The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 05/30/2021 | Report No: ESRSAFA205 May 30, 2021 Page 1 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Zambia AFRICA EAST Republic of Zambia Ministry of Health, Zambia National Public Health Institute (ZNPHI) Project ID Project Name P176400 Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project Parent Project ID (if any) Parent Project Name P174185 Zambia COVID-19 Emergency Response and Health Systems Preparedness Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 6/2/2021 6/25/2021 Population Financing Public Disclosure Proposed Development Objective The project development objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 in Zambia and strengthen national public health systems for preparedness. Financing (in USD Million) Amount Current Financing 0.00 Proposed Additional Financing 0.00 Total Proposed Financing 0.00 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? Yes May 30, 2021 Page 2 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The AF will provide upfront financing to help the government purchase and deploy COVID-19 vaccines that meet the World Bank’s vaccine approval criteria (VAC) and strengthen relevant health systems that are necessary for a successful deployment and to prepare for future pandemics. The support will include: Procurement of vaccines to vaccinate 5 percent of Zambia’s population; Deployment costs of World Bank financed vaccines plus deployment costs associated with vaccinating 20 percent of the population using vaccines from COVAX Advance Market Commitment(AMC) and other COVID-19 vaccines meeting the World Bank VAC that will be made available during the life of the project; Improved diagnostics in genomic sequencing and surveillance; and Expanded activities of the COVID-19 response which are essential to protect lives. The GFF grant co-financing will further leverage the opportunity to strengthen COVID-19 related systems for deployment of vaccines, including strengthening health systems to address disruption of essential reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) services, but will not support COVID-19 vaccine purchase. The World Bank financing for the COVID-19 vaccines and their deployment will follow the World Bank’s VAC. Vaccines will be provided by the Government of Zambia free of cost. The proposed changes include: 1) Components and cost: (i) Sub-component 1.1 has been split into two namely, Sub-component 1.1(a) COVID-19 Surveillance, Case Investigation and Rapid Response Capacity, and Sub-component 1.1(b) Vaccine Introduction. o The following activities have been dropped under Sub-component 1.1: (a) establishment of operation of the central and provincial Public Health Emergency Operation Centers (PHEOC) (b) support to the PHEOC including strengthening the call response center; (c) Disease surveillance activities as part of IDSR through: (i) the Public Disclosure development/updating of surveillance protocols; (ii) establishment of Influenza-Like Illnesses and Severe Acute Respiratory Infections (ILI/SARI) sentinel sites; (iii) capacity building in surveillance, including the training of community volunteers in event-based surveillance in high-risk districts, and training of staff in the IMS, epidemic preparedness and response; and (iv) disease surveillance information systems, including data audit; (d) assessment of the implementation of International Health Regulations including related operational costs for all activities to release US$2.3 million to support scale up of proposed priority case management interventions that have been informed by lessons learned during implementation of Zambia’s COVID-19 response second wave and reallocation of these resources to component 2 under case management. The dropped activities will be funded under the ACDCP (P167916). o The following activities will continue to be supported under the parent project: (i) coordination of COVID-19 response at national and subnational levels; (ii) COVID-19 risk assessments to identify high-risk areas, events and population groups; (iii) rapid response teams to conduct contact tracing for COVID-19 and emergency response vehicles; and (iv) establishment/rehabilitation of quarantine facilities for suspected COVID-19 cases; (ii) Specific changes under each component include: a. Component 1 • Procurement of COVID-19 vaccine. • Strengthening of systems for vaccine deployment, including distribution and administration of the COVID-19 vaccine. • Enhanced capacity for genomic sequencing and surveillance. • Expanded risk communication and community engagement to overcome vaccine/brand hesitancy and maintain demand for essential services. May 30, 2021 Page 3 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) b. Component 2: • Reallocation of funds from Component 1 to expand oxygen production and strengthen delivery systems for medical oxygen therapy; and expansion of isolation health facilities/wards. • Expansion of IPC including strengthening WASH in healthcare facilities and health care waste management. • Expansion of activities to strengthen capacity to ensure continuity of essential health services. c. Component 3 • Establishment and operational costs of a sub-PIU in the MOH for implementation of vaccine introduction. • Enhancing digital health solutions such as the DHIS2 COVID-19 vaccine delivery tool kit including expansion of Logistimo functionality up to the vaccination sites. • Enhancing platforms for third party monitoring. 2) Results framework: The results framework is being revised to add new indicators for the proposed AF and dropping or modifying original indicators to capture new activities. 3) Institutional and implementation arrangements: These will be adjusted to reflect the shift in the Implementing agency and changes to the project implementation arrangements and oversight structures. 4) Disbursement Arrangements. Creation of an operational account in MOH to finance operation costs for vaccine deployment and maintenance of essential RMNCAH-N services 5) Closing date: The closing date of the parent project will be extended by one year from December 31, 2022 to December 31, 2023. The extension is necessitated by: (i) consideration of the implementation timeline of the NVDP which proposes to vaccinate 21 percent of the rest of the population (18 years and older) under Phase 2, given the uncertainties related to the availability of vaccines globally and their efficacy against new variants of the virus, and (ii) to allow for implementation of activities to be supported by the additional US$10 million GFF grant Public Disclosure Activities by Components 1. Component 1: Emergency Public Health Response to COVID-19. US$23.85 million equivalent: US$18.98 million IDA (US$5.98 million parent project; US$11.50 million AF); US$ 4.87 million GFF (US$2.07 million GFF parent project; US$ 2.80 million Additional Grant). (i) Sub-component 1.1(a): COVID-19 Surveillance, Case Investigation, and Rapid Response Capacity. US$2.20 million equivalent: US$1.80 million IDA (parent project after reallocation US$1.00 million; AF Allocation; US$1.00 million AF); US$ 0.2 million additional GFF. The AF under this sub-component will finance: Expansion of emergency response activities including: (i) Enhancing COVID-19 hotlines, sensitive to the unique needs of vulnerable and marginalized populations as well as gendered roles and responsibilities, and social norms in multicultural society; (ii) SMS to provide callers with information about COVID-19 vaccination, referrals, and information about how to access other essential health services during the pandemic, including serving as an additional channel for grievance redress; (iii) Supporting short term staff requirements, equipment, operational costs for hotlines and call centers, and PPE for health care staff providing vaccinations; (iv) Related operational costs for supervision and coordination. There will be need for extensive coordination between national and local authorities and the multidisciplinary participation required in the implementation of the vaccination strategy; and (v) Operating costs for mobilizing additional short- term consultants who will support vaccine deployment. (ii) Subcomponent 1.1(b): Vaccine Introduction. US$13.50 million equivalent: US$11.50 million AF, US$ 2.0 million additional GFF. The AF under this sub-component will finance: (a) Procurement of COVID-19 vaccines for 5 percent of the total population including vaccination supplies and other ancillary products. The Subcomponent 1.1(b)(1) will only be financed by IDA. May 30, 2021 Page 4 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) (b) Deployment of COVID-19 vaccines funded by both the World Bank and the COVAX AMC and other vaccines that meet the World Bank VAC criteria including: (i) Procurement of climate-friendly cold chain equipment such as cold boxes, LED fridges, assorted spares for cold chain equipment and strengthening of the cold chain network; (ii) Maintenance of existing cold chain equipment; (iii) Procurement of 15 ton containerized fuel-efficient or alternative fuel trucks, vehicles and motorcycles, as well as low-emission transportation such as bicycles and marine transport for transportation of vaccines; (iv) Training in vaccine management and deployment, cold chain management, and climate disaster management at national and subnational levels; (v) Printing, dissemination and distribution of stock control cards, guidelines, protocols, and SOPs for the COVID-19 vaccine. (c) Support to infrastructural security enhancements for the COVID-19 vaccine during storage, in transit and at vaccination sites: (i) Installation of CCTV systems at points of entry and national storage warehousing;(ii) Expansion of Logistimo up to the district level; (iii) Installation of GPS trackers to vaccine transportation vehicles including strengthening communication systems in transit; (iv) Infrastructural security enhancements such security doors and installing burglar bars on windows and CCTV for provincial and district levels; (v) Help bridge transport gaps for the last mile vaccine distribution system; and (vi) Training of drivers on transportation of COVID vaccines including related security issues. (d) Support the design and deployment of digital health platforms including implementation of the DHIS2 COVID- 19 vaccine delivery tool kit. This will support digitalization of vaccine introduction throughout the service delivery supply chain to: (i) Register vaccine population target groups, track immunization, and reporting to avoid elite capture; (ii) Digitalize stock control cards for vaccines and linking to the Logistimo system; (iii) Digitalize pharmacovigilance as well as post vaccination surveillance of any AEFI; (iv) Vaccination certification; and (v) The GRZ’s long-term investment in digitalization of information systems and telemedicine. Public Disclosure (iii) Sub-component 1.2: Laboratory Capacity and Specimen Transport. US$3.83 million equivalent: US$2.78 million IDA (US$2.48 million parent project; US$ 0.30 million AF); US$1.05 million GFF parent project). The AF will finance: (i) Genomic sequencing and phylogenetic analysis for SARS-CoV-2 to understand the changing disease trajectory; (ii) Enhanced laboratory capacity for genome testing in three selected laboratories, including procurement of reagents; (iii) Training of laboratory technicians in genomic sequencing; and (iv) Specimen transportation and related operational costs. (iv) Sub-component 1.4: Risk Communication and Community Engagement. US$2.65 million equivalent: US$1.03 million IDA (US$0.83 million parent project IDA, US$0.20 million AF); US$1.62 million GFF (US$1.02 million parent project GFF; US$0.60 million additional GFF). The AF under this subcomponent will finance: (i) Printing, dissemination, and implementation of the communication strategy and related operational cost; (ii) SBCC to facilitate uptake of the COVID-19 vaccine, address vaccine hesitancy, enhance preparedness for vaccination against other climate-related diseases, and implement sub-national awareness of COVID-19 vaccine campaigns. SBCC will also take into account vaccines related misinformation (e.g. misconceptions about vaccines causing fertility problems, stigmatization of workers administering vaccines, immunization information for pregnant women, focusing on the acceptance of the vaccine among women), and implement sub-national awareness of COVID-19 vaccine campaigns; (iii) Development and implementation of SBCC messages and materials for RMNCAH-N services; (iv) Putting in place comprehensive risk registers and mitigation measures to address identified risks during implementation of the NVDP; and (v) Procurement of suitable PPE for frontline health workers in the community and community volunteers conducting house-to-house visits under the project. 2. Component 2: Resilient Health Service Delivery. US$21.15 million equivalent. (US$11.72 million IDA {US$9.22 parent project, US$2.3 million reallocation, US$0.2 million AF IDA}; US$9.43million {US$2.93 million GFF parent project; US$6.50 million additional GFF}). May 30, 2021 Page 5 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) (i) Sub-component 2.1: Case Management US$9.49 million equivalent: US$6.91 million IDA (US$4.61 million parent project; US$2.3 million reallocation); US$2.58 million (US$0.58 million GFF parent project; US$2.0 million additional GFF). The GFF additional grant and reallocation of US$2.3 million from sub-component 1.1 to this sub- component will finance: (i) Expansion of the oxygen production capacity and delivery system, and ensuring enough oxygen concentrators, cylinders, and other related accessories for management of critically ill patients; (ii) Expansion of isolation facilities and wards that are well equipped, with functional oxygen delivery systems including procurement of PPEs and other medical supplies; (iii) Recruitment of short-term skilled human resources for health to fill the gap in emergency and isolation facilities and intensive care units (ICUs) including provision of hazard allowance for male and female health workers in these facilities and ICUs; (iv) Production of blood and blood components (red cells, platelets, fresh frozen plasma, cryoprecipitate) as part of support for a sustainable blood supply system. (ii) Sub-component 2.2. Infection Prevention and Control. US$5.08 million equivalent: US$2.97 million IDA (Parent IDA US$2.77million, US$0.2million AF IDA); US$2.11 million GFF (US$0.61 million GFF parent project; US$1.50 million additional GFF}). The AF will finance: (i) Expansion of IPC in all health facilities, including but not limited to those where COVID-19-related services are delivered; (ii) Access to safe water and sanitation and setting up of functional hand hygiene in health facilities and for all health care workers at all points of care; (iii) Safe management of general health care waste; and (iv) Management and disposal of health care waste from the COVID-19 vaccination program. (iii) Sub-component 2.3: Strengthening Capacity for Essential Services Continuity. US$6.58 million equivalent: (US$1.84 million IDA; US$1.74 million GFF parent project); US$3.0 million Additional GFF. The additional grant will support expansion of activities to ensure continuity of essential health services and strengthen health system Public Disclosure resilience in the face of diverse stresses, including the COVID-19 pandemic. This work will also support emerging priorities in the RMNCAH-N Investment case under preparation (as of April 2021). It is anticipated that further resource mobilization among all stakeholders supporting these efforts will be required. Expanded activities will include: (i) Improving maternal and newborn intrapartum service quality, through establishment of provincial-level specialized intrapartum care units and newborn special care units; (ii) Contributing to the strengthening of emergency obstetric care and safe surgery, including procurement of equipment and training of anesthetists in targeted provinces; (iii) Building on the work completed under a Bank Executed Trust Fund (BETF) as part of the GFF-facilitated Service Delivery Learning Program; (i) Implement SOPs for safe delivery of essential services in the COVID-19 context and the revised RMNCAH-N monitoring and evaluation (M&E) framework; (v) Piloting digitalization of civil registration and vital statistics (CRVS) (birth and death) indicators at provincial and district hospital level; (vi) Building capacity of health providers to use innovative technologies and approaches including competency-based pre- and in-service training, as well as digital health tools for supportive supervision; (vii) Strengthening integration of immunization with other preventive, curative and rehabilitative services, such as those for family planning, non-communicable diseases, HIV, and TB; and (viii) Strengthening prevention and treatment of Gender-Based Violence (GBV) and addressing gender gaps in service delivery. 3. Component 3: Project Management, Monitoring and Evaluation, Operational Research, and Governance and Accountability. US$4.00 million equivalent. US$3.3 million IDA (US$2.5 parent project IDA; US$0.8million AF); US$ 0.7 million Additional GFF grant. (i) Sub-component 3.1: Project Management, M&E and Operational Research. US$2.60 million equivalent: (US$2.0 million parent project IDA; US$0.6 million Additional GFF). The AF under this sub-component will finance: (i) Establishment of a sub-Project Implementation Unit (S-PIU) in the MOH department of Public Health with relevant PIU May 30, 2021 Page 6 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) staff to support the implementation of the COVID-19 vaccine introduction as well as continuity of essential services; (ii) Polling and rapid surveys to monitor population and health worker perception of vaccine and vaccine brands. (ii) Sub-component 3.2: Strengthening Governance and Accountability in the Implementation of the National COVID-19 Response Plan. US$1.4 million equivalent: US$1.3million IDA (US$0.5 million parent project; US$0.8million AF); US$0.1 million Additional GFF). The AF will support third party monitoring for vaccine deployment to ensure equal access to the COVID-19 vaccine and the DHIS2 vaccine delivery tool kit roll out. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The additional resources will finance scale-up of selected activities that are part of Zambia’s National Deployment and Vaccination Plan (NVDP) including but not limited to the following priority areas: procurement of vaccines including distribution and administration of vaccines, strengthening the cold chain network, strengthening the vaccine in- country transportation systems, pre-introductions orientations, sexual behavior change communication (SBCC) and risk communication, planning and implementation, monitoring and evaluation. The proposed AF will form part of an expanded health response to the pandemic, which is being supported by development partners under the coordination of the Government of Zambia. Critically, the additional financing seeks to enable the acquisition of vaccines and strengthening of the vaccine administration systems to support Zambia’s objective to have a portfolio of options to access vaccines under the right conditions (of value-for-money, regulatory standards and delivery time among other key features). It is envisaged that the project will be implemented in both urban and rural areas in the existing health facilities, use existing cold storage chains, transportation (including last mile delivery) and improved Public Disclosure healthcare waste management as directed in the parent project ESMF. D. 2. Borrower’s Institutional Capacity The Zambia National Public Health Institute (ZNHPI) under Ministry of Health is the Project Coordination Unit (PCU) for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P174185) and this AF. The PCU and MOH have gained experience in managing World Bank-financed projects prepared using the Bank’s operational policies. Projects implemented include the Health Services Improvement Project (P145335), Southern Africa Tuberculosis and Health Systems Support Project (P 155658), the Africa CDC Regional Investment Financing Program (P167916) and the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P174185) prepared under the ESF. Lessons learned to-date indicate the need for the Bank to provide training for PCU and MOH to understand the Bank’s safeguards requirements, preparation and implementation of E&S instruments, and monitoring compliance throughout project implementation. At the time of this assessment, activities under the parent project had not commenced, providing limited information to draw conclusions on the Borrower’s capacity to implement an ESF project. The PCU is new to the ESF and therefore, the Bank’s E&S Specialists provided technical assistance during preparation of the parent project and will continue extending support for the AF. The MoH assigned focal persons to work on the preparation of E&S instruments for the parent project as an interim measure prior to recruitment of an Environmental Specialist, Social Specialist and Communications Specialist as part of the PCU. The recruitment of E&S and Communications Specialists has delayed. All the projects listed above, except for the recently approved parent project, have developed Grievance Redress Mechanisms (GRMs) which have been aligned with existing health complaints systems and are frequently monitored by designated focal persons. The department of Health Promotion Environmental and Social Determinants in the MOH performs the function of collaborating with various stakeholders including Non-Governmental organisations and communities in the design, May 30, 2021 Page 7 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) production and implementation of key IEC materials. This department has qualified experts with relevant experiencing in engaging stakeholders under the Health Services Improvement Project (P145335). Currently, members of this department and the ZNPHI are spearheading development of the Risk Communication and Community Engagement strategy. Zambia has taken a number of measures to improve its health care management capacity in recent years. Among other things, it has prepared a National Health Care Waste Management Plan 2015- 2019 so that health care wastes could be properly managed. The National Health Care Waste Management Plan 2015- 2019 has been updated to include non-incineration technologies and now have in place a National Health Care Waste Management Plan 2017-2021. An infection control and waste management plan has also been prepared for the BSL3 laboratory to be financed by the Africa CDC Regional Investment Financing Project. The country’s Environmental Management Act was revised in 2011 in partnership with the University of Zambia, MOH Directorates and the Zambia Environmental Management Agency to give specific or general directions to local authorities regarding collection and disposal of waste and to formulate and provide standards and regulations for the sound management of health care waste. ZNPHI has prior experience deploying biosecurity and waste management consistent with WHO guidelines. However, there have been some gaps in terms of management of health care waste management which among others include: (i) inadequacies of the regulatory framework; (ii) poor health-care waste management practices; (iii) poor information systems on health care waste generation and disposal; (iv) inadequate knowledge and practical skills of those involved in health care waste management; (v) lack of appropriate equipment and technologies; (vi) lack of regional/centralized disposal facilities in non-urban areas; (vii) low segregation of waste according to categories such as by type, color of bags and bins and size. Medical waste management in the health institutions need considerable improvement. Furthermore, MOH has not yet implemented projects using the World Bank Environmental and Social Framework (ESF). The ESF places greater responsibility on the Client and heightened emphasis integrated Public Disclosure environmental and social risk management. To this effect, MOH’s capacity to assume oversight in managing environmental and social risks as espoused in the ESF will be assessed during project implementation and appropriate gap filling measures proposed accordingly. The MoH regularly rolls out vaccine programs throughout the country and is organised to conduct the Covid-19 vaccination program. This is notwithstanding the inherent E&S risks that require mitigation to ensure the AF project’s success. Further capacity building resources are available to the MoH such as the WHO’s online resources for Covid-19 vaccinators i.e. an e-learning course: COVID-19 vaccination training for health workers, the WHO vaccine introduction toolkit and various online guidance from other UN agencies. Communication strategies are anticipated to improve for the parent and AF projects by the inclusion of a Communications Specialist who will be responsible for coordinating stakeholders and ensuring SEP activities are aligned and accurate information is disclosed. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The activities associated with the Additional Financing (AF) project will complement the positive impacts of the parent project by facilitating COVID-19 containment, reducing Covid-19 related hospital admissions, vaccine procurement, its deployment and administration. The predicted environmental risks associated with the AF project include (i) the generation of additional Covid-19 related healthcare waste in the form of sharps, swabs and PPE; (ii) May 30, 2021 Page 8 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) OHS risks linked to healthcare workers involved in handling and administering vaccines, those working in the health care waste stream and logistical workers involved in the cold storage chain; (iii) risks and impacts from loss or spoiled vaccines due to a mismanaged vaccine cold chain and poor vaccine handling and transportation practices; (iv) Community Health and Safety risks from the handling, transport and disposal of vaccine associated healthcare waste; (v) risks to a successful country wide vaccination program due to a hesitancy or a refusal to receive the Covid- 19 vaccine because of religious, traditions, beliefs or negative online influences; and (vi) potential environmental impacts from the cold storage chain such as the use of obsolete refrigeration equipment containing freons with chlorofluorocarbons (CFCs) that are ozone depleting substances (ODS) and Hydrofluorocarbons (HFCs) with a high Global Warming Potential (GWP). The current plan is not to increase the capacity of vaccine related infrastructure (vaccine centres, additional storage) either by construction or renovation of existing facilities or increase the cold storage capacity by the procurement of refrigeration or refurbishment of equipment. However, the ESMF will be updated to cover these potential risks if plans evolve and the additional capacity is required. Improved health care waste management under the parent project will support waste segregation, storage, transportation and safe disposal of healthcare waste generated by COVID-19 laboratory and medical activities. The additional healthcare waste generated by the AF activity will include sharps, vials, expired vaccines, swabs and PPE and should be managed under the parent project’s healthcare waste management improvements. However, further due diligence through an update of the ESMF, is required to confirm the proposed healthcare waste management capabilities are sufficient for the AF project. Relevant risks identified and managed under the parent project includes healthcare worker’s exposure to COVID 19, testing and handling of supplies, healthcare waste management and community health and safety issues related to the handling and transportation and disposal of healthcare waste and procurement and use of sub-standard PPEs. There are many risks inherent within the cold chain that includes Public Disclosure environmental impacts from refrigeration equipment (CFCs, HFCs), poorly maintained refrigeration equipment, theft, lack of security or law enforcement availability, mishandling, unavailability of climate control vehicles, technical failures in temperature and coolant, human error, road infrastructure and accessibility to HCF and rural areas, vaccine accountability and tracking of deliveries and shipments, etc. The risks to cold chain logistical workers are from transportation risks (vehicle licensing, training, accidents) and contact with ultra-low temperatures. All health workers involved in the implementation of Covid-19 vaccines should possess adequate knowledge and skills to ensure safe and efficient Covid-19 vaccination administration. The client intends to use existing vaccine supply chains to roll out the AstraZeneca vaccine (2 – 8 oC refrigeration requirement) from port of entry to administering the vaccine. There are OHS risks with using untrained vaccine administrators because of wasted vials, breakages, a lack of needles and no dedicated HCF vaccine storage or poorly maintained refrigeration equipment and a lack of vaccine administration areas at HCFs. Social Risk Rating Substantial The social risk is considered substantial. Associated social risks include elite capture due to the limited number of COVID-19 vaccine doses to be procured, and the exclusion of vulnerable groups such as persons living with disabilities, the elderly, those with co-morbidities and refugees from accessing vaccines. The risk of exclusion is attributed to vulnerable groups being in the low income bracket with limited financial muscle to access health services; distance to health facilities due to remoteness particularly rural areas that are characterized by poor road infrastructure which may affect transportation of vaccines; and lacking accurate information on roll out of vaccinations and not having a full appreciation of the eligibility criteria for vaccines. The risk of community resistance to vaccination may potentially affect the successful implementation of the planned intervention. Existing social norms, religious beliefs, previous adverse or unwanted reactions to vaccination and misinformation could be May 30, 2021 Page 9 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) detrimental for the project and may result in fear and lack of trust in the process among target populations. Community and health and safety maybe compromised due to improper handling, transportation and disposal of vaccine associated healthcare waste. No security personnel will be used for this operation Risk of military use is low as the roll out of vaccines will be managed by trained health personnel within MOH. GBV/SEA/SH measures under the parent will apply. No civil works are envisaged on the project. MOH is committed to ensure an equitable roll out of the COVID-19 vaccines in the first phased targeted at individuals essential in sustaining COVID-19 response, maintaining core societal functions, those at greatest risk of severe illness or death and their caregivers, prisoners and refugees. This will be based on available data on the prevalence of COVID-19 cases and adherence to the WHO SAGE Values Framework for the allocation and prioritization of COVID-19 vaccination and the Roadmap for prioritizing uses of COVID-19 vaccines in the context of limited supply. This will be aligned with the National COVID- 19 Vaccine Deployment Plan (NVDP) which is currently being developed. The NVDP will contain a vaccine targeting plan that will be subjected to Bank review and approval by project effectiveness to ensure the approach is inclusive in targeting vulnerable groups and non-nationals. Ongoing public myths on the COVID-19 vaccines may potentially affect the successful implementation of the vaccination program due to public hesitancy or a refusal to receive the vaccine. This is also exacerbated by religious and traditional beliefs as well as negative online influences. Implementation of a robust communication strategy will be critical to ensure accurate information is disseminated and meaningful consultations held with various stakeholders prior to rolling out of vaccines, and using a phased approach aligned with the roll out of vaccination. Stakeholder engagement will assume an inclusive approach bring together local leadership, community health workers, CSOs, media, religious leaders and other stakeholders. No forced vaccinations will be conducted without the consent of, patients. receiving the vaccine will be required to offer their consent. The SEP prepared for the parent project will be updated to reflect additional requirements for Public Disclosure vaccines and will be re-disclosed. Furthermore, the list of stakeholders will be revised to capture risk groups such as refugees not included in the initial SEP. Timelines for SEP activities will be revised and the role of the Risk Communication Department within MOH enhanced to lead the component on behaviour change. Current provisions for grievance management, including measures for addressing GBV/SEA/SH remain relevant and adequate for this AF. An update of the LMP will be conducted to reflect any include changes in staff complement. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: Proposed activities under this AF will have positive environmental and social impacts in facilitating the procurement of COVID-19 vaccines, strengthening the Country's immunization program. The planned vaccination roll out will help contain the spread of COVID-19 by supplementing preventive measures currently under implementation. However, the project could also cause substantial environmental, social, health and safety risks. The social assessment integrated in the ESMF under the parent project addressed risks of unequal access to prevention and treatment services. Similarly, the risk of exclusion and elite capture is likely to arise during implementation of the AF. Disadvantaged groups such as the elderly, those with co-morbidities, persons living with disabilities, refugees and non-nationals, and rural populations may experience challenges in accessing vaccine due to May 30, 2021 Page 10 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) unequal distribution patterns, failure to adhere to WHO guidelines on prioritizing and selection of population groups for vaccines, and long distances to the nearest health facilities in order to receive vaccination. The inequality is further exacerbated by low income status among disadvantaged groups which may inhibit their ability to access health care services and lack of access to information on the vaccination roll out. The social assessment and corresponding measures identified in the ESMF which include management of GBV/SEA risks remain relevant for the AF, however, updates will be conducted to include social risks associated with the roll of vaccines and is reflected in the ESCP. Implementation of a robust risk communication strategy will be critical to ensure accurate information is disseminated and meaningful consultations held with various stakeholders prior to rolling out of vaccines, using a phased approach that is aligned with the rollout of vaccination. Stakeholder engagement activities will be conducted in a proportionate manner based on identified gaps in access to information for rural populations that have limited access to technology and social media platforms where information on the vaccination roll-out may be published compared to their urban counterparts. The process of consultations will assume an inclusive approach bring together local leadership, community health workers, CSOs, media, religious leaders and other stakeholders. The SEP will be updated to reflect additional requirements for vaccines, including additional outreach activities to be conducted and cost implications. The revised SEP will be disclosed. Revision timelines are indicated in the ESCP. The project GRM is not yet functional, depriving target populations from having channels for registering complaints and providing feedback. A Social Specialist to monitor implementation of safeguard requirements including operation of GRM and addressing GBV/SEA risk mitigation is yet to be recruited. The recruitment process has delayed and poses Public Disclosure a risk for the AF as updating of the ESMF and SEP may not be completed within a reasonable timeframe to allow for commencement of project Subsequently, this could affect compliance monitoring under the AF. The PIU has limited experience in implementing projects under the ESF. Despite having staff seconded from MOH to support preparation of the parent project, the Bank provided significant handholding during preparation of the ESMF and SEP, a situation that may re-occur if the recruitment process is not completed prior to negotiation of the AF. The current ESMF provides the necessary guidance to identify potential E&S impacts and mitigation measures associated with COVID-19 surveillance, monitoring, treatment and containment. The parent project ESMF and SEP will be disclosed in April 21. The ESMF will be updated to incorporate further environmental and OHS risks resulting from AF project activities linked to safe vaccine administration, the cold chain, community and healthcare waste generation and its management. The mitigation measures will be incorporated into the parent ESMF and will be based on WB EHSG, GIIP and updated WHO technical guidance. The parent ESMF Infectious Control Waste Management Plan (ICWMP) is wide ranging and contains sufficient guidance and mitigation measures to control expected E&S impacts and risks from AF healthcare waste generation. This includes the section on pharmaceutical and cytotoxic waste where the management of expired vaccines, discarded residues in vials, boxes and bottles are covered. The ICWMP also includes the management of sharps and needlestick injuries. The parent ESMF deals with infectious healthcare waste incineration and its required compliance with emission standards and the use of autoclaving for infectious healthcare waste sterilisation. However, safe vaccine administration (health care workers or local vaccinators are trained to store and handle vaccines properly, reconstitute and administer vaccinations correctly and have the right equipment and materials to do their job will require further E&S risk assessment to ensure that training and qualification of vaccinators and other key workers are conducted before vaccines are May 30, 2021 Page 11 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) delivered to designated health care facilities and that medical and non-medical supplies are provided on time. E&S risks and impacts not previously identified in the parent project ESMF will be incorporated. The cold chain storage presents its own set of risks and impacts. The cold chain storage will require vaccines to be stored and transported within the WHO-recommended temperature ranges. An assessment of the cold chain storage should be merged into the parent ESMF at the earliest opportunity and before project effectiveness. Moreover, it will be crucial to ensure safe vaccine transport and storage to avoid unnecessary vaccine spoiling, wastage and inefficient use of vaccines within the AF project. Vaccine transport will require assessment of the ES risks and impacts considering the potential for a wide roll out across the country. It is not known if the There are no plans to rehabilitate of construct rehabilitation of existing MoH infrastructure to accommodate the AF activities. is required. If there are construction or renovations at HCF sites to increase vaccine storage or delivery capacity, then environmental impacts related to construction or upgrades of vaccine storage would be considered. The ESMF for the parent project adequately covers construction and renovation OHS impacts and risks and that is consistent with the parent project.. The community risks from increased traffic and noise is likely and mitigation measures in the parent project ESMF. Any rehabilitation or construction activities will follow the same provisions as laid down in the ESMF such as the development of an Environmental and Social Management Plan (ESMP) to ensure impacts and risks are adequately covered during the construction and operational phases. The parent ESMF will require the incorporation of mitigation measures to ensure the quality of vaccines are maintained throughout the cold supply chain in accordance with WHO guidance for storage and transportation of vaccines. The existing parent project ESMF will be updated to include the risks and impacts from the AF in the planning and Public Disclosure design and operational stages. This includes vaccines, vaccine storage, distribution equipment, vaccine manufacturers requirements, vaccine readiness and prioritization assessments, surveillance of adverse events following immunization, vaccination campaigns, vaccine delivery and storage, sharps management and OHS to protect workers and the community. ESS10 Stakeholder Engagement and Information Disclosure The current SEP prepared for the parent project remains relevant and provides a systematic approach for engaging stakeholders and lists key outreach activities to be implemented. The revision of the SEP will be revised and re- disclosed before project effectiveness, to capture required to updates the list of stakeholders and inclusion of additional activities related to the roll out of vaccines. These include multi sectoral committees that have been set up to support finalization and implementation of the NVDP, and the extension of project benefits to groups such as refugees and non-nationals that will need to be consulted. Risk communication under component 3 and promotion of behaviour change will be assigned greater prominence on the project to dispel public misconceptions about the vaccine. Dissemination of accurate information on safety of vaccines, principles of fair, equitable and inclusive vaccines access and allocation as guided by WHO on prioritizing use of vaccines in limited context, as well as rationale for prioritizing certain groups will need to undertaken on an on-going basis during the roll out of vaccines. There will be a need to strengthen coordination of key actors from MOH Department of Health Promotions, Ministry of Community Development and other line ministries. The PIU through the Communications Specialist will be responsible for coordinating stakeholders and ensuring SEP activities are aligned and accurate information is disclosed. Through implementation of stakeholder engagement, hesitancy to the vaccine will be monitored to inform May 30, 2021 Page 12 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) decision making and development of responsive IEC materials that will be easily accessed by the public and is culturally appropriate. The Client’s ability to efficiently and effectively implement stakeholder engagement activities within a short timeframe has not been confirmed as activities under the parent project are yet to commence in earnest. Both human and financial implications will need to be reviewed by factoring in additional scope of the AF. The revised SEP will be reviewed by the Bank and re-disclosed to the public. The Grievance Redress Mechanism (GRM) under the parent project will be extended to the AF. However, the GRM is yet to be operationalized, largely attributed to the absence of a Social Specialist that will have the responsibility of implementing and monitoring the GRM. Once recruited, the Social Specialist will ensure project beneficiaries and the public are made aware of the existing GRM; available complaint channels and ways to register complaints through use of complaint boxes at various uptake locations, text messages and in-person submissions; resolution process which will set out the length of time complaints will be addressed and the option of an appeal process if complainants are not satisfied with the resolution of their case. The GRM will need to be accessible and implemented in a transparent and culturally appropriate manner. The project will be required to set up a record management system to document complaints receipt and resolution, and provide periodic updates in the project report. B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions The LMP under the parent project remains relevant for the AF. This includes having clear working conditions for Public Disclosure workers and corresponding compensation, promotion of equal opportunities, prevention of forced labour, setting age restrictions to avoid child labour, establishment of worker grievance mechanism and observance of occupational health and safety requirements. Any changes in staffing requirements, including secondment of staff where necessary will be reflected in the revised LMP. This will include direct, indirect or community workers to be engaged on the project. Community workers will perform the function of mobilising community members to participate in the vaccination process. They will be provided with adequate training and personal protective gear to avoid COVID 19 transmission and other occupational hazards. All health workers involved in the implementation of Covid-19 vaccines are required to have adequate knowledge and skills to ensure safe and efficient Covid-19 vaccination administration. The ESMF should be updated to assess the risks of health workers involved in the vaccine program under this AF project and provide adequate training for front line health workers and to avoid untrained workers providing vaccine administration. The current PIU team required training on the World Bank’s Environmental and Social Framework and, were unfamiliar with the requirements of ESS 2. However, the draft parent ESMF does provide adequate mitigation measures to ensure front line health workers are equipped with PPE, hygiene measures are in place, prevention of needlestick injuries, the safe disposal of syringes and swabs and that worker welfare facilities are available. Moreover, the parent project ESMF will require an annex that details the procedures for health care workers to follow in vaccine administration, handling and storage including OHS risks where workers are in contact with ultra-low temperatures. The training records for all health care workers should be readily available at each vaccination centre. The risks to logistics workers in the cold chain are from transportation risks (vehicle licensing, training, accidents and incidents) and contact with ultra-low May 30, 2021 Page 13 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) temperatures. These additional risks will be included in the appropriate sections within the parent ESMF. The E&S risks and impacts from minor construction and renovation activities are covered in the parent project ESMF, only if this risk materialises and there is need for additional HCF infrastructure. However, there could be a cumulative traffic impact from construction traffic and vaccine deliveries, but there are comprehensive risk mitigation measures in the parent project ESMF to reduce the risk of construction traffic and pedestrian collisions. Vaccine delivery vehicles are not expected to contribute greatly to the traffic and pedestrian collision risk. The E&S impacts and risks could consist of electricity, asbestos, excavations, working at heights, fire, material handling, noise, hazardous materials, slips, trips and fall hazards and risks. In addition, emissions from vehicles and machinery, soil pollution, ground and water pollution, dust generation and the accumulation of construction waste is expected. ESS3 Resource Efficiency and Pollution Prevention and Management ESS 3 is relevant because the AF project will generate hazardous healthcare waste and if not carefully managed will emit pollutants to the air, water and land. The cold chain storage that ensures vaccines are stored and transported within WHO-recommended temperature ranges could result in the use of poorly maintained or obsolete refrigeration equipment containing freons with chlorofluorocarbons (CFCs), e.g., R22 and R12 that are ozone depleting substances (ODS) and have a high global warming potential or freons with high a Global Warming Potential (GWP) such as Hydrofluorocarbons (HFCs). In addition, the energy efficiency of refrigeration equipment is directly affected by the system type and design and the planned refrigeration equipment for the Zambian vaccine cold chain storage needs to be assessed and equipment with freons that are ODS and GWP phased out. Moreover, it will be crucial to ensure safe Public Disclosure vaccine transport and well maintained refrigeration equipment to lower the risks of unnecessary vaccine wastage and inefficiencies within the AF project. The AF’s expected healthcare waste is likely to be sharps, face masks, swabs and plasters. Poor management of this waste will pollute the air, water, and land that in turn may cause health problems to the local community. The parent project’s ICWMP contains mitigation measures that covers the classification of healthcare waste, HCW management measures (segregation, handling, storage, collection, transport, treatment and disposal), hygiene, management of healthcare personnel and management of non-hazardous waste such as packaging. In addition, it includes a section on pharmaceutical and cytotoxic waste where the management of expired vaccines, discarded residues in vials, boxes and bottles are detailed and the safe management of sharps and prevention of needlestick injuries. ESS 3 requires the avoidance of the release of pollutants, control the concentration and the use of guidelines and standards. The parent project’s ESMF states that all incinerators used by the parent project will be regularly serviced and will fulfil the air emission standard proposed in the WBG EHS guidelines (2007) (and Environmental Management (Licensing) Regulations, 2013) for dioxins and furans and all bottom and fly ash from the incinerator will be tested before disposal (according to Environmental Management (Licensing) Regulations, 2013) to determine the concentration of heavy metals. Health care waste incineration methods vary throughout Zambia from brick lined (small scale, low resource, air assisted, dual chamber burn at 800-1200oC to eliminate dioxins and furans) and rotary kiln incinerators to burn pits. All project related HCFs will apply to the Zambia Environmental Management Agency for an emission license in accordance with Part 2 Section 4 of the Environmental Management Licensing regulations 2013. Those incinerators operating under the license will require air measuring devices and pollution control May 30, 2021 Page 14 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) equipment at the plant. Under the parent project, open burning of healthcare waste is prohibited and those HCFs without access to on-site incinerators will transport the HCW to an off-site or to the nearest medical incineration facility or will use other HCW treatment methods which include; use of non-burn technologies through either medical waste microwaves or autoclaves, chemical disinfection and maceration. The parent ESMF states only incinerators which meet the environmentally acceptable standards and legal requirements for air emissions or waste disposal will used. There is a risk that only a limited amount of incinerators will meet the required standards and this aspect of the parent and AF project requires close monitoring. A backlog of healthcare waste could be created from the parent project if only a limited number of incinerators are operational and compliant with air emission standards. Health facilities in the country have poorly developed waste-segregation practices due to an increased generation of diverse types of healthcare waste due to the multiplication and expansion of healthcare facilities because of population growth, ongoing immunizations and treatment of various conditions including emerging and re-emerging communicable and non-communicable diseases. Mitigation measures will include the classification of healthcare waste, sharps, hazardous waste (face masks, swabs and plasters). Under the parent project onsite waste management and disposal will be reviewed regularly and training on protocols contained in the ICWMP conducted. The parent project ESMF details the steps to manage healthcare waste that will adopted and used at all parent project sites. The HCF subcontracts a waste management contractor licensed by ZEMA to collect and transport HCW to a designated site for treatment and final disposal. There are no procedures for consignment notes and no Public Disclosure assessment completed for the subcontractor’s ability to transport and dispose of HCW safely off-site in the parent project ESMF. The parent ESMF will require updating to include a baseline assessment of ZEMA licensed hazardous waste contractors, their training and certification, a list of officially licensed HCW/hazardous waste sites, the final destination for HCW and the implementation of a consignment note system at all project locations. The PIU will audit any off-site waste disposal required on a monthly basis and institute any remedial measures required to ensure compliance with applicable laws, WB ESHG and GIIP. Any deficiencies in the waste management system should be pointed out to the head of the HCF in writing, together with recommendations for remedial measures. The time limit for implementation of remedial measures should be specified and the head of the HCF should be informed of the follow-up date. In the case of off-site waste treatment facilities, incinerator operators, road haulage contractors, and landfill operators should also be audited. Periodic review of waste management practices by both the PIU and the health-care establishments should result both in improved protection of occupational and public health and in enhanced cost-effectiveness of waste disposal. The cold chain consists of transport and storage equipment, trained personnel and efficient management procedures. It will be critical to ensure all three components are combined and effective to enable safe vaccine transport, storage and waste minimisation. This will include the requirement to ensure that cold storage equipment is energy efficient, well maintained and no new equipment is procured that contains freons that are ODS and have high GWP. In an effort to maximise climate co benefits within the cold chain storage chain, the AF will finance climate friendly cold storage chain equipment. This includes the procurement and installation of Solar Direct Drive Refrigerators and WHO PQS certified climate friendly refrigerators/freezers to reduce GHG emissions from fossil fuels. In any activities to install cold-chain equipment in healthcare facilities, emphasis will be place in using clean energy solutions (such as May 30, 2021 Page 15 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) solar and battery systems) to provide continuous power to health facilities and cold-chain equipment, and to reduce operating costs. The parent project’s ESMF will require incorporation of the cold chain and an E&S risk and impact assessment completed on each of its three components. Some of the Covid-19 vaccines will require working cold chains ranging from, ultra-cold temperatures to temperatures between 2 and 8 degrees Celsius. There is a high risk of vaccine spoiling and loss if the cold chains are not appropriate for a particular vaccine, transported in ‘warm’ vehicles, storage areas are vulnerable to theft, vandalism, fire, there is no chain of custody systems in place leading to batch loss or misplacement, equipment malfunction and breakdown (including vehicles, power outages without back up power, leaking coolant, temperature failure, poor temperature circulation), insufficient redundancy in the system (lack of fuel, coolant, spare parts), poor road infrastructure and vehicle bottlenecks (flooded roads, weak bridge and culverts for specific vehicle widths and weights), human error (poor handling, breakages, damaged containers, bad practices by incorrect temperature setting, leaving doors open and delays in paperwork). The traditional E&S risk and impacts associated with transport will likely create noise and air pollution, including nitrous oxides and particulates, and transport is a significant contributor to global warming through emission of carbon dioxide. Mitigation measures would likely include the use of cleaner low sulphur diesel, optimal loads resulting in less journeys, speed reduction encouraging fuel efficiency and regular vehicle maintenance. To ensure support, redundancy and mitigate impacts on the environment and ensure a wide vaccine coverage the AF could finance the procurement of refrigeration and deep freeze equipment, renovation and construction of cold storage and vaccine reception centres. Public Disclosure ESS4 Community Health and Safety The priority of the parent and AF projects are to protect communities from Covid-19 infection. The AF is expected to use existing health care facilities (HCFs) for vaccination sites such as major sites at hospitals and minor sites at the smaller community level. Therefore, under the AF no renovations or construction activities are expected to take place. The smaller community level vaccination sites could generate risks from a lack of PPE allowing Covid-19 transmission, needlestick injuries, a shortage of trained staff to administer the vaccine and monitor community members for adverse reactions to the vaccine, administering spoiled vaccines because of inadequate staff training, cold chain storage and poor clinical waste management practices leading to open burning of healthcare waste (HCW) and air pollution. The risks to the community from the parent project include transport and disposal of hazardous waste. Due to the planned relatively small scale renovations under the parent project, traffic increases in and around targeted HCFs are expected. Further traffic increases are expected at and around HCFs due to Covid 19 vaccine deliveries. Mitigation measures include the implementation of Traffic Management Plans at renovation sites, minimizing pedestrian interaction with construction vehicles, collaboration with local communities, responsible authorities to May 30, 2021 Page 16 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) improve signage, visibility, and overall safety of roads, particularly along stretches located near schools or other locations where children may be present, collaborating with local communities on education about traffic and pedestrian safety (e.g. school education campaigns), using locally sourced materials, whenever possible, to minimize transport distances, locating associated facilities such as worker camps close to project sites and arranging worker bus transport to minimizing external traffic, avoidance of peak traffic flow, adherence to speed limits, driver licensing and training, vehicle licensing and vehicle serviceability. The community risks from increased traffic and noise is also expected and mitigation measures will follow the same provisions in the parent project ESMF. Transportation of hazardous waste from the HCF is to be only undertaken by licensed carriers to undergo incineration, sterilisation or by another Bank approved method. Risk communication strategies will ensure the community is further engaged in Covid-19 spread prevention. Hygiene and personal protection procedures developed for the parent project will prevent AF related workers leaving the workplace to infect their communities. Enforcement of LMP provisions and observance of worker codes of conduct will be upheld. Improper HCW disposal will heighten public health risks due to exposure to carcinogens from incineration, surface water contamination from contaminated run off and injuries and infections to waste pickers and children. ESS3 provides a detailed assessment of the risks and impacts of HCW on the environment and specifies adequate control measures. The existing complement of health personnel and community health volunteers have been deemed adequate to roll out the vaccination programme. Security personnel will not participate in the nationwide exercise. In the event of military engagement, this action will be subjected to Bank approval before enforcement. MOH will ensure that prior to engagement of security personnel, (i) a written notice will be sent to the Bank indicating the name of the security unit; and (ii) ensure that all activities carried out by security personnel will be supervised by MOH and the PCU to Public Disclosure ensure compliance with environmental and social provisions. Furthermore, MOH and the PCU will assess risks associated with engagement of security personnel and implement appropriate mitigation measures to manage such risks and impacts, including a stand-alone Security Management Plan, guided by the principles of proportionality and GIIP, and by applicable national law. MOH and the PCU will be required to adopt codes of conduct for security personnel, and screen such personnel to verify that they have not engaged in past unlawful or abusive behaviour, including sexual exploitation and abuse (SEA), sexual harassment (SH) or excessive use of force. MOH will enter into a memorandum of understanding (MoU), with the Ministry of Home Affairs and set out arrangements for engaging security personnel under the Project, including compliance with the relevant requirements of this AF. Security personnel will be adequately instructed and trained, prior to deployment and on a regular basis, on the use of force and appropriate conduct. The SEP will also include a communication strategy on the involvement of security personnel under the Project. Any concerns related to security conduct will be addressed through the project GRM. Current considerations for GBV/SEA/SH in the parent project and measures applicable for direct, contracted and community workers will remain relevant for the AF. Training on handling of public complaints related to GBV/SEA/SH, upholding confidentiality and having a survivor centered approach will be required for staff at the COVID-19 call centre (909) to boost public confidence in the use of this facility to register complaints and incidences of GBV/SEA/SH that may be experienced during the vaccination roll out. Preparation of a training plan is included in the ESCP. The vaccine related regulatory authority for this project is the MoH in cooperation with the Zambia Medicines Regulatory Authority (ZAMRA). ZAMRA is the Statutory National Medicines Regulatory Body to regulate and control the manufacture, importation, storage distribution, supply, sale and use of medicines and allied substances. The service delivery for the vaccine is conducted by the staff of the MoH. The MoH are in the process of developing the vaccine consent forms because the Covid-19 vaccine will not be mandatory according to the National Expanded Immunization Program (EPI) manual, those who agree will be considered to have consented (expressive consent). May 30, 2021 Page 17 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) The MoH has some gaps in its existing Adverse Events Following Immunization (AEFI) surveillance system and does not meet minimum capacity of Vaccine Safety Surveillance (VSS). VSS is characterized by low AEFI reporting. The majority of cases were reported during the Supplemental Immunization Activities (SIAs) and the routine AEFI surveillance remains weak failing to reach the minimum target of 10 annual AEFI reports per 100 000 surviving infants (Indicator based on SAGE Decade of Vaccines working group). AEFI reports do not meet the minimum reporting requirements because of missing mandatory information and non-articulation of AEFI descriptions. The MoH did finalize and distribute AEFI guidelines to HCFs, but healthcare worker training on AEFI has been intermittent. Gaps exist in provincial and district AEFI level implementation because training and capacity building has been focused at the national government level. In terms of AEFI Causality assessment, a functional AEFI Committee comprising of 11 experts from diverse clinical and para-clinical expertise is in place. Members were nominated and trained on Causality Assessment of AEFI cases. The committee will require training in COVID-19 vaccine safety surveillance. The project will support the borrower to establish effective systems by extensive training on AEFI reporting at the provincial and district levels. This is to ensure provincial and district responsible reporting entities such as healthcare staff working the provincial and district level are able to identify, manage and report AEFI cases in accordance to standardized routing, timelines and activities as per national AEFI guidelines. To strengthen management of AEFI and prepare for potential risk of anaphylaxis, healthcare workers shall be trained to identify, manage and report cases of mild, moderate, severe and fatal AEFI. The country shall ensure availability of AEFI kits at all service delivery points. The MoH and ZAMRA shall strengthen the existing monitoring system to ensure real-time monitoring through the introduction of online platforms and applications and the AEFI reporting package to improve knowledge sharing and communication mechanisms, ensure they are aligned to the requirements for COVID-19 vaccine safety according to WHO guidelines and to complement paper-based reporting from the facility where immunization takes place to Public Disclosure district and national level. It is planned to train investigation teams at the national, provincial and district levels to investigate mild, moderate, severe and fatal AEFIs. The MoH shall print, distribute and disseminate national AEFI guidelines that conform to WHO global manual on surveillance AEFI and case investigation forms to subnational levels that includes the lower levels of service delivery i.e. district and facility level. To improve risk communication and response to serious AEFI the MoH and ZAMRA shall develop a COVID-19 vaccine Risk Communications and Community Engagement (RCCE) strategy and related social mobilization plans which shall include preparedness for responding to vaccine-related events and AEFI. A crisis communications plan shall be developed to respond to Events Based Surveillance (EBS) and AEFI. For post vaccine monitoring and surveillance the MoH and ZAMRA shall seek to strengthen routine passive surveillance (spontaneous reporting) and initiate active surveillance. Data collected on AEFIs using Passive Surveillance is through spontaneous reporting or detection by HCWs. There are Standards of Operations for AEFI surveillance with both paper and web-based provisions for reporting. Plans are underway to use the DHIS2 tracker platform. Emergency preparedness and response structure and measures are supported by a multi- disciplinary preparedness, readiness and response structure based on the WHO’s ten interconnected technical and operational pillars. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not currently relevant. No civil works, including renovations and constructions, are expected for the Project. Administering of the COVID-19 vaccine will be undertaken in existing health facilities across the project. The risk of May 30, 2021 Page 18 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) land acquisition, restrictions on land use and involuntary settlement shall be considered under the ESMF, and related activities, if any, shall be carried out in accordance with ESS5. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources No civil works including renovations and construction are expected at this time under this AF because administering of the COVID-19 vaccine will be undertaken in existing health facilities across the country. Therefore, the risks and impacts from the AF project on natural resources and biodiversity is low at this time. However, relevant aspects of ESS 6 shall be considered, as needed. Mismanagement of HCW, hazardous waste and incineration use could affect living natural resources and the AF and parent project’s activities will be closely monitored. Excessive air emissions of heavy metals and particulate matter from medical waste incinerators under less well-controlled combustion efficiency conditions potentially carcinogenic compounds in the surrounding ambient air could become environmental stressors through deposition on surface water, soil and plants causing affecting local ecosystems. In particular, heavy metals could bioaccumulate or persist in living organisms and in the environment leading to human and animal toxicity. Mitigation measures include the installation of emission monitoring devices and pollution control equipment at all HCF incinerators with emission licences and monitor emissions. Downwind locations of healthcare waste incinerators are particular susceptible and should be periodically monitored for air quality and soil and surface water contamination. All procedures embedded within the ESMF and ESMP, ICWMP must be followed to maintain a low risk. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities Public Disclosure No groups of indigenous peoples or sub-Saharan African historically underserved communities were identified in the ESMF assessment under the parent project. The assessment is relevant for the AF as the project footprint remains unchanged. The presence of the San in communities bordering Zambia and Angola has not been confirmed as a criteria assessment is yet to be conducted. These are considered migrant populations and for purposes of this project they will be covered under ESS1 to ensure they have equitable access to vaccines and under ESS10 through the use of local languages during consultations and application of culturally appropriate channels for disseminating information on the roll out of vaccines. ESS8 Cultural Heritage ESS 8 is currently not relevant for tangible cultural heritage due to no civil works planned or requirements for land use for the AF project. ESS9 Financial Intermediaries N/A C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No May 30, 2021 Page 19 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: N/A IV. CONTACT POINTS World Bank Contact: Musonda Rosemary Sunkutu Title: Senior PHN Specialist Telephone No: 5338+3216 / 260-21-125-2811 Email: rsunkutu@worldbank.org Contact: John Bosco Makumba Title: Senior Operations Officer Public Disclosure Telephone No: 5338+3243 / 260-21-125-2811 Email: jmakumba@worldbank.org Borrower/Client/Recipient Borrower: Republic of Zambia Implementing Agency(ies) Implementing Agency: Ministry of Health Implementing Agency: Zambia National Public Health Institute (ZNPHI) V. FOR MORE INFORMATION CONTACT May 30, 2021 Page 20 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects Public Disclosure May 30, 2021 Page 21 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) VI. APPROVAL Public Disclosure May 30, 2021 Page 22 of 23 The World Bank Additional Financing for the Zambia COVID-19 Emergency Response and Health Systems Preparedness Project (P176400) Task Team Leader(s): Musonda Rosemary Sunkutu, John Bosco Makumba Practice Manager (ENR/Social) Iain G. Shuker Cleared on 28-May-2021 at 16:28:24 GMT-04:00 Public Disclosure May 30, 2021 Page 23 of 23