The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 11/23/2020 | Report No: ESRSAFA056 Nov 24, 2020 Page 1 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Mongolia EAST ASIA AND PACIFIC Mongolia Ministry of Health Project ID Project Name P175730 Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance Parent Project ID (if any) Parent Project Name P173799 MONGOLIA COVID-19 EMERGENCY RESPONSE AND HEALTH SYSTEM PREPAREDNESS PROJECT Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 12/10/2020 12/15/2020 Population Financing Public Disclosure Proposed Development Objective The proposed project development objective is to strengthen Mongolia’s capacity to prevent and respond to the COVID-19 outbreak and strengthen national systems for public health 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 C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] Nov 24, 2020 Page 2 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) The Additional Financing will expand the scope of the parent project in its efforts to support Mongolia government's efforts in strengthening the preparedness and response to COVID-19 pandemic while simultaneously preparing the health system for future public health emergencies. The primary objectives of the AF are to enable affordable and equitable access to COVID vaccines and help ensure effective vaccine deployment in Mongolia through enhanced vaccination system strengthening and to further strengthen preparedness and response activities under the parent project. Activities will be expanded to include 1) risk communication and community outreach around the nation-wide covid- 19 vaccination to increase awareness and “vaccine literacy”, build trust, and reduce stigma around any COVID-19 vaccine for a larger target population; 2) the preparation of detailed vaccine deployment plan based on WHO Fair Allocation Framework and development of a monitoring and evaluation (M&E) system to record the details of the recipients of vaccine as well as vaccine adverse effects; 3) engaging local community-based organizations design, adapt, and scale up innovative service delivery and community mobilization plans; 4) human resource deployment and training for effectively delivering a COVID-19 vaccination program; 5) procurement COVID-19 vaccines; 6) construction of required storage facility and cold chain upgrade as well as minor civil works for WASH and environmental health. D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] Public Disclosure The Parent Project, the COVID-19 Emergency Preparedness and Response Project, was prepared under the COVID-19 Strategic Preparedness and Response Plan (SPRP) (P173799) using the Multiphase Programmatic Approach (MPA), approved by the Board on April 2, 2020. The project is being implemented throughout Mongolia with the aim of contributing to COVID-19 surveillance and response. The parent project covers the capital Ulaanbaatar, through the fit out of three COVID-19 dedicated treatment facilities, as well as other regions of Mongolia by preparing 21 provincial hospitals and 9 district hospitals for dealing with COVID-19 surveillance and treatment. No major civil works are expected in this project; if any works are supported, they should be minor and take place in existing facilities within existing footprints. An example would be in Ulaanbaatar, where one of the three hospitals that will be fitted out urgently with equipment and supplies to treat COVID-19 patients is a new hospital, whose construction is nearing completion but is not operational yet. In summary, the parent project is funding activities to slow down and limit as much as possible the spread of COVID- 19 in the country and improve preparedness for future public health emergencies. The first component covers a comprehensive communication and behavior change intervention, strengthening capacity for active case detection and response, building an enabling platform for One Health and strengthening the capacity of health work force to manage the current and future public health emergencies. The second project component looks at strengthened clinical care capacity of confirmed COVID cases through financing plans for establishing specialized units in selected hospitals, treatment guidelines, hospital infection control interventions and procurement of essential additional inputs for treatment such as oxygen delivery systems, medicines, laboratory equipment and consumables. These measures will be instituted across health facilities. Nov 24, 2020 Page 3 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) Component 3 of the project is funding project management and Component 4 is a Contingency Emergency Response Component (CERC), which will allow the Government of Mongolia to provide immediate and effective response in the event of an eligible crisis or emergency. Environmental and social risks associated with the parent project activities are related to worker and community health and safety, pollution and public health risks from inappropriate management of liquid and solid waste materials arising from the clinical care operations, and social risks associated with exclusion of people such as vulnerable and disadvantaged people (including ethnic minority communities). The project is not expected to impact natural habitats or cultural heritage sites. No proposed activities have the potential to lead to involuntary resettlement issues. US$ 50.7 million additional financing (AF) is proposed to support the costs of expanding activities of the Parent Project. The primary objectives of the AF are to further strengthen preparedness and response activities under the parent project and to help ensure equitable and effective vaccine deployment in Mongolia through enhanced vaccination system strengthening. The PDO of the parent project will remain the same, as will the parent project component structure. An increase in scope and cost will be required to support: (i) vaccine and drug purchase; (ii) systems strengthening and service delivery efforts to ensure effective vaccine deployment; and (iii) monitoring, tracking of vaccines use and recording of any adverse reactions to vaccination. An intense focus on expanding immunization capacity is necessary to ensure that the health systems can effectively Public Disclosure implement a comprehensive COVID-19 vaccine deployment strategy. This includes a critical assessment of and actions to ensure functional, end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management; rigorous cold chain expansion and control; robust service and coverage tracking systems; well trained, motivated and supervised vaccinators; tailored large-scale communication and outreach campaigns at household, community and national level; people-centered service delivery models that can reach different target populations effectively; and effective political leadership. Mongolia may also need to consider and enhance relevant institutional frameworks for the safe and effective deployment of vaccines, including voluntary vaccination practices; regulatory standards for vaccine quality; guidelines for acceptable minimum standards for vaccine management including cold chain infrastructure; safe management and disposal of sharps; and policies to ensure robust governance, accountability, and citizen engagement mechanisms. D. 2. Borrower’s Institutional Capacity Project management arrangements under the e-health Project (P131290), currently functioning satisfactorily, have been adapted to utilize existing capacity in Ministry of Health (MOH) and coordinate project activities with all stakeholders. Through its central departments and provincial offices, the MOH is responsible for implementation of the parent project. Current E-Health Project Steering Committee (PSC), chaired by the Minister of Health is used for oversight and to provide strategic policy advice and guidance to the Project, as well as to the MOH. Membership of the PSC has been extended to include additional members from MOH, National Center for Communicable Disease, Center for Zoonosis Disease and Public Health Institute. The PSC is also responsible for ensuring synergies between the project activities and the State emergency preparedness plan. The multi-sectoral aspects of the COVID-19 response are being guided by the National Emergency Commission chaired by Deputy Prime Minister. Nov 24, 2020 Page 4 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) The existing E-Health Project Implementation Unit (PIU) has been expanded and staffed with relevant experts including medical equipment specialist/engineer, emergency officer, etc. As the risk profile of this project is very different (Cat C) and the PIU had no safeguards resources within its team or any experience with the Bank’s environmental and social safeguards requirements, let alone the Environmental and Social Framework (ESF), the PIU team also needed to recruit E&S specialists for the COVID-19 Emergency Response Project. The Borrower committed to the recruitment of (1) a stakeholder engagement specialist, (2) an environmental health specialist, and (3) an facility health and safety specialist. Recruitment of the required specialists has been delayed as the result of a number of factors, including implications of COVID-19. To date, only one position has been filled. The PIU’s Environmental Health Specialist commenced in October 2020 and is supporting the MOH to prepare, communicate and implement the Project’s Environmental and Social Management Framework (ESMF), Stakeholder Engagement Plan (SEP), Labor Management Procedure (LMP) and associated plans. The ESMF is in draft and is currently under Bank review. The SEP and LMP have been reviewed and revised by the Borrower, and are ready for submission for clearance. The Environmental Health Specialist’s inputs will be increased to help support oversight of scaled up activities under the AF. A Stakeholder Engagement Specialist and Facility Health and Safety Specialist remain to be hired to complete PIU staffing. They are expected to be in place within a month. Enhanced oversight from the Bank E&S team has been provided during the early stages of the Parent Project's implementation and will continue to be required. With support from UNICEF and WHO, the MOH is appraising the country’s readiness for deployment of the COVID-19 vaccine using the Vaccine Introduction Readiness Assessment Tool (VIRAT) and the Vaccine Readiness Assessment Framework (VRAF). These tools assess institutional, operational and financial capacity, gaps and need and the full Public Disclosure assessment is expected to be completed by early 2021 . The AF will engage these partner organizations in various roles such as procurement agents and suppliers and as providers of specialized technical assistance such as vaccine registration and risk communication. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The Parent Project is expected to have long term positive environmental impacts, insofar as it should improve COVID- 19 surveillance, monitoring, treatment and containment. The scaled up activities financed by the AF are expected to further enhance these positive impacts, through the additional investments in WASH facilities and waste management equipment, as well as vaccine administration. The environmental risks are nonetheless considered Substantial because of inherent occupational and community health and safety risks and the issue of medical waste management. The main environmental risks are: (i) the occupational health and safety issues related to testing and handling of supplies and the possibility that they are not safely used by laboratory technicians and medical crews; (ii) the occupational health and safety (OHS) issues related to the treatment of COVID-19 patients; and (iii) medical waste management and community health and safety issues related to the handling, transportation and disposal of healthcare waste. This includes waste resulting from vaccine Nov 24, 2020 Page 5 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) delivery such as sharps and the disposal of used and expired vaccine vials as a result of the AF activities. Waste materials generated from labs, quarantine facilities, screening, treatment and vaccination facilities 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 handle the waste. Other risks associated with the AF activities include (1) community health and safety risks from incorrect vaccine storage, handling and transportation practices leading to vaccine quality deterioration, and (2) construction environmental impacts associated with the construction and upgrade works of a vaccine storage facility and WASH facilities, incl. dust, noise, air emissions, erosion, waste and traffic disturbance. The latter are localized, temporary and easily manageable through good practice construction environmental management procedures. To mitigate the parent project risks, the MoH had committed to prepare an ESMF during early project implementation that covers the environmental and social assessments to be undertaken and mitigation measures to be implemented for the various proposed activities as part of the parent project, including minor fit out works, establishment and operation of quarantine and laboratory facilities, health care waste management, infectious disease prevention and control activities, as well as in the event of an emergency that triggers the CERC. A draft ESMF has been submitted to the Bank team for review on 18 November 2020. Mitigation measures are largely based on WHO technical guidance on COVID-19 response , World Bank EHS Guidelines and other GIIP, including an elaboration of responsibilities within the MoH, training requirements, timing of implementation and budgets. Procurement of goods (testing kits, medical equipment such as oxygen suppliers, etc.) and risk communication activities were initiated as soon as the parent project was approved. However, the ESMF should be finalized, cleared and disclosed before Public Disclosure establishing the isolation units, quarantine facilities, and/or undertaking construction activities at any scale. In addition, any activities that have been screened for environmental and social risks will not be carried out without the completed, consulted and disclosed ESMF and subsequent assessment, where necessary. The draft ESMF is now also expected to be updated and re-disclosed to account for the AF funded activities, with environmental risks largely focused around vaccine procurement, distribution and administration, as well as minor works related to vaccine storage and WASH facilities. The draft ESMF is expected to require only minor revision, as it already includes an Infection Prevention and Control and Waste Management Plan (IPC&WMP) and an Environmental Code of Practice (ECOP) to mitigate construction related impacts. Social Risk Rating Substantial The social risks are also considered Substantial. The Project will not involve resettlement or land acquisition. The key social risk is that vulnerable and high-risk social groups are unable to access facilities and services, due to their income, and distance from health centers. The measures put in place to address the pandemic such as confinement and physical distancing that affect livelihoods and access to services are likely to increase the risks of women and girls experiencing violence. Full societal inclusion is not only fundamental to improved social development outcomes, but given the nature of COVID, if parts of society (by geography, income, gender or any other measure) are excluded, the overall efficacy of the engagement will be compromised. Nov 24, 2020 Page 6 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) While the Government of Mongolia is planning and implementing robust measures including setting-up higher-level coordination mechanism to prevent and respond to COVID-19, there is need to develop adequate preparedness actions to ensure disadvantaged and vulnerable groups have awareness and able to receive appropriate preventive support (such as awareness of basic hygiene etc) or treatment in Ulaanbaatar and in rural areas. There is an ethnic minority group – Kazakh- who reside in the western part of Mongolia and speak and read in Kazakh language. Similarly, there are indigenous herder communities in Huvsgul aimag where road access is challenging. The MoH, in the ESCP, committed to the provision of services including vaccination, supplies and communication based on the urgency of the need, in line with the latest data related to the prevalence of the cases and respective vaccination deployment strategy. Another particular risk that has come to the fore based on the ongoing implementation experience of Global COVID- 19 MPA is the increased incidence of reprisals and retaliation especially against healthcare workers and researchers. This risk will be mitigated through explicit inclusion in robust stakeholder identification and consultation processes at the individual operation level. Under parent project Component 1, Emergency Response, more than 17 different project activities for risk communication are underway, including (a) public health information and communication campaigns for disease prevention and management through mass media platforms; (b) instituting infection control guidelines and service standards; and (c) training of key front-line staff, including emergency doctors, nurses and paramedical staff. The Ministry of Health (MOH) developed 265 infographics and 181 video spots and shared these via Facebook, reaching out cumulatively to about 10 million people. All mobile phone users receive information on prevention of the COVID- Public Disclosure 19 once a day. However, challenges in implementation of this component remain, largely stemming from a lack of clarity in institutional roles within the MOH, lack of real champions, slow progress in setting up advisory committees and unfamiliarity with Bank procurement processes. Partly as a result of these challenges, MoH has only just finished updating preliminary Stakeholder Engagement Plan (SEP) prepared for the parent project to engage citizens and for public information disclosure. The updated SEP includes a Grievance Redress Mechanism which specifically considers the needs of indigenous and other communities. Initial work by UNICEF, WHO and MoF indicate that after primary health care workers (due to occupational requirements), vaccines will be prioritized to high risk patients, the elderly, pregnant woman and family members of heath care service providers. Once this is completed and subsequent batches of vaccine are received, an additional 40% of the population can be vaccinated, selected based on the WHO Fair Allocation Framework. 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: Both the Mongolia COVID-19 Emergency Response and Preparedness parent project and additional financing activities will have positive environmental and social impacts as they should improve COVID-19 surveillance, monitoring, containment and response in accordance with WHO guidelines and GIIP, as well as prepare the country Nov 24, 2020 Page 7 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) for future health emergencies. However, the project could also cause substantial environmental, health and safety risks due to the dangerous and potentially infectious nature of the pathogen, chemicals, vaccines and other materials to be used in the project-supported laboratories and health facilities, as well as the associated waste materials. Multiple disadvantaged or other vulnerable groups stand to benefit, starting with the elderly and those with compromised immune systems due to pre-existing conditions. The community engagement activities proposed under component 1.1 will seek to ensure inclusion of these groups. In terms of prioritization of population groups that will receive vaccination first, the WHO Fair Allocation Framework guidance will be followed. This is addressed under ESS 10 and the ESCP. Moreover, with support from the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), the MOH is in the process of conducting a readiness assessment on the basis of the Vaccine Readiness Assessment Framework (VRAF), the Vaccine Introduction Readiness Assessment Tool (VIRAT). The assessment is expected to be completed by early 2021. The PIU has drafted an ESMF to provide guidance to the screening of E&S risks associated with the parent project activities, and determination of the appropriate instrument to manage these risks. The draft version of the ESMF contains Infection Prevention and Control & Waste Management Plan (IPC&WMP) to safeguard health care workers, patients and the larger community from transmission and infection by the COVID-19 virus as the result of their daily routines of testing, quarantining and treating patients and managing the safe disposal of the resulting medical waste. The ESMF also provides a Code of Environmental Practice for the execution of the refurbishment and fitting out of quarantine and ICU units within existing health facilities. The draft EMSF is based largely on adopting WHO guidance, World Bank EHS Guidelines and other GIIP. It provides for the application of international best practices in COVID-19 diagnostic testing and handling the medical supplies, disposing of the generated waste, and treating confirmed cases. Public Disclosure The ESMF also covers mitigation of other E&S risks associated with the use of security personnel; prevent and respond to sexual exploitation and abuse, and sexual harassment and has an exclusion list for project activities that may not be undertaken unless the appropriate OHS capacity and infrastructure is in place (e.g., BSL3 level). The AF funded procurement, distribution and administration of vaccines equally has the ability to lead to occupational and community health and safety risks as follows: - Vaccine safety and efficacy: to mitigate the potentially adverse health effects of administering unsafe vaccines, the funds can only be used for the procurement of thoroughly tested and approved vaccines. The Bank will accept as the threshold either (i) approval by 3 Stringent Regulatory Authorities (SRAs) in three regions or (ii) WHO prequalification and approval by 1 SRA. In addition, the AF includes a monitoring component of adverse health effects of the vaccine on people that received it. - Safe transport and storage of the vaccine: the vaccines that are currently in the final stages of testing and are likely to be approved soon have different storage temperature requirements, ranging from temperatures as low as - 70C to refrigerator temperatures of 2-8C. Particularly the former vaccines (those based on mRNA technology) are prone to rapid decay and ineffectiveness when not stored at the proper temperature, which could lead to high wastage. Wasted vaccines may be dangerous, or at the very minimum ineffective, when administered. Ultra cold storage and transportation is a challenge in global supply chains, and particularly so in Low and Middle Income Countries that lack the required storage and transport infrastructure. With support from UNICEF and WHO, the MOH is appraising the country’s readiness for deployment of the COVID-19 vaccine using the Vaccine Introduction Readiness Assessment Tool (VIRAT) and the Vaccine Readiness Assessment Framework (VRAF). These tools assess Nov 24, 2020 Page 8 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) institutional, operational and financial capacity gaps. The AF will fund necessary investments in cold storage and logistics to enable the safe delivery of vaccines throughout the country. - Vaccine equitable distribution and access: risks of elite capture or inability to distribute the vaccine safely to the more remote areas could lead to vulnerable people missing out on vaccination. A social assessment is integrated within the ESMF that is currently being finalized. This social assessment addresses the relevant project risks and impacts, including the (i) risk that project-related impacts fall disproportionately on individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable; and (ii) risk of prejudice or discrimination toward individuals or groups in providing access to development resources and project benefits, particularly in the case of those who may be disadvantaged or vulnerable. Prioritization and selection of population groups to be vaccinated first will be conducted in accordance with emerging WHO guidance including the Values Framework for the allocation and prioritization of COVID-19 vaccination, the Roadmap for Prioritizing Population Groups for Vaccines against COVID-19 and the Fair Allocation Framework. Examples of target priority groups include frontline health and care workers at high risk of infection, older adults, and those people at high risk of death because of underlying conditions like heart disease and diabetes. The environmental impacts related to construction, upgrades of vaccine storage and WASH facilities are expected to be of manageable, temporary and of local impact as they are related to general construction activities on already known and previously used sites. These impacts most commonly include: a) dust and noise due to excavation, demolition and construction; b) management of demolition construction wastes and accidental spillage of machine oil, lubricants, etc.; c) damage to unknown archaeological sites; d) traffic disturbance; e) surface or ground water pollution; and f) soil pollution or erosion. Public Disclosure The draft ESMF for the parent project will be updated and disclosed within 1 month of the AF effectiveness date, to account for the AF related activities, which focus on the procurement, distribution and administration of safe vaccines, in addition to expanding existing activities under the parent project, including vaccination awareness and risk communication campaigns, training of vaccinators and other workers, minor civil works related to vaccine storage and WASH facilities. These activities can largely be managed using the mitigation measures proposed in the draft ESMF for the parent project, but specific guidance on the selection of priority population groups to be vaccinated and monitoring of adverse health effects from vaccination will be included in accordance with emerging WHO guidance. Measures to ensure the quality of vaccines is maintained throughout the supply chain in accordance with WHO guidance for storage and transportation of vaccines will also be incorporated. Where necessary, existing measures and tools in the ESMF (IPC&WMP, ECOP, checklists) will be revised to ensure they fully cover the additional risks associated with the AF funded activities. The final ESMF will be prepared, consulted, disclosed and implemented within 1 month of AF effectiveness. ESS10 Stakeholder Engagement and Information Disclosure Component 1.1 is the Risk Communication and Community Engagement activity which will be a fundamentally important part of project implementation. As detailed under “Social Risk Rating” above, a wide range of activities for risk communication have commenced. This component will be expanded with activities to inform the public of the rationale for vaccinating selected target populations; vaccine safety; the process for vaccine deployment; and Nov 24, 2020 Page 9 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) possible side-effects to foster confidence in a new vaccine. Effective communication and outreach will be imperative to increase awareness and “vaccine literacy”, build trust, and reduce stigma around any COVID-19 vaccine for a larger target population. Financing will support implementation of UNICEF’s interpersonal communication package including any translation and adaptation to local conditions required. In addition, possible activities such as reviewing existing literature, including any similar experiences from Expanded Program of Immunization (EPI), and undertaking in-depth beneficiary research on perceptions and obstacles to vaccine uptake as background for preparation of mass media campaigns that are tailored to the Mongolian context. Information will be prepared in Mongolian languages and adapted to varied contexts within Mongolia, distributed across high-penetration platforms, and fostering support and endorsement through trusted community and national leaders. Various approaches will be used to improve vaccine literacy among the general population and target vulnerable groups identified by the project. Some of the key priorities will include conducting online consultations regarding beneficiary perceptions and obstacles to vaccine uptake; sensitization to counter misconceptions about the disease, vaccine introduction and any negative perceptions and disseminating in due time vaccination-related information such as overview of the COVID-19 vaccine program, priority risk groups, commodity availability, and tracking of those who need to receive a second dose, etc. The AF will support (i) development of a network of health workers and community volunteers; (ii) contracting of local community organizations, private sector and individuals to facilitate behavior change messaging, community mobilization, and undertake additional laboratory and vaccine logistic functions and also carry out beneficiary feedback, (iii) coordination with Mainstreaming Social Accountability in Public Disclosure Mongolia (MASAM) in leveraging the existing web-based citizens’ platforms (e.g. www.1818.mn or https://covid19.mohs.mn/), targeted at the primary health care services, towards improving two-way communication with the public and CSO networks to reach targeted beneficiaries as well as citizens across the country (iv) targeted messages to prevent and respond to the risk of gender-based violence (GBV), and/or train frontline health workers on how to identify, appropriately handle incidents and refer patients for additional services. Based on WHO guidance, the overall purpose of the stakeholder engagement and consultation process is to build trust in the prevention and response of misinformation that may interfere with decision-making in the population for Coronavirus disease (COVID-19) and to adhere to public health advice. This will include scientifically sound information on relevant vaccines. This work would be based on WHO guidance (WHO Guidance - Risk Communication and Community Engagement) and would seek to provide proper awareness raising and timely information dissemination to (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. The preliminary SEP drafted for the Project has been updated and is based on relevant WHO guidance including a guide to preventing and addressing social stigma associated with COVID-19 (to reduce social stigma and discriminatory behaviors against people of certain ethnic backgrounds as well as anyone perceived to have been in contact with the virus). The project can thereby rely on standards set out by WHO as well as international good practice to (i) facilitate noted appropriate stakeholder engagement and outreach towards a differentiated audience (concerned citizens, suspected cases and patients, relatives, health care workers, etc.); and (ii) promote the proper handling of quarantining Nov 24, 2020 Page 10 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) interventions (including dignified treatment of patients; attention to specific, culturally determined concerns of vulnerable groups; and prevention of Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) as well as minimum accommodation and servicing requirements) The parent project SEP will be updated to reflect the additional engagement requirements associated with the AF funded roll out of a broad scale vaccination program. The initial beneficiaries of the vaccination program will be frontline health and care workers at high risk of infection, older adults, and those people at high risk of death because of underlying conditions like heart disease and diabetes. This will need to be communicated and managed carefully. The updated SEP is based on existing information and rapid qualitative and/or quantitative assessments to learn about the communities (knowledge, attitudes and perceptions about COVID-19 and vaccines, most at risk population, communication patterns and channels, language, religion, influencers, health services and situation) . Upon this assessment, a plan of action will be prepared which will include responsible parties, period and needed financial and human resources. The final SEP will be shared with relevant stakeholders via culturally appropriate means (and having regard to logistical and technological constraints). The SEP will be disclosed at MoH website and printed copies will be placed in health centers in all provinces and hospitals in Ulaanbaatar. The E-Health PIU will ensure that there is no prejudice or discrimination toward project-affected individuals or communities, including other interested parties. Particular consideration will continue to be given to the disadvantaged and vulnerable groups including elderly and people with pre-conditions during the life of the project, especially where adverse impacts may arise, or development benefits are to be shared. The GRM will respond to complaints throughout the project lifecycle and has been devised to promptly respond to Public Disclosure any project grievances. The existing E-health project unit will undertake day-to-day management of GRM; it defines ways in which users can submit their grievances, which may include submissions in person, by phone, text message, mail, email or via a website (http://ehp.mn/eng/); and includes a log where grievances are registered in writing and maintained as a database, publicly advertised procedures, setting out the length of time users can expect to wait for acknowledgement, response and resolution of their grievances, transparency about the grievance procedure, governing structure and decision makers; and an appeals process (including the national judiciary) to which unsatisfied grievances may be referred when resolution of grievance has not been achieved. The project GRM is also enhanced by placing additional channel to register and respond to complaints/feedback linked with deployment of vaccination as the primary objectives of the AF is to enable affordable and equitable access to COVID vaccines in Mongolia. Details of the GRM operation are described in draft SEP. 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 Labor Management: Sub-component 1.3 – Human Resource Development, will finance activities related to preparedness, capacity building and trainings. Under the AF, activities in this component will be expanded to include a human resource deployment and training plan for effectively delivering a vaccine program. This would need to be rolled out across the country in the shortest possible time to existing staff and additional vaccinators (retired health staff, Red Cross members, pharmacists etc.) on provision of the vaccine, infection control, pharmacovigilance and Nov 24, 2020 Page 11 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) environmental safety measures as well as interpersonal communication tools to counter any resistance to the vaccine. The labor arrangements will depend to a large extent on the final implementation arrangements. Most project funded personnel will be full time employees of the Government (project management personnel, medical staff etc) and equipment and medical suppliers and will therefore be Direct Workers, Contract Workers or Primary Supply Workers. Elements of the project activities (including community engagement work under Component 1.1) may also include use of Community Workers. Through the AF, direct contracting of WHO and UNICEF for the roll out of vaccine awareness campaigns, vaccine procurement, distribution and administration will also occur. The Government is finalizing the preparation of a Labor Management Plan (LMP) which (i) responds to the specific health and safety issues posed by COVID-19, and (ii) protects workers’ rights as set out in ESS2. The LMP distinguishes between the different types of workers as identified under ESS 2 and identify specific protections for each type/category. The exact number of direct workers and contracted workers engaged in the project over the whole cycle of the project is not yet known, but, a reasonable estimation provides that it could reach up to 17,000. The final LMP will be disclosed at project website within the timeframe indicated in ESCP. The LMP will be implemented throughout the lifespan of project. Healthcare workers (HCWs) play a critical role in outbreak response and are the backbone of a country's defenses to limit or contain the spread of disease. They face higher risks of potential COVID-19 infection in their efforts to protect the greater community and are exposed to hazards such as psychological distress, fatigue and stigma. They will be prioritized for early vaccination. Worker safety: Healthcare associated infections due to inadequate adherence to occupational health and safety Public Disclosure standards can lead to illness and death among health and laboratory workers. The laboratories to be supported by the project will process COVID-19 and will therefore have the potential to cause serious illness or potentially lethal harm to the laboratory staff and to the community, so effective administrative and containment controls will be put in place to minimize these risks. Environmentally and socially sound health facilities management will require adequate provisions for minimization of occupational health and safety risks, proper management of hazardous waste and sharps, use of appropriate disinfectants, proper quarantine procedure for COVID-19, appropriate chemical and infectious substance handling and transportation procedures, etc. These measures are covered in the IPC&WMP contained in the draft ESMF and are based on the national healthcare delivery standards and norms set by the MoH in addition to WHO guidance. ESS3 Resource Efficiency and Pollution Prevention and Management Medical and chemical wastes (including water, reagents, infected materials, etc.) from the labs, quarantine, and screening posts to be supported (drugs, supplies and medical equipment) can have significant impact on environment and human health. Wastes that may be generated from medical facilities/ labs could include liquid contaminated waste, chemicals and other hazardous materials, and other waste from labs and quarantine and isolation centers including sharps, used in diagnosis and treatment. The AF component adds additional waste types including syringes and vaccine vials, as well as expired or wasted vaccines. Nov 24, 2020 Page 12 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) Healthcare waste management is undergoing a transformation, which is well advanced in Ulaanbaatar but lags behind in other parts of Mongolia. In Ulaanbaatar, a central healthcare waste treatment facility has been in operation since 2011 by the company Element LLC, which operates under a public–private partnership agreement between Ulaanbaatar City, the Ministry of Health and Element LLC. Element LLC collects medical waste from all public and private healthcare facilities in Ulaanbaatar City on a routine basis and, after autoclave disinfection, disposes of this waste in the Narangiin Enger disposal site. The facility consists of two autoclave units for biological waste and one unit for needles and sharps, with a total capacity of 2,800 kg/d. The situation regarding healthcare waste management in hospitals in other parts of Mongolia is not known in detail. A national assessment on healthcare waste management was conducted in 2006–2007. It showed that 90 per cent of the facilities are burning medical waste in small, low temperature incinerators without any air filter or are practising open burning. By 2011, 33 per cent of aimag hospitals and 41 per cent of soum hospitals had shifted to non- incineration technology for healthcare waste treatment. Sterilized waste is then sent to local disposal sites. Hospitals are using pits for biological waste located on the hospital territory. International organizations provided high- pressure steam autoclaves and trained personnel in 28 soum hospitals in nine aimags with WHO support, 35 soum hospitals in 10 aimags with Millennium Challenge Account–Mongolia support, and 90 soum hospitals and five aimag hospitals with ADB support, in 2009–2011 . A health care waste management plan has been developed as part of the Parent Project's IPC&WMP contained in the draft ESMF to ensure the waste management practices at the various hospitals receiving assistance from the project comply with WHO guidance and international best practice for infectious and hazardous waste management. The Public Disclosure HCWMP will be expanded to include the waste types emerging to the AF components – including sharps, used and expired vaccine vials. Each beneficiary medical facility/lab, following the requirements of the ESMF and the IPC&WMP being prepared for the Project, WHO COVID-19 guidance documents, and other best international practices, will prepare and follow the IPC&WMP to prevent or minimize such adverse impacts. Any activities that have been screened for environmental and social risks will not be carried out until a completed, consulted and disclosed ESMF (including IPC&WMP) is in place. The ESMF will include guidance related to transportation and management of vaccines, samples and medical goods or expired chemical products and wasted vaccines. Resources (water, air, etc.) used in quarantine facilities and labs will follow standards and measures in line with US-Center for Disease Control (CDC) and WHO environmental infection control guidelines for medical facilities. The necessary training in the implementation of the WMP will be provided to medical and laboratory workers, as well as the workers contracted through the waste management provider Element LLC. Construction waste materials associated with the fit out of ICUs and isolation units in existing hospitals and health facilities will be managed in accordance with good practice waste management procedures, which will be covered in the ECOP for minor civil works. This ECOP and in particular the waste management procedures will also be relevant to the management of waste materials derived from activities funded under the AF Project, including new construction and upgrades of vaccine storage and WASH facilities. Nov 24, 2020 Page 13 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) ESS4 Community Health and Safety Protecting the safety of communities from infection with COVID-19 is a central part of the project. Medical and general waste from the labs, health centers, and quarantine and isolation centers have a high potential of carrying micro-organisms that can infect the community at large if they are is not properly disposed of. There is a possibility for the infectious microorganism to be introduced into the environment if not well contained within the laboratory or due to accidents/ emergencies e.g. a fire response or natural phenomena event. The ESMF currently being finalized documents: (i) how project activities will be carried out in a safe manner with (low) incidences of accidents and incidents in line with Good International Industry Practice (WHO guidelines); (ii) measures in place to prevent or minimize the spread of infectious diseases; and (iii) emergency preparedness measures. The draft ESMF will be reviewed and revised to ensure it includes additional appropriate community health and safety measures to safeguard the public from adverse impacts related to the AF project activities, including monitoring of adverse impacts and side effects of vaccines on recipients of the vaccinations. In order to assure vaccine safety and efficacy, safe storage and transportation conditions will need to be maintained. This is likely to involve storage at ultra-cold temperatures of down to -70C. The AF will ensure adequate investment in cold storage and logistics to avoid vaccines being wasted. The draft ESMF will be expanded with best practice measures for assuring quality control of the vaccines during storage and transportation throughout the country. Laboratories, quarantine and isolation centers, and screening posts, will thereby have to follow respective procedures with a focus on appropriate waste management of contaminated materials as well as protocols on the transport of samples and workers cleaning before leaving the work place back into their communities. The project will thereby Public Disclosure follow the requirements established by WHO and to be adapted into the project ESMF. Some project activities may give rise to the risk of Gender Based Violence (GBV), in particular Sexual Exploitation and Abuse (SEA) and Sexual Harassment (SH) risks. The draft ESMF for this project includes a GBV risk assessment and preventive measures. The project will promote the avoidance of SEA by relying on the WHO Code of Ethics and Professional Conduct for all workers in the quarantine facilities as well as the provision of gender-sensitive infrastructure such as segregated toilets and enough light in quarantine and isolation centers. The project will also ensure that quarantine and isolation centers, screening and vaccination posts are operated effectively throughout the country, including in remote and border areas. In case quarantine and isolation and/or vaccination centers are to be protected by security personnel, it will be ensured that the security personnel follow a strict code of conduct and avoid any escalation of situation, taking into consideration the above noted needs of quarantined persons as well as the potential stress related to it. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement The Project will not involve resettlement or land acquisition. ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources Nov 24, 2020 Page 14 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) No major construction or rehabilitation activities are expected in this project and all works will be conducted within existing facilities. Hence, likely impacts of the project on natural resources and biodiversity are low and so this standard is not considered relevant. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities An ethnic minority group – Kazakh- reside in the western part of Mongolia and speak and read in Kazakh language. Similarly, there are indigenous raindeer herding communities living in the northern forested areas of the country where road access is challenging. To ensure these communities are effectively integrated into the project, the MoH has undertaken a social assessment (SA) that has been integrated into the draft ESMF and identifies the specific constraints and opportunities including informing and delivering the vaccine for these communities. The ESMF is now nearing completion. As detailed under ESS 1 (above), the social assessment addresses the relevant project risks and impacts, including the (i) risk that project-related impacts fall disproportionately on individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable; and (ii) risk of prejudice or discrimination toward individuals or groups in providing access to development resources and project benefits, particularly in the case of those who may be disadvantaged or vulnerable. Indigenous People and Ethnic Minority communities are key considerations in this SA. The SA will be updated to ensure that access to vaccinations are equitably distributed which will assist in ensuring these (often remote) communities are adequately protected by an approved vaccine. Public Disclosure Matters relating to these communities will be managed therefore via the SA in the ESMF as well as the SEP. There is need to design and implement adequate preparedness actions targeted to disadvantaged and vulnerable groups (elders, women/children, people with disability and ethnic minorities who speak and read other than Mongolian, patients with lung, cardiovascular, renal disease, cancer, type I and II diabetes, adults above 60 years old, pregnant woman and family members of heath care service providers (on average 2-3 members) through adopting WHO guidance which are designed to support risk communication, community engagement staff and responders working with national health authorities. MoH will also update the draft SEP to ensure culturally appropriate communication strategies are developed. ESS8 Cultural Heritage This standard is currently considered Not Relevant as the project is not expected to support any construction or rehabilitation activities that would involve the movement of earth (thereby potentially having an impact on tangible cultural heritage), or other activities that could have an impact on intangible cultural heritage. In the unlikely event of major earth works taking place in relation to any project activities, a chance finds procedure has been prepared and integrated into the draft ESMF for the project. ESS9 Financial Intermediaries Nov 24, 2020 Page 15 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) This standard is Not Relevant to the proposed project interventions, as no financial intermediaries will be used. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Areas where “Use of Borrower Framework” is being considered: none IV. CONTACT POINTS Public Disclosure World Bank Contact: Dinesh M. Nair Title: Senior Health Specialist Telephone No: 5788+7786 / 86-10-58617786 Email: dnair@worldbank.org Contact: Anna L Wielogorska Title: Lead Procurement Specialist Telephone No: 5777+7320 / 84-243-9367320 Email: awielogorska@worldbank.org Contact: Pagma Genden Title: Operations Officer Telephone No: 5725+8243 / 976-70-078243 Email: pgenden@worldbank.org Borrower/Client/Recipient Borrower: Mongolia Implementing Agency(ies) Implementing Agency: Ministry of Health V. FOR MORE INFORMATION CONTACT Nov 24, 2020 Page 16 of 17 The World Bank Mongolia COVID-19 Emergency Response and Health System Preparedness Project Additional Finance (P175730) The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Dinesh M. Nair, Anna L Wielogorska, Pagma Genden Practice Manager (ENR/Social) Ann Jeannette Glauber Cleared on 23-Nov-2020 at 03:53:14 GMT-05:00 Public Disclosure Nov 24, 2020 Page 17 of 17