or other cultural heritage. ESS9 Financial Intermediaries The project is not engaged with financial intermediaries. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: not applicable Sep 08, 2021 Page 9 of 10 The World Bank Additional financing for the Chad COVID-19 Strategic Preparedness and Response Project (P176385) IV. CONTACT POINTS World Bank Contact: Andy Chi Tembon Title: Senior Health Specialist Telephone No: +1-202-458-4879 Email: atembon@worldbank.org Contact: Nicolas Rosemberg Title: Economist, Health Telephone No: 675-361-3033 Email: nrosemberg@worldbank.org Borrower/Client/Recipient Borrower: Republic of Chad Implementing Agency(ies) Implementing Agency: Ministère de la Santé Publique V. FOR MORE INFORMATION CONTACT The World Bank Public Disclosure 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Nicolas Rosemberg, Andy Chi Tembon Practice Manager (ENR/Social) Maria Sarraf Cleared on 17-Aug-2021 at 10:29:38 GMT-04:00 Safeguards Advisor ESSA Nathalie S. Munzberg (SAESSA) Concurred on 08-Sep-2021 at 10:58:5 GMT-04:00 Sep 08, 2021 Page 10 of 10