The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 23-Sep-2021 | Report No: PIDA32499 Aug 02, 2021 Page 1 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Uganda P177273 Additional Financing to P174041 Uganda COVID-19 Response and Emergency Preparedness Project Parent Project Name Region Estimated Appraisal Date Estimated Board Date Uganda COVID-19 Response and AFRICA EAST 05-Oct-2021 23-Nov-2021 Emergency Preparedness Project Practice Area (Lead) Financing Instrument Borrower(s) Implementing Agency Health, Nutrition & Population Investment Project Ministry of Finance, Ministry of Health Financing Planning and Economic Development Proposed Development Objective(s) Parent The objective of the Project is to prevent, detect and respond to COVID-19 and strengthen national systems for public health emergency preparedness in Uganda. Components Component 1: Case Detection, Confirmation, Contact Tracing, Recording, Reporting Component 2: Strengthening Case Management and Psychosocial Support Component 3: Project Management, Monitoring and Evaluation Component 4: Vaccines Acquisition and Deployment Component 5: Strengthening Continuity of Essential Health Services PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 168.00 Total Financing 168.00 of which IBRD/IDA 152.00 Financing Gap 0.00 DETAILS -NewFinEnh1 Aug 02, 2021 Page 2 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) World Bank Group Financing International Development Association (IDA) 152.00 IDA Credit 122.00 IDA Grant 30.00 Non-World Bank Group Financing Trust Funds 16.00 Global Financing Facility 16.00 Environmental and Social Risk Classification Substantial Other Decision (as needed) Pre-Appraisal PID B. Introduction and Context Country, Sectoral, and Institutional Context 1. The COVID-19 pandemic has disrupted social services and livelihoods and created significant health and economic costs in Uganda. Uganda, like other countries, is suffering major disruptions in the delivery and utilization of social services. These disruptions are most accentuated during lockdowns instituted to curtail transmission during new waves. For example, key health sector interventions were between 11-28 percent lower than expected for the period April and June 2020 (compared with historical trends)1’2; health facility deliveries and availability of the basket of essential medicines reduced by 3 percent and 7 percent, respectively; facility- based maternal mortality increased by 7.6 percent and immunization coverage reduced by between 10-20 percent. 2. The first case of COVID-19 was reported on March 21, 2020. Since then, Uganda has experienced two waves of the outbreak, peaking in December 2020 and July 2021. As of August 31, 2021, Uganda had registered 119,825 cases and 3,006 deaths, from all the 136 districts3, translating into a case fatality rate of 2.9 percent. Uganda managed to contain the first wave of COVID-19, which resulted in about 42,102 cases and 343 deaths as of May 5, 2021. The second wave, however, was more aggressive and accounted for 65 percent of all cases and 89 percent of all deaths registered to date. Infections were also more widespread, affecting younger age groups than seen in the previous wave. The second wave was driven by a combination of factors, including the spread of more transmissible variants of COVID-19; low case detection, inadequate tracing and treatment capacity; sub- 1 MoH. Annual Health Sector Performance Report FY 2019/2020 2 Monitoring essential health services in times of COVID-19 3 WHO. COVID-19 Daily Situational Report Uganda 05 September 2021 Aug 02, 2021 Page 3 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) optimal adherence to public health and social measures; and low coverage of COVID-19 vaccination. The Government of Uganda (GoU) has warned of the threat of a third wave of the outbreak, considering continued weak adherence to public health measures. The high rates of infection and death overwhelmed the national health system as hospitals were filled, forcing government to institute a 42-day lockdown and to opt for home- based COVID-19 case management, among other measures. 3. The GoU initiated its COVID-19 vaccination campaign in March 2021, with the aim to vaccinate 22 million (proportion of population above 18 years old). By August 31, 2021, the Government of Uganda had received a total of 1,753,360 doses of the AstraZeneca and 647,080 doses of Moderna vaccines from the COVAX Facility as well as donations of additional doses (100,000) of Astrazeneca from India, and 300,000 doses of Sinovac from the Peoples Republic of China. As of August 31, a total of 1,395,318 people had received at least one dose of either Astrazeneca or Sinovac4, accounting for 3.2 percent of the national population, and 242,310 people had been fully vaccinated (i.e. received two doses). The pace of vaccination has been adversely impacted by an export ban in India for AstraZeneca, which delayed deliveries through COVAX Facility, and the general global vaccine supply constraints. The GoU has set a national vaccine coverage target of 49.6 percent (i.e. proportion of population above 18 years), and expects to receive vaccine doses through a number of sources including the COVAX Facility, the African Union Vaccines Acquisition Trust (AVAT), direct purchase and donations. Thus far, the GoU has made commitments to procure vaccines for 70.5 percent of the population by December 2023, making provision of the eventual vaccination of children between the ages of 12 and 17 years, as well as the potential need for revaccination (as evidence becomes available). 4. Uganda’s investments in health service delivery and health security (including COVID-19 response) extend to all citizens, including refugees. As the largest refugee hosting country in Africa with over 1.49 million refugees, Uganda is recognized globally as having one of the national refugee policies most aligned with the Global Compact on Refugees. The 2006 Refugee Act guarantees refugees fundamental rights, including the right to work, enjoy freedom of movement, own property, and access social services, including health services. The Refugee Regulations stipulate the integration of refugee matters in National Development Plans. Currently, the government is actively integrating social service delivery for refugees into the routine government service delivery systems, including the COVID-19 response. C. Proposed Development Objective(s) Original PDO The objective of the Project is to prevent, detect and respond to COVID-19 and strengthen national systems for public health emergency preparedness in Uganda. Current PDO No change to the original PDO is proposed under the AF. Key Results 6. The Project’s progress towards achievement of the Project Development Objectives and overall implementation progress was rated Moderately Satisfactory in the last Implementation Status and Results Report (ISR) dated April 23, 2021. As of August 31, 2021, disbursements amounted to US$2.7million (18 percent) of the total Project 4 Moderna doses arrived on September 6, 2021. Aug 02, 2021 Page 4 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) cost. The disbursed resources were provided through a Pandemic Emergency Financing Facility (PEFF) grant, which became effective on August 31, 2020 and closed on March 31, 2021 with 100 percent disbursement ratio. The resources were used to: (i) expand COVID-19 testing through the purchase of additional PCR test kits and reagents for diagnosis of co-morbidities; (ii) strengthen Point of Entry (PoE) screening and contact tracing; (iii) procure Personal Protective Equipment; (iv) deploy COVID-19 frontline workers; and (v) enhance Project management. At the PDO-level, the PEFF grant has contributed to an increase in the proportion of COVID-19 suspected cases with laboratory confirmation within 72 hours. 7. The Project Implementation Unit (PIU) of the parent Project has been effectively coordinating implementation with support from the MoH leadership. The unit effectively implemented the grant component of the Project, thereby, contributing to increasing the number of laboratory tests for suspected COVID-19 cases, screening at priority points of entry, and training of personnel in critical and acute medical care. They also managed to prepare relevant ESF instruments ahead of the expected effectiveness of the credit component of the Project. Further implementation of the project stalled after conclusion of the PEFF funded activities due to delays in meeting the effectiveness conditions for the IDA Credit financed component whose Financing Agreement was signed on June 30, 2021. The Project was declared effective on August 3, 2021. D. Project Description 8. The Uganda COVID-19 Response and Emergency Preparedness Project (UCREPP, P174041), in the amount of SDR 9.2 million (US$12.5 million equivalent) plus US$2.7million in grant from the Pandemic Emergency Financing Facility (PEFF), was approved by the Board on July 15, 2020. Its PDO is to prevent, detect and respond to COVID-19 and strengthen national systems for public health emergency preparedness in Uganda. UCREPP is one of over a hundred projects approved under the COVID-19 Strategic Preparedness and Response Program (SPRP) using the Multiphase Programmatic Approach (MPA), approved by the Board on April 2, 2020. The PEFF component of the Project became effective on August 31, 2020. The IDA credit became effective on August 3, 2021. 9. On April 6, 2021 the GoU requested Additional Financing (AF) to UCREPP to support the national COVID-19 vaccination campaign. The preparation of the AF commenced following the effectiveness of UCREPP. The total estimated cost of the AF is US$168 million, consisting of US$122 million in IDA credit, US$27 from the Window for Host Communities and Refugees, US$3 million from matching IDA grant, and US$16 million from the Global Financing Facility (GFF). The AF is being prepared under the vaccines AF to the SPRP approved on October 13, 20205. The primary objectives of the AF are to enable affordable and equitable access to COVID-19 vaccines, to help ensure effective vaccine deployment in Uganda through vaccination system strengthening, and to further strengthen preparedness and response activities under the parent Project. The AF will ensure host communities and refugees are included within this objective. 10. The changes proposed for the AF entail expanding the scope and coverage of activities in the parent Project, UCREPP, and adjusting its overall design. As the proposed activities to be funded under the AF for UCREPP are aligned with the original PDO, the PDO will remain unchanged. The content of the components and the Results Framework of the 5 The Bank approved a US$12 billion WBG Fast Track COVID-19 Facility (FTCF or “the Facility�) to assist IBRD and IDA countries in addressing the global pandemic and its impacts. Of this amount, US$6 billion came from IBRD/IDA (“the Bank�) and US$6 billion from the International Finance Corporation (IFC). The IFC subsequently increased its contribution to US$8 billion, bringing the FTCF total to US$14 billion. The Additional Financing of US$12 billion (IBRD/IDA) was approved on October 13, 2020 to support the purchase and deployment of COVID-19 vaccines as well as strengthening the related immunization and health care delivery system. Aug 02, 2021 Page 5 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) parent Project will be adjusted to reflect the expanded scope and new activities proposed under the AF. The proposed changes are summarized as follows: 11. Component 1: Case Detection, Confirmation, Contact Tracing, Recording, [US$ 3 million, of which US$2 million is funded through the WHR and US$ 1 million is through the matching IDA grant]: This component focuses on strengthening disease surveillance capacity, including improving early detection and reporting of COVID-19 cases, and surveillance of climate-related diseases in refugee settlements and Refugee Hosting Districts (RHDs). This component will specifically expand coverage of the existing activities, envisioned in the parent Project, to RHDs and refugee settlements, which remain poorly-equipped to contain COVID-19 and other epidemics—especially given the constant threat of cross- border transmission. A total of US$3 million from the WHR and matching IDA grant, will be used to strengthen the capacity of Village Health Teams (VHTs) for enhanced contact tracing, health promotion and disease prevention within refugee- hosting communities for 126 RHDs. The planned activities to support host communities and refugees will be implemented as part of the integrated National COVID-19 Resurgence Plan, which already accounts for refugees. 12. In addition, Project costs under the PEFF will be reallocated to reflect modifications made during implementation to respond to the evolving country needs. At approval, the planned costs for Component 1, under the PEFF was US$2.1 million. US$400,000 was reallocated from Component 1 to Component 2, to substantially increase the procurement of PPEs as well as the payment of hazard allowances for frontline workers. The total cost under PEFF, under Component 1, will thus be amended to US$1.7 million. 13. Component 2: [US$ 6 million, of which US$ 5 million is funded through the WHR and US$ 1 million is through the matching IDA grant].The objective of this component is to: (i) respond to the disease burden of COVID-19; (ii) improve infection prevention control within hospitals; enhance clinical and intensive care capacity; and (iii) equip key personnel to adequately manage COVID-patients and their families. The component also provides resources for psychosocial support for clinicians and care providers, as well as interventions to address sexual exploitation and gender-based violence. This component will scale up activities of the two existing sub-components of Strengthening COVID-19 Case Management (2a) and Psychosocial Support and Gender-Sensitive Considerations (2b) to cover host communities and refugees. 14. In addition to the new activities proposed, US$400,000 will be allocated to this component from Component 1 and US$34,000 from Component 3. This will raise the total cost under the PEFF, for this component to US$717,852 from US$284,000. 15. Component 3: Project Management, Monitoring and Evaluation: [US$3 million of which US$1 million is funded through the WHR, US$1 million through the IDA grant and US$1 million through the Global Financing Facility for Women, Children and Adolescents (GFF)]. The AF will support: (i) recruitment of additional staff under the existing PIU, which will ensure effective management and monitoring in RHDs and implementation of the HSIRRP; (ii) procurement of ICT tools to facilitate data capture, analysis and reporting; and (iii) strengthening of internet connectivity to allow real- time data reporting from the sub-national levels (including RHDs) to the central database. The National Information Technology Authority - Uganda (NITAU) will be consulted on all ICT related activities. The parent Project costs, for this component, under the PEFF will be reduced to US$277,000 from the planned US$311,000 in the parent Project. 6 These activities will not include Kampala – the thirteenth refugee hosting district—which by GoU’s current policy does not receive refugee support from UNHCR or the World Food Program (WFP). Aug 02, 2021 Page 6 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) 16. Component 4: Vaccine Acquisition and Deployment [US $ 137 million, of which US$ 122 million is IDA credit, US$10 million is from the WHR, and US$5 million is from the GFF]:The AF will introduce a new component focused on vaccine purchase and deployment. Under this component, the government of Uganda will procure vaccines to vaccinate 11.7 million people (26.4 percent of the population), in Phase 2 of its vaccination campaign, scheduled to begin in January 2022. The vaccines acquired will be used for all eligible candidates, including host communities and refugees. At the national level, the AF will primarily fund vaccine acquisition, estimated at US$117 million. US$15 million will be dedicated for deployment, with emphasis on: vaccine delivery and immunization; risk communication and community sensitization; strengthening supportive supervision; enhancing reporting and immunization data management; and strengthening pharmacovigilance to address adverse events following immunization. The resources for deployment and operations are minimal given complementary funding from other development partners, notably GAVI. The policies for prioritizing intra- country vaccine allocations in Uganda have been completed and were informed by WHO’s Framework for the allocation and prioritization of COVID-19 vaccination. 17. For host communities and refugees, out of the US$137 million for Component 4, US$10 million from the WHR has been earmarked for vaccination under this AF and will be sufficient to vaccinate 700,000 host community members and refugees within the RHDs of: Yumbe; Kikuube; Ishingiro, Kyegegwa; Kikuube; Obongi; Kamwenge; Kirandongo; Lamwo; Koboko; Madi Okollo, Terego. The deployment systems for refugee settlements are those of national systems which at the district level work closely with UNHCR, OPM and NGOs in the health sector to reach people of concern across host communities and refugees. Component 5: Strengthening Continuity of Essential Health Services [US$19 million, of which US$9 million is from the WHR and US$10 million is from the GFF]: This component will enhance continuity of services across five priority areas. The sub-components are described as follows: • Subcomponent 5a. Upgrade Health Infrastructure and Equipment for Enhanced Service Delivery (US$7 million, including US$6 million from WHR and US$1 million from GFF): This sub-component will support infrastructure upgrades in refugee settlements and RHDs, and in selected facilities outside of the RHDs. • Sub-Component 5b: Strengthen Emergency Medical Services (EMS) (US$5 million, of which US$2 million is from the GFF, and US$3 million from the WHR). The COVID-19 pandemic has underscored the need to bolster emergency management and referral systems. The sub-component will support efforts to improve current EMS capacity with a view to reinforcing regional structures for enhanced referrals and dispatch services. • Sub-Component 5c: Improve the availability of essential health commodities (US$3 million from the GFF) . The sub-component will support acquisition of medicines, essential health supplies and commodities to support the delivery of essential health services. • Strengthening Community Systems for Continuity of Essential Health Services (US$2 million from GFF). This sub- component will support community health organizations, Village Health Teams, local leaders, to help raise awareness about COVID-19, as well as other health risks, including those related to reproductive health, non- communicable diseases, and other public health threats. It will also provide equipment and training, as needed to enhance the performance of community health workers. • Sub-Component 5e: Strengthening infection prevention and control in health facilities through multi-sectoral engagement (US$ 2million from the GFF). The activity will build off initial engagements between HNP, the GFF and the WASH GP to: conduct an assessment of water and sanitation gaps in the health sector, procure critical WASH amenities, waste disposal bins; and train on norms to prevent microbial resistance in the health facilities. . Aug 02, 2021 Page 7 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Legal Operational Policies Triggered? No Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 Summary of Assessment of Environmental and Social Risks and Impacts . E. Implementation Institutional and Implementation Arrangements 18. The Ministry of Health (MoH) will be the implementing agency for all activities under the project. While the National Medical Stores (NMS) is and will continue to be the main procurement and supply agency for medicines, routine vaccines and essential health supplies, the administering of COVID-19 vaccines and related supplies will be overseen by the MoH, which will contract UN agencies given the complex global COVID-19 vaccines supply systems. Once the vaccines arrive in country, they will be received, stored, and distributed country-wide by the NMS in the same way they manage the other routine commodities. The Project Implementation Unit (PIU), which oversees day-to-day activities of the project including supervision, M&E, safeguards and fiduciary aspects will be enhanced to include vaccine management expertise such vaccine as logistics, procurement, and deployment under the national immunization program. The MoH will continue receiving technical support from other development partners including the WHO and UNICEF on vaccine procurement and deployment and demand generation. While the National COVID-19 Taskforce chaired by the Prime Minister and the related arms namely the COVID-19 Incidence Management Team and the Strategic Management Committee will provide overall oversight for the national vaccination program, the Project will also be guided by the following specific health sector coordination mechanisms: Vaccine Advisory Committee, National Coordination Committee and the National Immunization Technical Advisory Committee. The Office of the Prime Minister and UNHCR which are particularly important coordinator of refugee health services are not only part of the National and District COVID-19 Task Force but will also be members of the Project Steering Committee. . CONTACT POINT World Bank Julia Mensah Senior Health Specialist Rogers Ayiko Senior Health Specialist Aug 02, 2021 Page 8 of 9 The World Bank Additional Financing to Uganda COVID-19 Response and Emergency Preparedness Project (P177273) Borrower/Client/Recipient Ministry of Finance, Planning and Economic Development Implementing Agencies Ministry of Health Diana Atwine Permanent Secretary datwine1273@gmail.com FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Julia Mensah Task Team Leader(s): Rogers Ayiko Approved By Practice Manager/Manager: Country Director: Camille Anne Nuamah 23-Sep-2021 Aug 02, 2021 Page 9 of 9