Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD4643 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT PAPER ON A PROPOSED ADDITIONAL GRANT IN THE AMOUNT OF SDR 116.1 MILLION (US$164.3 MILLION EQUIVALENT) OF WHICH US$27 MILLION IS FROM THE WINDOW FOR HOST COMMUNITIES AND REFUGEES AND A GRANT FROM THE GLOBAL FINANCING FACILITY FOR WOMEN, CHILDREN AND ADOLESCENTS IN THE AMOUNT OF US$16.0 MILLION TO THE REPUBLIC OF UGANDA FOR UGANDA COVID-19 RESPONSE AND EMERGENCY PREPAREDNESS PROJECT November 23, 2021 UNDER THE COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROGRAM (SPRP) USING THE MULTIPHASE PROGRAMMATIC APPROACH (MPA) WITH A FINANCING ENVELOPE OF UP TO US$ 6 BILLION APPROVED BY THE BOARD ON APRIL 2, 2020, AND UP TO US$ 12 BILLION ADDITIONAL FINANCNG APPROVED BY THE BOARD ON OCTOBER 13, 2020 Health, Nutrition & Population Global Practice Eastern and Southern Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Exchange Rate Effective October 31, 2021 Currency Unit = Ugandan Shillings (UGX) UGX 3,554 = US$1 US$1 = SDR 0.70652404 FISCAL YEAR January 1 – December 31 Regional Vice President: Hafez M. H. Ghanem Country Director: Keith E. Hansen Regional Director: Amit Dar Practice Manager: Francisca Ayodeji Akala Task Team Leaders: Julia Mensah, Rogers Ayiko ABBREVIATIONS AND ACRONYMS AEFI Adverse Events Following Immunization AF Additional Financing AMC Advance Market Commitment ANC Antenatal Care Afreximbank African Export-Import Bank AU African Union AVAT African Union Vaccines Acquisition Trust AVATT AU Vaccine Acquisition Task Team CDC Centers for Disease Control CHS Community Health and Safety COVAX COVID-19 Vaccines Global Access CPF Country Partnership Framework CRRF Comprehensive Refugee Response Framework DHIS District Health Information System DTF District COVID-19 Task Forces EAPHLNP East African Public Health Laboratory Networking Project eLMIS Electronic Logistics Management Information System ESCP Environmental and Social Commitment Plan ESF Environmental and Social Framework ESIA Environmental and Social Impact Assessment ESMF Environmental and Social Management Framework ESRS Environmental and Social Review Summary ESS Environmental and Social Standards EUL Emergency Use Listing EVD Ebola Virus Disease FM Financial Management GAVI Gavi, the Vaccine Alliance GFF Global Financing Facility for Women, Children and Adolescents GoU Government of Uganda GRS Grievance Redress Service HEIS Hands-on Expanded Implementation Support HMIS Health Management Information System HSIRRP Health Sector Integrated Refugee Response Plan IBRD International Bank for Reconstruction and Development IDA International Development Association IEC Information Education Communication IPV Intimate Partner Violence ISR Implementation Status and Results Report MoGLSD Ministry of Gender, Labor and Social Development MoH Ministry of Health MPA Multiphase Programmatic Approach NCC National Coordination Committee NDA National Drug Authority NITAG National Immunization Technical Advisory Group NMS National Medical Stores NTF National COVID-19 Task Force NVDP National Vaccines Deployment Plan OPM Office of the Prime Minister PDO Project Development Objective PEFF Pandemic Emergency Financing Facility PIU Project Implementation Unit PoE Point of Entry PPE Personal Protective Equipment PQ Prequalification RHD Refugee Hosting District RMNCAH Reproductive, Maternal, Newborn, Child, and Adolescent Health RRH Regional Referral Hospital RSW Regional Sub-Window for Refugees and Host Communities (under IDA18) SAGE Strategic Advisory Group of Experts on Immunization SCD Systematic Country Diagnostic SEA Sexual Exploitation and Abuse SPRP COVID19 Strategic Preparedness and Response Program UCREPP Uganda COVID-19 Response and Emergency Preparedness Project UgIFT Uganda Intergovernmental Fiscal Transfers UNEPI Uganda National Expanded Program for Immunization UNHCR United Nations High Commission for Refugees UNICEF United Nations Children’s Fund URMCHIP Uganda Reproductive, Maternal and Child Health Services Improvement Project USAID United States Agency for International Development VAC (Uganda) Vaccine Advisory Committee VAC (World Bank) Vaccine Approval Criteria VDDM Vaccine Delivery and Distribution Manual VIRAT Vaccine Introduction Readiness Assessment Tool VLMIS Vaccine Logistics Management Information System VRAF Vaccine Readiness Assessment Framework WBG World Bank Group WHO World Health Organization WHR Window for Host Communities and Refugees Uganda Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING .................................................... 9 A. Introduction ......................................................................................................................................................... 9 B. Consistency with the Country Partnership Framework (CPF) ............................................................................ 14 C. Project Design and Scope ................................................................................................................................... 14 D. Project Performance .......................................................................................................................................... 15 E. Rationale for Additional Financing/Restructuring.............................................................................................. 15 F. National Capacity and COVID-19 Vaccination Plan ............................................................................................ 17 II. DESCRIPTION OF ADDITIONAL FINANCING ................................................................................. 25 A. Proposed Changes.............................................................................................................................................. 25 B. Sustainability ...................................................................................................................................................... 39 III. KEY RISKS................................................................................................................................... 39 IV. APPRAISAL SUMMARY ............................................................................................................... 48 A. Technical, Economic and Financial Analysis ....................................................................................................... 48 B. Financial Management....................................................................................................................................... 51 C. Procurement ...................................................................................................................................................... 51 D. Legal Operational Policies .................................................................................................................................. 52 E. Environmental and Social................................................................................................................................... 52 F. Climate ............................................................................................................................................................... 54 V. WORLD BANK GRIEVANCE REDRESS ........................................................................................... 56 VI SUMMARY TABLE OF CHANGES ................................................................................................... 57 VII DETAILED CHANGE(S) .................................................................................................................. 57 VIII. RESULTS FRAMEWORK AND MONITORING ................................................................................. 63 ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS ........................... 85 ANNEX 2: THE COVID-19 SITUATION IN UGANDA ............................................................................... 86 ANNEX 3: HOST COMMUNITY AND REFUGEE IMPACTS OF COVID-19 AND RESPONSE ........................ 89 ANNEX 4: REVISED DISBURSEMENT CATEGORIES ............................................................................... 94 List of Tables Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment ............ 18 Table 2: National Vaccine Coverage and Acquisition Plan ................................................................... 22 Table 3: Summary of national vaccine acquisition plan ...................................................................... 23 Table 4: Priority Groups for National COVID-19 Vaccination Uganda (including refugees) .................. 30 Table 5: Project Cost and Financing (US$ million) ............................................................................... 31 Table 6: Summary of COVID-19 Vaccine Sourcing and Bank Financing (as of October 6, 2021) ............ 32 Table 7: Risk Mitigation Measures for Procurement ........................................................................... 42 Table 8. Climate Adaptation Activities Financed by the Project .......................................................... 55 Table 9: Climate Mitigation Activities Financed by the Project ........................................................... 56 List of Figures Figure 1: Organogram for Vaccine Deployment Implementation and Oversight ................................. 35 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) BASIC INFORMATION – PARENT (Uganda COVID-19 Response and Emergency Preparedness Project - P174041) Country Product Line Team Leader(s) Uganda IBRD/IDA Julia Mensah Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P174041 Investment Project HAEH2 (10210) AECE2 (6542) Health, Nutrition & Financing Population Implementing Agency: Ministry of Health ADD FIN TBL1 Is this a regionally tagged project? No Bank/IFC Collaboration No Expected Approval Date Closing Date Guarantee Environmental and Social Risk Classification Expiration Date 15-Jul-2020 31-Dec-2022 Substantial Financing & Implementation Modalities Parent [✓] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [✓] Hands-on Expanded Implementation Support (HEIS) Development Objective(s) 1 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) MPA Program Development Objective (PrDO) The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Project Development Objectives (Phase 094) The objective of the Project is to prevent, detect and respond to COVID-19 and strengthen national systems for public health emergency preparedness in Uganda. Ratings (from Parent ISR) RATING_DRAFT_NO Implementation Latest ISR 15-Oct-2020 23-Apr-2021 12-Nov-2021 Progress towards achievement of PDO MS MS MS Overall Implementation Progress (IP) MS MS MS Overall ESS Performance S S S Overall Risk S S H Financial Management MS MS MS Project Management MS MS MS Procurement MS MS MS Monitoring and Evaluation MS MS MS BASIC INFORMATION – ADDITIONAL FINANCING (Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project - P177273) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P177273 Additional Financing to Restructuring, Scale Up No Uganda COVID-19 Response and Emergency Preparedness Project Financing instrument Product line Approval Date Investment Project IBRD/IDA 16-Dec-2021 2 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Financing Projected Date of Full Bank/IFC Collaboration Disbursement 31-Dec-2024 No Is this a regionally tagged project? No Financing & Implementation Modalities Child [✓] Multiphase Programmatic Approach [MPA] [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [ ] Hands-on, Enhanced Implementation Support (HEIS) [ ] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments IBRD % IDA 12.50 2.99 10.02 23 % Grants 2.70 2.70 100 % MPA Financing Data (US$, Millions) Financing MPA Program Financing Envelope 18,000,000,000.00 MPA FINANCING DETAILS (US$, Millions) MPA FINANCING DETAILS (US$, Millions) Approved Board Approved MPA Financing Envelope: 18,000,000,000.00 MPA Program Financing Envelope: 18,000,000,000.00 3 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) of which Bank Financing (IBRD): 9,900,000,000.00 of which Bank Financing (IDA): 8,100,000,000.00 of which other financing sources: 0.00 PROJECT FINANCING DATA – ADDITIONAL FINANCING (Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project - P177273) PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 15.20 180.30 195.50 Total Financing 15.20 180.30 195.50 of which IBRD/IDA 12.50 164.30 176.80 Financing Gap 0.00 0.00 0.00 DETAILS - Additional Financing NewFinEnh1 World Bank Group Financing International Development Association (IDA) 164.30 IDA Grant 164.30 Non-World Bank Group Financing Trust Funds 16.00 Global Financing Facility 16.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Uganda 0.00 164.30 0.00 164.30 National PBA 0.00 137.30 0.00 137.30 Refugee 0.00 27.00 0.00 27.00 4 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Total 0.00 164.30 0.00 164.30 COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ✔ ] Yes [ ] No Explanation The project is being processed using the following waivers granted through the MPA: a partial waiver relating to the application of Anti-Corruption Guidelines to unsuccessful bidders in the context of retroactive financing and of framework agreements in place between the borrower and suppliers and financed under retroactive financing or advanced procurement. Has the waiver(s) been endorsed or approved by Bank Management? Approved by Management [✔] Endorsed by Management for Board Approval [ ] No [ ] Explanation The management approved the waiver on April 2, 2020 as part of the Global SPRP MPA approval. The same waivers approved for the Global COVID MPA were extended to the Additional Financing on October 13, 2020. The retroactive financing (40%) was approved by Management on November 12, 2021. 5 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) ESStandards Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance Assessment and Management of Environmental and Social Risks and Impacts Relevant Stakeholder Engagement and Information Disclosure Relevant Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and Management Relevant Community Health and Safety Relevant Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Relevant Local Communities Cultural Heritage Not Currently Relevant Financial Intermediaries Not Currently Relevant ESStandardsNote NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks 6 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) PROJECT TEAM Bank Staff Name Role Specialization Unit Team Leader (ADM Julia Mensah HAEH2 Responsible) Rogers Ayiko Team Leader HAEH2 Procurement Specialist (ADM Annet Tamale Katuramu EAERU Responsible) Financial Management Michael Eriu Okuny EAEG1 Specialist (ADM Responsible) Social Specialist (ADM Abdoul Wahabi Seini SAES2 Responsible) Environmental Specialist (ADM Brenda Joanne Basalwa SAEE2 Responsible) Anne Margreth Bakilana Team Member Program Leader HAEDR Benjamin Christopher Team Member Sr. Operations Officer AEMUG Reese Brendan Michael Hayes Team Member Sr. Health Specialist HHNGF Christine Kasedde Environmental Specialist Env. Specialist SAEE2 Collins Chansa Team Member Sr. Economist Health HAEH1 Elizabeth Mabel Asege Team Member Consultant HAEH2 Ekochu Evarist F. Baimu Counsel Sr. Counsel LEGAM Franklin Mutahakana Team Member Sr. Operations Officer AEMUG Harriet Nattabi Team Member Water Resources Specialist SAEW3 Hope Turyasingura Team Member Team Assistant AECE2 Nanshemeza Jessica Leete Werner Team Member E. T. Consultant HAEH2 Flannery Maiada Mahmoud Abdel Team Member Finance Officer WFACS Fattah Kassem Maliam Acio Aalangdong Social Specialist Social Dev. Specialist SAES2 Sr. Social Development Margarita Puerto Gomez Team Member SAES2 Specialist Mohammad Ilyas Butt Procurement Team Procurement Analyst EAERU Naoko Ohno Team Member Sr. Operations Officer HEAHN 7 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Ndiga Akech Odindo Team Member Associate Counsel LEGAM Rebecca Chepkemboi Team Member Finance Assistant WFACS Choge Sandra M Kuwaza Team Member Finance Analyst WFACS Sujani Eli Team Member Operations Assistant HAEH2 Extended Team Name Title Organization Location 8 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING A. Introduction 1. This Project Paper seeks the approval of the Bank’s Board of Executive Directors to provide financing (in the amount of SDR 116.1 million (US$164.3 million equivalent) of which US$27 million is from the COVID-19 IDA Sub-window for host communities and refugees [WHR]. The Additional Financing (AF) will support the costs of expanding activities under the Uganda COVID-19 Response and Emergency Preparedness Project (UCREPP, P174041) as part of the COVID-19 Strategic Preparedness and Response Program (SPRP), using the Multiphase Programmatic Approach (MPA) (P173789), approved by the Board on April 2, 2020, and the vaccines AF to the SPRP (P175450) approved on October 13, 2020. 2. The proposed AF would scale up the Project activities by primarily enabling affordable and equitable access to COVID-19 vaccines in Uganda through ensuring effective vaccine deployment and vaccination system strengthening; further strengthening preparedness and response activities under the parent project including overall systems strengthening for resilience in the face of future emergencies; and supporting the continuity of essential health services. The AF will also ensure that host communities and refugees are included within these objectives. 3. The proposed AF will provide upfront financing to help the government purchase and deploy COVID-19 vaccines that meet the Bank’s vaccine approval criteria (VAC), strengthen relevant health systems that are necessary for a successful deployment and prepare for the future. The National Vaccines Deployment Plan (NVDP) has set a vaccination target of 49.6 percent of its national population (i.e. 22 million people). The proposed AF will help vaccinate more than half of this target, specifically 26.4 percent of the country’s population, equivalent to 11.7 million people. In addition, the COVID-19 Vaccines Global Access (COVAX) Advance Market Commitment (AMC) will help vaccinate 20.7 percent of the population (9.1 million people), while the government’s commitments through COVAX cost sharing and the African Vaccines Acquisition Trust (AVAT) will provide vaccines for an additional 11.3 percent (i.e., 5 million people) and 6.1 percent (i.e., 2.7 million people) respectively (Table 2 provides a detailed list of vaccines sources and commitments). Ultimately, the Government of Uganda (GoU) expects to inoculate 67.7 percent of its population including refugees who are included in the NVDP and children under 18 years. GoU has applied for additional doses under the GAVI/COVAX humanitarian 1 buffer but this application is yet to be approved. The vaccine-eligible population (18 years and above) living in refugee hosting districts is 2,201,000, of which 698,000 are refugees. 4. Bank financing for the COVID-19 vaccines and deployment will follow Bank’s VAC. As of October 31, 2021, the Bank will accept, as threshold for eligibility of International Bank for Reconstruction and 1 The Humanitarian Buffer – a key component of the COVAX facility – will ensure access to COVID-19 vaccines for high-risk populations (including refugees) in humanitarian settings. GAVI/COVAX notes that this Buffer will act as the last resort for some of the most vulnerable populations on earth, who have the least resources to cope if they were to get sick from COVID-19. Source : https://www.gavi.org/vaccineswork/covax-humanitarian-buffer-explained. 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Development or International Development Association (IBRD/IDA) resources in COVID-19 vaccine acquisition and/or deployment under all Bank-financed projects, the following: (i) the vaccine has received regular or emergency licensure or authorization from at least one of the SRAs identified by the World Health Organization (WHO) for vaccines procured and/or supplied under the COVAX Facility, as may be amended from time to time by WHO; or (ii) the vaccine has received WHO Prequalification (PQ) or WHO Emergency Use Listing (EUL) or (iii) has met such other criteria as may be agreed in writing between the Recipient and the Association. The updated list of vaccines that currently meet the VAC requirements is provided in Annex 1. The country will provide free of cost vaccination to the population, including to refugees. 5. GoU requested additional resources to support COVID-19 response through a letter dated April 6, 2021. Subsequently, in August 2021, the GoU also requested grant financing from the GFF to support continuity of essential health services in the context of COVID-19 response and recovery. Therefore, the proposed AF will expand Uganda’s health response to the pandemic with support from other development partners. The AF will help Uganda acquire vaccines from a range of sources to support the country’s objective to acquire a portfolio of vaccines under the right conditions (of value-for-money, regulatory approvals, and delivery time among other key features) from COVAX, African Union’s AU Vaccine Acquisition Trust (AVAT), and other eligible bilateral arrangements. The COVAX Facility (the “Facility”) has put in place a framework that will anchor Uganda’s strategy and access to vaccines. In this regard, in addition to receiving vaccines (free of charge) through COVAX AMC, the GoU has entered into an agreement with COVAX to purchase additional doses of approved vaccines through cost sharing arrangements. On July 5, 2021, the GoU signed a Framework Agreement with COVAX to secure doses through its cost sharing arrangements. Subsequently, it signed a Confirmation Agreement on September 16, 2021, for 2.5 million doses of Sinopharm. Uganda will also source vaccines through AVAT, a partnership involving the AU Special Envoy for COVID-19, Africa Centers for Disease Control (CDC), the African Export- Import Bank (Afreximbank) and the UN Economic Commission for Africa (UNECA). On July 5, 2021, the GoU signed an agreement with AVAT to procure 9 million doses of Johnson & Johnson (J&J) and has paid a total of US$15.5 million towards the costs, to date. 6. The project will also undergo level II restructuring. Beyond the addition of a components for vaccine acquisition and deployment and another for continuity of essential services, the Project will undergo level II restructuring to: (i) revise the original component costs, (ii) modify the Results Framework, and (ii) extend the closing date of the parent Project by 24 months to December 31, 2024. Country COVID-19 Context and Response 7. The first case of COVID-19 was reported in Uganda on March 21, 2020, with the number of cases reaching peaks of the first and second waves in December 2020 and June 2021, respectively. As of October 23, 2021, Uganda had registered 125,758 cases and 3,200 deaths, 2 translating into a case fatality rate of 2.5 percent. The second wave, which started in May 2021, was aggressive, and accounted for 65 percent of all cases and 89 percent of all deaths. The second wave was driven by a combination of factors, 2 WHO. COVID-19 Daily Situational Report Uganda 05 September 2021. 10 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) including the spread of more transmissible variants of Coronavirus; low case detection, inadequate tracing and treatment capacity; sub-optimal adherence to public health and social measures; and low coverage of COVID-19 vaccination. The high rates of infection and death, during the second wave, threatened to overwhelm the national health system as hospitals were filled, forcing government to institute a second lockdown (for 42 days) and scale up home-based COVID-19 care, among other measures. The lockdown ended on July 31, 2021. 8. Beyond the direct health impacts of COVID-19, delivery of other essential health services has been adversely affected. According to a recent study by the World Bank, Uganda was one of 18 countries where essential services suffered the most significant disruptions due to the pandemic. By April 2020, lower than expected volumes were recorded for: outpatient consultations (-23%); first antenatal care (ANC) visit (-5%); fourth ANC visit (-9%); institutional deliveries (-15%); and provision of the third dose of pentavalent vaccine (-18%). While most of the services rebounded by the end of June 2021, they have not reached the expected levels and are likely to drop again if effective COVID-19 interventions are not put in place. The low utilization of essential services is explained by factors such as lockdown measures, fear of infection among health workers and clients, inadequate supply of medicines and commodities, and shutdown of some service delivery platforms such as school health and community-based services. Uganda’s frail system for Emergency Medical Services has also been strained by the outbreak, making it difficult to provide timely care to severely ill patients. 9. The GoU initiated COVID-19 vaccination campaign in March 2021. As of October 23, 2021, the country had received a total of 8,891,410 doses of COVID-19 vaccines comprising of AstraZeneca, Moderna and Pfizer from the COVAX Facility, donations from the Governments of China, France, India, Ireland, Norway, the United States of America, the United Kingdom. The government had also made commitments to and purchased vaccines from the AVAT mechanism and COVAX. Of the vaccines received, 3,189,173 doses (i.e., 34 percent) have been administered thus far. A total of 2,483,233 people had received at least one dose of either AstraZeneca, Pfizer, Moderna or Sinovac 3 vaccines, accounting for 5.6 percent of the national population, a coverage that is far below the NVDP target of 49.6 percent. Out of the number of people vaccinated, 705,940 (1.6 percent) had received full doses (i.e., two shots 4). The vaccine campaign thus far has prioritized five main high-risk groups: security personnel, health care workers, teachers, people above 50 years, and people with comorbidities. Of this group the highest uptake has been among the essential workers with coverage rates (fully vaccinated) of 45 percent for health care workers, 28 percent for security personnel and 22 percent for teachers. The government is accelerating efforts to vaccinate all teachers prior to the reopening of schools in January 2022 and seems on track to meet that target. In contrast vaccination of people above 50 years and people with comorbidities stands at only 5 percent and 2.5 percent for the first and second dose, respectively. 10. The low uptake of vaccines to date has been attributed to initial delays in vaccine delivery, initial hesitancy (especially by high-risk groups such as teachers and health care workers), and low staff motivation. Within the last month, though the GoU has made significant improvements in vaccinating 3 Moderna doses arrived on September 6, 2021. 4 No shots of Johnson and Johnson had been administered at time of preparing this Project Paper 11 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) essential workers with the first doses, notably health care workers (90 percent), teachers (66 percent) and security personnel (63.5 percent). However, the country faces the risk of vaccine expiries, particularly of Pfizer and AstraZeneca doses. While efforts to improved communications has improved since the COVID- 19 outbreak, there is still a significant gap, which continues to affect vaccine uptake especially among the elderly and people with comorbidities. 11. While more recent information on vaccine hesitancy is not yet unavailable, two COVID-19 High Frequency Phone Surveys 5, conducted by the World Bank in October/November 2020 and February 2021 suggested that over 80 percent of people would “agree to take an approved coronavirus vaccine if available at no cost.” For refugees surveyed in separate High Frequency Surveys 6, 88 percent of respondents indicated that they would “agree to be vaccinated if free and safe vaccine is available.” Experience in the roll out, however, suggests that vaccine hesitancy may continue to be an issue and will need to be addressed proactively. To tackle the challenges, the government is ramping up efforts to vaccinate at least 4.8 million 7 people by December 31, 2021, by expanding the eligible population for vaccination including students aged 18 years old and above, providing incentives for health care workers, and increasing the number of vaccination points to include markets, community playgrounds and recreational centers. The Policy and Institutional Environment for Refugees in Uganda and Linkage to the Proposed AF 12. Uganda hosts the largest number of refugees in Africa. Their number has more than doubled since 2015 to over 1.5 million with South Sudanese making up the largest nationality (924,835 people), followed by those from the Democratic Republic of the Congo (433,062) and Burundi (51,039). 8 A further 90,629 refugees come from Eritrea, Ethiopia, Rwanda, Somalia, Sudan and 23 other countries. Ninety-four percent of the refugees live in settlements across 12 RHDs with a population of 4,437,500 people (excluding Kampala), while the remainder live among mainly urban communities. 13. COVID-19 has significantly impacted hosting communities and refugees. A World Bank study on Monitoring Socio-economic Impacts of Covid-19 on Refugees in Uganda 9 shows that refugees are faring worse on key dimensions of welfare, and their recovery is slow compared with Ugandans in general. Based on this, the study indicates that the post-COVID-19 recovery for refugees will be fragile and, as such, refugees will require continued and strengthened support during and after the pandemic to escape the 5 World Bank. 2021. COVID-19 Impact Monitoring: Uganda, Round 4-5. Washington, DC: World Bank. 6 World Bank. 2021. Monitoring Social and Economic Impacts of COVID-19 on Refugees in Uganda: Results from the High- Frequency Phone - Third Round. Washington, DC: World Bank. 7 While the GoU made commitments for enough vaccines to inoculate 19 percent of its population by December 31, 2021, the unpredictable delivery schedules for the vaccines, coupled with the limited number of vaccines currently available in country has necessitated a more modest goal of 4.8 million. 8 Office of the Prime Minister/UNHCR. 2021. Uganda Comprehensive Refugee Response Portal. https://data2.unhcr.org/en/country/uga. 9 World Bank. 2021. Monitoring Social and Economic Impacts of COVID-19 on Refugees in Uganda: Results from the High- Frequency Phone Survey (Round 1, 2, 3). World Bank, Washington, DC. © World Bank. 12 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) “poverty trap.” Furthermore, protection risks to Uganda’s refugees such as gender-based violence (GBV) have been exacerbated during COVID-19 10. 14. The proposed AF, through the WHR Regional Sub-Window (RSW) for COVID-19, will support Uganda’s inclusive approach to refugees, by strengthening GoU efforts to protect hosting districts/communities and refugees from the effects of COVID-19. The World Bank, following consultation with UNHCR, 11 has determined that Uganda’s refugee protection framework remains adequate for accessing financing from the IDA19 WHR. Uganda is recognized globally for its national refugee policies which are closely aligned with the Global Compact on Refugees. Uganda is a state party to international or regional instruments protecting refugees and its laws, policies, and its practices are consistent with international refugee law, guaranteeing non-refoulement and adequate protection for refugees and asylum seekers. Uganda has ratified: the 1951 Refugee Convention; the 1967 Protocol relating to the Status of Refugees; the 1969 Organization of African Unity Convention Governing the Specific Aspects of Refugee Problems in Africa; and nine international and regional human rights instruments relevant for refugee protection. These are domesticated into Uganda’s legal system through the 2006 Refugee Act and its 2010 Refugee Regulations as well as other laws which accord protection to life and liberty of all persons, such as the Bill of Rights in the 1995 Constitution and the Penal Code Act. The Refugee Act guarantees refugees fundamental rights, including the right to work, enjoy freedom of movement, own property, and access social services, including health services. The Refugee Regulations stipulate the integration of refugee matters in National Development Plans. Uganda’s asylum policies and protection framework advance the integration of refugees and foster an enabling environment for them to live in safety and with dignity. Uganda is also implementing the Comprehensive Refugee Response Framework (CRRF). to support refugees and refugee host communities. Uganda has reiterated its ongoing commitments to refugee protection in the context of COVID-19 in Uganda’s Strategy Note on Support to Refugees and RHDs. 15. Uganda has remained committed to its refugee policies promoting the integration of refugees into national systems despite the pressures of COVID-19. The proposed WHR-financed elements of this AF demonstrate substantial policy content by supporting the implementation of the Health Sector Integrated Refugee Response Plan (HSIRRP), and the integration of refugees within the costed NVDP. The HSIRRP sits under the CRRF and has three objectives: (i) increasing equitable access to and utilization of quality health services for refugees and host communities; (ii) mobilizing and managing health resources towards building a resilient health system to cope with the increased demand on health services; and (iii) strengthening governance, coordination, leadership, and management of the integrated refugee health response. The AF will address all three objectives of the HSIRRP. All components will deliver services, vaccines, and related supplies—in line with the national policy frameworks for refugees as well as with the national Resurgence Plan and NVDP. A detailed description of the AF’s support for refugees is provided in Annex 3. 10 World Bank. 2020. Gender-Based Violence and Violence Against Children: Prevention and Response Services in Uganda’s Refugee-Hosting Districts. World Bank, Washington, DC. 11 Based on the Uganda Refugee Protection Assessment Update 2, 18 August 2021. 13 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) B. Consistency with the Country Partnership Framework (CPF) 16. The proposed project is aligned with the Country Partnership Framework (CPF) for 2016 – 2021 (Report No. 101173-UG), discussed by the Board on April 21, 2016, and the Performance and Learning Review of the CPF (Report No. 157534-UG). The proposed AF is consistent with the Strategic Focus Area 1, Governance, Accountability, and Service Delivery, and Objective 2, Improved Social Service Delivery of the CPF. The country program was adjusted to effectively respond to COVID-19. This includes: (i) activating a Contingent Emergency Response Component under the Uganda Reproductive Maternal and Child Health Services Improvement Project (URMCHIP, P155186); (ii) preparing a new COVID-19 operation focusing on health (UCREPP, P174041); (iii) providing a grant through the Global Partnership for Education for the COVID-19 Emergency Education Response Project (P174033) and (iv) providing budget support through an Emergency Fiscal and Growth Stabilization Development Policy Operation (P173906) aimed at alleviating the negative impact of the COVID-19 and locust invasion by maintaining macro-fiscal stability and supporting businesses and households. Further, the updated Systematic Country Diagnostic (SCD, Reference No: P500017), which will inform the next CPF, reinforces the strategic priorities of the current CPF and envisions an intensified focus on health system strengthening, with a focus on COVID-19 response, including vaccination. The proposed AF, like the parent project (UCREPP, P174041), is aligned with both global health and IBRD/IDA priorities on improving pandemic preparedness. The proposed AF is also consistent with national and health sector development plans such as the third National Development Plan, the Health Sector Development Plan (2020/21–2024/2025), the National Action Plan for Health Security (2019–2023), the National COVID-19 Resurgence Plan (2021-2022), and the NVDP. C. Project Design and Scope 17. The Project Development Objective (PDO) remains unchanged and is to prevent, detect and respond to COVID-19 and strengthen national systems for public health emergency preparedness in Uganda. The parent Project 12 supported the three components namely Component 1 (Case Detection, Confirmation, Contact Tracing, Recording, Reporting); Component 2 (Strengthening Case Management and Psychosocial Support); and Component 3 (Project Management, Monitoring and Evaluation). As detailed in section II (description of the additional financing), the AF will add two components. These are Component 4 (Vaccine Acquisition and Deployment) and Component 5 (Strengthening Continuity of Essential Health Services). It also seeks to scale up interventions under all these components in the RHDs. 12Detailed description of the Project can be found at the following link: https://wbdocs.worldbank.org/wbdocs/drl/objectId/090224b087bc19f0 14 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) D. Project Performance 18. Progress towards achievement of the PDO and overall implementation progress were rated Moderately Satisfactory in the last Implementation Status and Results Report (ISR) of November 2021. As of November 4, 2021, disbursements amounted to US$ 5.7 million (36.2 percent) of the total Project cost. Disbursements were slowed following the closure of the grant component due to delayed effectiveness of the IDA credit (US$12.5 million) caused by a combination of factors, including the January 2021 general election and long processes for Parliamentary and Cabinet approval of loans, which were completed in March and May 2021, respectively. The Financing Agreement was signed on June 30, 2021, and the Project was declared effective on August 3, 2021. Since effectiveness, the GoU has committed US$9.6 million, of which US$3 million was disbursed on October 22, 2021. Thus far, the Project resources have contributed to increasing the proportion of people screened at Ports of Entry for COVID-19, increasing the cumulative number of COVID-19 testing, and enhancing the capacity of laboratories to confirm COVID-19 tests within 72 hours or less. Overall, project management has thus far been satisfactory. 19. The Environmental and Social (E&S) performance of the parent project is satisfactory. Despite the effectiveness lag, preparatory activities in line with the project Environmental and Social Management Framework (ESMF) are underway. Environmental and Social Impact Assessment (ESIAs) for the proposed completion of constructed laboratories at Lira and Fort Portal Regional Referral Hospitals have been completed and await final approval by the Bank prior to submission to the National Environment Management Authority. 20. Fiduciary performance under the parent project is moderately satisfactory. The accounting and internal control arrangements are reasonable but require improvement, particularly regarding accountability for project funds. A detailed assessment of FM performance for the parent Project has been conducted by the World Bank and this review puts the FM rating as Moderately Satisfactory. The procurement arrangements are also largely reasonable with the main challenge being delays in completing key procurements. Accordingly, the procurement rating for the project is rated Moderately Satisfactory. 21. The proposed AF has been screened for short- and long-term climate change and disaster risks. The parent project was not screened during preparation, given the exception made for operations under the SPRP in FY20. E. Rationale for Additional Financing/Restructuring 22. The AF will primarily support Uganda’s efforts to acquire COVID-19 vaccines and finance deployment activities. To date, Uganda has received vaccine donations or procured vaccine doses in small quantities thereby raising distribution and deployment costs amid severe resource constraints and poor uptake of vaccines. The AF will provide upfront resources to support procurement of significant volume of vaccines (to cover up to 11.7 million people, 26.4 percent of the national population) and consumables 15 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) as well as deployment efforts such communication, community engagement, data and information management and staff costs. 23. Given the low vaccination coverage at the country level and the country’s vulnerability to resurgence of the outbreak, the proposed AF will also provide support to scale up efforts to boost disease surveillance and case management capacity, including in refugee settlements and hosting districts cross-border areas, and RHDs. The AF will also support continuity of delivery of essential health services, especially for reproductive, maternal, child and adolescent health (RMNCAH) services, which constitute a large share of the national disease burden. The proposed AF will, thus, form part of an expanded health response to the pandemic and support the scale-up of a limited set of interventions, aligned with the national COVID-19 Resurgence Plan (June 2021–June 2022), 13 and the Continuity of Essential Health Services Strategy/Guidelines. 24. The AF also includes a Level II restructuring that will refine the Project’s design, reallocate costs across components, introduce a new component and subcomponents, modify the Results Framework, and extend the closing date of the parent project by 24 months to December 31, 2024. These modifications are necessary to enhance development effectiveness and strengthen alignment between Project interventions and the evolving country context. 25. The AF will also complement the contributions of other development partners in the context of the GoU’s overall COVID-19 response. It will also work through the national HSIRRP Secretariat, hosted at the MoH, and COVID-19 national structures that incorporate refugees. Box 1 provides a summary of development assistance to Uganda on COVID-19 response. 13 The Resurgence Plan is costed at US$358.9 million. Whereas partners have committed up to US$ 215 million towards this plan, a funding gap of approximately US$ 144 million remains. 16 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Box 1: Roles for Partner Agencies in Implementation WHO Financing Amount (Grant) Providing technical leadership for vaccine introduction, providing technical support US$3,550,988 to National Immunization Technical Advisory Group to define COVID-19 vaccination (as contributions from UNDP, policy objectives, strategy, targets, and vaccine safety issues. Developing guidelines Norway, and Germany with and conducting training on Adverse Event Following Immunization (AEFI) surveillance significant focus on the for COVID-19 vaccine related issues and other issues of vaccine pharmacovigilance, vaccination program) etc. GAVI/COVAX Financing Amount (Grants) Providing vaccines to cover the first prioritized 20 percent of the population as well US$128,074,800 as additional doses through cost-sharing arrangements; providing technical (vaccine donations) assistance in COVID-19 vaccines procurement. Deployment of vaccines US$3,554,186 African Union Vaccine Acquisition Trust (AVAT) Providing vaccines through African Union partnership with Afreximbank, and Janssen Pharmaceutical, UNICEF. JICA (through UNICEF) Financing Amount (Grant) Provision of cold chain equipment including medical equipment for cold-storage US$1,640,442 facilities at national and sub-national levels, and transportation to ensure vaccination in the country. Support towards procurement of COVAX vaccines. Global Fund Financing Amount (Grant) Support towards all pillars of the resurgence plan, in particular continuity of essential US$86,000,000 services for TB, HIV and malaria; support to the scale up of COVID-19 Testing, Procurement of Personal Protective Equipment (PPEs). Oxygen delivery capacity. UNHCR Financing Amount (Grant) Provision of supplies for vaccination; Provision of PPEs for use across the country and US$ 351,010 supporting all pillars of the resurgence plan within refugee communities. USAID Financing Amount (Grant) Provision of data collection tools for vaccination (consent forms, registers, adverse US$440,939 events reporting forms, stock monitoring reporting books). Through USAID implementing partners, ensuring the continuity of essential services and risk communication. CDC Financing Amount (Grant) Provision of data collection equipment. On-going support to the Emergency US$103,360 Operation Centre. Clinton Health Access Initiative (CHAI)/Bill & Melinda Gates Foundation Financing Amount (Grant) Support to national and district monitoring, supervision, and performance US$ 176,000 management of vaccine activities to improve delivery and management, including post-market surveillance inspection and rapid assessments to determine barriers to vaccine deployment and uptake. Total US$223,891,725 F. National Capacity and COVID-19 Vaccination Plan (i) Vaccine Readiness Assessment 17 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 26. Between September 2020 and May 2021, Uganda conducted three vaccine readiness assessments with the latest specifically undertaken to provide updates on gaps in vaccine readiness and estimate the cost of vaccine deployment with the support of international organizations including the African Union, WHO, UNICEF, GAVI, WBG, USAID, UNHCR, CHAI, PATH, and CDC. This assessment used the combined Vaccine Readiness Assessment Framework (VRAF) and Vaccine Introduction Readiness Assessment Tool (VIRAT), VIRAT/VRAF 2.0. Uganda’s readiness progressively improved from 50 percent in September 2020 to over 85 percent by May 2021 14. Findings from the latest assessment which are summarized in Table 1 below show key gaps in financing for procurement and deployment of vaccines; service delivery/vaccination platforms; health information systems; identification and management of vaccine safety; and demand generation and risk communication. Many of these areas are covered under the scope of this proposed AF. Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment 15 (October 2021) Readiness Domain Readiness of government Key gaps to address before/during deployment Planning and • National Vaccines Deployment Plan is in place • Planning for vaccine procurement and deployment is an Coordination • Functional committees have been established iterative process with partners. (National COVID-19 Strategic Committee, National • Current vaccine target coverage is 49.6 percent, but GoU Vaccine Advisory Committee (VAC), Scientific has made commitments to vaccinate 67.7 percent of the Advisory Committee, Incidence Management population, in anticipation of the need to inoculate Team, National Immunization Technical Advisory children and offer booster shots if necessary. Group (NITAG), National Coordination Committee). • Adequate planning is required to ensure timely • Regional and District Task Forces have been deployment within 2 years. activated. • Waste management equipment is not yet sufficient. Management of reverse logistics is not systemic lacking transportation infrastructure and a related information system to synchronize received stock vials with waste vials Budgeting • Current NVDP budget of about US$ 392 million was • NVDP still has a funding gap of approximately US$128.6 developed with multiple stakeholders excluding the million proposed AF, (covering vaccines, supplies and • GoU needs to have formal mechanism that estimates operational costs). funding needs based on modelling scenarios and informs • COVAX AMC to cover 20.7 percent of the population the budgeting process in time to ensure vaccine needs (about 9 million people) are included in government budget documents. • Need to plan for vaccinating children and offering booster • Proposed AF will cover vaccine procurement for shots, as well as mainstreaming COVID-19 vaccination in 26.4 percent of the population; GoU will cover the routine immunization. remainder. 14 https://app.powerbi.com/view?r=eyJrIjoiOTgzZDRkZWUtOTEwNC00N2E1LTllMDItMmM5ZTM2MmNhYzVkIiwidCI6ImY2MTBjM GI3LWJkMjQtNGIzOS04MTBiLTNkYzI4MGFmYjU5MCIsImMiOjh9 15 A multi-partner effort led by WHO and UNICEF developed the Vaccine Introduction Readiness Assessment Tool (VIRAT) to support countries in developing a roadmap to prepare for vaccine introduction and identify gaps to inform areas for potential support. Building upon the VIRAT, the World Bank developed the Vaccine Readiness Assessment Framework (VRAF) to help countries obtain granular information on gaps and associated costs and program financial resources for deployment of vaccines. To minimize burden and duplication, in November 2020, the VIRAT and VRAF tools were consolidated into one comprehensive framework, called VIRAT-VRAF 2.0. 18 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Readiness Domain Readiness of government Key gaps to address before/during deployment Regulatory • The National Drug Authority (NDA) is mandated by • Missing vaccine information—for example, number of an Act of Parliament 16 to approve the use of years of protection and potential need and frequency for medicines including vaccines in public health booster doses. emergencies. • NDA bases approval on WHO Emergency Use Listing (EUL). Prioritization, • Current priority target groups are health workers • Among priority groups, about 45% percent of health care Targeting, Surveillance (0.34 percent), security personnel 0.57 percent) workers are fully vaccinated and 22 percent of teachers teachers (1.24 percent), persons above 50 years are currently immunized, and only 5% of elderly persons (7.57 percent), and persons 18-50 years with co- above 50 years. morbidities (39.9%). Service delivery • COVID-19 vaccine deployment uses the existing • There is still room for scaling up the number of vaccine Uganda National Expanded Program for service delivery points if target groups and numbers are Immunization (UNEPI) framework for last mile to be reached. distribution. • Scaling up vaccine sites poses readiness challenges for the • MoH has accredited over 2500 public and private additional sites including PPEs, allowances for health facilities to deliver vaccination services workers and proper orientation. • Guidelines for ensuring vaccine potency and correct administration were developed and health workers trained in their use. Training and • All districts have been trained on the different • Need for mentorship and support supervision of supervision components of vaccine delivery. vaccinators by district health teams (DHTs) since the • Training of vaccinators was delivered online. online training was not highly effective in some locations due to internet network disruptions. • There is a need for continuous training of additional health workers as the service delivery points are scaled up. Monitoring and • Vaccinating sites register/record and aggregate line • Occasional stockouts of data collection tools at the Evaluation listed data, relay to the district biostatisticians who vaccinating sites. in turn capture this data into the District Health • Inadequate Monitoring and Evaluation (M &E) personnel, Information System (DHIS2) Client Tracker that aids ICT equipment and internet access limit the capacity to national visibility and analysis. capture close to real time uptake data at vaccination • A set of six critical indicators are being monitored sites. nationally and at site level. • Not all data collection is digitalized; most is still manual • Access to line listed data is highly restricted due to with sub optimal quality and information transmission confidentiality requirements; aggregate data has delays. fewer restrictions and is used to monitor uptake and stock status. Vaccine, cold chain, • Uganda has a well-established vaccines logistics • Systems and protocols for tracking and monitoring stock logistics and system for primary storage and distribution of management and distribution of vaccines and key infrastructure COVID-19 vaccines and the MoH policy for supplies needs updating. managing waste is provided in the EPI Guidelines. • Operating procedures need to be developed especially • Cold chain capacity has been expanded to include for ultra-cold chain vaccines. storage of vaccines that need temperatures below • Monitoring of wastage at vaccination sites as well as +8o. stock status during deployment needs strengthening. Safety surveillance • All staff at vaccination sites have been trained in • Mechanisms for no fault liability funds should be AEFI surveillance and provided with AEFI kits which determined since there are no specific compensation schemes or guidelines for unintended health 16 Section 8(4) of the National Drug Policy and Authority Act (Cap 206). 19 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Readiness Domain Readiness of government Key gaps to address before/during deployment include guidelines, and tools for data collection on consequences of vaccines, including no-fault liability AEFI. funds. • The National AEFI Committee and the Causality Assessment Committee share information on AEFIs regularly with UNEPI and the National Coordination Committee. Demand generation • The Demand Generation and Risk Communication • Dissemination of key IEC messages is underfunded and and communication Sub-committee develops appropriate strategies and has not happened to required levels needed to counter communication packages to engage communities anti-vaccination messages. and advocate for COVID-19 vaccination to reduce • Low uptake of vaccines by high-risk group necessitates severe disease and deaths, protect the national intensified risk communication among these groups. health system and contribute to return to normal social and economic life. (ii) National COVID-19 Vaccine Deployment Plan (NVDP) 27. The GoU prepared a costed NVDP, which draws on the findings of the VRAF/VIRAT 2.0 assessment and gap analysis. The NVDP was developed, in line with WHO guidance and recommendations of the Strategic Advisory Group of Experts on Immunization (SAGE). The NVDP was endorsed on February 9, 2021 but is intended to be routinely updated to reflect changes in the national plan/approach/priorities. Refugees are fully integrated into the plan consistent with Uganda’s policy of integrating refugees’ health and other social services into the routine government service delivery systems. 28. Uganda with support from WHO and partners conducted Intra-action Review of the first phase of COVID-19 vaccination in July 2021. Key lessons learned relate to stakeholder engagement and risk communication, access to immunization points, monitoring, evaluation and data management, and risk communication. From the outset, the MoH involved a wide range of stakeholders in the vaccination program planning; however, the private sector, community leaders and Village Health Teams (VHTs) were not adequately engaged. While the MoH had invested substantially in risk communication, there remained a need to intensify ongoing efforts, especially to enhance vaccine uptake and address misinformation. At the initial stages, there were only five vaccination points per district, and this greatly affected access. To address this problem, Uganda has now increased the number of vaccination centers including level III health facilities, outreaches sites, and special campaign sites. Collaboration with the, VHTs has also been enhanced. Uganda also has a major vaccination data backlog due to use of a paper- based data collection system at service delivery points that need to be upload onto the electronic information systems (DHIS-2). Measures to address these challenges have been incorporated into the Project design. In particular, the AF provides up to US$20.12 million for deployment which includes measures to address the identified challenges. 29. Policy and Oversight: The procurement of vaccines, policy, strategy, and overall oversight is the mandate of the MoH while the actual vaccination exercise is delivered by health facilities at local government level. Once procured, the vaccines are stored and distributed to the health facilities by the National Medical Stores in accordance with the NVDP and the micro plans of the respective entities. District cold chain technicians distribute the vaccines directly to the health facilities, which then either 20 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) administer them on-site or through outreaches. The health facilities are mandated to identify eligible beneficiaries, vaccinate, and prepare reports for submission through DHIS2 to facilitate national oversight of the exercise and course correction, where warranted. 30. Post vaccination surveillance: One of the objectives of the NVDP is to monitor and evaluate preparedness, implementation, and occurrence of Adverse Events Following Immunization (AEFIs). People experiencing serious AEFIs on-site are counselled and treated using an AEFI kit provided by the immunization team. Cases of AEFIs are documented and transmitted to the MoH as part of the routine reports on the immunization activity. The reports reach the MoH through two channels, either through the DHIS-2 e-tracker or a phone call to the National Drug Authority (NDA), which enters the clients’ details and symptoms into a database. Each serious AEFI case is investigated by a National Investigation team that has regional presence. A national causality assessment committee is in place to assess the potential causes of the AEFIs. 31. Digital tools and technologies included in the NVDP: The country is leveraging the DHIS-2 to facilitate close to real-time collection, transmission, and analysis of the COVID-19 vaccination reports. The tool captures three key components of data, i.e., the vaccine stock chain, the vaccination data, and the AEFIs both as aggregate for all data components and individual elements. It has a dashboard/DHIS-1 tracker, which facilitates reporting by frontline workers using mobile phones, tablets, and computers. Prior to entry into the DHIS-2, the data is manually documented on Client Cards, Client Registers, vaccines, and Injection Materials Control book, AEFI forms and vaccine stock report. Other forms of digital technologies being explored include the use of SMS text messaging to alert people of second dose of vaccination. There is scope to further strengthen the role of digital technologies in the vaccination exercise and in COVID-19 response more generally. The Bank has facilitated discussions between the MoH, the Digital Development Partnership, and the National Information Technology Authority (NITA-U), to explore leveraging resources through other Bank-financed projects, with a focus on digital technologies, to bridge current gaps. 21 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Table 2: National Vaccine Coverage and Acquisition Plan [Based on the available estimates as of October 23, 2021] Source of financing Population Targeted (IBRD, IDA, (Total Population Vaccines Number of doses Estimated World Contract Vaccines already arrived in the TF, Govt, 44.21 million) needed* total U$ Bank’s VAC Status country Other) (million) Status of the vaccine % Number Source Name Price Shipping Name Doses ($/dose) ($/dose) Phase 1 (by December 31, 2021) COVAX AstraZeneca COVAX 6.4% 2,845,291 7 N/A 5,690,582 39,834,074 Meets VAC On-going AstraZeneca 4,130,160 Donation Vaccine COVAX COVAX 0.7% 323,540 MODERNA 21 N/A 647,080 13,588,680 Meets VAC On-going MODERNA 647,080 Donation COVAX COVAX 1.9% 837,135 PFIZER 21 N/A 1,674,270 35,159,670 Meets VAC On-going PFIZER 1,674,270 Donation INDIA AstraZeneca INDIA* 0.1% 50,000 N/A N/A 100,000 N/A Meets VAC N/A AstraZeneca 100,000 Donation Vaccine CHINA SINOVAC GOVT OF CHINA* 1.1% 500,000 N/A N/A 1000,000 N/A Meets VAC N/A SINOVAC 1,000,000 Donation Vaccine Government of Irish AstraZeneca 0.4% 167,750 N/A N/A 335,500 N/A Meets VAC N/A AstraZeneca 335,500 Ireland Donation Vaccine Donation Johnson & Johnson & Mastercard 1.6% 700,000 from N/A N/A 700,000 N/A Meets VAC N/A N/A Johnson Johnson Mastercard GoU (existing Johnson & Johnson & 3.9% 1,727,982 AVAT 8.97 N/A 1,727,982 15,500,000 Meets VAC TBC 657,600 funds) Johnson Johnson GoU (existing 2.9% 1,272,727 COVAX SINOPHARM 5.5 N/A 2,545,455 14,000,000 Meets VAC TBC SINOPHARM 346,800 funds) Phase 1 Total 19.1% 8,424,425 14,420,869 118,082,424 8,891,410 Phase 2 (By December 31, 2023) GoU (existing Johnson & Johnson & 2.2% 972,241 AVAT 8.97 N/A 972,241 8,721,002 Meets VAC TBC - funds) Johnson Johnson 22 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Source of financing Population Targeted (IBRD, IDA, (Total Population Vaccines Number of doses Estimated World Contract Vaccines already arrived in the TF, Govt, 44.21 million) needed* total U$ Bank’s VAC Status country Other) (million) Status of the vaccine % Number Source Name Price Shipping Name Doses ($/dose) ($/dose) Johnson & After project Johnson & GoU/WB 12.7% 5,599,777 AVAT 8.97 N/A 5,599,777 50,230,000 Meets VAC - Johnson effectiveness Johnson After project GoU/WB 13.7% 6,070,000 COVAX SINOPHARM 5.5 N/A 12,140,000 66,770,000 Meets VAC SINOPHARM - effectiveness COVAX COVAX 5.2% 2,319,525 AstraZeneca 7 N/A 4,639,050 32,475,800 Meets VAC TBC AstraZeneca - donation COVAX COVAX 6.4% 2,822,709 PFIZER 21 N/A 5,645,418 118,553,778 Meets VAC TBD PFIZER - Donation GoU 3.6% 1,572,073 COVAX SINOPHARM 5.5 N/A 3,144,145 17,292,798 Meets VAC TBD SINOPHARM - GoU 4.9% 2,150,000 COVAX PFIZER 21 N/A 4,300,000 90,300,000 Meets VAC TBD PFIZER N/A Phase 2 Total 48.6% 21,506,325 36,440,631 384,343,378 - - - NATIONAL TOTAL 67.7% 29,930750 - - - 50,861,500 502,425,802 - - - 8,891,410 Note: GoU has procured or committed to procure doses to vaccinate 67.7% of its population even though the national target is currently 49.6%. The additional doses are intended to cater for the vaccination of 12–17-year-old children and the potential need for revaccination/booster dose for priority groups. Table 3: Summary of national vaccine acquisition plan Mechanism of acquisition Population Number of people Doses Amount (UGX) COVAX AMC 20.70% 9,148,200 18,296,400 239,604,652 GOU Direct Purchase 17.40% 7,695,023 12,689,823 145,813,799 UCREPP Additional Financing 26.40% 11,669,777 17,739,777 117,000,000 Other donations 3.20% 1,417,750 2,135,500 N/A Total 67.70% 29,930,750 50,861,500 502,418,451 23 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Box 2: Liability and Indemnification Issues in Vaccine Acquisition Key Issues: • The rapid development of vaccines increases manufacturers’ potential liability for AEFI. • Manufacturers want to protect themselves from this risk by including immunity from suit and liability clauses, indemnification provisions, and other limitations of liability clauses in their supply contracts. • Contractual provisions and domestic legal frameworks can all operate to allocate that risk among market participants, but no mechanism will eliminate this risk entirely. For COVAX-financed vaccines for AMC countries: • COVAX has negotiated model indemnification provisions with manufacturers for vaccines purchased and supplied under the COVAX AMC. • In providing vaccines through COVAX AMC, COVAX requests COVAX AMC Participants to have in place an indemnity agreement directly with manufacturers, and the necessary indemnity and liability frameworks for that purpose – either in the form of the COVAX model indemnification arrangements or prior bilateral arrangements with manufacturers. • The COVAX Facility will have a no-fault compensation scheme (“NFCS”) for AMC countries as part of its risk mitigation strategy. This will cover vaccines supplied only through COVAX AMC. • Uganda will have to consider what it will take to implement these indemnification provisions (including statutory implementation) and how they can avail of the benefits of the no-fault compensation scheme. For vaccines purchased through AVAT: • The Advance Purchase Agreement (“APA”) signed on March 28, 2021, by AVAT, Janssen Pharmaceutica NV (“Janssen”) and the African Export-Import Bank includes indemnification provisions in favor of Janssen for vaccines purchased and supplied under the APA. Participating countries will assume those indemnification obligations upon execution and delivery of a deed of adherence to the APA. • As a condition for the delivery of vaccine doses under the APA, participating countries shall also participate in or establish and adequately fund an NFCS in accordance with certain minimum requirements. Participating countries shall either: (i) participate in the NFCS to be established by AVAT, or (ii) establish and maintain their own NFCS. For the avoidance of doubt, AMC countries will not be able to rely on their participation in the COVAX NFCS to meet the conditions under the Janssen APA. • For vaccines purchased through AVAT, Uganda will have to consider how to implement the indemnification provisions and NFCS requirements under the APA with Janssen. For vaccines purchased outside of COVAX and AVAT: • Uganda will need to enter direct indemnification arrangements with manufacturers. • Uganda does not currently have legislation in place to provide statutory immunity for manufacturers. Uganda does not have national no-fault compensation scheme. The established NDA is filling the gap on the authorization of importation, relying on recommendations of WHO EUL and other countries that have SRAs. • Adoption of any such indemnification provisions or compensation scheme would have to be in accordance with Uganda’s own national strategy and framework. Possible World Bank support to Uganda, depending on needs, may include: Information sharing on: (i) statutory frameworks in Organization for Economic Cooperation and Development countries and other developing countries; and (ii) overall experience in other countries; (ii) training and workshops for government officials to familiarize them with the issues; and (iii) provision of Hands-on Expanded Implementation Support (HEIS) for World Bank-financed contracts. 24 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) II. DESCRIPTION OF ADDITIONAL FINANCING A. Proposed Changes 32. The AF will finance project scale up through supporting (i) vaccine acquisition and deployment, (ii) continuity of essential services affected by the pandemic and (iii) expand the coverage of interventions to address the needs of host communities and refugees. Activities proposed under the AF are well aligned with the original PDO and the PDO will remain unchanged. The content of the components and the Results Framework of the parent project are adjusted to reflect the expanded scope and new activities proposed under the AF. The proposed changes are summarized as follows: 33. The Additional Financing will increase the overall cost of the Project to US$195.5 million (consisting of US$15.2 million in the parent project plus US$180.3 million AF), by scaling up existing activities, adding new activities, and expanding coverage to host communities and refugee settlements. These adjustments reflect the changing epidemiological changes of the pandemic and response needs. It also involved Level II Restructuring to (i) add a new Component 4 and Component 5, (ii) update the Results Framework, (iii) reallocate costs across components, (iv) extend the project closing date by 24 months to December 31, 2024, and (v) update the institutional arrangements. Component 4 on vaccine acquisition and deployment to introduce activities related to Uganda’s COVID-19 vaccine program. A total of US$137.15 million (out of the US$ 180.3 million, 76 percent) is envisioned for this new component while Component 5 will support Continuity of Essential Health Services. Changes to the Results Framework include introduction of two PDO level indicators, revision of targets and addition of sub indicators mainly to measure investments in RHDs and closing gender gaps. (i) Proposed New Activities: 34. Vaccine purchasing is included in the Global COVID-19 MPA (SPRP). The support for vaccines, which was anticipated in the initial Global COVID-19 MPA, is being added to the parent project as part of the containment and mitigation measures to prevent the spread of COVID-19 and minimize deaths. Uganda will primarily procure COVID-19 vaccines through COVAX and AVAT. Given the recent emergence of COVID-19, the government envisions the potential need for re-vaccination if/when warranted by peer- reviewed research. In the case that re-vaccination is required, limited priority populations (such as health workers and the elderly) will need to be prioritized for re-vaccination given constraints on vaccine production capacity and equity considerations (i.e., tradeoffs between broader population coverage and re-vaccination). 35. The AF will support investments to bring immunization systems and service delivery capacity to the level required to successfully deliver COVID-19 vaccines at scale and strengthen pandemic preparedness. To this end, the proposed AF is geared towards assisting the GoU, working with Africa CDC, GAVI, UNHCR, UNICEF, WHO, and other development partners, to overcome some of the bottlenecks as identified in the COVID-19 vaccine readiness assessment in the country. 25 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 36. Component 1: Case Detection, Confirmation, Contact Tracing, Recording, Reporting [Total Financing of US$9.3 million of which Additional Financing is US$3 million (consisting of US$2 million from the WHR and US$1 million from matching IDA grant for host communities and refugees)]: This component focuses on strengthening disease surveillance capacity, including for climate-related diseases. It will expand coverage of existing activities to host communities and refugee settlements, which remain vulnerable given the constant threat of cross-border transmission (of COVID-19 and other diseases). The component will scale up COVID-19 testing capacity, strengthen Point of Entry screening, provide training/capacity building for field epidemiology, enhance laboratory diagnostics capacity, and build the capacity of VHTs and other community health actors to perform community surveillance (using the third version of the Infectious Disease and Response Guidelines) 17 RHDs. Further, as part of the proposed Level II restructuring of the parent Project, the component costs under the parent Project will be revised to a total of US$6.3 million, consisting of US$ 4.6 million in IDA credit and US$1.7 million in Pandemic Emergency Financing Facility (PEFF) funds. 37. Component 2: Strengthening Case Management and Psychosocial Support [Total Financing of US$22.95 million, of which AF is US$15.15 million (consisting of US$9.15 million IDA grant, US$5 million from the WHR and US$1 million from the matching IDA grant for host communities and refugees]: The objective of this component is to: (i) respond to the disease burden of COVID-19; (ii) improve infection prevention and control within hospitals and enhance clinical and intensive care capacity; and (iii) equip key personnel to adequately manage COVID-patients. The component also provides resources for psychosocial support for clinicians and care providers, as well as interventions to address sexual and GBV. • Sub-component 2a: Strengthening COVID-19 Case Management [Total financing of US$21.75 million, of which AF is US$14.15 million (consisting of US$9.15 million from IDA grant and US$ 5 million from WHR]: Under the AF, this sub-component will support the provision of better- quality services to COVID-19 patients, including those in intensive/critical care and home-based care. It will: (i) increase the volume of inputs such as Personal Protective Equipment (PPE), intensive care unit beds, supplies, medicines, consumables for management of COVID-19 cases and comorbidities; (ii) expand training in COVID-19 critical care delivery models and home-based care as well as in broader emergency response to climate shocks; (iii) finance hazard allowances to eligible frontline workers and rapid response teams; (iv) renovate intensive care units and isolation facilities in regional referral hospitals and general hospitals, including those serving RHDs and refugee settlements. • Sub-component 2b: Psychosocial Support and Gender-Sensitive Interventions [Total Financing of US$1.20 million, of which AF is US$1 million from the IDA grant for host communities and refugees]: US$1 million will be used to support psychosocial services for residents of host communities and refugee settlements. Linked to Subcomponent 5b, the Project, in coordination with the Ministry of Gender, Labor and Social Development (MoGLSD), will: (i) train health care workers in host communities and refugee settlements on managing GBV cases; (ii) provide 17 These activities will not include Kampala, the thirteenth refugee hosting district, which by GoU’s current policy does not receive refugee support from UNHCR or the World Food Program (WFP). 26 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) psychosocial and other support (e.g. GBV kits) to survivors; (iii) sensitize host communities and refugees on GBV and resources for accessing protection services (hotlines, community mechanisms, etc.); and (iv) improve the quality of data on gender-based violence in host communities and refugee settlements, in order to inform interventions. 38. In addition to the new activities proposed, the component costs under the parent project will be revised to US$7.8 million, consisting of US$7.1 million under IDA credit and US$0.7 million under PEFF. 39. Component 3: Project Management, Monitoring and Evaluation [Total Financing of US$4.10 million of which AF is US$3 million (consisting of US$1 million from the WHR; US$1 million from the IDA grant; and US$1 million from the GFF)]. The AF will support: (i) recruitment of additional staff under the existing PIU which will ensure effective management and monitoring of activities; (ii) procurement of ICT tools to facilitate data capture, analysis, and reporting; and (iii) strengthening of internet connectivity to allow real-time data reporting from the sub-national levels (including RHDs) to the central database. Coordination and implementation between MoH, Office of the Prime Minister (OPM), UNHCR and other refugee-hosting stakeholders will be strengthened through: (i) appointing a program officer, within the PIU, for the refugee related activities linked to the HSIRRP secretariat; (ii) improving the governance and leadership mechanisms at central to district level, necessary to implement the HSIRRP; (iii) appointing designated liaisons at the district-level, who working with District Health Officers, will monitor and ensure the integration of Project-funded activities within refugee health services; (iv) covering all logistical and implementation costs associated with activities in RHDs and refugee settlements. 40. In order to enhance MoH’s monitoring and evaluation (M&E) capacity, the GFF grant will support: (i) finalization and dissemination of the National Health Digitalization Strategy, the development of which is already underway and will help bolster the dissemination of health data (including on COVID-19); (ii) development of national protocol/guidelines/tools for health data analysis, information synthesis and data utilization; (iii) training of HMIS managers, health sector managers and other key stakeholders on insight-driven health data analysis, information synthesis and data utilization and; (iv) upgrading of the DHIS-2 (to incorporate COVID-19 indicators). Finally, the resources will help to improve the quality of national health surveys such as the demographic and health surveys, including updating modules – where necessary – to better capture and interpret impacts of COVID-19. Furthermore, under the proposed Project restructuring, the component cost of the parent project will be revised to US$1.1 million, consisting of US$0.8 million in IDA credit and US$0.3 million in PEFF. 41. Component 4: Vaccine Acquisition and Deployment [US$137.15 million, of which US$124.15 million is IDA grant, US$10 million is from the WHR, US$1 million is from IDA grant for host communities and refugees, and US$2 million is from the GFF]: The AF will introduce a new component focused on vaccine purchase and deployment. Under this component, the GoU will procure vaccines to vaccinate 11.7 million people (26.4 percent of the population), in Phase 2 of its vaccination campaign, scheduled to begin in January 2022. The vaccines acquired will be available to everyone under the eligibility criteria, including refugees. The policies for prioritizing intra-country vaccine allocations in Uganda have been completed and were informed by WHO’s Framework for the allocation and prioritization of COVID-19 vaccination. 27 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) For vaccine acquisition, a total of US$10 million from the WHR has been earmarked, which will be sufficient to vaccinate a total of 1.5 million host community members and refugees within the 12 RHDs of focus 18. This breakdown is outlined in Annex 3, Table 1. 42. A total of US$20.15 million of IDA and GFF resources from this component, will be dedicated to vaccine deployment nationwide (including in refugee settlements and RHDs 19), with emphasis on strengthening critical areas such as: vaccine delivery and immunization; risk communication and community sensitization; strengthening supportive supervision; enhancing reporting and immunization data management (including engaging data entrants for expedited data capture); payment of hazard allowances to eligible health workers; and strengthening pharmacovigilance to address adverse events following immunization. 43. Component 5: Strengthening Continuity of Essential Health Services [US$22 million, of which US$9 million is from the WHR and US$13 million is from the GFF]. This component will enhance continuity of services across four priority areas. The sub-components are described as follows: • Sub-component 5a: Upgrade Health Infrastructure and Equipment for Enhanced Service Delivery (US$10 million, including US$6 million from WHR and US$4 million from GFF): This sub- component will support infrastructure upgrades in hosting communities and refugee settlements. A total of US$6 million from WHR will support: (i) renovation of selected health facilities; (ii) blood collection and procurement of blood storage equipment and blood administration supplies for health center IVs in RHDs and refugee settlements; (iii) renovation of isolation and other facilities located near points of entry (borders) routinely used by refugees and asylum seekers. The proposed interventions complement ongoing support provided through UgIFT and UNHCR, both of whom are providing wage and non-wage recurrent expenditures to RHDs. In addition to support from WHR, US$4 million from the GFF will be used to upgrade, equip, and refurbish operating theatres in at least one General Hospital and/or one Health Center IV. The refurbished theatres are intended to enhance the management of obstetric emergencies, a leading cause of maternal death in Uganda. The GFF resources will also support blood collection and storage equipment as needed, to improve availability of blood. • Sub-component 5b: Strengthen Emergency Medical Services (US$4.4 million, of which US$2.4 million is from the GFF, and US$2 million from the WHR). This sub-component will support: (i) the finalization of Emergency Medical Services (EMS) policy, guidelines, and standards (including establishment of a toll-free emergency number); (ii) procurement of ambulances equipped with supplies and products for pre-hospital care; (iii) finalization and dissemination of updated guidelines on referral pathway, including development of Standard Operating Procedures; (iv) training EMS personnel and sensitizing community members on first aid response; (v) 18 The RHDs are Adjumani, Yumbe, Isingiro, Kyegegwa, Kikuube, Obongi, Kamwenge, Kiryandongo, Lamwo, Koboko, Madi Okollo, and Terego. 19 The deployment systems for refugee settlements are those of national systems, which at the district level work closely with UNHCR, OPM and NGOs in the health sector to reach people of concern across host communities and refugees. 28 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) establishment of Regional and National Ambulance Call and Dispatch Centers in the East and West regions; (vi) improvement of dispatch and fleet information management systems, ensuring integration of emergency service and related surveillance metrics into the national HMIS, and supporting the expansion of these services into underserved parts of the country. Similar interventions will be supported in refugee hosting districts and refugee settlements, with the WHR supporting: (i) establishment of Regional and National Ambulance Call and Dispatch Centers serving RHDs in the North and South regions; and (ii) acquisition and equipment of new ambulances for selected Health Center IVs and hospitals within the 12 20 RHDs to support routine referrals and the COVID-19 response. • Sub-component 5c: Improve the availability of essential health commodities (US$4 million, of which US$3 million from the GFF and US$1 million from WHR): This sub-component will support the procurement of pharmaceuticals, commodities, and supplies for other essential health services (e.g., RMNCAH, NCDs) to compensate for acute shortages, exacerbated by the COVID-19 shock, and a decline in donor financing. Besides procuring these supplies, the sub-component will also provide technical assistance to explore feasible options for enhancing pharmaceutical procurement and supply chain management, which remains a key driver of frequent stock-out of essential medicines and supplies. Given the significant demand for these commodities nationally, additional funds will be mobilized by the MoH through other development partners. The WHR resources will support availability of specified essential health commodities in RHDs and refugee settlements, • Sub-component 5d: Strengthening Community Systems for Continuity of Essential Health Services (US$1.6 million from GFF). Drawing from the National Community Engagement Strategy, the AF will strengthen structures for community health and enhance the capacity of VHTs and other community actors to support demand generation for health services; mobilize eligible populations for vaccinations; and provide integrated community-based health services for COVID- 19, community-case management of childhood illnesses, tuberculosis, pneumonia, malaria, non- communicable diseases, and sexual and reproductive health interventions. • Sub-component 5e: Strengthening infection prevention and control in health facilities through multi-sectoral engagement (US$2 million from the GFF). The activity will build on initial engagements between HNP, the GFF and the WASH GP to address water and sanitation gaps in the health sector. Specifically, the Project will procure critical WASH amenities (e.g., waste disposal bins and liners) for national referral hospitals and COVID-19 treatment units as well as train health care workers on norms to prevent microbial resistance in the health facilities. 44. The AF will support the population groups as summarized in Table 4 below, which integrates refugees across the identified vulnerable groups. The table follows the recommendations of SAGE and are reflected in the NVDP. It only covers the population above 18 years old. 20 Not including Kampala as the thirteenth RHD. 29 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Table 4: Priority Groups for National COVID-19 Vaccination Uganda (including refugees) 21 Ranking of Vulnerable Population Group Number of People % of the Population Groups First Health Workers 150,000 0.34% Second Security personnel 250,000 0.57% Third Teachers 550,000 1.24% Fourth Persons aged>50 3,348,500 7.57% Fifth Persons aged 18-50 with 500,000 1.10% comorbidities Sixth Persons between 18 and 50 not 17,138,011 38.80% covered in the above groups TOTAL 21,936,511 49.62% (ii) Financing Arrangements 45. The increase in scope and coverage as outlined above will be reflected in an increase in indicative Project cost from US$15.20 million to US$195.50 million with the full amount of the AF being added across all components (see Table 5 below). While the allocation to Component 4 will be US$137.15 million to reflect the additional financing made available for vaccine acquisition and deployment, the additional allocation to Components 1, 2, 3 and 5 will be US$3 million, US$15.15 million, US$3 million, and US$22 million, respectively with a focus on scaling up existing programs in disease surveillance and case management, and expanding these services to host communities and refugees as well as enhancing the continuity of essential health services. Table 5 below provides a summary of the proposed AF by component. 21 Under Uganda’s ‘Open Door’ policy, all refugees are integrated and considered as part of the national population. The national target for vaccination therefore includes all residing in Uganda, as well as refugees—who are considered a part of society and cut across each of the six areas already identified above. See Annex 3 for more details in RHDs. 30 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Table 5: Project Cost and Financing (US$ million) AF ONLY PARENT ONLY All Sources Refugee Window TF AF + Parent PEFF IDA Grant Parent PROJECT COMPONENTS IDA AF Total WHR IDA Grant GFF Total Total [1] (Revised) Component 1: Case Detection, Confirmation, Contact Tracing, Recording, 6.30 4.60 1.70 3.00 0.00 2.00 1.00 9.30 Reporting Component 2: Strengthening Case Management and Psychosocial 7.80 7.10 0.70 15.15 9.15 5.00 1.00 22.95 Support Subcomponent 2a: Strengthening COVID-19 Case Management 7.60 6.90 0.70 14.15 9.15 5.00 0.00 21.75 Subcomponent 2b : Psychosocial Support and Gender-Sensitive 0.20 0.20 0.00 1.00 0.00 0.00 1.00 1.20 Considerations Component 3: Project Management, Monitoring and Evaluation 1.10 0.80 0.30 3.00 1.00 1.00 0.00 1.00 4.10 Component 4 : Vaccines Acquisition and Deployment 137.15 124.15 10.00 1.00 2.00 137.15 Vaccine Acquisition 117.00 107.00 10.00 0.00 117.00 Vaccine Deployment 20.15 17.15 0.00 1.00 2.00 20.15 Component 5: Strengthening Continuity of Essential Health Services 22.00 9.00 13.00 22.00 Subcomponent 5a: Upgrade of Health Infrastructure in Refugee 10.00 6.00 4.00 10.00 Settlements and RHDs Subcomponent 5b: Strengthen Emergency Medical Services 4.40 2.00 2.40 4.40 Subcomponent 5c: Improve the availability of essential health 4.00 1.00 3.00 4.00 commodities Subcomponent 5d: Strengthen Community Structures for Continuity of 1.60 1.60 1.60 Essential Health Services Subcomponent 5e: Strengthening infection prevention and control in 2.00 2.00 2.00 health facilities through multi-sectoral engagement Total Costs 15.20 12.50 2.70 180.30 134.30 27.00 3.00 16.00 195.50 31 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Table 6: Summary of COVID-19 Vaccine Sourcing and Bank Financing (as of October 6, 2021) Source of vaccine financing and population Doses National plan coverage (percent) purchased with Estimated target World Bank-financed World Bank allocation of Specific vaccines and sourcing plans (population COVAX Through finance World Bank (percent) Through Through Other* (2 doses financing grant direct COVAX AVAT assumed) purchase GoU and other Phase 1: 9.1% 10% Uganda has planned for a total of N/A N/A Partner Financing By the end of 14,420,869 vaccines in the first phase of December 2021 its vaccination efforts that began in March 2021 and are expected to end in 19.1% December 2021. These are comprised of a mixture of vaccines that all meet VAC requirements, namely AstraZeneca, SINOVAC, Moderna, Pfizer, Johnson and Johnson (J&J) and SINOPHARM. Of these, the country has so far received 8,891,410 COVID-19 vaccines most (about 6.5 million) as COVAX Facility donations. Other sources are GoU direct purchases from both the AVAT mechanism and COVAX. Uganda has also received a total of 2,435,500 vaccine doses as donations from the governments of India, China, and Ireland. 32 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Source of vaccine financing and population Doses National plan coverage (percent) purchased with Estimated target World Bank-financed World Bank allocation of Specific vaccines and sourcing plans (population COVAX Through finance World Bank (percent) Through Through Other* (2 doses financing grant direct COVAX AVAT assumed) purchase This AF Phase 2: 11.6% 13.7% 12.7% 10.6% During Phase 2, GoU shall procure 5,599,777 (J&J). Purchase: By the end of 37,140,631 vaccine doses from the AVAT 12,140,000 US$ 117 December 2023 mechanism, and through direct (Sinopharm) million purchase from COVAX. Of these, 17.7 Deployment: 48.6% million doses will be procured using Bank US$ 20.15 financing. million Other: The country is also expected to receive US$ 43.15 its final quota of COVAX Facility million donation. Total 17,739,777 180.30 million 33 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) (iii) Retroactive Financing 22 46. In view of the limited global supply for vaccines, the Project will provide the option of using retroactive financing to expedite the delivery of vaccines. By adopting retroactive financing and associated flexible procurement processes, the Project will ensure that vaccines are quickly mobilized and delivered. Expenditures to be financed by retroactive financing must be consistent with three eligibility criteria: (i) the expenditures shall be relevant to the PDO; (ii) the goods or services shall have been procured in a manner consistent with the Bank’s procurement regulations; and (iii) the expenditures shall cause low environmental and social risks and impacts and be aligned with the Bank’s Environmental and Social Standards. Retroactive financing will reimburse the delivery of goods and services needed to support the vaccination program including the purchase of vaccines, ancillary supply kits, warehousing, and distribution costs. A waiver for retroactive financing up to 40 percent of the total IDA financing was discussed during the negotiations and approved by Management on November 12, 2021. (iv) Institutional Arrangements: 47. The MoH will be the implementing agency of the Project which is fully embedded within the institutional and coordination structures of the health sector. The Project Implementation Unit (PIU) in the MoH will continue to undertake day to day management and coordination of the Project including the associated fiduciary, safeguard, monitoring, and evaluation functions in collaboration with relevant departments and agencies under the ministry. Through the proposed AF, the original implementation and institutional arrangements for the parent project will be enhanced to accommodate the expanded scope and coverage of the AF. This will include: (i) recruiting additional personnel to support implementation; (ii) strengthening collaboration across the different departments and programs within the MoH including Expanded Program on Immunization (EPI), Health Sector Partners and Multi-sectional Coordination and Emergency Medical Services and with the Office of the Prime Minister and UNHCR on refugee related issues; (iii) enhancing supervision by assigning component leads for vaccine acquisition and deployment, refugee-specific activities, and continuity of essential health services; and (iv) strengthening stakeholder engagement with development partners and civil society organizations. The MoH will work closely with other sectors to implement the proposed interventions, some of which go beyond the health sector— such as those on gender. The Project’s Steering Committee will be expanded to ensure representation from the key entities including OPM. As noted in the Project Implementation Manual, the Steering Committee—chaired by the Permanent Secretary—will meet quarterly to oversee Project implementation and provide policy guidance as needed. 48. The MoH has enhanced institutional and coordination arrangements for its immunization program to incorporate requirements for COVID-19 vaccination. Specifically, the following structures have been set up or strengthened to provide oversight and technical leadership of the vaccination campaign, under the overall leadership of the National COVID-19 Response Task Force. These structures 22 Per guidance received from Ministry of Finance Planning and Economic Development, Retroactive Financing will be where and if applicable. 34 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) are: (i) National Vaccine Advisory Committee (VAC) 23; (ii) Strategic Committee of the Ministry of Health; (iii) COVID-19 Incidence Management Team; (iv) National Coordination Committee (NCC); and (iv) National Immunization Technical Advisory Group (NITAG). Key partners supporting the COVID-19 response in Uganda include Africa CDC, AVAT, GAVI, Global Fund, WHO, UNHCR, UNICEF, the United States Agency for International Development (USAID), and the World Bank. These organizations are members of the various COVID response committees. Figure 1 below provides an organogram for the implementation and oversight of the NVDP and its relationship to the overall COVID-19 Task Force. The National Drug Authority (NDA) provides technical guidance on issues related to vaccine regulation, approval, and safety while the National Medical Stores (NMS) is mandated to procure and distribute essential medicines and vaccines. Both agencies have demonstrable experience in executing their respective mandates; however, the increased pressures due to the pandemic require significant additional operational resources. Figure 1: Organogram for Vaccine Deployment Implementation and Oversight National COVID-19 Scientific Advisory Strategic Advisory Task Force Committee Committee Incident Management Team National COVID-19 Coordination National COVID-19 Vaccine Coordination Vaccine Advisory National Immunization Technical Committee Advisory Group - NITAG National Coordination • Develop and update the National Deployment and Vaccination Plan (NPVP) with input from relevant bodies and in alignment Committee with WHO guidance and SAGE can be developed by adapting the Pandemic Influenza NDVP). 1. Planning, Resource • Identify and plan for the national vaccine access/procurement approach (COVAX facility, bilateral Mobilization & Coordination purchase agreement, through UN agency, self-procurement) and complete required paperwork. • Map key roles & responsibilities for deployment of vaccine and ancillary products 2. Vaccine Cold Chain & Logistics • Assess dry storage and cc capacity at all levels with regard to COVID-19 vaccine characteristics and fill identified supply and logistics gaps. SUB-COMMITTEES • Update protocols for infection prevention & control including adequate PPEs • Identify potential COVID-19 vaccine delivery strategies leveraging both existing platforms and other 3. Service Delivery approaches to best reach target groups • Design a demand plan (including advocacy, communication, social mobilization, risk & safety 4. Demand Generation & Risk communication, community engagement and training to generate confidence, acceptance and Communication demand for COVID-19 vaccines. Must include crisis communication preparedness planning. • Develop or adapt existing surveillance and monitoring framework with set of recommended indicators 5. Monitoring, Evaluation & (coverage, acceptability, disease surveillance, etc.) for COVID vaccines. Safety Surveillance • Plan active surveillance of vaccine-related adverse events for specific COVID-19 vaccines. • Ensure the national regulator or authority has clarified the requirements and document needed for 6. Regulation regulatory approvals of vaccine vaccines. 23The National Vaccine Advisory Committee is made up of the top management of the MoH, heads of key development partner agencies—the CDC, UN agencies, USAID, World Bank—and civil society. 35 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 49. Uganda has a refugee health integration steering committee and a secretariat that oversees implementation of the HSIRRP. The AF will contribute to the implementation of the plan and will therefore be coordinated under the above frameworks and structures. Implementation of refugee health is integrated into MoH systems with 76 percent of the refugee serving health facilities already managed by MoH. The refugee health integration steering committee will also help strengthen coordination and integration between host communities and refugees on refugee health issues, 50. At the interagency level, UNICEF and UNHCR will play important collaborative roles in Project implementation. UNICEF will be contracted directly, through the MoH, to support the procurement and deployment of vaccines, per the agreements made through the COVAX Facility, and through AVAT. The government may explore additional arrangements beyond these two for UNICEF. UNHCR will be engaged closely in the implementation of activities in the refugee settlements and hosting districts and ensure effective coordination with the Refugee Inter-Agency Health and Nutrition Working Group. The Project activities envisioned take into consideration current and planned investments on refugee health being supported by UNHCR and are intended therefore to complement an overall framework of development assistance meeting the needs of host communities and refugees. (v) Changes in Disbursement Categories 51. No reallocations will be made across disbursement categories for the parent project. However, deployment costs will be added to Category 1 of the current withdrawal schedule, and a new Category 2 will be added for vaccine purchase only. All sources of financing may be used for Category 1; but only IDA grant including WHR can be used for vaccine purchase. As noted in the GFF Continuity of Essential Health Services guidelines, the GFF funds will not be used for vaccine purchase. Annex 4 provides a table to explain the breakdown. (vi) Results Framework 52. Changes have been made to the Project indicators to better measure overall progress towards the PDO and investments in COVID-19 vaccination and scale up of original activities and redress of gender gaps that the project seeks to address. The proposed changes are summarized in Box 3 below and have been updated in the RF together. Box 3: Summary of Proposed Changes to the Results Framework Indicator Proposed change Rationale PDO Level Proportion of targeted Regional Proportion of moderate and Reduced the scope of the original indicator to Referral Hospitals with clinical severe COVID-19 cases managed clinical management and refocused on regional capacity to manage COVID-19 at designated regional and and national referral hospitals that have been cases in line with clinical national referral hospital COVID designated as COVID-19 Treatment Units guidelines treatment units in accordance (CTUs) to improve measurement. with the national COVID-19 case management protocols 36 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Proportion of COVID-19 suspected Proportion of suspected COVID-19 Refined by adding the time of sample collection cases, having laboratory cases having laboratory as the start time for measuring lead time to confirmation within 72 hours confirmation results within 48 results and revised the end target upward. hours of sample collection Percentage of population New PDO indicator included to measure vaccinated, which is included in New progress in COVID-19 vaccination coverage. The the priority population targets project provides substantial resources to defined in national plan support national vaccination efforts. The AF is [disaggregated by sex] expected procure vaccine to cover 11.7 million people i.e., 26.4 percent of the total population of Uganda although the actual proportion of beneficiaries is estimated at 25 percent, assuming a wastage rate of 5 percent Total number of people in RHDs To quantify direct beneficiaries in RHD and and refugee settlements New refugee settlements from priority interventions benefiting from key Project under the project including number of patients interventions per year accessing health facilities for a total of 6 HC IVs, 10 HC IIIs that will be upgraded with funding; number of persons served by two emergency call and dispatch centers; number of persons immunized with COVID-19 vaccines; number of people tested for COVID-19; and number of patients accessing services at ICUs/HDUs/Isolation Units (in 2 RRHs, 3 general hospitals and one HCIV). Intermediate Results Level Component 1: Case Detection, Confirmation, Contact Tracing, Recording and Reporting Cumulative number of laboratory Number of laboratory tests done Revised targets upward to reflect enhanced tests done for suspected COVID-19 for suspected COVID-19 cases access to testing technologies in refugee cases using approved testing settlements and RHDs and the extended closing technologies date Cumulative number of Cumulative number of Revised the end-year target upwards to reflect laboratories enrolled on ISO 15189 laboratories enrolled on ISO 15189 extension of closing date accreditation maintaining or accreditation maintaining or achieving ISO 15189 accreditation achieving ISO 15189 accreditation Cumulative number of staff This area is adequately covered by other trained in laboratory diagnosis of Drop partners and hence not key part of the project SARS-CoV-2 and other important pathogens Number of targeted hospitals Revised Updated the annual targets to reflect the whose laboratory spaces have extended project duration been remodeled/upgraded Proportion of RRHs enrolled on This area is adequately covered by other the LQMS scoring >90% in the Drop partners and hence no significant annual biowaste management resources have been prioritized for it under the audits project. 37 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Proportion of people travelling Proportion of people travelling Included the targeted number PoEs (at least through the targeted designated through twelve high priority PoEs twelve) in the indicator statement to make PoEs screened screened for COVID-19 and other monitoring easier; the original indicator diseases of public health statement was subject to the challenge of importance changing number of PoEs. Component 2: Strengthening Case Management and Psychosocial Support Proportion of targeted hospitals Government has obtained resources from with functional oxygen delivery Drop Global Fund and other partners to scale up equipment oxygen supply across the country and hence not prioritized it under this project. Cumulative number of targeted Number of isolation Expanded priority areas of support to hospitals whose isolation and/or facilities/intensive care units/high include high dependency units (HDU). ICU facility has been upgraded dependency units upgraded or remodeled countrywide Cumulative number of staff Number of staff trained in critical, Expanded technical areas to included training in trained in critical and acute acute, and emergency medicine other aspects of emergency medical services medical care and increased the end year target. Number of health care workers Measure HR capacity to manage GBV cases and and community stakeholders New provided psychosocial support given the trained in managing GBV cases heightened prevalence of sexual violence and and psychosocial support mental health complications during the COVID countrywide era. Component 3: Project Management, Monitoring and Evaluation Proportion of Grievances captured To monitor redress of stakeholder grievances in the Complaints Register for and complaints. UCREPP that have been “CLOSED Revised OUT” in accordance with GRM under the Project Proportion of District Task Forces Measure efforts by districts to track and (DTFs) reviewing technical reports address gaps in the non-pandemic essential on continuity of Essential Health New health services. services in the past quarter Component 4: Vaccines Acquisition and Deployment New Number of vaccines doses New New indicator to measure volume of vaccines procured by the Project procured. Component 5: Strengthening Continuity of Essential Health Services New Number of Health facilities and Measure investments in transforming hospitals refurbished/renovated New temporary health centers within refugee countrywide (Number) settlements into permanent facilities. Number of emergency call and Indicator introduced to monitor the new activity dispatch centers established and New of establishing emergency call and dispatch functional to address medical 38 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) emergencies, GBV and centers including for GBV and psychosocial psychosocial support support. Number of ambulances procured Measure number of ambulances procured to and supplied countrywide under New support referrals and the national emergency the project medical services. Proportion of Village Health Teams Indicator added to reflect investment in in at least twenty (20) COVID-19 community health workforce as a way to hotspot districts equipped to address access and cost challenges especially provide COVID-19 prevention, New among women and the poor in districts most homebased care, and other affected by COVID-19. essential health services Units of whole blood issued to Measure investments in support of improved health facilities nationally in a year New blood donor mobilization, processing, supply and facility level storage Percentage of facilities that had Measures Project's contribution towards over 95% availability of a basket of New enhancing availability of essential commodities 41 commodities in the previous including for maternal and newborn care and quarter non – communicable diseases. B. Sustainability 53. There is strong political commitment in Uganda to mobilize both domestic and external financial resources for COVID-19 response, including for vaccine purchase and deployment. Having the funds through the proposed AF for vaccine purchase and deployment will establish an enabling environment for other donors, multilateral development banks and UN agencies to also support efforts in the country. Investments under the parent project and the AF are expected to strengthen the health system in the country, ensuring institutional sustainability to deal with infectious diseases. The WHR-financed elements will complement existing World Bank financed projects supporting the health sector in RHDs. Sustained domestic financing, however, will be critical to maintaining the gains that will be realized under UCREPP. III. KEY RISKS 54. The overall risk to achieving the PDO, with the expanded scope and AF for vaccination, is High even after considering mitigation measures. This is due to uncertainties and the unprecedented nature and scale of the crisis, namely: (a) rapidly evolving epidemiological context, requiring regular revision of the COVID-19 response strategy; (b) challenges related to financing and implementing a massive national campaign, against a backdrop of limited WHO-approved/authorized vaccines on the market; and (c) the risk of elite capture where some groups could seek to get preferential treatment in the vaccination program. 55. Residual Macroeconomic and Fiduciary risks are rated High. Individual residual risks for the following areas are rated Substantial: (i) Political and Governance; (ii) health sector institutional capacity; (iii) Sector Strategies and Policies; (iv) Technical Design; (v) Stakeholders; and (vi) Environmental and Social. The newly added refugee protection risk is rated Moderate. Below is a description of the risk rating for each area, and the proposed interventions under the AF to mitigate the risks. 39 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 56. Political and Governance: [Residual risk: Substantial]. There are substantial risks to the proposed AF related to the commitment and ability of the authorities to ensure appropriate targeting of the AF- supported vaccines to reach the priority populations, based on objective public health criteria, and ability to manage public sentiments should there be a gap between vaccine targets and vaccine delivery. There is also risk of fraud and substandard quality during the purchase and deployment of vaccines, as well as the risk of elite capture and corruption in the implementation of the vaccination program. Thirdly, the long and extensive national-level clearances (as experienced with the parent project) could also delay implementation of the vaccination campaign in Uganda. However, given that the AF is 100 percent grant with no requirement for Cabinet and Parliamentary approval, it is assumed that there will be no delays in obtaining clearances. Other identified risks will be mitigated by: (i) sensitizing communities on vaccine deployment as well as building the capacity of key national and county stakeholders on advocacy, communication and social mobilization to strengthen accountability and transparency; (ii) ensuring adherence to the World Bank’s anti-corruption guidelines for vaccine purchase and deployment, and robust financial management oversight on the use of funds, as elaborated in the fiduciary risks below; (iii) the GoU’s commitment to fast-track the effectiveness of the Project in order to capitalize on the availability of vaccines through mechanisms like COVAX and AVAT. The parent Project’s Political and Governance risk was rated high mainly due to the anticipated high level decision-making delays in project approval and potential implementation delays arising from uncertainties around the January 2021 general elections. 57. On fraud and corruption specifically, Uganda has put in place adequate measures to minimize the risk of fraud and corruption in the COVID-19 vaccination program and has taken demonstrable steps to quickly identify and resolve issues that arise using a broad range of government approaches. The following entities work collaboratively to ensure vaccines reach the intended beneficiaries: MoH, National Medical Stores (NMS), National Drug Authority (NDA), State House Health Monitoring Unit (SHHMU), Inspector General of Government (IGG), Office of the Auditor General (OAG), and Parliament. The MoH does overall planning and oversees the entire vaccination exercise; NDA reviews and approves use of vaccines and undertakes post-market surveillance to assure the quality of products on the market; and NMS is mandated to ensure value for money in the procurement and supply to districts and health facilities. The OAG periodically reviews expenditures, and its reports are reviewed by Parliament. The MoH, SHHMU and NDA have toll free telephone lines and citizen engagement platforms through which they receive information from the general population and whistle blowers. 58. Macroeconomic: [Residual Risk: High]. Uganda is experiencing severe fiscal pressures and faces the risk of not having sufficient resources for the purchase and deployment of vaccines at scale and other COVID-19 related response interventions. The MoH and World Bank believe that increasing COVID-19 vaccine coverage is key to mitigating the negative impact of the pandemic on the health sector and the economy. Macroeconomic risk will be mitigated by providing financing—through this proposed AF—for vaccine purchase and promoting prioritized deployment to vulnerable groups. With increased vaccination coverage, economic activities will also increase, and this will—in turn—help to soften the direct impacts of the pandemic on the national economy. The residual macroeconomic risk for the Project, however, is rated high since given uncertainties on other financing beyond the World Bank. 40 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 59. Sector Strategies and Policies: [Residual Risk: Substantial]. The large- scale acquisition and deployment of COVID-19 vaccines entails certain significant risks. First, global demand for vaccines continues to exceed supply, and vaccines that meet the Bank’s VAC may not be available in a timely manner. Second, a mass vaccination effort stretches capacity, in limited-capacity environments such as Uganda, entailing risks. There is also the risk of the country being unable to acquire and deploy vaccines in a timely fashion, thereby further delaying a return to ‘normalcy’ and herd immunity, making the country susceptible to future resurgences, and accompanying lockdowns/other restrictions. The proposed Bank support for Uganda, to develop vaccination acquisition strategies and investment in deployment system capacity, aim to mitigate these risks. Furthermore, to address the challenges associated with rolling out the vaccination campaign, the MoH is operationalizing the NVDP in line with WHO guidelines and, will also leverage the use of digital technology to register, monitor and track vaccinated individuals. The MoH will also utilize its routine immunization stock control and monitoring system through the eLMIS, which also includes refugee clinics accredited by the MoH. These efforts are all intended to serve as mitigants. However, the residual risk for Sector Strategies and Policies is increased to Substantial. 60. Technical Design: [Residual risks: Substantial]. While the technical design of the Project is sound, but major technical risks exist in relation to the complexity of expanding the scope and coverage of the Project, particularly to include refugee hosting communities, new activities, and stakeholders. The additional beneficiaries, activities, and stakeholders will require strong coordination within the MoH, between the MoH and other stakeholders in the health sector, and between the health sector and other sectors in the country. The limited capacity in refugee settlements will also make it difficult to implement Project-related activities. To mitigate these risks, component leads will be appointed to ensure effective coordination and timely implementation of activities. Collaboration with UNHCR will also be strengthened to ensure that activities in refugee-hosting communities are implemented in a timely fashion. The UNHCR and other key development partners will be appointed to the Project’s Steering Committee, along with key focal persons involved in immunization at the MoH and other government departments. 61. Institutional Capacity: [Residual Risk: Substantial]. The proposed AF is designed to address key institutional capacity risks related to vaccine deployment and distribution, but residual risks remain Substantial. This is because vaccine cold-chain and distribution capacity, notably for Ultra Cold Chain, are currently inadequate in Uganda—and could pose hindrances to national roll out of vaccines like Pfizer and Moderna. Furthermore, the capacity of the PIU will be reinforced to effectively implement all aspects of the Project, beyond vaccination. Residual risks remain substantial as these new staff will need to be appropriately oriented on the World Bank processes to ensure rapid implementation over the short implementation period of 36 months. 62. Stakeholders. [Residual Risk: Substantial]. The COVID-19 pandemic and the vaccination campaign has generated misinformation globally. Amidst slow uptake of vaccines in Uganda, the AF will support activities to enhance risk communication to various stakeholders and through community structures to dispel incorrect notions. However, this remains a substantial risk given the unique challenges of combatting misinformation. 41 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 63. Fiduciary: [Residual Risk: High]. The Procurement and Financial Management (FM) risks initially assessed for the parent project cover risks associated with the procurement and distribution of critical equipment and consumables for response to COVID 19, including fraud and corruption risks. Risks specific to vaccine procurement and financial management include: • Procurement: [Residual Risk: Substantial].The key procurement risk associated with vaccines relates to: (i) the complexity of the vaccines market given the significant market power enjoyed by vaccine manufacturers; (ii) inability of the market to supply adequate quantities of vaccines to meet the demand; (iii) the limited market access due to advance orders by developed countries; (iv) weak bargaining position; and (v) potential delays in triggering emergency procurement procedures at the country-level, which could delay procurement and contract implementation, including payments. These risks under this AF will be mitigated by providing options to support the country’s vaccine acquisition needs for direct or advance purchase through the AVAT and COVAX facilities where UNICEF is the Procurement Agent and possible technical assistance through the World Bank Facilitated Procurement (BFP). Although the BFP option was not used in the parent project MoH at one point expressed interest and IDA periodically provided information about available offers. The parent Project’s procurement risk was rated high due to the newness of COVID-19 interventions and uncertainties relating to the ability of global supply to meet demand; overtime these risks reduced as global capacity improved. • Mitigation measures agreed under the parent project have been fully or partially implemented while others are continuous by design. • The Procurement Post Review (PPR) conducted by the World Bank on the parent project (UCREPP, P174041) and the URMCHIP (P155186) Contingent Emergency Response Component noted some gaps in documentation of procurement processes and absence of contract management information to confirm contracts’ execution in accordance with terms and conditions. The Bank is monitoring the implementation of the risk mitigation measures for the PPR and will incorporate lessons learned into implementation of this Project. • Uganda has received some vaccines as donations directly from countries. While procurement regulations do not apply to these, all other vaccine requirements – VAC, data protection, no forced vaccination – and general requirements such as Anti-corruption and Governance (ACG) guidelines and Environmental and Social Framework (ESF), would apply if deployed through the Bank’s financing. • The summary below presents risks and mitigation measures MoH should undertake to improve the procurement function’s accountability. Table 7: Risk Mitigation Measures for Procurement Risk Mitigation measure/s Inadequate procurement, and Quarterly rapid response audits by the internal audit department to identify and contract management controls and remedy deviations from procedures. A copy of the findings is to be shared with practices. the Bank. Set up a mechanism to ensure that the delivery, inspection, and acceptance protocols are consistently applied, and all records kept on individual files. Inadequate due diligence on selected Justification for direct selection shall consider the market situation in accordance suppliers to ensure no falsified with the provisions of the World Bank Procurement Regulations. 42 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Risk Mitigation measure/s information, that they are qualified, have a proper record of For a limited market approach, the source of the list of suppliers invited to submit accomplishment, and no conflict of bids or quotations for items other than vaccines shall be the prequalified list. interest. Direct Selection method for purchase of vaccines through COVAX, AVAT or any other eligible supplier under IDA Financing and prior review of all vaccine procurements. Immediate reporting to the World Bank for sanctioning firms found to engage in fraud. Negative publicity on COVID related The MoH shall publish on its own website and on the PPDA Portal details of procurement processes that contracts and tenders; details of companies awarded tenders and beneficial undermines the credibility of the ownership. procurement function and may discourage some bidders from Monthly reports to the World Bank indicating contract award information participating. including the Beneficial Owners of the firms. Timely uploading of contract award notices in the STEP. For each contract, the basis of the cost estimate should be maintained on file. Processing delays due to increased Deploy an additional procurement officer to the project and provide appropriate workload for procurement staff. and timely orientation to minimize delays. • Financial Management (FM): [Residual Risk: High]. The key risks relate to: (i) advanced payments required by suppliers/manufacturers (but with no securities offered by manufacturers; no benefit for use of Letter of Credit or Special Commitment); (ii) payments required prior to shipment of vaccines with tight payment deadlines (less than 5 days); (iii) untimely funds flow or lack of liquidity; (iv) lack of adequate controls over the transparent, prioritized distribution and administration of vaccines, particularly for the most vulnerable population groups; (v) safeguarding and tracking of vaccines once delivered to the country (incl. proper cold storage); (vi) weak oversight of vaccine deployment; (vii) fraud and corruption risks at various points of the distribution and deployment system. This AF will use the same mitigation measures as in the parent project, including strengthening control systems, facilitating the timely flow of funds, ensuring adequate liquidity to finance Project activities, and timely submission and processing of payments to suppliers/manufactures. Furthermore, verification, inspection and audits will be enhanced, to track, document and validate inoculations and ensure alignment with deployment plans. Financial audits over the use of financing for the entire project, including retroactive financing and vaccine acquisition will be carried out. Internal audit units, both at Ministry and district level, will be involved in the verification of deliveries, inoculations, payments as well as review the entire processes of vaccination. Confirmation of delivery of the right quantity and quality of goods and services including vaccines, and certification of services rendered will be required before payment. Payments will be made to beneficiaries’ bank accounts to mitigate the risk of loss or diversion of funds. The fund flow arrangements include flexibility of direct payments to suppliers and contractors. This will facilitate efficient implementation of the operation. The Bank team will closely monitor the Project and provide appropriate FM support in response to the evolving COVID-19 crisis. In particular, the team will enhance virtual engagement with the PIU to 43 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) obtain relevant information regarding the effectiveness of project financial management arrangements. However, the combination of risks in FM, including historically low absorption rates and the onboarding of new staff—with limited experience in Bank FM—suggests that the FM risks remain High even after mitigation measures are implemented. 64. Environmental and Social (E & S): [Residual Risk: Substantial]. The key environmental risks associated with the proposed AF activities include: (i) occupational health and safety (OHS) risks related to the pandemic and dependent on the availability, supply and appropriate use of PPE for healthcare workers, new infections, injuries and accidents while handling and administering of vaccines, handling of medical machinery and equipment, testing and potential unsafe handling and use of these supplies by health workers and laboratory technicians; (ii) community health and safety risks (CHS) associated with increased spread of COVID-19 during the vaccination campaigns, vaccine safety and efficacy (potential adverse health effects from procuring unsafe vaccines and inadequate vaccine storage, handling and transportation practices may lead to vaccine quality deterioration), traffic and road safety risks from transportation of vaccines, handling and transportation of medical waste for off-site disposal; (iii) soil and water contamination due to poor disposal of healthcare waste and improper handling of vaccines; (iv) construction-related impacts (air and noise emissions, disposal and management of rehabilitation and construction waste, traffic management, OHS issues, CHS issues, and environmental pollution) from the upgrading works at health facilities in RHDs. The vaccination campaign will increase the environmental repercussions of plastic waste including syringes, which adds to the waste already generated by single- use PPE. Waste materials generated from laboratories, quarantine facilities, screening, treatment, and vaccination campaigns to be supported by the parent project and AF require special handling and awareness, as they may pose an infectious risk to healthcare workers in contact or handling the waste. With the identified mitigation measure put in place, the environmental risks are moderate. 65. The anticipated Social risk is substantial considering capacity challenges faced by the GoU to manage the pandemic especially when the case load is elevated and response capacity is overwhelmed during waves of the pandemic. In the current COVID-19 context, the potential social risks associated with the AF include: (i) increased incidences of reprisals and retaliation especially against healthcare workers and researchers which may be mitigated through inclusion in a robust stakeholder identification and consultation processes; (ii) patient-centric risks for those receiving treatment for COVID-19 symptoms, including GBV or SEA of patients in quarantine centers which may be mitigated through operating an appropriate Grievance Redress Mechanism (GRM) for project affected persons; (iii) discrimination towards minority groups or limited communication channels to inform their communities of preventive measures against COVID-19 contagion which may be mitigated through implementing inclusive measures targeting them in the updated ESMF and SEP; (iv) risks related to any mandatory national vaccination program that may be imposed on citizens which might disregard their religious, cultural, social and traditional community practices and values. 66. In view of these risks, the Project will put in place measures to ensure that vaccine delivery targets the most vulnerable populations, particularly women, the elderly, poor, refugees, vulnerable and underserved populations, and other minorities in accordance with criteria specified in the NVDP. The 44 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) NVDP was informed by WHO guidance and the recommendations of SAGE and with inputs from the National Immunization Technical Advisory Group (NITAG) and Vaccine Advisory Committee (VAC). The NVDP has been broadly disseminated to the public and is the current framework around which vaccines are being deployed. The GoU will ensure that this plan, and any updates made to it, will be subject to timely and meaningful consultations in accordance with ESS10. All targeting criteria and implementation plans have been reflected in the country’s national vaccination program. The NVDP appropriately prioritizes health workers, other essential workers, and the most vulnerable populations, including the elderly, people with co-morbidities, and people in high-population density locations such as slums and refugee settlements. The Bank will also continue to provide technical and implementation support to assist the government with its deployment in line with fair and equitable guidelines in the NVDP and as directed by WHO. 67. Regarding treatment of refugees, there is a low risk of exclusion in vaccination and other benefits of the Project. This is because, as noted earlier, refugees have been comprehensively integrated at the policy, planning, coordination and implementation levels of COVID-19 vaccine deployment and health service delivery in Uganda. Refugees are also fully integrated within the NVDP. UNHCR co-chairs the Health Development Partners Group and has a close working relationship with MoH in response to COVID-19 and refugee inclusion. At the sub-national level there is close collaboration between district officials, MoH, NGOs, OPM, and UNCHR within refugee settlements on COVID-19 response and prevention. Furthermore, UCREPP AF has attributable project targets for refugees under the results framework, which will ensure WHR resources will finance refugees and host community members as agreed. 68. Currently, there is no mandatory and/or forced vaccination in Uganda. However, if mandatory vaccination is declared in Uganda, the following due process protocol will be undertaken to: (i) obtain consent; (ii) enable affected persons to seek justified exceptions; and (iii) differentiate between mandatory schemes (allowed with due process) and forced vaccination (not allowed). The risk of misinformation (“fake news”) in social media networks may also impede national outbreak efforts, and can be mitigated through mounting an extensive campaign to counter misinformation and raise awareness. In addition, the grievance mechanisms required under the ESF will be established and equipped to address community, worker, and/or individual grievances related to such issues. This includes requirements related to being able to have grievance redress mechanism (GRM)s in place to address labor and working conditions, and SEA/Sexual harassment (SH). 69. The role of the military in the vaccination program has been limited to the use of military health personnel to administer vaccines in military health facilities and sites within their catchment areas, including barracks. Given the limited availability of vaccines in country, and as the number of vaccines and demand for country-wide distribution increases, the government could consider the use of security apparatus (notably, the police) to protect these valuable commodities. However, should that occur, the government would be required to specify the mitigation measures to be undertaken in line with the Environmental and Social Standard 4 (ESS4) and proceed to develop (and submit to the Bank) a detailed Security Management Plan. The Environmental and Social Commitment Plan (ESCP) will be accordingly 45 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) modified/updated to reflect the mitigation measures that the relevant agencies, including the Ministry of Defense and Veterans’ Affairs will undertake to manage any new associated E & S risks and to align with the ESF. As part of this AF, the ESMF of the parent project will be updated to incorporate core principles for managing potential security risks. 70. The authorities have confirmed that the Army Construction Brigade will not be involved in civil works under this AF. On July 1, 2021, H.E. the President issued a directive to Ministries of Education and Health to the effect that construction of Schools and Health facilities be undertaken by the Army Construction Brigade. On October 11, 2021, the Ministry of Finance advised that the directive not be applied to activities supported by development partners and be limited to projects financed 100 percent by GoU until a mutual agreement has been reached with Development Partners. Further, the President in a letter to the Minister of Education and Sports dated November 1, 2021 exempted Development Partner supported projects from this Directive. 71. Citizen Engagement. The Project will engage citizens during implementation through supported interventions, such as hotlines and community sensitization on COVID-19 risks, as well as tracking the use of the Project-embedded grievance redress mechanism through the following indicator in the results framework: “Proportion of Grievances captured in the Complaints Register for UCREPP that have been “CLOSED OUT” in accordance with GRM under the Project.” At the time of processing the AF, the parent Project’s GRM had not been rolled out due to delayed effectiveness of the main (credit) component of the project that would have supported preparatory GRM activities. Accordingly, no grievances have been registered or addressed to date. 72. Gender inequalities and norms are critical considerations when designing policies and interventions in emergency situations and pandemics. They play an important role in who gets access and how fast, to critical health services. Gender norms also influence risk of exposure to disease, as well as of spreading it. At the same time, biological sex can influence how susceptible a person is to disease and how well they respond to treatment and/or vaccines. In a pandemic, this has multiple implications. On the one hand, pandemic response must be cognizant of the gender-based differences in access to and use of services due to limited mobility and financial capacity; and on the other hand, support needs to be provided to at-risk groups such as family caregivers (the majority of whom are women) to reduce their risk of getting ill and/or passing it on to others. Moreover, pandemics can create or exacerbate the conditions that especially put women and girls at greater risk of gender-based violence. 73. Biologically, women and men may have a different risk level to a pathogen or response to treatment. Females and males may also differ in their immunological responses due to underlying conditions. The elderly, especially women, are especially vulnerable to illness and lack of access to services. Pregnant women are especially at risk during a pandemic/epidemic. Women, whether as formal or informal care givers, are at the forefront of the healthcare response for the sick and elderly. This makes them more vulnerable to infection. 74. The project design seeks to address gender gaps in the burden of COVID-19 and access to interventions. Administrative data of August 11, 2021 showed that 57 percent of COVID-19 cases were 46 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) males while there was gender parity in access to at least one dose of the COVID-19 vaccines by mid- October 2021 with males accounting for 50.4 percent. Any gender differences reflect variations in exposure risks to Coronavirus and access to services. The proposed project interventions such as strengthening of outreaches and community health systems are meant to take services closure to the households thereby addressing access challenges such as distance and cost of transport. Increasing investments in risk communication and community engagement will enhance information and knowledge on the pandemic and interventions thereby curtailing the negative impact of disinformation especially among rural women. An indicator is incorporated in the results framework to measure gender access to services and vaccinations (percentage of population vaccinated, which is included in the priority population targets defined in national plan [disaggregated by sex]. 75. In summary, the measures to address E & S risks in the parent project remain relevant. The MoH will update the ESMF of the parent project to reflect the additional risks, introduced as part of the new activities under the AF, specifically the expanded civil works and the vaccination exercise. Updates to the ESMF, will also cover impacts of the AF activities in RHD and refugee settlements. The ESMF (including the Infection Control and Waste Management Plan (ICWMP), Labor Management Procedures (LMP), GBV/SEA/SH Action Plans, Security Management Plan, and other updates, as required by the World Bank Environmental and Social Standards, will be consulted upon, finalized, and disclosed by project effectiveness. Other Risks: 76. Refugee Protection: 24 [Residual Risk: Moderate]. The AF introduces a new risk to the Project, focused on refuge protection. Though the residual risk is considered moderate, a full explanation and mitigants are explained in the Project Paper, since this is a new risk being included in the Project. The World Bank, in consultation with UNHCR, has confirmed in August 2021 that Uganda’s protection framework is adequate for accessing funding under the WHR with no significant changes from the last assessment. UNHCR has provided the World Bank with an overall positive assessment of Uganda’s protection framework indicating that Uganda is adopting comprehensive humanitarian and development programs aimed at mitigating protection risks faced by refugees. However, in the event of a change in policy making, there is a risk that Uganda’s asylum space and refugee policies could become more restrictive in response to the strain on services and the natural environment, continuing refugee population growth, COVID-19, and political pressure. Additional refugee specific risks include: the high proportion of women and girls and other vulnerable people within the refugee population which poses specific protection challenges, including GBV and access to health services strained under the pressure of COVID-19. These risks are being jointly managed through effective in-country coordination mechanisms which include UNHCR, OPM, MoH, development and humanitarian partners and other GoU stakeholders under the CRRF Steering Group. The World Bank co-chairs the CRRF Development Partners Group which provides another effective platform to ensure joint management of the above risks, including on protection issues, with the GoU and other humanitarian and development organizations. The Project will work through these forums and the Health Sector Integrated Refugee Response Plan which was developed 24 This is an “other” risk within the World Bank’s Systematic Operations Risk Rating Tool code classification. 47 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) to institutionalize refugee health support within national systems. The World Bank will work closely with UNHCR to continually monitor the protection environment throughout project implementation. 77. Data Protection: [Residual Risk: Moderate] Large volumes of personal data, personally identifiable information and sensitive data are likely to be collected and used in connection with the management of the COVID-19 outbreak - including in the course of deploying and administering COVID- 19 vaccines - under circumstances where measures to ensure the legitimate, appropriate and proportionate use and processing of that data may not feature in national law or data governance regulations, or be routinely collected and managed in health information systems. To guard against abuse of that data, the Project will incorporate good international practices for dealing with such data in such circumstances. Such measures may include, by way of example, data minimization (collecting only data that is necessary for the purpose); data accuracy (correct or erase data that are not necessary or are inaccurate), use limitations (data are only used for legitimate and related purposes), data retention (retain data only for as long as they are necessary), informing data subjects of use and processing of data, and allowing data subjects the opportunity to correct information about them, etc. In practical terms, operation will ensure that these principles apply through inter alia assessments of existing or development of new data governance mechanisms and data standards for emergency and routine healthcare, data sharing protocols, rules or regulations, revision of relevant regulations, training, sharing of global experience, unique identifiers for health system clients and strengthening of health information systems. IV. APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis 78. The economic rationale for investment in a COVID-19 vaccine is strong, considering the massive and continuing health and economic losses due to the pandemic. As of October 23, 2021, Uganda had registered 125,758 cases and 3,200 deaths, from all the 136 districts, 25 translating into a case fatality rate of 2.5 percent. The actual number of infections are likely to be higher than the confirmed cases due to inadequate testing and health surveillance in the country. And while the second wave of the COVID-19 outbreak in Uganda is characterized by the more virulent Delta variant, case management is poor and vaccination rates are extremely low. For instance, at the peak of the second wave in mid-June 2021, it was projected that Uganda needed 25,000 oxygen cylinders per day but the oxygen generating plants in the country could only provide 3,000 oxygen cylinders per day. 26 This contributed to an increase in the number of deaths. Furthermore, as noted earlier, to date only 2,483,233 people have received at least one dose of the two dose vaccines, accounting for 5.6 percent of the national population. This vaccination rate is far below the target of vaccinating 22 million people aged 18 and above. Low levels of vaccination are contributing to high levels of morbidity and death. 79. The COVID-19 crisis has exacerbated Uganda’s pre-existing macroeconomic vulnerabilities. Before the COVID-19 crisis, the country’s real per capita GDP growth rate was about 1.2 percent on 25 WHO. COVID-19 Daily Situational Report Uganda 05 September 2021. 26 https://www.path.org/articles/what-fueling-covid-19-crisis-africa/. 48 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) average between 2015 and 2019, 27 and below other countries in Eastern Africa such as Kenya, Tanzania, Ethiopia, and Rwanda. Uganda’s economy (in real GDP terms) grew at 2.9 percent in FY20, less than half the 6.8 percent recorded in FY19, due to the COVID-19 crisis. 28 In 2020, real per capita GDP growth rate dropped to -0.5 percent from 3.1 percent in 2019 due to a reduction in economic growth propagated by the COVID-19 pandemic. 29 Economic activity stalled due to a lockdown that lasted over four months, border closures for everything but essential cargo, and spillover effects of disruption in global demand and supply chains due to the pandemic. This resulted in a sharp contraction in public investment and deceleration in private consumption, which negatively affected industrial and service sectors, particularly in the informal sector. 30 COVID-19 has already had a profound negative impact on Uganda’s labor markets, poverty alleviation, vulnerability, and human capital development. The number of poor people in Uganda is projected to increase by 2.6 million in the short-term due to the pandemic. 31 These shocks have severely affected poor households due to insufficient coverage, design, and scope of social protection programs, and limited access to finance and insurance. Further, refugees have been affected by the COVID-19 shocks more than the Ugandans and this has exacerbated the existing high level of food insecurity among the refugees. For example, refugee-run businesses have been slower to recover from COVID-19 associated shocks while they have also been less likely to get labor income from farms and family businesses as compared to the Ugandans. 32 This has increased their dependency on humanitarian assistance. 80. Prompt procurement and deployment of a vaccine is the best option to reversing the above trends and generating benefits that can exceed vaccine-related costs. Even with imperfect implementation, a COVID-19 vaccine that is introduced and deployed effectively to priority populations can assist in significantly reducing mortality and the spread of the coronavirus and accelerating a safe reopening of key sectors that are impacted. It can also reverse human capital losses by ensuring schools are reopened. The effective administration of a COVID-19 vaccine will also help avoid the associated health care costs for potentially millions of additional cases of infection, associated health-related impoverishment, and death. Global experience with immunization against diseases shows that by avoiding these and other health costs, vaccines are one of the best buys in public health. For the most vulnerable population groups (including refugees), especially in countries without effective universal health coverage, the potential health-related costs of millions of additional cases of COVID-19 infection in the absence of a vaccine represent a significant or even catastrophic financial impact and risk of impoverishment. The pandemic is also having dire effects on other non-COVID health and nutrition outcomes and worsened refugee food security. Increased morbidity and mortality due to interruption of essential services because of COVID-19 containment measures can hinder access to care for other health needs of the population, especially maternal, child health and nutrition services. This could also lead to new outbreaks of preventable diseases, with their own related deaths, illnesses, and long-term costs. Simultaneous epidemics are overwhelming public health systems in countries that have few resources to 27 According to official data from UBOS. 28 World Bank (2020). Uganda Systematic Country Diagnostic Update. 29 https://data.worldbank.org/indicator/NY.GDP.PCAP.KD.ZG?locations=UG. 30 Ibid. 31 UNDP (2020). 32 World Bank. 2021. Monitoring Social and Economic Impacts of COVID-19 on Refugees in Uganda: Results from the High- Frequency Phone - Third Round. Washington, DC: World Bank. 49 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) begin with, and where services are also needed to address the needs of people with chronic health conditions. 81. While the uncertainty around the costs and effectiveness of a COVID-19 vaccine makes it difficult to calculate its cost-effectiveness, the effective launch of a COVID-19 vaccine will have direct benefits in terms of averted costs of treatment and disability, as well as strengthened health systems. Estimated COVID-19 treatment costs for low- and middle-income countries is US$50 for a non-severe case and US$300 for a severe case. This excludes the costs of testing of negative cases, as well as the medical costs associated with delayed or forgone care-seeking, which usually results in higher costs. Under this AF, it is estimated that up to 11.7 million people (26.4 percent of the national population, including refugees) will be fully vaccinated. This is valued at US$137.15 million for both procurement and deployment. On the other hand, treating eight million non-severe COVID-19 cases would cost US$400 million while treating the same number of severe COVID-19 cases would cost US$2.4 billion. This means that vaccination is by far the most cost-effective option. Further, investments in vaccine delivery systems generate health and economic benefits beyond just delivering the COVID-19 vaccine. First, investments in last-mile delivery systems to administer the COVID-19 vaccine to remote communities will require strengthening community health systems, which can have spillover effects to effective delivery of other services and help to close the urban-rural gap. Second, as the COVID-19 vaccine is introduced and lockdowns and movement restrictions are eased, patients can continue to access care for other conditions. Third, the economic benefits of slowing down the economic downturn are likely to significantly exceed the US$117 million needed to vaccinate 26.4 percent of the population through this AF. Therefore, an effectively deployed COVID-19 vaccine presents significant health and economic benefits. 82. The economic benefit from investments under the Project are likely to exceed the anticipated benefits from COVID-19 vaccine acquisition and deployment. This is because a grant of US$16 million (on top of the AF of US$164.3 million from IDA, including WHR) will be provided by the GFF to sustain the provision of reproductive, maternal, newborn, child, and adolescent health (RMNCAH) services. By investing in the continuum of RMNCAH services, diseases and deaths that have arisen due to the disruption of health services since the advent of COVID-19 will be averted. Increased coverage of RMNCAH services can be instrumental in improving the health and nutrition of children and women, and most of the interventions are highly cost-effective. For instance, Carvalho et al. (2012) observed that improved family planning, skilled birth attendance, and provision of quality intrapartum care could prevent 75 percent of maternal deaths at a cost of less than US$200 per life saved each year. 33 Using a full-income approach, Stenberg et al. (2016) 34 have estimated the benefit-cost ratios for increased investment in RMNCAH interventions in low-income countries like Uganda at 7.2 and 16.9 for the periods 2013–2035 and 2013–2050, at 3 percent and 5 percent discount rates, respectively. This implies that investing in RMNCAH through the AF will yield very high returns. 33 Carvalho, N., A. S. Salehi, and S. J. Goldie. 2012. “National and Sub-National Analysis of the Health Benefits and Cost- Effectiveness of Strategies to Reduce Maternal Mortality in Afghanistan.” Health Policy and Planning 28 (1): 62–74. 34 Stenberg, K., Sweeny, K., Axelson, H., Temmerman, M., Sheehan, P., 2016. “Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health.” In Disease Control Priorities (third edition): Volume 2, Reproductive, Maternal, Newborn, and Child Health, edited by R. Black, M. Temmerman, R. Laxminarayan, N. Walker. Washington, DC: World Bank. 50 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) B. Financial Management 83. In line with the guidelines, as stated in the Financial Management Practices Manual issued by the Financial Management Sector Board on March 1, 2010, a financial management assessment was conducted for the parent project. The financial management arrangements were found to be satisfactory and acceptable to manage project resources. These arrangements will be leveraged for the AF as well. Additional guidelines for Covid-19 emergency operations have also been considered for the AF. Under the parent project, the Ministry of Health is responsible for the financial management function. The overall fiduciary responsibility rests with the Ministry’s Accounting Officer through the Head of Finance and Accounts. The Project Accountant of the UCREPP is responsible for the Project financial management arrangements, with the assistance of an Accounts Officer provided by the PIU, for establishing and maintaining effective Project accounting systems. The current policies, guidelines, and procedures in use by the parent project will be strengthened by additional measures to mitigate the heightened risks of vaccine deployment, including updating the PIM, which is a dated covenant, and preparation of a Vaccine Delivery and Distribution Manual (VDDM) as well as the Vaccine Delivery and Distribution Plan, as described in the Financing Agreement. 84. The disbursements will be based on Statements of Expenditures (SOEs), and the Bank, will review the expenditures in the SOEs on a quarterly basis. The Project will open separate Designated Accounts (DA’s) denominated in US$ at the Bank of Uganda for respective funding sources where payments, in United States Dollars (USD), for project activities will be made. Local currency project accounts will also be opened for payments denominated in local currency. Direct payments from IDA to the beneficiaries- suppliers and contractors can also be made upon request by the project following the laid down procedures. This will facilitate efficient implementation of the emergency operation. Flow of funds to the lower levels of implementation will follow the laid down government procedures which are currently used by the parent project. The current policies, guidelines, and procedures in use by the parent project will apply to this operation as well. The adoption of the VDDM is considered as a condition of disbursement for the vaccine deployment component. 85. The Project FM residual risk is High. The assessment is based on the risks identified with the parent project and their respective mitigation measures. The implementation of the mitigation measures will be reviewed, and the FM risk will be reassessed as part of the continuous implementation support provided to the Project. In view of the High risk and challenging implementation monitoring, the use of independent third-party monitoring (TPM) to mitigate FM risks is recommended. C. Procurement 86. Procurement under the AF will be carried out in accordance with the World Bank’s Procurement Regulations for IPF Borrowers for Goods, Works, Non-Consulting and Consulting Services, dated November 2020. As with the parent project, the AF will be subject to the World Bank’s Anticorruption Guidelines, dated October 15, 2006, revised in January 2011, and as of July 1, 2016. The Project will use the Systematic Tracking of Exchanges in Procurement (STEP) to plan, record, and track procurement 51 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) transactions with timely progress update of completed processes in the system for monitoring purposes. The simplified Project Procurement Strategy for Development (PPSD) prepared for the parent Project shall be updated during the initial three months of Project implementation. The Procurement Plan for the initial months will be prepared and agreed to by negotiations. 87. The major planned procurements under this AF will include: (i) COVID-19 Vaccines; (ii) rapid diagnostic and PCR testing kits, (iii) additional Point of Entry screening devices; (iv) Personal Protective Equipment, supplies, medicines, consumables for management of COVID-19 cases and comorbidities; (v) refurbishment of more intensive care units and other civil works under the parent Project; (vi) ambulances; (vii) medicines and essential health supplies/commodities; (viii) and consultancies/staffing; (ix) equipment. The procurement approach for non-vaccine procurements will be the same as under the parent project. 88. The current demand for COVID-19 vaccines exceeds the supply in the market which makes it more difficult for client countries to negotiate terms and conditions. Procurement of vaccines will therefore follow Direct Selection by purchase through COVAX and AVAT or any other eligible supplier using World Bank funding. Contracts for vaccines purchases financed by the Bank will be subject to the Bank’s prior review irrespective of value and procurement approach. 89. The residual procurement risk for the AF is Substantial. The procurement of vaccines presents unique risks highlighted in paragraph 67. The Bank’s oversight of procurement will be done through increased implementation support and, where requested by Borrowers, through Hands-on Expanded Implementation Support (HEIS) and Bank Facilitated Procurement (BFP). The Bank’s prior- and post-review arrangements apply as specified in the procurement plan). D. Legal Operational Policies . Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . E. Environmental and Social 90. Activities under the AF should have positive impacts as it will improve capacity for surveillance, monitoring and containment of COVID-19 benefiting Uganda in general. However, it could also cause environmental, social, health and safety (ESHS) risk due to the dangerous nature of the pathogen (COVID- 19) and reagents and equipment used in the project-supported activities as well as a broader social risk of exclusion and discrimination in access to vaccines by groups that require it most and VMGs. For the parent project, the environmental risks are associated with civil works, the operation of the labs, the quarantine and isolation centers, screening posts, and management of generated medical waste by the participating facilities. Due to the delay in project effectiveness, E&S activities under the parent project have been limited to preparation of the ESIA for the proposed construction of laboratories at Lira and Fort Portal Regional Referral Hospitals. The AF will finance infrastructure for COVID-19 isolation, labs, and ICU 52 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) units, procurement of medicines, supplies, and medical equipment, vaccine acquisition and deployment. For the AF, in addition to the risks from the parent project that are relevant to the planned activities in the RHDs and refugee settlements, there are additional risks with the vaccination program under Component 4. The environmental, health and safety risks will be associated with civil works, the operation of the labs, the quarantine and isolation centers, screening posts, and management of generated medical waste (biological, chemical waste, and other hazardous by-products) by the participating facilities in RHDs that will be used for COVID-19 diagnostic testing, isolation of patients, and vaccination sites. Risks include construction-related risks; increased spread of COVID-19 during the vaccination campaigns, issues related to vaccine safety and efficacy (potential adverse health effects from procuring unsafe vaccines and inadequate vaccine storage, handling and transportation practices may lead to vaccine quality deterioration), traffic and road safety risks from transportation of vaccines, handling, and transportation of hazardous/infectious waste for off-site treatment and disposal. These risks will be mitigated with occupational health and safety standards and specific infectious control strategies, guidelines and requirements as recommended by WHO and CDC. Effective administrative and infectious controlling and engineering controls would be put in place to minimize these risks, which will be outlined in the updated Environment and Social Management Framework (ESMF) for the parent project. The environmental, health, and safety risks associated with the civil works can easily be managed through standard construction mitigation measures. Climate change can affect the trajectory of the COVID-19 pandemic and impact groups that are most susceptible to the virus including healthcare workers, the elderly, those with pre-existing conditions, people with disabilities and other disadvantaged groups. These vulnerabilities will be addressed through targeting and improving health care interventions described above as well as enhanced surveillance and monitoring. 91. The parent project prepared, held consultation on and disclosed an ESCP, SEP, ESMF (including LMP). The ESMF, which includes an Infection Control Waste Management Plan (ICWMP) was prepared in line with WHO Interim Guidance (February 12, 2020) on “Laboratory Biosafety Guidance related to the novel corona virus (2019-nCoV)”, WHO standards on COVID-19 response and other guidelines. 1. The risks under the proposed AF are covered by Environmental and Social Standards (ESS) 1, ESS 2, ESS 3, ESS 4, ESS 7 and ESS 10. The parent project’s E&S instruments (ESMF and LMP) are currently being updated to reflect the AF activities, the potential environmental and social risks and impacts related to the AF activities and identify appropriate mitigation measures to address them. The updated ESMF will be finalized, consulted upon, and disclosed by project effectiveness date. The revised ESMF will highlight: (i) environmental health and safety guidelines/measures for staff involved in the vaccination administration, campaign and appropriate PPE required; (ii) monitoring mechanisms for vaccine implementation, the health and safety standards; (iii) practices related to cold chain storage, handling and transportation of vaccines to minimize on associated risks on environment pollution and standards to ensure reliability of the cold chain equipment to maintain the potency of vaccine and quality of immunization service; (iv) the arrangements on the handling, treatment and disposal of vaccine waste; (v) communication and outreach to VMGs and hard to reach areas; (vi) GBV/SEAH risks management; (vii) the GRM; and (viii) the management of security risks. 53 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 92. In addition to the ESMF, the client will implement the activities set out in the ESCP. The Environmental and Social Review Summary (ESRS), ESCP, and SEP of the parent project have been updated. The project implementation will ensure appropriate stakeholder engagement, proper awareness raising and timely information dissemination. This will help: (i) avoid conflicts resulting from false rumors; (ii) ensure equitable access to services for all who need it; and (iii) address issues resulting from people being kept in quarantine. These will be guided by standards set out by WHO as well as other international good practices including social inclusion and prevention of SEA and SH. F. Climate 93. The Project has been screened for short- and long-term climate change and disaster risks, and droughts, extreme precipitation, and flooding were identified as potential high-risk factors. Uganda is a land-locked country in East Africa with a primarily tropical climate and two rainy seasons per year. Future projections indicate that monthly temperatures are expected to increase by 1.8˚C by 2050. 35 Monthly annual precipitation is expected to decrease in some areas and increase in others, particularly on the western shores of Lake Victoria. While Uganda’s natural climate is moderate, the country is susceptible to climate hazards like mudslides, landslides, flooding, and droughts, which have occurred with increased frequency and severity over the last 30 years. Flooding has become more frequent, largely due to increases in intense rainfall, impacting 200,000 Ugandans annually over the last twenty years, and exacerbating the country’s climate hazards. 36 The country’s vulnerability to natural disasters is magnified by elevated levels of poverty and high dependence on climate-sensitive sectors: agriculture, fisheries, tourism, and forestry. Rising heat conditions are increasing the country’s vulnerability to drought, which affected close to 2.4 million people between 2004 and 2013, leading to human and livestock deaths, diminished water levels, and crop failures. 37 Additionally, non-climate stressors, like inadequate infrastructure, render the country ill-equipped to manage the growing population in conjunction with possible climatic shocks, particularly in urban areas. 94. Drought and floods also exacerbate the spread of climate-related diseases, particularly vector borne and diarrheal diseases, which are estimated to cause 6.4 percent of deaths (2017) in Uganda, primarily among children under five years of age. 38 Uganda reports an estimated 11,000 Cholera cases annually, concentrated in rural, refuge hosting districts that border the Democratic Republic of Congo (DRC), South Sudan, and Kenya, as well as Kampala’s crowded urban slums. 39 In addition, the country has one of the highest rates of malaria globally. The country’s malaria incidence is 289 per 1,000 people, comprising 5 percent of the global malaria burden. 40 Meningitis is also endemic in the country, which is 35 World Bank Group. Uganda Country Climate Profile, 2021. https://climateknowledgeportal.worldbank.org/country/uganda. 36 Ibid. 37 Uganda Country Climate Profile, 2021. 38 WHO. Preventing Diarrhea through better water, sanitation and hygiene: Exposures and impacts in low- and middle-income countries. 2014. 39 Monje, Fred, Alex Riolexus Ario, Angella Musewa, Kenneth Bainomugisha, Bernadette Basuta Mirembe, Dativa Maria Aliddeki, Daniel Eurien, et al. 2020. “A Prolonged Cholera Outbreak Caused by Drinking Contaminated Stream Water, Kyangwali Refugee Settlement, Hoima District, Western Uganda: 2018.” Infectious Diseases of Poverty 9 (1): 154. https://doi.org/10.1186/s40249- 020-00761-9. 40 World malaria report 2019. Geneva: World Health Organization; 2019. 54 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) one of the 26 countries in Africa comprising the ‘meningitis belt’, vulnerable to the disease. 41 Further, Uganda is also at elevated risk for importation of Ebola Virus Disease (EVD) from neighboring DRC. Researchers predict climate change will increase in the frequency and intensity of EVD outbreaks. 42 95. The GoU has shown its commitment to address climate change and the AF is fully aligned with the country’s climate priorities. Uganda ratified the Paris Agreement and submitted its Nationally Determined Contributions to the UN Framework Convention on Climate Change (UNFCCC) in 2016, in support of the country’s efforts to realize its development goals as laid out in its Poverty Reduction Strategy Paper (2010) and its National Climate Change Policy (NCCP; 2015). The AF, particularly adaptation measures and climate-related disease surveillance measures to be implemented through the project, are fully aligned with the NCCP’s health sector priority to “strengthen adaptive mechanisms and enhance early-warning systems and adequate preparedness for climate change–related disease” The AF is also fully aligned with climate priorities in Uganda’s CPF, including ensuring infrastructure investments are climate proof and strengthening adaptation for climate change. 96. The AF intends to address these vulnerabilities and enhance climate resilience and adaptation through the following measures. Table 8. Climate Adaptation Activities Financed by the Project Project Component Activity Climate-related action How will activity address climate-related vulnerabilities? Component 1: Case • Strengthen • Include specific modules on • Improve detection Detection, Confirmation, surveillance of climate- surveillance of climate-related of climate related Contact Tracing, Recording, related diseases diseases in surveillance training diseases towards and Reporting (US$ 1 (Cholera, meningitis, • Expand laboratory capacity to increased resilience million IDA) malaria, Typhoid, and include diagnostics for climate- EVD) related diseases • Include climate-related diseases in screening and surveillance materials developed Component 3: Project • Monitor climate • Monitor implementation of • Strengthen project Management, Monitoring activities under the climate related activities in the capacity to adapt to, and Evaluation (US$1 project project prepare for, and respond million, IDA) to climate risks Component 4: Vaccine • Climate sensitive • Planning for vaccine • Ensure adequate Procurement and planning deployment will make adjustments distribution of vaccines to Deployment (US$18.15 to ensure that contingency plans are flood prone areas and million, IDA towards in place so that vaccines are continuation of deployment) delivered during floods, and vaccination during vaccines adequately reach flood- flooding prone areas 41 World Health Organization, 2017. Uganda vaccinates against Meningitis type A in the 39 high-risk districts. https://www.afro.who.int/news/uganda-vaccinates-against-meningitis-type-39-high-risk-districts. 42 Redding, D.W., Atkinson, P.M., Cunningham, A.A. et al. Impacts of environmental and socio-economic factors on emergence and epidemic potential of Ebola in Africa. Nature Communications 10, 4531 (2019). https://doi.org/10.1038/s41467-019-12499- 6. 55 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) • The MoH is also using climate- friendly cold chain facilities for the storage of vaccines. 97. The Project intends to mitigate the impacts of climate change through the following measures which aim to contribute to greenhouse gas reductions: Table 9: Climate Mitigation Activities Financed by the Project Project Component Activity Climate-related action Intended mitigation Component 2, Sub- Rehabilitation to • Install LED lights to improve Contribute to reductions in greenhouse component 2a: improve the energy efficiency of facilities gas emission by shifting intensive care Strengthening energy efficiency • Use reflective paint on facilities to units from lighting that uses more COVID-19 Case of intensive care improve passive cooling energy to LED lighting, which uses less Management units • Solar panels may be installed in energy and reducing the amount of (US$9.15 million, select intensive care units energy used for cooling by reducing the WHR) temperature of intensive care units through reflective paint Component 5, Rehabilitation to • Install LED lights to improve Contribute to reductions in greenhouse Subcomponent 5a: improve the energy efficiency of facilities gas emission by shifting facilities from Upgrade of Health energy efficiency • Use reflective paint on facilities to lighting that uses more energy to LED Infrastructure in of primary improve passive cooling lighting, which uses less energy and Refugee Settlements healthcare • Solar panels may be installed in reducing the amount of energy used for and RHDs (US$6 facilities select facilities cooling by reducing the temperature of million, WHR; US$4 facilities through reflective paint million GFF) V. WORLD BANK GRIEVANCE REDRESS 98. Communities and individuals who believe that they are adversely affected by a World Bank (WB) supported project may submit complaints to existing project-level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, because of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org. 56 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) VI SUMMARY TABLE OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Disbursements Arrangements ✔ Implementing Agency ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ VII DETAILED CHANGE(S) MPA PROGRAM DEVELOPMENT OBJECTIVE Current MPA Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Proposed New MPA Program Development Objective 57 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) EXPECTED MPA PROGRAM RESULTS Current Expected MPA Results and their Indicators for the MPA Program Progress towards the achievement of the PDO would be measured by outcome indicators. Individual country- specific projects (or phases) under the MPA Program will identify relevant indicators, including among others: • Country has activated their public health Emergency Operations Centre or a coordination mechanism for COVID-19; • Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents; • Number of acute healthcare facilities with isolation capacity; • Number of suspected cases of COVID-19 reported and investigated per approved protocol; • Number of diagnosed cases treated per approved protocol; • Personal and community non-pharmaceutical interventions adopted by the country (e.g., installation of handwashing facilities, provision of supplies and behavior change campaigns, continuity of water and sanitation service provision in public facilities and households, schools closures, telework and remote meetings, reduce/cancel mass gatherings); • Policies, regulations, guidelines, or other relevant government strategic documents incorporating a multi- sectoral health approach developed/or revised and adopted; • Multi-sectoral operationalmechanism for coordinated response to outbreaks by human, animal and wildlife sectors in place; • Coordinated surveillance systemsin place in the animal health and public health sectors for zoonotic diseases/pathogens identified as joint priorities; and • Mechanisms for responding to infectious and potential zoonotic diseases established and functional; and • Outbreak/pandemic emergency risk communication plan and activities developed and tested Proposed Expected MPA Results and their Indicators for the MPA Program COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Component 1: Case 7,233,852.00 Revised Component 1: Case 9.30 Detection, Confirmation, Detection, Contact Tracing, Recording, Confirmation, Contact 58 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Reporting Tracing, Recording, Reporting Component 2: 6,810,595.00 Revised Component 2: 22.95 Strengthening Case Strengthening Case Management and Management and Psychosocial Support Psychosocial Support Component 3: Project 1,156,100.00 Revised Component 3: Project 4.10 Management, Monitoring Management, and Evaluation Monitoring and Evaluation 0.00 New Component 4: Vaccines 137.15 Acquisition and Deployment 0.00 New Component 5: 22.00 Strengthening Continuity of Essential Health Services TOTAL 15,200,547.00 195.50 LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline Closing(s) Closing for Withdrawal Applications IDA-67620 Effective 31-Dec-2022 31-Dec-2022 31-Dec-2024 30-Apr-2025 TF-B2865 Closed 31-Jan-2021 31-Mar-2021 31-Mar-2021 31-Jul-2021 DISBURSEMENT ARRANGEMENTS Change in Disbursement Arrangements Yes Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2020 492,242.80 492,242.80 2021 23,322,549.30 23,814,792.10 2022 100,000,000.00 123,814,792.10 2023 60,000,000.00 183,814,792.10 59 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 2024 10,000,000.00 193,814,792.10 2025 1,685,207.90 195,500,000.00 SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance  Substantial  Substantial Macroeconomic  High  High Sector Strategies and Policies  Substantial  Substantial Technical Design of Project or Program  High  Substantial Institutional Capacity for Implementation and  Substantial  Substantial Sustainability Fiduciary  High  High Environment and Social  Substantial  Substantial Stakeholders  High  Substantial Other  Substantial  Moderate Overall  High  High LEGAL COVENANTS2 LEGAL COVENANTS – Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Sections and Description Project Implementation Unit: Schedule 2; Section I.A.2 (c) Without limitation to (a) and (b) above, the Recipient through the Ministry of Health, shall no later than four (4) months after the Effective Date recruit to the Project Implementation Unit: (i) procurement officer; (ii) project accountant; and (iii) a program officer for the refugees and host communities activities; all under the terms of reference and with qualifications and experience acceptable to the Association. Project Steering Committee: Schedule 2; Section I.A.3. The Recipient shall no later than three (3) months after the Effective Date update the membership of - and thereafter maintain throughout the period of implementation of the Project - the Project Steering Committee with mandate, terms of reference, composition, and resources satisfactory to the Association, chaired by the Permanent Secretary in the Ministry of Health and comprising, inter alia, representatives from Office of the Prime Minister, Ministry of Health, Ministry of Finance, Ministry of Gender, Labor and Social Development, UNHCR a representative of civil society, that shall meet on a quarterly basis and shall be responsible for providing oversight as well as policy and strategic guidance for the Project as further detailed in the Project Implementation Manual. Withdrawal Conditions; Withdrawal Period: Schedule 2; Section III.B.2 The Recipient undertakes that no Financing proceeds or resources may be used for law-enforcement, security, 60 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) military, or paramilitary purposes or for any payments made to any law-enforcement, security, military, or paramilitary forces without the express approval of the Association. Project Implementation Manual: Schedule 2; Section I.B.1 (a) The Recipient shall: (i) (A) update the project implementation manual to incorporate among other things vaccine delivery and distribution arrangements including adding an annex containing Vaccine Delivery and Distribution Manual, all in a manner and substance satisfactory the to the Association. Standards for COVID-19 Vaccine Approval: Schedule 2; Section I.F All Project COVID-19 Vaccines shall satisfy the Vaccine Approval Criteria. Annual Work Plans and Budgets: Schedule 2; Section I.B.2 (a) prepare and furnish to the Association on an annual basis, by no later than March 31 of each year, commencing on March 31, 2022, the annual work plan and budget containing all activities proposed to be included in the Project during the following Fiscal Year, and a proposed financing plan (setting forth the proposed amounts and sources of financing for expenditures required for such activities); Notwithstanding the foregoing, unless otherwise agreed by the Association, an updated Annual Work Plan and Budget to incorporate the new activities supported by this Financing shall be prepared by the Recipient by not later than one (1) month after the Effective Date. Conditions Type Financing source Description Effectiveness IBRD/IDA Article V. 5.01 (a) the Association is satisfied that the Recipient has an adequate refugee protection framework Type Financing source Description Effectiveness IBRD/IDA Article V. 5.01 (b) the Recipient has updated the Project Implementation Manual as detailed in Section I.B.1 (a) of Schedule 2 to this Agreement, in a manner and substance satisfactory to the Association Type Financing source Description Effectiveness IBRD/IDA Article V.5.01 (c) the Recipient has designated to the Project Implementation Unit: an account assistant, a technical specialist for vaccination-related activities and a procurement assistant, all under terms of reference and with qualifications and experience acceptable to the Association Type Financing source Description Effectiveness IBRD/IDA Article V. 5.01 (d) the Recipient has: (i) updated, consulted upon, adopted, and publicly disclosed the updated Environmental and Social Management Framework and updated Stakeholder Engagement Plan, in manner and substance satisfactory to the Association; and (ii) updated the Grievance Redress Mechanism (GRM) to reflect extended Project activities, all in manner and substance satisfactory to the Association 61 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Type Financing source Description Effectiveness IBRD/IDA Article V. 5.02: the Effectiveness Deadline is the date ninety (90) days after the Signature Date 62 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Uganda RESULT NO PDO Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project Project Development Objective(s) The objective of the Project is to prevent, detect and respond to COVID-19 and strengthen national systems for public health emergency preparedness in Uganda. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 To strengthen Uganda's capacity to respond to the COVID-19 outbreak Proportion of moderate and severe COVID-19 cases managed at designated regional and national referral hospital COVID treatment 25.00 25.00 50.00 65.00 85.00 units in accordance with the national COVID-19 case management protocols (Percentage) Rationale: Action: This indicator has been Reduced the scope of the original indicator to clinical management and refocused on regional and national referral hospitals that have been designated Revised as COVID-19 Treatment Units (CTUs) to improve measurement. Proportion of suspected COVID-19 cases having laboratory 50.00 75.00 85.00 90.00 95.00 confirmation results within 48 63 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 hours of sample collection (Percentage) Rationale: Action: This indicator has been Refined by adding the time of sample collection as the start time for measuring lead time to results and revised the end target upward. Revised Percentage of population vaccinated, which is included in the priority population targets defined 0.00 12.00 18.00 25.00 in national plan [disaggregated by sex] (Percentage) Rationale: New PDO indicator included to measure progress in COVID-19 vaccination coverage. The project provides substantial amount of resources to support Action: This indicator is New national vaccination efforts. The AF is expected procure vaccine to cover 11.7 million people i.e., 26.4 percent of the total population of Uganda although the actual proportion of beneficiaries is estimated at 25 percent, assuming a wastage rate of 5 percent Proportion of national population, vaccinated through 0.00 7.00 10.00 12.50 Bank financing, that are female (Percentage) Rationale: Action: This indicator is New sub-indicator to track vaccine coverage among females Proportion of national population, vaccinated through 0.00 7.00 10.00 12.50 Bank financing, that are male (Percentage) 64 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Rationale: Action: This indicator is New sub-indicator to track vaccine coverage among males Total number of people in RHDs and refugee settlements benefiting 0.00 1,500,000.00 2,500,000.00 3,000,000.00 from key Project interventions (Number) Rationale: To quantify direct beneficiaries in RHD and refugee settlements from priority interventions under the project including # patients per year accessing Action: This indicator is New health facilities for a total of 6 HC IVs, 10 HC IIIs that will be upgraded with funding (IOI15b, 15c); # persons served by 2 C&D Centres (IOI 18b, 17a); # persons immunized; # people tested and # patients accessing services at ICUs/HDUs/Isolation Units: (IOI9b) in 2 RRHs, 3 general hospitals and one HCIV. Total number of people in refugee settlements benefiting 0.00 200,000.00 800,000.00 1,000,000.00 from key Project interventions (Number) Rationale: Action: This indicator is New Measures the number of people benefiting from various priority interventions under the project in refugee settlements Total number of people in RHDs benefiting from key Project 0.00 600,000.00 1,500,000.00 2,000,000.00 interventions (Number) Rationale: Action: This indicator is New To measure the number of people in RHDs benefiting from key Project interventions PDO Table SPACE 65 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Component 1: Case Detection, Confirmation, Contact Tracing, Recording and Reporting Number of laboratory tests done for suspected COVID-19 cases using 194,872.00 1,400,000.00 3,000,000.00 4,500,000.00 6,000,000.00 approved testing technologies (Number) Rationale: Action: This indicator has been Revised targets upward to reflect enhanced access to testing technologies in refugee settlements and RHDs and the extended closing date Revised Number of laboratory tests done for COVID-19 suspected 95,000.00 18,500.00 300,000.00 420,000.00 cases in RHDs (Number) Rationale: Action: This indicator is New To measure COVID-19 testing capacity in RHDs Number of laboratory tests done for COVID-19 suspected 40,000.00 100,000.00 155,000.00 210,000.00 cases in refugee settlements (Number) Rationale: Action: This indicator is New To measure COVID-19 testing capacity in refugee settlements Cumulative number of laboratories enrolled on ISO 15189 accreditation maintaining or 4.00 5.00 5.00 6.00 7.00 achieving ISO 15189 accreditation (Number) Action: This indicator has been Rationale: Revised Revised the target upwards to reflect extension of closing date 66 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Cumulative number of staff trained in laboratory diagnosis of SARS- 250.00 700.00 CoV-2 and other important pathogens (Number) Rationale: Action: This indicator has been This area is adequately covered by other partners and hence not key part of the project Marked for Deletion Number of targeted hospitals whose laboratory spaces have been 0.00 0.00 0.00 1.00 2.00 remodeled/upgraded (Number) Rationale: Action: This indicator has been Updated the annual targets to reflect the extended project duration. Revised Proportion of RRHs enrolled on the LQMS scoring >90% in the annual 30.00 70.00 biowaste management audits (Percentage) Rationale: Action: This indicator has been This area is adequately covered by other partners and hence no significant resources have been prioritized for it under the project. Marked for Deletion Proportion of people travelling through twelve high priority PoEs screened for COVID-19 and other 10.00 90.00 90.00 95.00 95.00 diseases of public health importance (Percentage) Rationale: Action: This indicator has been Revised Included the targeted number PoEs (at least twelve) in the indicator statement to make monitoring easier; the original indicator statement was subject to the challenge of changing number of PoEs. 67 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Component 2: Strengthening Case Management and Psychosocial Support Proportion of targeted hospitals with functional oxygen delivery 20.00 90.00 equipment (Percentage) Rationale: Action: This indicator has been Government has obtained resources from global fund and other partners to scale up oxygen supply across the country and hence not prioritized it under Marked for Deletion this project. Number of isolation facilities/intensive care units/high 0.00 0.00 0.00 5.00 10.00 dependency units upgraded or remodeled countrywide (Number) Rationale: Action: This indicator has been Revised to include high dependency unit (HDU) facilities. Revised Number of isolation facilities/Intensive Care Units/High Dependency Units 0.00 3.00 6.00 6.00 upgraded or remodeled in RHDs and refugee settlements (Number) Rationale: Action: This indicator is New Measure isolation, ICU and HDU capacity in RHDs and refugee settlements Number of staff trained in critical, acute, and emergency medicine 35.00 100.00 300.00 400.00 500.00 (Number) 68 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Rationale: Action: This indicator has been Included training in other aspects of emergency medical services and raised the end year target. Revised Number of staff trained in in critical, acute, and emergency 0.00 60.00 100.00 100.00 medical services in refugee settlements (Number) Rationale: Action: This indicator is New Measure HR capacity for management of COVID-19 cases Proportion of staff trained in critical, acute, and emergency 0.00 40.00 45.00 50.00 medical services that are female (Percentage) Rationale: Action: This indicator is New Measure women empowerment through training of emergency medical services Number of health care workers and community stakeholders trained in managing GBV cases and 0.00 150.00 250.00 300.00 psychosocial support countrywide (Number) Rationale: Measure HR capacity to manage GBV cases and provided psychosocial support given the heightened prevalence of sexual violence and mental health Action: This indicator is New complications during the COVID era Number of health care workers and community stakeholders trained in managing GBV cases 0.00 75.00 150.00 200.00 and psychosocial support in RHDs (Number) 69 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Rationale: Measures HR capacity in managing GBV cases and provision of psychosocial support in RHDs that have seen a surge in GBV cases and mental health Action: This indicator is New complications. Component 3: Project Management, Monitoring and Evaluation Proportion of Grievances captured in the Complaints Register for UCREPP that have been “CLOSED 0.00 0.00 50.00 70.00 85.00 OUT” in accordance with GRM under the Project (Percentage) Rationale: Action: This indicator has been To monitor redress of stakeholder grievances and complaints Revised Proportion of District Task Forces (DTFs) reviewing technical reports on continuity of Essential Health 0.00 60.00 75.00 90.00 services in the past quarter (Percentage) Rationale: Action: This indicator is New Measure efforts by districts to track and address gaps in the non-pandemic essential health services Vaccines Acquisition and Deployment (Action: This Component is New) Number of vaccine doses procured 0.00 12,000,000.00 15,000,000.00 17,000,000.00 by the Project (Number) Rationale: Action: This indicator is New New indicator to measure volume of vaccines procured 70 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Number of vaccine-eligible refugees vaccinated through the 0.00 300,000.00 350,000.00 400,000.00 Project (Number) Rationale: Action: This indicator is New New indicator to track the number of vaccine-eligible refugees vaccinated Number of people in refugee hosting districts vaccinated 0.00 400,000.00 850,000.00 1,100,000.00 through the Project (excluding Kampala) (Number) Rationale: Action: This indicator is New Number of people vaccinate in refugee hosting districts (less the population of Kampala) Strengthening Continuity of Essential Health Services (Action: This Component is New) Number of Health facilities and hospitals refurbished/renovated 0.00 0.00 4.00 10.00 countrywide (Number) (Number) Rationale: Action: This indicator is New Measure investments in transforming temporary health centers within refugee settlements into permanent facilities. Number of temporary health centers within refugee settlements with improved 0.00 0.00 3.00 5.00 permanent infrastructure (Number) 71 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Rationale: Action: This indicator is New Measure investments in transforming temporary health centers within refugee settlements into permanent facilities Number of General Hospitals and health centers IVs 0.00 0.00 3.00 5.00 refurbished in RHDs (Number) Rationale: Action: This indicator is New Measure general hospitals and HCIVs refurbished in RHDs Number of emergency call and dispatch centers established and functional to address medical 0.00 2.00 4.00 4.00 emergencies, GBV and psychosocial support (Number) Rationale: Action: This indicator is New Indicator introduced to monitor the new activity of establishing emergency call and dispatch centres including GBV and psychosocial support Number of ambulances procured and supplied countrywide under 0.00 20.00 30.00 40.00 the project (Number) Rationale: Action: This indicator is New Measure number of ambulances procured to support referrals and the national emergency medical services. Ambulances procured for refugee settlements and RHDs 0.00 0.00 15.00 25.00 (Number) 72 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 Rationale: Action: This indicator is New Measure logistics support for emergency evacuation. Proportion of Village Health Teams in at least twenty (20) COVID-19 hotspot districts equipped to provide COVID-19 prevention, 0.00 25.00 50.00 60.00 homebased care, and other essential health services (Percentage) Rationale: Indicator added to reflect investment in community health workforce as a way to address access and cost challenges especially among women and the Action: This indicator is New poor segments districts most affected by COVID-19. Units of whole blood issued to health facilities nationally in a year 253,000.00 256,000.00 258,000.00 260,693.00 (Number) Rationale: Action: This indicator is New Measure investments in support of improved blood donor mobilization, blood processing, supply and facility level storage Percentage of facilities that had over 95% availability of a basket of 46.00 50.00 54.00 57.00 41 commodities in the previous quarter (Percentage) Rationale: Measures Project's contribution towards enhancing availability of essential commodities including for maternal and newborn care, NCD which are part Action: This indicator is New of the approved package of 41 essential commodities. IO Table SPACE 73 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Proportion of moderate and severe Administrative M&E Specialist, CHS COVID-19 cases managed at designated Review of Administrative data and Epidemiology and regional and national referral hospital Quarterly data and verification verification Disease Surveillance, COVID treatment units in accordance with reports reports CHS Clinical Services the national COVID-19 case management protocols Numerator: Number of suspected COVID-19 cases having laboratory Review of the confirmation results within EOC Situation Review of the EOC 48 hours of sample Reports Situation Reports M&E Specialist, CHS Proportion of suspected COVID-19 cases collection Quarterly (SITREP) and (SITREP) and the Reports Epidemiology and having laboratory confirmation results the Reports of of the National Task Disease Surveillance within 48 hours of sample collection Denominator: Total the National Force. number of suspected Task Force COVID-19 cases having laboratory diagnosis using approved testing technologies Numerator: population vaccinated, which is included in the priority Percentage of population vaccinated, population targets defined Administrative Review of administrative M&E Specialist, Head, which is included in the priority Biannually in national plan data data UNEPI, CHS - PHE population targets defined in national plan [disaggregated by sex] Denominator: Total national population 74 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Numerator: females vaccinated, which is M&E Specialist, CHS Administrative included in the priority Review of administrative Integrated Proportion of national population, data and population targets defined Biannually data and verification Epidemiology & Disease vaccinated through Bank financing, verification in national plan reports Surveillance and ACHS that are female reports. UNEPI Denominator: Total national population Numerator: males vaccinated, which is M&E Specialist, CHS Administrative included in the priority Review of administrative Integrated Proportion of national population, data and population targets defined Biannually data and verification Epidemiology & Disease vaccinated through Bank financing, verification in national plan reports. Surveillance and ACHS that are male reports. UNEPI Denominator: Total national population Total number of people in RHDs and refugee settlement benefiting from priority interventions under the project including # patients per year EPI Manager, M&E accessing health facilities Total number of people in RHDs and Administrative Review of administrative Specialist and for a total of 6 HC IVs, 10 Annual refugee settlements benefiting from key data data Commissioner Public HC IIIs that will be Project interventions Health Emergencies upgraded with funding (IOI15b, 15c); # persons served by 2 C&D Centres (IOI 18b, 17a); # persons immunized; # people tested and # patients accessing services at 75 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) ICUs/HDUs/Isolation Units: (IOI9b) in 2 RRHs, 3 general hospitals and I HCIV. Number of people Administrative M&E Specialist and Review of Administrative Total number of people in refugee benefiting from various data in the HIS Commissioner in charge Biannually data in the HIS and settlements benefiting from key priority interventions and Project of Refugee Health Project Reports Project interventions under the project in Reports Coordination refugee settlements Review of routine health information/data and Project reports. Will add the number of people benefiting from the following interventions: • # patients per year accessing health facilities Routine for a total of 6 health M&E Specialist and HC IVs, 10 HC IIIs Total number of people in RHDs The number of people in information/d Commissioner in charge Biannual that will be benefiting from key Project RHDs benefiting from key ata and of Refugee Health upgraded with interventions Project interventions Project Coordination funding (IOI15b, reports 15c) • # persons served by 2 C&D Centres (IOI 18b, 17a) • # persons immunized • # people tested • # patients accessing 76 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) services at ICUs/HDU/Isolati on units: (IOI9b) o 2 RRHs o 3 general hospitals o 1 HC IV ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Administrative data and Periodic data collection Cumulative number of verification using structured M&E Specialist, CHS Number of laboratory tests done for COVID-19 laboratory tests Biannually reports – checklists and review of Epidemiology and suspected COVID-19 cases using approved conducted using PCR, Laboratory administrative data and Disease Surveillance. testing technologies GeneXpert and approved Registers, verification reports RDTs combined RDS, SITREPs. Number of laboratory tests done for COVID-19 for M&E Specialist and Laboratory Review of Laboratory Number of laboratory tests done for suspected cases in RHDs. Biannually Commissioner of Public reports reports COVID-19 suspected cases in RHDs This includes both the Health Emergencies number of host and refugee communities Number of laboratory tests done for Number of laboratory tests Laboratory Review of laboratory M&E Specialist and Biannually COVID-19 suspected cases in refugee done for COVID-19 activity data and reports Commissioner settlements suspected cases in refugee reports Laboratory Public Health 77 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) settlements. Emergencies Cumulative number of Cumulative number of laboratories Periodic laboratories enrolled on Periodic data collection, M&E Specialist, CHS enrolled on ISO 15189 accreditation Annually SLIPTA/SANAS the LQMS maintaining or Structured Checklist Planning maintaining or achieving ISO 15189 audits reports achieving ISO 15189 accreditation accreditation. Cumulative total number of laboratory staff trained in Cumulative number of staff trained in Training Review of training M&E Specialist, CHS laboratory diagnosis of Quarterly laboratory diagnosis of SARS-CoV-2 and reports. reports. Planning. Novel SARS-CoV-2 and other important pathogens other important pathogens. Health Infrastructure Cumulative number of Number of targeted hospitals whose Inventory Periodic data collection, M&E Specialist, CHS targeted laboratory spaces Annually laboratory spaces have been MoH; Activity Structured Checklist. Planning. have been remodeled/upgraded Progress remodled/upgraded. Reports. Numerator: Number of project supported health facilities that score >90% Periodic bio- Proportion of RRHs enrolled on the LQMS from the biowaste waste Periodic data collection, M&E Specialist, CHS Quarterly scoring >90% in the annual biowaste management audits management Structured Checklist. Planning. management audits conducted annually. audits reports Denominator: Total number of health facilities supported by the project. Proportion of people travelling through Numerator: Number of Ministry of Numerator: Number of M&E Specialist, CHS Quarterly twelve high priority PoEs screened for people screened at the Health and people screened at the Epidemiology and COVID-19 and other diseases of public targeted designated Points Ministry of targeted designated Disease Surveillance. 78 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) health importance of Entry Internal PoEs. Denominator: Denominator: Total Affairs PoE Total number of number of passengers Reports passengers travelling travelling through the through the targeted targeted designated Points designated PoEs of Entry screened screened. Numerator: Number of Health targeted hospitals with Review of the Health Infrastructure functional oxygen delivery Infrastructure and M&E Specialist, CHS and Proportion of targeted hospitals with equipment. Denominator: Quarterly Equipment Inventory Clinical Services, CHS Equipment functional oxygen delivery equipment Total number of hospitals Reports Infrastructure Inventory targeted for supply of Reports oxygen delivery equipment. Administrative Cumulative number of data and targeted hospitals with Periodic data collection verification upgraded or remodeled Biannually using structured M&E Specialist, CHS Number of isolation facilities/intensive reports. isolation/ICU /HDU facility. checklists and review of Planning, CHS care units/high dependency units Health This activity mainly focuses administrative data and Infrastructure upgraded or remodeled countrywide Infrastructure on regional referral verification reports Inventory hospitals but could include reports other priority levels of care. Number of isolation Sum of isolation M&E Specialist and facilities/Intensive Care Units/High facilities/Intensive Care Project Review of project Annually Commissioner Health Dependency Units upgraded or Units/High Dependency reports reports Infrastructure remodeled in RHDs and refugee Units upgraded or settlements remodeled in RHDs and 79 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) refugee settlements Cumulative number of staff trained in various Review of M&E Specialist, CHS Review of training Number of staff trained in critical, acute, disciplines critical, acute, Biannually training Clinical Services, CHS reports. and emergency medicine and other aspects of reports. Human Resources. emergency medical services Number of staff trained in Number of staff trained in in critical, in critical, acute, and Training Review of project Biannually Project Coordinator acute, and emergency medical emergency medical reports training reports services in refugee settlements services in refugee settlements Measures proportion of Commissioner Proportion of staff trained in critical, staff trained in critical, Training Review of training Biannually Emergency Medical acute, and emergency medical acute, and emergency reports reports Services services that are female medical services that are female Number of health care workers and community MoH and MoGLSD Number of health care workers and stakeholders trained in Training Review of training Commissioners community stakeholders trained in Biannually managing GBV cases and reports reports responsible for GBV and managing GBV cases and psychosocial psychosocial support Psychosocial support support countrywide countrywide supported by the Project Number of health care MoH and MoGLSD Number of health care workers and workers and community Training Review of training Commissioners community stakeholders trained in stakeholders trained in Biannually activity activity reports responsible for GBV and managing GBV cases and psychosocial managing GBV cases and reports Psychosocial support support in RHDs psychosocial support in RHDs Proportion of Grievances captured in the Numerator: Number of Biannually UCREPP GRM Review of GRM M&E Specialist, CHS 80 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Complaints Register for UCREPP that have grievances captured in the Register documents Health Infrastructure been “CLOSED OUT” in accordance with Complaints Register for Division and Safeguards GRM under the Project UCREPP that have been Officers “CLOSED OUT” in accordance with the project GRM Denominator: Total number of grievances captured in the Complaints Register for UCREPP Numerator: District Task Forces (DTFs) that reviewed technical reports Proportion of District Task Forces (DTFs) on continuity of Essential District Task Review of reports of the Assistant Commissioner reviewing technical reports on continuity Quarterly Health services in the past Force Reports DTFs Health Information of Essential Health services in the past quarter quarter Denominator: All the District Task Forces (DTFs) Administrative data and Review of administrative verification M&E Specialist, CHS, EPI Number of vaccine doses procured by the Number of vaccine doses Biannually data and verification reports – Manager Project procured under the Project reports Procurement Reports. Administrative Review of administrative Number of eligible data and Manager, EPI and Number of vaccine-eligible refugees Biannually data and verification refugees vaccinated verification Project M&E Officer vaccinated through the Project reports through the Project reports 81 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Administrative M&E Specialist, CHS Number of people in Review of administrative Number of people in refugee hosting data and Integrated Epidemiology refugee hosting districts Biannually data and verification districts vaccinated through the verification & Disease Surveillance vaccinated through the reports Project (excluding Kampala) reports. and ACHS UNEPI Project Administrative data and verification reports. Review of administrative M&E Specialist, CHS Cumulative number of Health Number of Health facilities and hospitals data, verification, health Health Infrastructure hospitals and health Annually Infrastructure refurbished/renovated countrywide infrastructure inventory Division and CHS Clinical facilities Inventory (Number) reports Services refurbished/renovated reports, Activity Progress reports Number of temporary Number of temporary health centers health centers within Construction Review of construction Commissioner Health Annually within refugee settlements with refugee settlements reports status reports Infrastructure improved permanent infrastructure transformed into permanent facilities Number of General Infrastructure Review of infrastructure Commissioner - Number of General Hospitals and Hospitals and health Annually reports reports Infrastructure health centers IVs refurbished in RHDs centers IVs refurbished in RHDs Number of emergency call Administrative Number of emergency call and dispatch and dispatch centers data and Review of administrative M&E Specialist, and centers established and functional to established and functional Annually verification data and verification CHSs Emergency address medical emergencies, GBV and of which two will service reports, reports Medical Services psychosocial support RHDs and the other two Review serving two other areas of Activity 82 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) the country Progress reports. Administrative data and Review of administrative M&E Specialist, CHSs verification Number of ambulances procured and Number of ambulances Annually data, procurement, and Emergency Medical reports – supplied countrywide under the project procured under the project verification reports Services Procurement Reports. Number of ambulances Procurement Review of procurement Ambulances procured for refugee Annually Project Coordinator procured for refugee reports reports settlements and RHDs settlements and RHDs Numerator: Number of VHTs equipped to provide community level COVID-19 prevention and homebased care and other essential health services thereby addressing female access Proportion of Village Health Teams in at Administrative and mobility challenges in Review of administrative M&E Specialist; CHS least twenty (20) COVID-19 hotspot data and 20 of the districts most Annually data and verification Community Health; districts equipped to provide COVID-19 verification affected by COVID-19 reports ACHS, DHI. prevention, homebased care, and other reports (hotspots). The list of these essential health services districts will be detailed in the PIM. Denominator: Number of VHTs in the specified 20 COVID-19 hotspot districts 83 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Number of units of whole Blood supply Review of blood supply Uganda Blood Units of whole blood issued to health blood issued to health Annually report reports Transfusion Services facilities nationally in a year facilities nationally in a year Annual Health Numerator: Number of Sector facilities that reported Performance Review of the AHSPR Commissioner, Percentage of facilities that had over 95% above 95% availability of Annually Reports and and Pharmacy Pharmaceutical Services. availability of a basket of 41 commodities 41 essential commodities Pharmacy Department Reports in the previous quarter Department Denominator: All the Annual Report facilities assessed ME IO Table SPACE 84 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) ANNEX 1: SUMMARY TABLE ON VACCINE DEVELOPMENT AND APPROVAL STATUS (As of September 15, 2021) Vaccine Stringent Regulatory Authority WHO PQ/EUL Emergency Use Approval BNT162b2/COMIRNATY United Kingdom: December 2, 2020 WHO Emergency Use Listing (EUL): Tozinameran (INN) - Canada: December 9, 2020 December 31, 2020 Pfizer BioNTech United States of America: December 11, 2020 European Union: December 21, 2020 Switzerland: December 19, 2020 Australia: January 25, 2021 mRNA-1273 - Moderna USA: December 18, 2020 WHO EUL: April 20, 2021 Canada: December 23, 2020 EU: January 6, 2021 Switzerland: January 12, 2021 UK: January 8, 2021 AZD1222 (also known as UK: December 30, 2020 WHO EUL: February 15, 2021, for ChAdOx1_nCoV19/ EU: January 29, 2021 vaccines manufactured by SK Bio commercialized as Australia: February 16, 2021 (overseas and Serum Institute of India COVISHIELD in India) - manufacturing); March 21, 2021 (for AstraZeneca/Oxford local manufacturing by CSL – Seqirus) Canada: February 26, 2021 Ad26.COV2. S - Johnson USA: February 27, 2021 WHO EUL: March 12, 2021 & Johnson Canada: March 5, 2021 EU: March 11, 2021 Switzerland: March 22, 2021 UK: May 28, 2021 Australia: June 25, 2021 BBIBP-CorV - Sinopharm WHO EUL: May 7, 2021, for vaccines manufactured by Beijing Institute of Biological Products Co Ltd E-Town Vaccine Industry Base No. 6 &9 Boxing 2nd Road Economic-Technological Development Area Beijing, P.R. China CoronaVac - Sinovac WHO EUL: June 1, 2021, for vaccines manufactured by Sinovac Life Sciences Co., Ltd. No. 21, Tianfu Street, Daxing Biomedicine Industrial Base of Zhongguancun Science Park, Daxing District, Beijing, P.R. China 85 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) ANNEX 2: THE COVID-19 SITUATION IN UGANDA 1. Uganda reported the first case of COVID-19 on March 20, 2020, signaling the beginning of the first wave of the epidemic. This was initially dominated by imported cases, especially along the border districts and cargo truck routes from neighboring countries, but gradually transitioned to sustained community transmission. It was further compounded by the election process for national and sub-national leaders. Figure 2 below illustrates the trend in COVID-19 cases from March 2020 through October 2021. Figure 1: COVID-19 epidemic curve, Uganda 2. As of October 23, 2021, the cumulative cases in the country were 125,758 with 3,200 deaths (including 2,845 refugee cases and 50 refugee deaths), and an overall case fatality of 2.5 percent. The seropositivity of tested samples peaked at 21 percent during the second wave but had dropped to 1.9 percent by October 23, 2021. Uganda is now transitioning from the second wave of the COVID-19 epidemic which was more aggressive. The second wave was driven by several factors including the following: poor adherence to non-pharmaceutical public health measures (i.e., social distancing, use of masks, and hand hygiene); the opening of economic activities for workplaces, schools, travel, etc.; the emergence of SARS-CoV-2 variants of concern. 3. To respond to the pandemic, the GoU developed, and is implementing, the National COVID-19 Preparedness and Response Plan/Resurgence Plan (the ‘Resurgence Plan’). The country’s public health infrastructure is relatively experienced in mounting outbreak responses, having dealt with epidemics including Ebola Virus Disease, Marburg, Crimean Congo Hemorrhagic Fever, Yellow Fever, Rift Valley Fever and Tuberculosis. The GoU’s investments in laboratory systems strengthening and pandemic preparedness, including under the East African Public Health Laboratory Networking Project (P111556), have also contributed to strengthening health system resilience. Nonetheless, the country has faced 86 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) challenges in its COVID-19 response, and during the outbreak, has instituted two stringent lockdowns, which have helped contain the outbreak, but have also impacted socio-economic wellbeing. The lockdown entailed in-country and out-country travel restrictions, closure of schools, prohibition of social gatherings and limitations in numbers aggregating for necessary functions like weddings and funerals, as well as closures of major business and trade centers in the Capital City, Kampala. 4. The GoU has also faced funding constraints in implementing its Resurgence Plan, which still has a significant financing gap. Since the identification of the first case, the Bank has provided timely support beginning with the activation of the Contingent Emergency Response Component (CERC) of the Uganda Reproductive Maternal and Child Health Services Improvement Project (URMCHIP, P155186) in March 2020. The CERC provided US$15 million for urgent needs in the immediate response efforts; and UCREPP (the parent Project for this AF) provided an additional US$2.7 million through the PEFF. The GFF has also provided catalytic trust fund resources (US$300,000) to provide just-in-time technical assistance to inform implementation in areas like risk communication and continuity of essential health services. 5. Uganda launched its COVID-19 vaccination campaign in March 2021 targeting about 22 million eligible people (49.6 percent of the population). The priority groups targeted include all health workers, security personnel, teachers, the elderly (aged 50 years or more) and people 18 to 50 years with comorbidities. As of October 23, 2021, the country had received 8,891,410 doses of AstraZeneca, Pfizer, J&J, Moderna, SINOVAC and Sinopharm vaccines A total of 2,422,233 people had received at least one dose of the two dose vaccines, equivale to 5.6 percent of the total population. Government has advanced funds totaling US$15.5 million to the AU-AVATT mechanism to fast-track the delivery of nine million doses of the J&J vaccine (the first batch of 196,800 of these arrived October 5, 2021), and US$14 million to procure 2,545,455 doses of the Sinopharm vaccine. 6. The main bottlenecks for the vaccination program are financial and logistical and they include: The main bottlenecks for the vaccination program are financial and logistical and they include: inadequate and irregular supply of vaccines; weak data collection and analysis on vaccine deployment statistics, gaps, challenges, and opportunities; poor reporting of adverse events following vaccination; limited staffing to deliver vaccines at scale and concurrently manage routine service delivery; and inadequate operational funds for vaccine delivery and the overall COVID-19 response. These bottlenecks are further discussed below: • Inadequate and irregular supply of vaccine doses. As of October 23, 2021, Uganda had received only 62 percent of the doses required to vaccinate 8.4 million people by the end of December 2021. Furthermore, Uganda has not yet effectively engaged the private sector in financing the cost of vaccines and their deployment and is cautiously exploring mechanisms to do so, while engaging donor countries to provide additional resources for vaccine procurement and deployment. • Post vaccination information management and adverse events surveillance weaknesses. Uganda relies on both paper-based and electronic information management tools to document and monitor the vaccination program, including AEFIs. Transmission and analysis of information as well as reporting on AEFIs is low. These information management challenges are being addressed through the following actions: (i) use of SMS for transmission of summary information to the 87 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) national District Health Information System (DHIS2), (ii) phone calls from the EPI to the districts, and (iii) provision of computers and tablets to districts and health facilities. Despite these actions, which are being supported by various parties including the National Information Technology Agency Uganda (NITA-U), uptake of electronic tools is still low, and this is compounded by low internet connectivity in some remote areas. Further, delayed data entry and validation is hampered by inadequate HR (Human Resource) numbers and skills, as well as equipment. There are ongoing discussions at the Bank to help strengthen data collection and use, through enhanced interventions supported by the pipeline AF to the Uganda COVID-19 Response and Emergency Preparedness Project. • Delayed data entry and validation. This was caused by inadequate HR numbers and skills, as well as equipment. This will be addressed through training and equipping of data entrants. • AEFI monitoring is being addressed by ensuring that each client receiving COVID-19 vaccination remains at the site for at least 30 minutes for close observation and monitoring. Once discharged, they are encouraged to report any adverse or unusual event to the health facility mainly through telephone call or SMS or physical visit to the health facility. Cases of AEFIs are documented and transmitted to the MoH as part of the routine reports on the immunization activity. The reports reach the MoH through the DHIS2 e-tracker or phone call to the National Drug Authority (NDA), which enters the client and AEFIs particulars in a VIGIBASE database. Each serious AEFI case is investigated by a national investigation team with regional presence. A national causality assessment committee is in place to assess the potential causes of the AEFIs. However, the AEFI Reporting rate has been low mainly because healthcare providers have only been reporting serious events; about 60 districts did not report any AEFI through the MoH’s DHIS2 causing discrepancies between the DHIS2 and NDA’s Vigiflow. The MoH intends to remedy these inadequacies by widely disseminating and publicizing the NDA platforms for reporting AEFI and conducting active follow up of AEFI cases with an established panel of medical experts, as well as completing data entry for the backlog of AEFI reports and harmonizing the data in DHIS 2 and Vigiflow. • Inadequate operational funds for vaccine delivery and the overall COVID-19 response. Deployment of COVID-19 vaccines (AstraZeneca) has been affected by shortage of funding for operational activities including training and deployment of personnel, distribution of vaccines and supplies, provision of health information management tools, monitoring and adverse events, coordination, risk communication, and community engagement. The overall test-trace-treat response strategy has also been affected by lack of funding. The government is actively mobilizing funds from domestic resources and partners for procurement of COVID-19 vaccines, essential medicines, and supplies, and to support COVID-19 deployment efforts. 88 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) ANNEX 3: HOST COMMUNITY AND REFUGEE IMPACTS OF COVID-19 AND RESPONSE Context 1. Uganda hosts the largest number of refugees in Africa primarily from neighboring countries. Their number has more than doubled since 2015 to over 1.5 million. Ninety-four percent of the population live in settlements, while the remainder live in urban areas. Females represent 52 percent of the population, and children, 59 percent. Table 1, details current distribution of refugees in Refugee Hosting Districts (RHDs), not including Kampala which houses 93,179 refugees. The table also reflects the population in each district that would be reached with a 26 percent vaccination rate. The population of refugees above 18 years, and therefore eligible for vaccination according to the NVDP is 698,000 and the number for vaccine-eligible people in RHDs is 2,201,000. Table 1: Refugees and Ugandan population in RHDs, August 17, 2021 43 26 percent Ugandan 26 percent S/# Location name Refugee Population vaccine Population vaccine 1 Adjumani 230,134 59,835 237,400 61,724 2 Isingiro 148,082 38,501 616,700 160,342 3 Kamwenge 76,844 19,979 475,600 123,656 4 Kikuube 127,908 33,256 376,600 97,916 5 Kiryandongo 72,279 18,793 322,300 83,798 6 Koboko 5,758 1,497 267,700 69,602 7 Kyegegwa 125,431 32,612 475,600 123,656 8 Lamwo 57,408 14,926 145,400 37,804 9& Madi Okollo & Terego 197,757 51,417 770,600 200,356 10 11 Obongi 125,641 32,667 50,300 13,078 12 Yumbe 239,141 62,177 699,300 181,818 TOTALS 1,406,383 365,660 4,437,500 1,153,750 COVID-19 Impacts 2. RHDs have been directly affected by the pandemic. Refugees have been more adversely affected by COVID-19 shocks than Ugandan nationals and slower to recover – with high level of food insecurity, aid dependency on limited food rations, and ten times more likely to suffer from depression. Eighty-one percent Uganda’s refugees are women and children, who are at high risk of gender-based violence (GBV). 44 Many of these risk factors have been exacerbated during COVID-19 and there are reports of increased negative coping mechanisms including child marriage and early pregnancy, survival sex, theft, GBV, and suicide. The most common causes of violence against women and children in hosting and refugee communities, include poverty, substance abuse, discriminatory gender roles, and widespread acceptance of violence, which are reinforced by social norms. In areas with larger concentrations of refugees, there is additional pressure placed on service delivery, and in some instances, has caused 43OPM, UNHCR. 2021. Uganda Comprehensive Refugee Response Portal, https://data2.unhcr.org/en/country/uga. 44World Bank. 2020. Gender-Based Violence and Violence Against Children: Prevention and Response Services in Uganda’s Refugee-Hosting Districts. Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/34494. 89 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) tensions with the local host communities. Below are selected economic and social impacts of COVID-19, as reported in three rounds of COVID-19 High Frequency Phone Surveys 45 conducted by the Bank between March 2020 and March 2021: • Economic Impact. Employment rates among refugee respondents declined from 43 percent in October/November 2020 to 32 percent in February/March 2021. This widened the gap further from the pre-lockdown employment rate of 56 percent—by 24 percentage points. • Socio-economic shocks. Exposure to COVID related shocks was much higher among refugees. Every refugee household experienced at least one shock between March and October/November 2020 compared to 42 percent of households among Ugandans. The most common shock among refugees was an increase in the price of key food items, followed by illness, injury or death of income earning household members. Reducing food consumption remained the most frequently used coping strategy by refugees. • Food Security. Food insecurity remains much higher among refugees than Ugandans. Ration cuts coupled with COVID-19 impact substantially deteriorated food security among refugees. It has gradually improved over the last 12 months following the impact of initial lockdowns but remains worse than in 2018. • Access to Basic Needs. Refugees reported significantly lower access to medicine, medical treatment, and sufficient drinking water in February/March 2021 than Ugandans. • Mental Health. Fifty-four percent of refugees reported depression compared with 5 percent among Ugandans, with women and those in the West Nile having the highest incidence. 3. However, in separate High Frequency Surveys 46 for refugees, 88 percent of respondents indicated that they would “agree to be vaccinated if free and safe vaccine is available” thus ensuring an enabling environment for COVID-19 vaccination. COVID-19 Refugee Response National Level 4. In Uganda, there is strong functional coordination of refugee humanitarian issues. The Office of the Prime Minister and UNHCR co-lead the refugee response in coordinating humanitarian assistance and protection in refugee settlements and RHDs. The response is supported by line ministries, district local governments and over 100 partners, including UN agencies, international and national NGOs, and refugee-led organizations. 5. Uganda is implementing the Comprehensive Refugee Response Framework (CRRF) and the Global Compact for Refugees. The CRRF in Uganda has a vision for a coordinated, accountable, and sustainable refugee response for socio-economic transformation for refugees and host communities by 2025. Under the CRRF, the HSIRRP is intended to integrated refugee health services into routine government services and address health related needs of refugees and the host communities and ensure access to quality health services for both through; improvement of staffing, upgrading of health facilities, and provision of medicine and health supplies to RHDs using the national distribution channels. This 45World Bank. 2021. COVID-19 Impact Monitoring: Uganda, Round 4-5. Washington, DC: World Bank. 46 World Bank. 2021. Monitoring Social and Economic Impacts of COVID-19 on Refugees in Uganda: Results from the High- Frequency Phone - Third Round. Washington, DC: World Bank. 90 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) operation delivers on priorities identified within the HSIRRP by supporting strengthening service delivery, key infrastructure, and health commodities. 6. The Office of the Prime Minister (OPM), UNHCR, and their partners work together with the Ministry of Health to manage COVID-19 in RHDs. They manage nineteen quarantine facilities in RHDs, train health workers, strengthen surveillance and infection prevention and control, and trace contacts of positive COVID-19 cases in refugee communities. Refugees have also been integrated into the national vaccination campaign, which began in mid-March 2021. As of October 31, 2021, refugee and refugee serving workers had received their first dose of vaccine as follows: 9,548 refugees, 2,862 health workers, 4,087 teachers and 5,430 other humanitarian workers. 7. To further improve the shock-responsiveness of social protection programs, there is an ongoing initiative to develop a dynamic National Single Registry (NSR). This would help to quickly identify vulnerable households that are most in need and minimize the risks of duplicating interventions. The World Bank is undertaking analytic work to see how shock-responsive social protection systems might look across humanitarian refugee systems and national systems to have an integrated response to forced displacement. Lessons 8. The GoU has gathered important lessons during the national response and in the initial phases of the COVID-19 vaccination campaign. As noted above, vaccine hesitancy, though registered in previous surveys to be low, have served as an impediment to vaccine rollout. To overcome vaccine hesitancy, misinformation, 47 and conflicting information surrounding COVID-19 in RHDs and refugee settlements, the Project will draw on U-LEARN COVID-19 surveys 48 in RHDs and use a diversified set of communication channels, adopting a range of different information channels to address the diversity of people’s needs and personal preferences. Within this, the use of community radio, and mobile loudspeakers will be prioritized in RHDs. The AF will also ensure communications are provided in refugee local languages to address these potential barriers identified by the MoH. MoH will work through VHTs, home-based care volunteers, religious leaders, refugees, and other community structures as important and trusted information-sharers on COVID-19 messaging. Focus of the AF: 9. The AF will support activities for RHDs and refugee settlements across all 5 components, with a focus on disease surveillance, vaccination, as well as continuity of essential health services. Interventions financed by the WHR and accompanying IDA grant will be solely focused on the 12 RHDs (minus Kampala) approved by the OPM, as well as refugee settlements in selected transit districts—as agreed with UNHCR—with high traffic of refugees, as agreed with UNHCR. Coordination of host community and refugee related aspect of the Project 47 U-LEARN. 2021. COVID-19 Rumour Tracking Bulletin. https://ulearn-uganda.org/download/covid-19-rumour-tracking-bulletin- 5/. 48 U-LEARN. 2020. Policy Brief: Maximizing the impact of COVID-19 communication with refugees: What can we do better? https://ulearn-uganda.org/download/policy-brief-maximising-the-impact-of-covid-19-communication-with-refugees-what-can- we-do-better/. 91 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 10. At the national level, several organizations are involved in the oversight, financing, and delivery of health services for refugee and host communities including OPM, Ministry of Health, UNHCR, UNICEF, and World Bank. They are members of the Refugee Health and Nutrition Technical Working Group and the Health Sector Integrated Refugee Response Plan Steering Committee which together oversee integration of refugee interventions health, nutrition, and vaccination programs into routine government service delivery system. Reports and recommendations of these entities feed into the National COVID-19 Task Force (NTF) and the National Comprehensive Refugee Response Framework Steering Committee, both coordinated by the OPM. The Project’s Steering Committee will be expanded to include OPM and UNHCR to ensure oversight of aspects relating to host communities and refugees. The World Bank is financing three projects outlined in Table 2 which strengthen health systems for host communities and refugees. The Project will ensure strong complementarity and synergies between these projects as outlined in the table. 11. District COVID-19 Task Forces (DTFs) coordinate overall COVID-19 response, including vaccination in refugee hosting local governments. The OPM, UNHCR, and other key implementing agencies involved in the delivery, integration, and coordination of health and vaccination services are members of the DTFs thereby ensuring adequate follow up of refugee health and vaccination issues at district, facility, and settlement levels. District coordination has worked well with close coordination in the surveillance, infection prevention and control, trace contacts and response to COVID-19 cases and their management between refugee settlements and district administration. Table 2. Summary of Synergies with Projects Financed under the IDA-18 and IDA-19 Host Community and Refugee Windows in Uganda Total RSW/ UCREPP Complementarities (US$, WHR Development Policy Project Status million) (US$, Objectives Implementation million) The Development Active 150 125 The objective is to Is implementing HSIRRP 1. Complementing existing Response to improve access to pillar (i) on Service health infrastructure Displacement basic social services Delivery, specifically constructed under DRDIP Impacts Project in (including health addressing: Action 3: through the Ministry of the Horn of Africa services), expand Improve delivery of Health, OPM and UNHCR – Additional economic facility-based health identified priorities linked Financing opportunities, and services and health to COVID-19 pressures. (P164101) enhance infrastructure for environmental providing treatment, care, management for rehabilitation and referral communities hosting services to refugees and refugees in the target host communities by areas. providing health center infrastructure. Gender Based Active 0.5 Not To mitigate GBV and This supports 1. Providing convincing Violence and Applicable prevent violence implementation of evidence base on GBV Violence Against – trust against children Uganda’s Child Policy issues across refugees and Children fund through engagement which integrates refugees, host communities. Prevention and financed. in productive and the HSIRRP minimum 2. Supporting the mitigation Response Services activities. health care package which of increased COVID-19 92 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Total RSW/ UCREPP Complementarities (US$, WHR Development Policy Project Status million) (US$, Objectives Implementation million) in Uganda’s identifies GBV under pressures which have Refugee-Hosting maternal and child health increased GBV rates. Districts (under and health promotion and 3. Supporting health (P164101) disease prevention services which will priorities. It also delivers complement social, legal the Elimination of Gender and referral systems Based Violence policy for supported under the Uganda. Project. Uganda Active 250 50 The Project’s This supports 1. Improved access to Intergovernmental objective is to implementation of HSIRRP health services under Fiscal Transfer improve the pillars (i), (ii) and (v) on UCREEP will be able to have (UgIFT) - adequacy and equity service delivery, human recurrent institutional costs Additional of fiscal transfers and resources and financing better met through Financing fiscal management of focusing on the strategic recurrent cost support and (P172868) resources by local actions to Harmonize management strengthened governments for human resource under UgIFT, and reduce health, education, remuneration packages in fiscal pressures caused by and water services. participating health COVID-19 impacts. facilities; and developing integrated national and district health plans and budgets that comprehensively address the needs of refugees and host communities. 93 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) ANNEX 4: REVISED DISBURSEMENT CATEGORIES Percentage of Expenditure to be Category Allocation across financing sources (US$ Million) Financed (Inclusive of taxes) IDA grant for host IDA GFF WHR communities and refugees 1. Goods, works, non- consulting services, and consulting services, 27.30 16.00 17.00 3.00 Such percentage as agreed to Training and Operating Costs of the Project 2. Vaccine purchase only 107.00 0.00 10.00 0.00 Such percentage as agreed to Total 134.30 16.00 27.00 3.00 94