Tajikistan Emergency COVID-19 Project ESMF Abbreviations and Acronyms AFB Acid-Fast Bacilli AMR Antimicrobial Resistance ALRI Agency for Land Reclamation and Irrigation under the Government of the Republic of Tajikistan BMBL Biosafety in Micro Biological and Biomedical Laboratories BMW Bio Medical Waste Management BSC Biological Safety Cabinets BSL Biosafety Level CDC Center for Disease Control and Prevention CEP Committee on Environmental Protection under the Government of the Republic of Tajikistan CoC Code of Conduct COVID-19 Coronavirus Disease 2019 CSO Civil Society Organization EOC Emergency Operating Centre ESF Environmental and Social Framework ESIA Environmental and Social Impact Assessment ESHS Environmental, Social, Health and Safety EHS Environmental, Health and Safety ERP Emergency Response Plan ESCP Environment and Social Commitment Plan ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan i Tajikistan Emergency COVID-19 Project ESMF ESS Environmental and Social Standard GBAO Gorno-Badakhshan Autonomous Province GBV Gender Based Violence GIIP Good International Industry Practice GM Grievance Mechanism GRM Grievance Redress Mechanism GRS (World Bank’s) Grievance Redress Service HCF Healthcare Facility HCW Healthcare Waste HEPA High Efficiency Particulate Air filter HIV Human Immunodeficiency Virus HR Human Rights HRW Human Rights Watch HWMS Healthcare Waste Management System HVAC Heating, Ventilation and Air Conditioning ICRC International Committee of the Red Cross/Red Crescent ICU Intensive Care Unit ICWMP Infection Control and Waste Management Plan IPC Infection and Prevention Control MPA Multiphase Programmatic Approach MOHSP Ministry of Health and Social Protection MEWR Ministry of Energy and Water Resources of the Republic of Tajikistan NGO Non-Governmental Organization ii Tajikistan Emergency COVID-19 Project ESMF OHS Occupational Health and Safety PPE Personal Protective Equipment PPSD Project Procurement Strategy for Development RAP Resettlement Action Plan RPF Resettlement Policy Framework RHC Rural Health Center SASP State Agency for Social Protection SEA Sexual Exploitation and Abuse/Harassment SEE State Ecological Expertise SEP Stakeholder Engagement Plan SH Sexual Harassment SMP Security Management Plan SOP Standard Operating Procedures TA Technical Assistance TB Tuberculosis TSA Targeted Social Assistance UNICEF United Nations Children’s Fund WASH Water, Sanitation, and Hygiene WHO World Health Organization WWTP Wastewater Treatment Plant iii Tajikistan Emergency COVID-19 Project ESMF Table of Contents Abbreviations and Acronyms ................................................................................................................. i Executive Summary ............................................................................................................................... vi I. Introduction and Background ....................................................................................................... 1 II. Project Description ......................................................................................................................... 5 III. Policy, Legal, and Regulatory Framework ................................................................................. 14 IV. Environmental and Social Baselines ........................................................................................... 30 Environmental Characteristics ............................................................................................................ 30 Socio-Economic Characteristics .......................................................................................................... 32 V. Environment and Social Risks and Mitigation........................................................................... 36 VI. ESMF Procedures ......................................................................................................................... 49 Infection Control and Waste Management ........................................................................................ 52 Labor Management .............................................................................................................................. 53 VII. Public Consultation and Disclosure............................................................................................. 54 Proposed strategy for information disclosure and consultation process ......................................... 55 Stakeholder Engagement...................................................................................................................... 56 Grievance Redress Mechanism (GRM) .............................................................................................. 57 World Bank Grievance Redress System ............................................................................................. 62 Institutional Arrangements, Responsibilities and Capacity Building .............................................. 62 Annex I - Screening Form for Potential Environmental and Social Issues ..................................... 64 Annex II - ESMP Checklist .................................................................................................................. 68 Annex III - Infection Control and Waste Management Plan (ICWMP) Template ........................ 87 Annex IV - Infection and Prevention Control Protocol..................................................................... 98 Annex V – Technical Note on Use of Military Forces to Assist COVID-19 Operations ............... 101 Annex VI – Technical Note on SEA/SH for HNP COVID Response Operations ......................... 107 Annex VII - Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 ............................................................................................................................................ 109 Annex VIII - Vaccine Delivery and Deployment Manual ............................................................... 118 Executive Summary .................................................................................................................... 118 The World Bank Tajikistan Emergency COVID-19 Project ...................................................... 118 Background: COVID-19 in Tajikistan ....................................................................................... 121 Institutional arrangements for TEC-19 additional financing ...................................................... 122 Supply of COVID-19 Vaccine.................................................................................................... 123 Vaccine procurement .................................................................................................................. 126 Vaccine distribution .................................................................................................................... 129 iv Tajikistan Emergency COVID-19 Project ESMF Who will get the vaccine ...................................................................................................................... 130 Delivery to Tajikistan ........................................................................................................................... 132 Distribution within Tajikistan ............................................................................................................. 132 Delivery at facilities .............................................................................................................................. 136 Human resources ................................................................................................................................. 138 Supply chain management................................................................................................................... 140 Waste management .............................................................................................................................. 140 Public awareness-raising ..................................................................................................................... 141 Monitoring & Evaluation............................................................................................................ 142 Adverse events following immunization (AEFI) ................................................................................. 142 Vaccine distribution ............................................................................................................................. 142 Procurement ................................................................................................................................ 143 Financial management and audits ............................................................................................... 144 Social and environmental risk management ............................................................................... 145 Annex IX - Resource List: COVID-19 Guidance ............................................................................. 157 v Tajikistan Emergency COVID-19 Project ESMF Executive Summary 1. Project Development Objective (PDO) Statement: To prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan. 2. The Project consists of the following four components: a. Component 1. Strengthening intensive care capacity (US$ 6.3 million). This component will finance the procurement of medical supplies and equipment needed for activities for emergency response such as: case detection, management and reporting; infection prevention and control; and, facility repurposing and surge capacity for treatment. Items procured will include: (i) drugs and medical supplies for case management and infection prevention; (ii) equipment, reagents, testing kits, and consumable supplies for laboratories; (iii) procurement and supply of the initial batch of COVID-19 vaccines, (iv) installation of oxygen stations with pressure swing adsorption (PSA) at up to 15 health facilities of the Republic Tajikistan; and (v) equipment and refurbishment for establishment of up to 100-beds at the intensive care units (ICU) across Tajikistan (locations to be determined). b. Component 2. Multisectorial response planning and community preparedness (US$ 1.0 million). This Component will support information and communication activities to increase the attention and commitment of government, private sector, and civil society, and to raise awareness, knowledge and understanding among the general population about the risk and potential impact of the pandemic and to develop multi-sectorial strategies to address the pandemic. These activities include: (i) the development of a multisectorial task force and support to national, regional and district bodies in mobilizing effective response activities; (ii) communication activities, across multiple channels, including a hotline coordinated by the MOHSP, and working with religious leaders for end of life practices; (iii) the development and dissemination of communication materials; (iv) training of media outlets on emergency response procedures; (v) training of community workers training at the Center for Healthy Lifestyles in Dushanbe; (vi) establishing sub-national (regional) COVID-19 hotlines to provide callers with information about COVID-19 and hotlines shall be utilized an additional GRM tool; and (vii) promoting public awareness about vaccination against COVID-19. vi Tajikistan Emergency COVID-19 Project ESMF c. Component 3. Temporary social support for vulnerable households (US$ 3.0 million). This Component will finance targeted, nutrition-sensitive cash transfers to provide time-limited support to vulnerable households, particularly food-insecure households with young children where food price shocks caused by the COVID-19 pandemic can negatively affect children’s nutrition status and jeopardize the human capital investments being made by the Government of Tajikistan and the World Bank. The AF will scale up the one-off Emergency Cash Transfer Program to cover new beneficiary groups, including the most vulnerable households with children under 7, female-headed households with children under 16, and households with children with disabilities under 18. Additional groups may also be included, including the poorest households, whether they have children or not. The transfers will be delivered using the existing Targeted Social Assistance (TSA) system implemented by the State Agency for Social Protection (SASP). The TSA system includes an additional module to allow for additional payments in emergency situations and the eligibility criteria can be adapted to target the most food insecure communities. The transfers will be triggered at the oblast-level based on the spikes in the prices of key food groups. Once triggered, the program will target TSA beneficiary households with young children. This component will finance the cash transfers, and cover the costs of benefit administration, including the cost of expanding the capacity of the beneficiary data base. The proposed cash transfers will also provide an opportunity to use accompanying measure to promote optimal nutrition, appropriate hygiene, and preventive health services, as well COVID- 19 infection prevention messaging (development of communication materials will be financed under Component 2). d. Component 4. Project Implementation and Monitoring (US$ 1.0 million). Implementing the proposed Project will require administrative and human resources that exceed the current capacity of the implementing institutions. For this reason, building on the existing strong project management capacity is critical for the rapid implementation and scale-up of project activities. The MOHSP will receive professional implementation and project management support, including for procurement and financial management (FM), from a designated new Project Implementation Unit (PIU). The core of the new PIU had been formed from the team of the well-performed Project Implementation Unit of the Tajikistan Social Safety Nets Strengthening Project (SSNSP), which was closed on June 30, 2020. Activities that will be financed include: (a) support for project management, including procurement, FM, environmental and social, monitoring and evaluation, and reporting; (b) operating costs; (c) project audits. 3. Project location. The project will be implemented countrywide. vii Tajikistan Emergency COVID-19 Project ESMF 4. Potential environmental impacts and risks. The seven major areas of risks for the project are: (i) risks related to rehabilitation of existing healthcare facilities; (ii) risks related to medical waste management and disposal; (iii) risks related to spread of the virus among health care workers; (iv) risks related to the spread of COVID-19 among the population at large; (v) risks / challenges associated with emergency cash transfers extended to vulnerable groups; (vi) additional risks associated with the installation and operation of oxygen stations with PSA in selected health care facilities; and (vii) risks associated with vaccination of the population against COVID-19, as well as in the framework of routine vaccination activities (MMR). The World Bank Environment and Social Framework (ESF) applies; therefore, the risks are covered by the following five of the ten World Bank Environmental and Social Standards (ESSs): ESS 1, ESS 2, ESS 3, ESS 4, and ESS 10. The environmental risk rating is “Substantial”. 5. The project will finance small scale infrastructure works for the rehabilitation and equipping of ten health centers to establish 100 ICU beds and possible rehabilitation of on- site incinerators for medical waste disposal. These interventions are expected to take place on the property of existing facilities; therefore, environmental issues (and impacts thereof) are expected to be temporary, predictable, and easily mitigable. 6. Improper handling of health care waste can cause serious health problems for workers, the community and the environment. Medical wastes have a high potential of carrying microorganisms and viruses that can infect people who are exposed to them, as well as the community at large if they are not properly disposed of. Wastes that may be generated from labs, ICUs, quarantine facilities, and screening posts to be supported by the COVID-19 preparedness and response could include a liquid contaminated waste (e.g. blood, other body fluids, and contaminated fluid) and infected materials (water used; lab solutions and reagents, syringes, bed-sheets, majority of waste from labs and quarantine and isolation centers, etc.) which requires special handling and awareness, as it may pose an infectious risk to healthcare workers in contact or handle the waste. It is also important to ensure the proper disposal of sharps. Ensuring contagion vectors are controlled through strict adherence to standard procedures and personal protective equipment (PPE) for all health care workers is also critical. viii Tajikistan Emergency COVID-19 Project ESMF Additional risks include an inadequate immunization supply chain management (ISCM), potential vaccine hesitancy, and risks associated with personal information sharing and cybersecurity. The AF is designed to reduce the risk associated with inadequate ISCM through direct investments in strengthening the existing vaccine supply chain management system based on international best practices and preparatory work carried out by the Government of the Republic of Tajikistan with the support of UNICEF. The Project will procure IT equipment and software required to deploy an e-system for ISCM at sub- national and district level. The AF will manage the risks of inadequate / inaccurate information deterring people from being vaccinated by investing directly in vaccination- related awareness campaigns (under Component 2). The data collection systems supported by the AF (supply chain management; Adverse Effects Following Immunization; patient registry) have been developed based on international best practice with the support of international partners (WHO, UNICEF). The main environmental risks associated with vaccination will be ensuring the safety of medical personnel and the safe implementation of post-introduction/vaccination waste management activities across all healthcare facilities/vaccination sites. 7. Potential social impacts and risks. The major areas of social risks, similar to environment, are: (i) risks related to spread of the virus among health care workers; (ii) risks related to the spread of COVID-19 among the population at large; (iii) rehabilitation of existing healthcare facilities (iv) risks / challenges associated with emergency cash transfers extended to vulnerable groups; (v) additional risks associated with the installation and operation of oxygen stations with PSA in selected health care facilities; and (vi) risks associated with vaccination of the population against COVID-19, as well as in the framework of routine vaccination activities (MMR). For risk areas (i) and (ii), key issues/risks to be managed focus on: (i) ensuring a soothing environment so as to avoid panic/conflicts resulting from false rumors and social unrest; (ii) assuring proper and quick access to appropriate and timely medical services, antiseptics and PPEs, that is not based on ability to pay or other factors; (iii) anticipating and addressing issues resulting from people being kept in quarantine; and (iv) addressing challenges associated with providing (financial) assistance for vulnerable people and the risk of ‘exclusion’ thereof. For risk area (vi), measures to address social and environmental risks include measures to assess and mitigate the impact, including risk management of medical waste handling during vaccination. Key social issues and mitigation measures focus around following aspects: (i) rolling-out a conducive and safe environment, complemented by WHO training opportunities in targeted health facilities, to avoid burnout and the spread of the virus among healthcare workers; (ii) set overarching goals with all stakeholders, ensure effective service delivery and increase the number of emergency cash transfer recipients to minimize the risk of “exclusion”. ix Tajikistan Emergency COVID-19 Project ESMF To manage these risks, the MOHSP has updated the SEP to a standard acceptable to the Bank and updated SEP is disclosed at the country level (MOHSP website) and the World Bank web-site: http://moh.tj/wp- content/uploads/2021/01/%D0%B0%D0%BD%D0%B3%D0%BB%D0%B8%D1%81% D0%B8-%D0%BD%D0%B2%D0%B2.pdf http://moh.tj/wp-content/uploads/2017/07/%D1%80%D1%83%D1%81%D0%B8- %D0%BD%D0%B0%D0%B2.pdf The proposed AF1 is expected to have a positive social impact at both the individual and community levels as it addresses the health sector emergency COVID-19 response. However, the social risk is assessed as significant as the Project will face several challenges, mainly related to accessibility and inequality; i) the broad public may face challenges in accessing vaccination sites and services given the pandemic; (ii) vulnerable social groups, especially in rural and remote mountainous areas, may find it difficult to access vaccines, facilities and services as vaccination sites may be located in more central locations; iii) social unrest and conflict due to limited availability of vaccines and tensions associated with the difficulties of the pandemic situation; iv) inadequate data protection measures and inadequate / ineffective stakeholders engagement, including communication about the vaccine introduction strategy; and v) risks associated with Adverse Events Following Immunization. 8. The financial assistance, targeted at poorer households, is meant to: (i) help offset the expected rise in food prices as a result of the COVID-19 emergency; and thereby (ii) help prevent food insecurity and losses to human capital. These cash transfers will be made through the existing World Bank financed Targeted Social Assistance (TSA) program which aims to improve the living conditions of the most vulnerable population through better targeting, introduced in 2011 with support from the European Union and the World Bank. The TSA uses a special formula to identify and target the poorest 15 percent of the population which is approximately the rate of extreme poverty in Tajikistan. Despite TSA being successful, in the current context, following key issues/ risks need to be addressed: (i) Risk of exclusion –while TSA’s targeting has been quite good, the same needs to be tweaked to COVID-19 situation which may impact certain groups of the population particularly hard; (ii) Timing - TSA should kick in as and when the food price rises which needs to be monitored; and (iii) Appropriate service delivery, to reach out to the identified people. Most of these impacts and the risks thereof can be contained by an effective and inclusive outreach program encompassing stakeholder engagement throughout the project cycle, allowing adjustment in TSA implementation on an on-going basis. With regards to risk area (iii), since the civil works envisaged in the project refer to repair and rehabilitation of existing buildings only, no land acquisition or involuntary resettlement impacts are expected. Considering all the risks identified, the social risk rating is “Substantial”. x Tajikistan Emergency COVID-19 Project ESMF 9. Environmental and Social Risk Rating. The project was prepared under the World Bank’s Environment and Social Framework (ESF) with both the Environmental and Social Risk Rating of " Substantial", resulting in an overall ESF Risk Rating of “Substantial”. 10. Institutional capacities to manage environmental and social risks and impacts. The Ministry of Health and Social Protection is the implementing agency for the project. It is designated as the central operational body within the Government and Standing Headquarters for COVID-19 prevention and response. The Project Implementation Unit (PIU) of the World Bank-funded Social Safety Network Strengthening Project (SSNSP) functioning under the MOHSP is responsible for the day-to-day management of project activities. The TEC-19 PIU is already established and functioning: SSNSP PIU staff had joined the TEC-19 PIU team and implement the various project components, including those related to update and implementation of the stakeholder engagement plan. The PIU will also deploy the staff needed for proper implementation of the environmental and social framework elements of the project, as this project will be implemented under the new ESF standards. 11. The PIU serves as the key implementation unit for all components. The PIU will also be responsible for preparing a consolidated annual work plan and a consolidated activity and financial report for the project components. For Components 1 and 2 directly related to COVID-19, the PIU will report to the Deputy Minister of Health and Social Protection/National Coordinator for COVID-19 Counteraction; while for Component 3, the PIU will report to the Deputy Minister of Health and Social Protection in charge of social protection area through State Agency on Social Protection under the MOHSP (SASP) similar to the current arrangements for SSNSP. Both Deputy Ministers will be accountable to the Minister of Health, who, in turn, will be reporting on project performance to the higher-level authorities. 12. Supported by the PIU, the MOHSP’s Division of Sanitary and Epidemiological Safety, Emergencies and Emergency Medical Care (DSESEEMC) will be responsible for carrying out stakeholder engagement activities, while working closely together with other entities, such as local government units, media outlets, health workers, etc. supported under Component 2 of the Project. The stakeholder engagement activities will be documented through quarterly progress reports, to be shared with the World Bank. The nature of the project requires a partnership and coordination mechanisms between national, regional and local stakeholders. xi Tajikistan Emergency COVID-19 Project ESMF 13. This Environmental and Social Management Framework (ESMF) is prepared and updated to assist the Government of Tajikistan in developing environmental and social instruments in response to COVID-19 situations following national regulations and the ESF. The ESMF provides guidelines for the development of appropriate prevention and mitigation measures for adverse impacts that might result from project activities. The ESMF also includes a checklist for Environmental and Social Management Plans (ESMPs), as Annex II, which includes measures for the safe installation and operation of oxygen stations; and a template for Infection Control and Waste Management Plans (ICWMPs), as Annex III. Annex IV - Protocol: Infection Control and Prevention; Annex V - Technical Note on Use of Military Forces to Assist COVID-19 Operations; Annex VI - Technical Note on SEA/SH for HNP COVID Response Operations; Annex VII - Recommended measures for Waste Management Handling due to COVID-19 Vaccination. The Annex II aims to provide an overarching action plan for the management of environmental, social, health and safety (ESHS) issues associated with the construction and operation of healthcare facilities in response to COVID-19. The ICWMP focuses on proper infection control and healthcare waste management practices during the operation of healthcare facilities. An ICWMP is considered part of an ESMP for specific activities. Recommendations for the operation of oxygen stations contain a checklist for the safe use of oxygen in health care facilities. Waste management plan following vaccination, both routine (MMR) and COVID-19, provides guidance on safe medical waste handling. 14. The ESMF covers all applicable provisions of the relevant ESSs. Additionally, other environmental and social instruments as required by the ESF, such as the Stakeholder Engagement Plan (SEP), are appropriately summarized or referenced in the ESMF and ESMP checklist. The type of environmental and social instruments and their timings of development and implementation are defined in the Environmental and Social Commitment Plan (ESCP). 15. Environmental and Social Management Framework (ESMF) structure. The document consists of eight chapters that outline environmental and social assessment procedures and mitigation requirements in line with the Bank’s ESF requirements and standards for the subprojects /project activities which will be supported by the Project. a. Chapter I includes the Introduction and Brief Description of the Project Context. It also outlines the rational and purpose of the ESMF prepared to provide guidance on adequate procedures to assess subprojects/project activities, which will be identified during project implementation. b. Chapter II describes the Project Development Objectives and Components. It also covers the overview of potential environmental and social risks and impacts associated with the project activities, as well as justification for environmental and social risk ratings. xii Tajikistan Emergency COVID-19 Project ESMF c. Chapter III describes the Legal, Regulatory and Policy Framework and provides an overview of laws and regulations that have relevance for environmental and social issues for the project. It also has a summary of the World Bank’s Environmental and Social Standards (ESS) that are designed to support Borrowers’ projects. d. Chapter IV narrates the Baseline Data on environmental and social background of the country, providing analysis of current environmental and social systems at the country level. e. Chapter V analyzes Potential Environmental and Social Risks and Impacts related to the project activities implementation, as well as proposed mitigation measures. f. Chapter VI includes Implementation Procedures to Address Environmental and Social Issues. It highlights the relevant instruments and specific actions planned to prevent, avoid, minimize, reduce or mitigate the environmental and social risks and impacts of the project over the project cycle to meet the ESS requirements. g. Chapter VII underlines the public consultation procedures and grievance redress mechanisms. h. Relevant Annexes are enclosed at the end of this document to compliment the above-mentioned chapters. 16. ESMF disclosure and consultation. On May 10-20, 2020 MOHSP conducted virtual consultations on the draft ESMF in Dushanbe city. The draft ESMF in English and Russian was disclosed on the MOHSP website on May 10, 2020 (http://moh.tj). MOHSP also officially submitted the final ESMF to the World Bank for disclosure in English on the WB external webpage by August 6, 2020. xiii Tajikistan Emergency COVID-19 Project ESMF Following the approval by the World Bank of two Additional Financing packages (AF-1 and AF-2), the World Bank provided additional consultations regarding ESMF amendments, including aspect related to the safe handling of medical waste due to COVID- 19 vaccination, as well as installation and safe operation of oxygen stations. Since one of the AF effectiveness conditions was the update and adoption of ESMF that will cover both AF-1 and AF-2, the ESMF was amended to include the scope of the activities anticipated under Additional Financing. The draft version of the updated ESMF was submitted to the World Bank for review and comments. All comments from the World Bank were integrated in the ESMF, after which the MOHSP published an announcement on the official website of the Ministry of Health and Social Protection of the Population to initiate a virtual consultation with the public and all stakeholders in order to collect additional comments from the public. All comments received were integrated in the updated version of the ESMF. All stages of updating the ESMF have been documented in an email to the World Bank. After reviewing the updated version, the World Bank provided concluding comments, which were also integrated in the final version of the ESMF. The final version of the ESMF, after clearance by the Bank, will be disclosed on the MOHSP’s website. Respective government agencies and other project stakeholders will use the final version of this document during the project implementation. xiv Tajikistan Emergency COVID-19 Project ESMF I. Introduction and Background 1. The outbreak of the coronavirus disease (COVID-19) caused by the 2019 novel coronavirus (SARS-CoV-2) has been spreading rapidly across the world since December 2019, following the diagnosis of the initial cases in Wuhan, Hubei Province, China. Since the beginning of March 2020, the number of cases outside China has increased thirteen fold and the number of affected countries has tripled. On March 11, 2020, the World Health Organization (WHO) declared a global pandemic as the virus has been spreading rapidly around the globe. As of April 23, 2020, the outbreak has resulted in an estimated 2.7 million cases and 187 795 deaths across 214 countries. 2. The World Bank Group has created a dedicated, Fast Track COVID-19 Facility to help developing countries address the emergency response to and impacts of the outbreak. The Fast Track COVID-19 Fast Facility is a globally coordinated, country-based response to support health systems and emergency response capacity in developing countries, focused largely on health system response, complemented by support for economic and social disruption. 3. Tajikistan’s health system faces long-standing challenges, exacerbating the immediate vulnerability to a COVID-19 pandemic. The health system is in a period of reform and transition since independence from the former Soviet Union, but progress has been slow. Tajikistan’s health care system is tax-financed, with the government being the primary purchaser of health services and little to no risk pooling. The share of government spending on health expenditures remains at 7.2% of GDP which is US $ 17 per capita, with out-of-pocket spending accounting for two-thirds (64%) of total health expenditures. In 2007, 11% of households indicated that they spend at least 10% of their income on health care, which is significantly higher than in any country of the region. The fiscal room for manoeuvre is limited and allocation for health remains inadequate due to slow growth and that budget focuses into infrastructure projects. The structure of public health expenditures, in which the bulk of expenditures is allocated on salaries and inpatient care, suggests that there is significant room for improvement in terms of cost efficiency. There are marked inequalities in the health care system, reflected in the financing and distribution of services and resources. Quality of care is another major concern, which is affected by the lack of investments in health facilities and technologies; an insufficient budget for and financial protection on pharmaceuticals; poorly trained health care workers, especially for pandemic response; and, a need for more specific protocols on pandemic response. This weak health system performance led the Global Health Security Index to assess Tajikistan as one of the least prepared countries for a pandemic, ranking 4 out of 5 in Central Asia 1, among the lowest in the region, highlighting the country’s vulnerability to the COVID-19 pandemic. 1 Global Health Security Index. 2019. Global Health Security Index: Building Collective Action and Accountability. Washington, D.C.: GHD Index. 1 Tajikistan Emergency COVID-19 Project ESMF 4. Recognizing these challenges, the Government of Tajikistan has begun to mobilize a pandemic preparedness response; at the time of project design the Emergency Response Plan (ERP) was in development so appropriateness of activities has been validated through discussion with MOHSP and WHO. A Standing Headquarters on Outbreak Prevention and Containment (in Tajik the Republican Headquarters for strengthening anti-epidemic measures to prevent transmission and emergence of new COVID-19 cases in the Republic of Tajikistan, here referred to as the Standing Headquarters) was established in February 2020 and has been recently reinforced through an order issued on March 18, 2020, which also elevated the Chairmanship to the Prime Minister. The National Public Health Laboratory has been designated as a reference laboratory for COVID-19 testing and is equipped with adequate diagnostic equipment and staffed by limited WHO-trained technicians. 5. Tajikistan Emergency COVID-19 Project was selected by the World Bank for COVID-19 financing because the Tajik health system was identified as being particularly vulnerable based on the WHO’s 2014 assessment 2 . The scope and the components of this project are fully aligned with the COVID-19 Fast Track Facility. Activities have been carefully selected in discussion with the Office of the Deputy Prime Minister in charge of Social Affairs, MOHSP and Ministry of Finance, as well as other development partners, drawing on the list of eligible activities outlined in Annex 1 of the COVID-19 World Bank Multiphase Programmatic Approach (MPA). Board paper. Project design also considered good practice in the component design from other COVID-19 projects. This project complements the longer-term efforts on health sector development and the corresponding pillar in the Country Partnership Framework (CPF), including the ongoing Health Services Improvement Project, which aims to broaden health expenditure allocation, improve the organizational structure and quality of the health system with a focus on PHC. This project was designed in accordance with clause 12 of the Bank's Policy on Investment Project Financing. 2 Assessment of Health System Crisis Preparedness – Tajikistan (2014). http://www.euro.who.int/en/countries/tajikistan/publications/assessment- of-health-system-crisis-preparedness-tajikistan-2014 2 Tajikistan Emergency COVID-19 Project ESMF 6. The proposed activities seek to balance financing immediate emergency response needs and longer-term health system strengthening. In the event of an outbreak, the Tajik health system could face a significant surge in demand for medical services. At present, Intensive Care Unit (ICU) capacity is estimated to be 600 beds in Tajikistan (ICU beds staffed and with functioning ventilators), although there is limited clarity on current bed occupancy rates. In the event of an outbreak in Tajikistan, surge capacity of ICUs will be needed. In Italy, which has 5,200 beds (86 beds per 100,000 population versus around 65 per 100,000 in Tajikistan), as of 11 March 2020, 1,028 beds have already been assigned to patients with SARS-CoV-2. This has already caused an extra pressure on the ICU system in northern Italy due to high bed occupancy rates as a result of the concentration of COVID-19 patients in northern Italy and problems with transporting COVID-19 patients to other parts of the country. Assuming Tajikistan eventually faces an outbreak like Italy’s, the limited ICU capacity, the challenges posed by limited number of these beds, and of transporting COVID-19 patients requiring respiratory support are anticipated to be even greater. Should an outbreak not materialize, these investments can be repurposed for ICU capacity for pediatric, neonatal, and adult ICUs. This would constitute a strategic investment and upgrading of the post-Semashko system. In addition, decisions about equipment selection have been informed by recent experience on appropriate technical specifications, reliability and maintenance costs and validated by development partners. 7. The proposed activities also consider recent market dynamics for medical supplies and the actions of development partners and the comparative advantages of development institutions. However, the component design also considered the recent market dynamics around global supply chains of medical and potential challenges around the availability of equipment. Components were structured to limit the risk of locking up funding for supplies that are not available due to the collapse of the supply chain and avoid duplication, given that UN agencies (WHO, UNICEF) are better placed to ensure supplies of personal protective equipment (PPE) in Tajikistan. Discussions around the activity selection have also considered equipment, supplies and materials that are already well- financed by other development partners. The Pandemic Supply Chain Network (PSCN) is monitoring supplies of three categories of COVID-19 supplies and equipment: infection prevention; diagnostics; and equipment and supplies for clinical treatment. To date, severe supply constraints are reported for infection prevention supplies (with “collapse” of the market for personal protective equipment) and diagnostics. Supplies for clinical care are less constrained (as of March 10, 2020), but market conditions are highly dynamic, and market pressures are certain to increase with COVID-19 critical cases on the rise and with some countries placing export restrictions on supplies and equipment. 3 Tajikistan Emergency COVID-19 Project ESMF 8. Environmental and Social Risks. The project was prepared under the World Bank’s Environment and Social Framework (ESF) with an Environmental Risk Rating of "Significant" and a Social Risk Rating of “Significant”, resulting in an overall ESF Risk Rating of Significant. The six major areas of risks for the project are: (i) risks related to rehabilitation of existing healthcare facilities; (ii); risks related to medical waste management and disposal; (iii) risks related to spread of the virus among health care workers; (iv) risks related to the spread of COVID-19 among the population at large; (v) risks associated with the installation and operation of PSA oxygen stations in selected health care facilities; and (vi) risks associated with access to COVID-19 vaccines. These risks are covered by the following Environmental and Social Standards (ESSs): ESS 1, ESS 2, ESS 3, ESS 4, and ESS 10 (see Chapter III for more information on the ESF and ESSs). The Project will fund only small-scale rehabilitation works within existing HCWs. These works may include minor rehabilitation of ICU unit up to 100 ICU beds; therefore, they will be mostly community-based activities and environmental issues (and impacts thereof) are expected to be temporary, predictable, and easily mitigable. There will be no land acquisition or involuntary resettlement impacts under the Project. The more substantial risks are around ensuring contagion vectors are controlled through strict adherence to standard procedures for medical waste management and disposal; the use of appropriate PPE for all health care workers; and working with local governments and communities to ensure that social distancing measures and quarantine regimes are strictly adhered is also vital for lowering the speed and incidence of infection. 9. This Environmental and Social Management Framework (ESMF) has been prepared to assist the Government of Tajikistan in developing environmental and social instruments in response to COVID-19 situations following national regulations and the ESF. The ESMF provides guidelines for the development of appropriate prevention and mitigation measures for adverse impacts that might result from project activities. The ESMF includes a checklist for Environmental and Social Management Plans (ESMPs), as Annex II, and a template for Infection Control and Waste Management Plans (ICWMPs), as Annex III. The former aims to provide an overarching action plan for the management of environmental, social, health and safety (ESHS) issues associated with the construction and operation of healthcare facilities in response to COVID-19. The latter focuses on proper infection control and healthcare waste management practices during for healthcare facilities. An ICWMP is considered part of an ESMP for specific activities. As part of the Additional Financing, recommendations were developed for the installation and safe operation of oxygen stations in healthcare facilities, which are an integral part of the ESMP. Also, recommended measures for Waste Management handling associated with the COVID-19 Vaccination have been developed (Annex VII). The “Vaccine Delivery and Deployment Manual” has also been developed (Annex VIII). 4 Tajikistan Emergency COVID-19 Project ESMF 10. The ESMF covers all applicable provisions of the relevant ESSs. Additionally, other environmental and social instruments as required by the ESF, such as the Stakeholder Engagement Plan (SEP), are appropriately summarized or referenced in the ESMF and ESMP checklist. The type of environmental and social instruments and their timings of development and implementation are defined in the project Environmental and Social Commitment Plan (ESCP), which forms part of the Project’s legal agreement between the World Bank and the Government of Tajikistan. II. Project Description 11.Project Development Objective (PDO) Statement: the objective of the project is to prepare and respond to the COVID-19 pandemic in the Republic of Tajikistan. 12. The Project consists of the following four components: a. Component 1. Strengthening intensive care capacity (US$ 6.3 million within the Parent Project financing; US$ 8.3 million within the AF-1 and US$ 4 million within the AF-2). As COVID-19 will place a significant burden on inpatient services, this Component will strengthen clinical care capacity. This will be achieved through channeling financing to the specialized Intensive Care Units in selected healthcare facilities, the procurement of medical supplies and equipment necessary for COVID-19 emergency, as well as through training and minor refurbishment required to upgrade and expand capacity to treat patients with the most severe manifestations of COVID-19. Given the global supply chain stress and the support from other development partners in Tajikistan for a number of items, procurement under this project is prioritized for ICU patients and health care workers. The Parent Project aimed at prevention, preparedness and response to the COVID-19 pandemic in the Republic of Tajikistan. The AF will fill the critical gap in the scope and the scale of the parent project, providing funding for safe and effective COVID-19 vaccines. Consistent with the global Multiphase Programmatic Approach framework, unless otherwise agreed, the World Bank will accept as the threshold for eligibility of IBRD/IDA resources in vaccine purchase (i) approval by three Stringent Regulatory Authorities (SRAs) in three regions or (ii) WHO prequalification and approval by one SRA. In addition, any COVID-19 vaccines benefiting from Bank financing (that is, deployed with capacity building and training/logistics, etc.), must also meet these same thresholds, even if vaccine purchase is not directly financed by the AF. These requirements have been discussed with and accepted by the MOHSP. 5 Tajikistan Emergency COVID-19 Project ESMF It is expected that COVAX will provide vaccine for 20 percent of the population. COVAX will fully subsidize the vaccine for 16 percent of the population and make vaccine for another four percent of the population available to the government at low prices negotiated with vaccine producers. The World Bank will provide funding for the vaccine for the four percent of the population not fully subsidized by COVAX. The vaccine will be purchased at low prices negotiated by COVAX with vaccine producers. Vaccines secured by COVAX – fully subsidized and those offered at negotiated prices – will be procured through the UNICEF Supply Division COVAX’s procurement agent. It is expected that the AF will cover the freight cost for all the vaccine needed to cover the 20 percent of the population. The proposed AF will also support expenditures on vaccine transportation, logistics, and ancillary supplies such as syringes, safety boxes, and PPE for the initial batch of the vaccine covering the 20 percent of the population of Tajikistan. Since other partners will finance some elements of service delivery, it is estimated that the financing currently available from partners will cover 50 percent of the total service delivery costs. As WHO has been providing training to health personnel on COVID-19 preparedness and response, the respective activity and related PDO-level indicator will be dropped from the parent project to avoid duplication and inefficiency. The AF will finance elements of general strengthening of the national immunization system and management capacity, including providing IT support for the roll out of the electronic supply management system, adapting and rolling out the system to track AEFI and patient registries. Given the uncertainty regarding the prices of vaccines, the design of Component 1 is flexible. If the prices of the vaccines available through COVAX turn out be lower than those used in estimating its budget – see Annex 3 – and if additional supply of vaccines will become available during the life of the AF, the design on Component 1 is flexible enough to allow for the purchase of additional doses that will cover 20 percent of the first priority population. Such doses will be procured for the next priority populations that will be identified in the National Vaccine Deployment Plan. Overall, it is envisioned that the initial vaccination program supported by the AF will become a pilot/model for a broader population-based immunization program when additional supply of COVID-19 vaccines becomes available. It is expected that the sources of funding for the expanded immunization will be identified in 2021. Those sources could potentially include IDA financing if IDA funds are available and are requested by the Government. 6 Tajikistan Emergency COVID-19 Project ESMF Additionally, the AF will support strengthening of oxygen supply by financing the establishment of pressure swing adsorption (PSA) oxygen refilling stations in up to 15 hospitals, including the 10 supported by the parent project. The PSA stations will have the capacity to provide oxygen directly to the hospital in which they are installed as well as refill oxygen tanks that can be used in other facilities. Oxygen will be used in the care of critically ill COVID-19 patients, and those who are less severely ill but still require oxygen therapy, though not necessarily intubation and ICU care. To accompany the oxygen supply investments, the AF will finance procurement of complementary equipment necessary for essential oxygen therapy for patients who do not require ventilation—for example vital sign monitors, pulseoximeters, nasal cannulas and catheters, oxygen masks, and BiPAP and CPAP machines. This funding will also cover training and maintenance, an initial supply of spare parts, and capacity strengthening for the MOHSP to manage the oxygen supply. In addition to improving the care of COVID-19 patients, strengthening the oxygen supply will have a positive effect on a much broader range of services offered in the supported hospitals by filling a critical capacity gap relating to general emergency services, emergency obstetrics, and inpatient maternal and child care. The AF will also finance procurement of medicines for COVID-19 therapy, including dexamethasone and other efficacious therapeutics that have credible approval for safety and effectiveness. 24. The AF will also provide emergency financing to fill the budget gap for procurement of routine vaccines for measles, mumps, and rubella (MMR), and PPE for health care staff providing vaccinations. i. Subcomponent 1.1 Infection prevention and control (US$ 1.14 million within the Parent Project financing; US$ 8.3 million + US$ 1 million within the scope of AF): This subcomponent will finance medical supplies and equipment needed to detect and prevent COVID-19 infection. The supplies and equipment will include PPE, COVID-19 testing kits, laboratory reagents, and other consumables. Under the Additional Financing, this subcomponent provides funding for COVID-19 vaccines. The AF will finance elements of general strengthening of the national immunization system and management capacity, including providing IT support for the roll out of the electronic supply management system, adapting and rolling out the system to track AEFI and patient registries. The AF, via this subcomponent 1.1, will also provide emergency financing to fill the budget gap for procurement of routine vaccines for measles, mumps, and rubella (MMR), and PPE for health care staff providing vaccinations. 7 Tajikistan Emergency COVID-19 Project ESMF ii. Subcomponent 1.2 Improving and establishing ICUs (US$ 5.16 million within the Parent Project financing; US$ 3 million within the scope of AF). This subcomponent will finance the medical supplies, equipment, limited operating expenses during the crisis, training, and refurbishment needed to establish at least 100 new fully equipped ICU beds across Tajikistan. The project will not finance any construction, but rather minor refurbishment required to add new fully equipped beds to existing ICUs, or to establish new ICUs within existing hospitals. These requirements will be based on a site survey undertaken by a firm acceptable to the World Bank. Items procured will include equipment required for intensive care diagnosis and treatment of COVID-19 patients. The location of ICUs will be selected based on existing services and expanding geographical access to health care services in order to ensure equitable access to highly specialist care across the country. Pain medications, antibiotics and other routine medicines for the ICUs will also be financed. Staff at all ICUs (both existing and new) will receive training in COVID-19 care and infection prevention, as well as longer- term capacity building in critical care provision. Also this Subcomponent within the AF scope will support strengthening of oxygen supply by financing the establishment of pressure swing adsorption (PSA) oxygen refilling stations in up to 15 hospitals, including procurement of complementary equipment necessary for essential oxygen therapy for patients who do not require ventilation. This funding will also cover training and maintenance, an initial supply of spare parts, and capacity strengthening for the MOHSP to manage the oxygen supply. The AF will also finance procurement of medicines for COVID-19 therapy, including dexamethasone and other efficacious therapeutics that have credible approval for safety and effectiveness. b. Component 2. Multisectoral response planning and community preparedness (US$ 1 million within the Parent Project financing; US$ 0.28 million within the scope of AF). This Component will support information and communication activities to increase the attention and commitment of government, private sector, and civil society, and to raise awareness, knowledge and understanding among the general population about the risk and potential impact of the pandemic and to develop multi-sectorial strategies to address the pandemic. A Strategic Coordination Advisor and a Communications Advisor would be financed under this Component to support the MOHSP in activities that will include: (a) support to a multisectorial task force to coordinate the COVID-19 emergency response in Tajikistan, and support to national, oblast and district bodies in mobilizing effective response activities (operating expenses, technical assistance, communication costs); (b) development of a national 8 Tajikistan Emergency COVID-19 Project ESMF communications and outreach strategy and implementation plan, including social and behavioral communication change across multiple channels, and implementation of community outreach focusing on preventive and social distancing measures aligned to the national communications and outreach strategy, including the development and dissemination of communication materials adapted for target audiences in the relevant languages, and the use of Mobile Engage; (c) training of journalists on responsible reporting and emergency response procedures, covering all media types and national and regional-based outlets; (d) supporting the training and activities which are COVID-19 specific to community public health teams (consisting of primary health care workers and trained community leaders) at jamoat level, coordinated by the Republican Center for Healthy Lifestyles, to increase awareness of preventive measures, to support case detection and contact tracing if pursued by the Government, and to promote community participation in slowing the spread of the pandemic. The AF will expand its scope and information and messages related to COVID- 19 vaccine to provide accurate and timely information to the population and minimize vaccine hesitancy. Additional advocacy campaigns financed by the proposed AF will include information about the vaccine and n about the government’s vaccine delivery strategies and plans, with a special emphasis on the prevention and mitigation of potential risks of vaccine hesitancy. These activities will build on the success of the implementation of the general COVID- 19 information and communication campaign (see the previous Section) already carried out, which used a multipronged approach including SMS messages through Mobile Engage, social media, television and radio communication, posters, and community outreach. The same channels will be used to promote accurate and timely information about the COVID-19 vaccine to inform the population and mitigate potential risks posed by vaccine hesitancy. The AF will finance further strengthening of the national hotline and the establishment of regional COVID-19 hotlines to provide callers with information about COVID-19 – symptoms, testing options, referrals – and information about how to access other essential health services during the pandemic. The hotlines will also be used as an additional grievance redress mechanism (GRM). The AF will finance staff time, equipment, and operational costs of the hotlines, and expanded capacity of the MOHSP server to accommodate increased traffic on the COVID-19 website and its growing content to ensure that the public can access it without interruptions c. Component 3. Temporary social support for vulnerable households (US$ 3.0 million within the Parent Project financing; US$ 8.32 million within the scope of AF). This Component will finance targeted, nutrition-sensitive cash transfers to provide time-limited support to vulnerable households, particularly 9 Tajikistan Emergency COVID-19 Project ESMF food-insecure households with young children where food price shocks caused by the COVID-19 pandemic can negatively affect children’s nutrition status and jeopardize the human capital investments being made by the Government of Tajikistan and the World Bank. The transfers will be delivered using the existing Targeted Social Assistance (TSA) system implemented by the State Agency for Social Protection (SASP). The TSA system includes an additional module to allow for additional payments in emergency situations and the eligibility criteria can be adapted to target the most food insecure communities. The transfers will be triggered at the oblast-level based on the spikes in the prices of key food groups. Once conditions are met, the program will target TSA beneficiary households with young children, who are TSA beneficiaries. This component will finance the cash transfers, and cover the costs of benefit administration, including the cost of expanding the capacity of the beneficiary database. The proposed cash transfers will also provide an opportunity to use accompanying measure to promote optimal nutrition, appropriate hygiene, and preventive health services, as well as COVID-19 infection prevention messaging (the development of the communication materials will be financed under Component 2). This component has been designed with the potential for scale-up in mind, recognizing that further financing may become available following this initial phase of emergency response. The AF will expand the one-off emergency cash transfer program through the National Registry of Social Protection to new beneficiary groups such as households with children under the age of seven, female-headed households with children under the age of 16, and households with children with disabilities. Additional groups, including the poorest households regardless of whether they have children or not may also be included; the eligibility criteria for those additional groups will be defined in the Project Operations Manual (POM). Beneficiaries who have already received transfers under the parent project will not be able to receive the transfers financed by the AF. The additional transfers are expected to have the same value (about US$50 per household), will use the same delivery mechanism (the TSA program administered by the SASP), and follow procedures described in the POM. A small portion of the financing under Component 3 will be used to: cover the administrative fees of Amonatbank; develop and disseminate information regarding the additional cash transfers; strengthen the TSA program and the National Registry of Social Protection based on the lessons learned from the parent project, including developing interoperability between the TSA beneficiary database, the National Registry of Social Protection, the civil registry maintained by the Ministry of Justice, and other relevant databases; increase the capacity of the TSA servers; and finance other capacity strengthening activities. The AF will allow the government to provide emergency cash payments to approximately 70,000 additional households. 10 Tajikistan Emergency COVID-19 Project ESMF d. Component 4. Project Implementation and Monitoring (US$ 1.0 million). Implementing the proposed Project will require administrative and human resources that exceed the current capacity of the implementing institutions. For this reason, building on the existing strong project management capacity is critical for the rapid implementation and scale-up of project activities. 3 The MOHSP will receive professional implementation and project management support, including for procurement and financial management (FM), from a designated new Project Implementation Unit (PIU). The core of the new PIU is formed from the team of the well-functioning Project Implementation Unit of the Tajikistan Social Safety Nets Strengthening Project (SSNSP), which had closed on June 30, 2020. The Emergency COVID-19 Response Project contracted the SSNSP PIU staff on a single-source basis (50 percent or more, as feasible and warranted, initially and 100 percent upon SSNSP closure). These staff include: Project Coordinator, FM Management Specialist, Procurement Specialist, 2 IT Specialists, and Administrative Assistant. Additional necessary staff was recruited to the PIU upon requirement (with agreed upon terms of reference which have received the World Bank’s no objection), such as an Environmental and Social Officer, a Monitoring and Evaluation Specialist, Interpreter/Translator, and specialized technical staff. In addition, according to the recommendations of the World Bank, it is planned to involve a consultant on infection control and medical waste disposal. This component also provides support for building the country's capacity for more sustainable response planning in the future. It will also be important to monitor remittance level and distributions, in terms of household wealth. This Component will also support the monitoring and evaluation of project activities. Activities that will be financed include: (a) support for project management, including procurement, FM, environmental and social, monitoring and evaluation, and reporting; (b) operating costs; (c) project audits. The AF will finance the operating costs of the PIU, including the extension of the PIU staff contracts for the additional time period covered by the AF, as well as the cost of mobilizing short-term consultants with expertise related to vaccines and mobilizing short-term consultants with expertise related to installation of oxygen stations and specialized medical equipment. 13. The Environmental Risk is rated Significant. The four major areas of risks for the project are: (i) risks related to rehabilitation of existing healthcare facilities and risks related to installation and operation of oxygen stations within healthcare facilities; (ii) risks related to medical waste management and disposal; risks related to vaccination, safe handling and disposal of medical waste; (iii) risks related to spread of the virus among 3 The rationale for using the SSNSP PIU over the Technical Support Group (TSG) of the Health Services Improvement Project (HSIP), both under the same MOHSP, is as follows: (i) strong performance and sustainable team dynamic over the whole 5-year implementation period of the SSNSP under MOHSP; (ii) availability of freed up staff time given approaching closing date of the SSNSP; (iii) forthcoming implementation of innovative activities under second additional financing for the HSIP, which by itself would be a challenging task and put additional strains on the TSG of HSIP. 11 Tajikistan Emergency COVID-19 Project ESMF health care workers; and (iv) risks related to the spread of COVID-19 among the population at large. These risks are covered by ESS 1, ESS 2, ESS 3, ESS 4, and ESS 10. 14. The project will finance small scale infrastructure works for the rehabilitation and equipping of ten health centers to establish 10-bed ICUs and possible rehabilitation of on- site incinerators for medical waste disposal. These interventions are expected to take place on the property of existing facilities; therefore, environmental issues (and impacts thereof) are expected to be temporary, predictable, and easily mitigable. 15. Improper handling of health care waste can cause serious health problems for workers, the community and the environment. Medical wastes have a high potential of spreading of microorganisms and viruses that can infect people who are exposed to them, as well as the community at large if they are not properly disposed of. Wastes that may be generated from labs, ICUs, quarantine facilities, and screening posts to be supported by the COVID-19 readiness and response could include a contaminated bio-substrates (e.g. blood, other body fluids, and contaminated fluid) and infected materials (PPEs, water used, syringes, used vials, bed-sheets and other linen, waste from labs and quarantine and isolation centers, etc.) which requires special handling and awareness, as it may pose an infectious risk to healthcare workers in contact or handle the waste. It is also important to ensure the proper disposal of sharps. 16. Ensuring contagion vectors are controlled through strict adherence to standard procedures and PPE for all health care workers is also critical. 17. Additionally, working with local governments and communities to ensure that social distancing measures and quarantine regimes are strictly adhered is also vital for lowering the speed and incidence of infection among project workers and affected persons. 18. There are no expected transboundary shipments of active COVID-19 Test Samples for analysis in another country. 19. The Social Risk Rating is Substantial. The major areas of social risks, similar to environment, are: (i) risks related to spread of the virus among health care workers; (ii) risks related to the spread of COVID-19 among the population at large; and (iii) rehabilitation of existing healthcare facilities. For risk areas (i) and (ii), key issues/risks to be managed focus on: (i) ensuring a soothing environment so as to avoid panic/conflicts resulting from false rumors and social unrest; (ii) assuring proper and quick access to appropriate and timely medical services, antiseptics and PPEs, that is based not only on ability to pay as well other factors; (iii) anticipating and addressing issues resulting from people being kept in quarantine; and (iv) addressing challenges associated with providing (financial) assistance for vulnerable people and the risk of ‘exclusion’ thereof. 20. The financial assistance, targeted at poorer households, is meant to: (i) help offset the expected rise in food prices as a result of the COVID-19 emergency; and thereby (ii) help prevent food insecurity and losses to human capital. This cash transfer will be made 12 Tajikistan Emergency COVID-19 Project ESMF through the existing TSA program which aims to improve the living conditions of the most vulnerable population through better targeting, introduced in 2011 with support from the European Union and the World Bank. The TSA uses a special formula to identify and target the poorest 15 percent of the population which is approximately the rate of extreme poverty in Tajikistan. With the World Bank support a centralized electronic information system and the database of the National Registry of Social Protection has been established at the Agency for Social Protection of the Population under the MOHSP. The system allows entering applications in the database at the district level, further verifying the data at the central level in Dushanbe, approving new benefits based on the results of the specialized formula, administering all payments through the network of banks, and reconciling all the payments, to ensure that every single Somoni reaches the eligible recipient. 21. The State Agency of Social Protection (SASP), which is in charge of administering the TSA has been in existence for some time and operates through Regional Centers. The plans are to establish greater number of such Centers across the country to facilitate work at the district level and communications between the center and the districts. 22. Despite TSA being successful, in the current context, following key issues/ risks need to be addressed: (i) Risk of Exclusion –while TSA’s targeting has been quite good, the same needs to be tweaked to COVID-19 situation which may impact certain groups of the population particularly hard; (ii) Timing - TSA should kick in as and when the food prices rise which need to be monitored; and (iii) appropriate service delivery to reach out to the identified people. Most of these impacts and the risks thereof can be contained by an effective and inclusive outreach program encompassing stakeholder engagement throughout the project cycle. With regard to risk area (iii), since the civil works envisaged in the project refer to repair and rehabilitation of existing buildings only, no land acquisition or involuntary resettlement impacts are expected. 13 Tajikistan Emergency COVID-19 Project ESMF III. Policy, Legal, and Regulatory Framework 24. Relevant National Laws and Regulations and International Treaties. An overview of laws and regulations that have relevance for environmental 4 and social issues for the Tajikistan Emergency COVID-19 Project is as follows (see Table 1). Table 1- List of National Laws and Regulations Title of Legal Document Date enacted (last Line Ministry/Agency amendment) responsible for implementation and enforcement Law on Environment 2011 (2017) Committee for Protection Environment Protection Water Code 2000 (2020) Ministry of Energy and Water Resources of the Republic of Tajikistan Law on Sanitary and 2003 (2011) Ministry of Health and Epidemiological Safety of Social Protection the Population Law on Ecological 2011 (2014) Committee for Monitoring Environment Protection Law on Ecological 2010 Committee for Education of Population Environment Protection Law on State Ecological 2012 Committee for Expertise Environment Protection Law on Targeted Social 2017 Ministry of Health and Assistance Social Protection Law on Social Work 2008 Ministry of Health and Social Protection Law on Appeals of 2016 All state and non-state Individuals and Legal bodies Entities 4 Used source for updating – Third Environmental Performance Review of Tajikistan, UNECE, 2017 14 Tajikistan Emergency COVID-19 Project ESMF Law on the Right to Access 2008 All state bodies Information Law on Public 2007 (2019) Ministry of Justice Associations Law on Public Meetings, 2007 (2019) Local municipalities/ Demonstrations and Rallies administrations Law on Local 2004 (2019) Local governments Governments Labor Code 2016 Ministry of Labor, Employment and Migration Law on Food Safety 2010 (2019) Food Safety Committee under the Government of Tajikistan National Health Strategy 2009 Ministry of Health and for 2010–2020 Social Protection Government Resolution # 2017 Ministry of Health and 547 on State Surveillance Social Protection Service of Health Care and Social Protection of Population Healthcare Code 2017 Ministry of Health and Social Protection National Environmental 2000 Ministry of Health and Health Action Plan Social Protection, CEP Law on Production and 2002 (2011) State Unitary Enterprise Consumption Waste “Khogajii Manziliyu Kommunali” Order on Healthcare Waste May 2005 Ministry of Health and Management No. 272 Social Protection Regulation on Emissions Committee for No. 800 Environment Protection 15 Tajikistan Emergency COVID-19 Project ESMF Sanitarian Rules on Safe 2009 Ministry of Health and Handling of Healthcare Social Protection Waste 25. In addition to national legislation and regulations on environmental and social 5 issues , Tajikistan is also party to several international treaties focused on environmental and social issues (see Table 2). Table 2 - List of International Treaties and Convention ratified by Tajikistan Basel Convention on the Control of Transboundary Movements of Hazardous • Wastes and their Disposal (2016) The Rotterdam Convention on Prior Informed Consent (PIC) Procedure for • Certain Hazardous Chemicals and Pesticides in International Trade (1998) • The Stockholm Convention on Persistent Organic Pollutants (2002) The Vienna Convention for the protection of the Ozone Layer and its Montreal • Protocol on substances that deplete the Ozone Layer (1998) • Occupational Safety and Health Convention (2009) • Tripartite Consultation (International Labor Standards) Convention, (2014) Convention on Biological Diversity (1997) and to its Cartagena Protocol on • Biosafety (2004) Convention for the Protection of the World Cultural and Natural Heritage • (1992) • The United Nations Convention to Combat Desertification (1997) 5 ILO Information System on International Labor Standards, checked on 06.11.2019 16 Tajikistan Emergency COVID-19 Project ESMF • The United Nations Framework Convention on Climate Change (1998) • The Ramsar Convention (2000) The Convention on the Conservation of Migratory Species of Wild Animals • (2001) Convention on International Trade in Endangered Species of Wild Fauna and • Flora (2016) • Convention for the Safeguarding of the Intangible Cultural Heritage (2006) • International Covenant on Economic, Social and Cultural Rights • Convention on the Elimination of all forms of Discrimination Against Women • Convention on Minimum Age for Admission to Employment (1993) • Convention on Worst Forms of Child Labor (2005) • Abolition of Forced Labor Convention (1999) • Employment Policy Convention (1993) • Labor Inspection Convention (2009) • UN Convention on the Rights of the Child CRC (1993) 26. Overview of Key National Environmental Legal Provisions. Key laws and regulations germane to the COVID-19 Emergency are discussed below. They include: a. The Law on Environmental Protection stipulates that Tajikistan's environmental policy should prioritize environmental actions based on 17 Tajikistan Emergency COVID-19 Project ESMF scientifically proven principles, and to balance consideration of economic and other activities that have an impact on the environment with that on nature preservation and sustainable use of resources. To secure public and individual rights to a safe and healthy environment, the Law requires an environmental impact assessment for any activity that could have a negative impact on the environment. It also defines environmental emergencies and ecological disasters and prescribes the order of actions to be taken in such situations, including the obligations of officials and enterprises to prevent and eliminate adverse consequences, and liabilities of the persons or organizations that caused damage to the environment or otherwise violated the Law. The Law also establishes state, ministerial, enterprise and public control over compliance with environmental legislation, which is affected by the Committee for Environment Protection, the Sanitary Inspectorate of the Ministry of Health and Social Protection, the Inspectorate for Industrial Safety, and the Mining Inspectorate. Public control is carried out by public organizations or trade unions and can be exercised with respect to any governmental body, enterprise, entity or individual. b. The National Legal Framework Law on Ecological Expertise stipulates that the mandatory cross-sectoral nature of state ecological “expertise” (SEE) shall be scientifically justified, comprehensive, and objective and which shall lead to conclusions in accordance with the law. The SEE precedes decision making about activities that may have a negative impact on the environment. Financing of programs and projects is allowed only after a positive SEE finding, or conclusion, has been issued. The following activities and projects will be subject to state ecological review: a) draft state programs, pre-planning, pre-project, and design documentation for economic development; b) regional and sectoral development programs; c) spatial and urban planning, development, and design; d) environmental programs and projects; e) construction and reconstruction of various types of facilities irrespective of their ownership; f) draft environmental quality standards and other normative, technology, and methodological documentation that regulates economic activities; g) existing enterprises and economic entities, etc. This law also stipulates that all types of economic and other activities shall be implemented in accordance with existing environmental standards and norms, and that sufficient environmental protection and mitigation measures will be put into place to prevent and avoid pollution and enhance environmental quality. ESA studies that have analyzed the short- and long-term environmental, genetic, economic, and demographic impacts shall be evaluated prior to making decisions on the selection of sites, construction or reconstruction of facilities, irrespective of their ownership. If these requirements are violated, construction will be terminated until necessary improvements are made, as prescribed by the Committee for Environmental Protection and/or other duly authorized control bodies, such as sanitary, geological, and public safety agencies. The Law includes: 18 Tajikistan Emergency COVID-19 Project ESMF i. The procedure of Environmental Impact Assessment (adopted by the Resolution of the Government of the Republic of Tajikistan as of 01.08.2014 #509 provides guidelines on the composition, order of development, coordination and approval of design estimates for construction of facilities, buildings and structures and EIA chapters and feasibility documents; and ii. The List of objects and types of activities for which preparation of documentation on the environmental impact assessment is mandatory (adopted by the Resolution of the Government of the Republic of Tajikistan as of 01.08.2014 #509). This extensive list contains 180 types of activities that are grouped according to four environmental impact categories (from (I) "high risk" to (IV) "local impact"). If the facility is not included in the list, then it is not required to pass an EIA or a SEE. c. The Law on Sanitary and Epidemiological Safety of the Population introduced the concept of sanitary and epidemiological expertise that establishes the compliance of project documentation and economic activities with the state sanitary and epidemiological norms and rules, as well as strengthened provisions on sanitary-hygienic, anti-epidemic and information measures. d. The National Guide on Prevention of Infections in Medical Institutions was also approved by Ministry of Health Order No. 1119 dated 27 December 2014. This document includes key provisions on prevention of infections in medical institutions, covering modern evidence-based information and CDC recommendations, and it is aimed at improving the quality of services in medical institutions in the country. e. Sanitarian Rules on Safe Handling of Healthcare Waste set the sanitary and epidemiological requirements and norms for the healthcare facilities generating medical wastes, as well as the organizations engaged in transportation, disposal and treatment of healthcare waste. It describes the healthcare waste classification, segregated collection methods, temporary storage and removal of medical wastes at the healthcare facilities, as well as sanitary and epidemiological requirements on off-site medical waste management. The implementation of these sanitary rules is controlled by the subdivisions and bodies of the State Sanitary and Epidemiological Service of the Republic of Tajikistan and the State Service on State Control of Medical Activities and Social Protection of Population. 19 Tajikistan Emergency COVID-19 Project ESMF f. The Water Code stipulates the policies on water management, permitting, dispute resolution, usage planning and cadaster. It promotes rational use and protection of water resources exercised by all beneficiaries and defines the types of water use rights, authority and roles of regional and local governments for water allocations among various users, collection of fees, water use planning, water use rights and dispute resolution. 27. Key National Legal Provisions on Social Issues and Citizen Engagement. Key social and citizen engagement laws and regulations germane to the COVID-19 Emergency are discussed below. They include: a. The Public Health Code (2017) governs the public relations in the field of health care and is directed to realization of constitutional rights of citizens and health protection. The Code includes sections on responsibilities of the healthcare system and the sanitary and epidemiological protection. b. Law on Targeted Social Assistance (2017) provides legal, financial and institutional basis for targeted social assistance delivery to low income citizens (households). Article 4 of the Law underlines the accessibility of the TSA to vulnerable households. Article 10 describes the TSA application forms and assignment procedures. Article 11 identifies two forms of the TSA, including monetary aid and in-kind support (food products, cloths, medicine etc.) c. Law on Freedom of Information is underpinned by Article 25 of the Constitution, which states that governmental agencies, social associations and officials are required to provide each person with the possibility of receiving and becoming acquainted with documents that affect her or his rights and interests, except in cases anticipated by law. i. According to the Decree ‘Approval of the Order of costs reimbursements related to provision of information’ adopted on January 1, 2010, all state institutions are enabled to charge fees for providing any kind of information to journalists and public officials. The decree states that one page of information provided should cost up to 35 Somoni (US$4). The decree enables state officials to charge for photocopying official documents or extracts of official documents and for obtaining information from government officials in writing. Payment can be collected not only for the supply of printed information, but also for verbal information and clarification of legislative acts, decrees and regulations 6. 6 ‘Commercial Laws of Tajikistan: An Assessment by the EBRD’. Office of the General Counsel. April 2012. European Bank for Reconstruction and Development. 20 Tajikistan Emergency COVID-19 Project ESMF d. The Law on Public Associations allows a public association may be formed in one of the following organizational and legal forms: public organization, public movement, or a body of public initiative. Article 4 of this law establishes the right of citizens to found associations for the protection of common interests and the achievement of common goals. It outlines the voluntary nature of associations and defines citizens’ rights to restrain from joining and withdrawing from an organization. This legislation requires that NGOs shall notify the Ministry of Justice about all funds received from international sources prior to using the funds and disclose financial information on their websites e. The Law on Public Meetings, Demonstrations and Rallies bans persons with a record of administrative offenses (i.e. non-criminal infractions) under Articles 106, 460, 479 and 480 of the Code for Administrative Offences from organizing gatherings 7. Article 12 of the Law establishes that the gathering organizers must obtain permission from local administration fifteen days prior to organizing a mass gathering. f. The Law on Appeals of Individuals and Legal Entities contains legal provisions on established information channels for citizens to file their complaints, requests and grievances. Article 14 of the Law sets the timeframes for handling grievances, which is 15 days from the date of receipt that do not require additional study and research, and 30 days for the appeals that need additional study. These legal provisions will be taken into account by the project-based Grievance Redress Mechanism. g. The Labor Code (1997) prohibits forced labor (Article 8). The Labor Code also sets the minimum age at which a child can be employed as well as the conditions under which children can work (Articles 113, 67, and 174). The minimum employment age is 15, however, in certain cases of vocational training, mild work may be allowed for those who are 14-years old (Article 174 of the Labor Code). In addition, there are some labor restrictions on what type of work can be done, and what hours of work are permissible by workers under the age of 18. Examples of labor restrictions include: those between 14 and 15 cannot work more than 24 hours per week while those under 18 cannot work more than 35 hours per week; during the academic year, the maximum number of hours is half of this, 12 and 17.5 hours, respectively. These limitations are consistent with the ILO Convention on Minimum Age. In addition, the Law on Parents Responsibility for Children’s Upbringing and Education, makes parents responsible for ensuring their children not involved in heavy and hazardous work and that they are attending school. 21 Tajikistan Emergency COVID-19 Project ESMF 28. Environmental Impact Assessment (EIA) 8 Administrative and Institutional Framework. The responsibilities for conducting necessary EIAs lies with the project proponent. The procedure for carrying out the EIA (Government Resolution No. 509 of 2014) establishes general requirements for the contents of the EIA documentation. The SEE for all investment projects is the responsibility of the Committee for Environmental Protection under the Government of Tajikistan (CEP) and its regional offices. Furthermore, according to the Law on the State Ecological Expertise, all civil works, including rehabilitation, should be assessed for their environmental impacts and the proposed mitigation measures reviewed and monitored by the CEP. 29. Screening categories. The laws on Environment Protection stipulate that the Government is to approve a list of activities for which the complete EIA is mandatory. The current guidelines for EIAs do not provide for any preliminary assessment of the project to decide on the need for an EIA (screening) or define the scope of the EIA’s contents. This is because the list of objects and activities for which the development of EIA materials is required is already very detailed. 30. The Law on EE provides for the rights of citizens to conduct Public Environmental Expertise (art. 7). Tajikistan is also a member party to the 1998 Aarhus Convention (July 17, 2001) that contains provisions for public EE. The 2014 Procedure (Order) for Conducting an EIA also describes procedures for public participation. Public participation procedures are envisaged for all categories of projects, although in practice they are mainly applied to Category I projects. The Procedure (Order) for conducting the EIA of 2014 changed the focus and timing of public discussions. Compared to the 2006 version of the Procedure for preparing EIAs which provided the opportunity for public inputs during the scoping stage while drafting the technical task, the 2014 version of the Procedure provides space for public discussions only after the preparation of the EIA report by the project's customer. 31. Implementation of environmental laws. A number of legal acts establish liability for violation of environmental laws, which can be enforced by several State bodies. In particular, the 2010 Code on Administrative Violations establishes administrative liability for organizations, their officers and individuals for a range of violations, including careless treatment of land, violation of rules for water use or water protection or failure to comply with a SEE. Administrative sanctions for environment related violations can be imposed by the administrative commissions of khukumats, courts, CEP inspectors, the Veterinary Inspectors of the Ministry of Agriculture, and the State Committee for Land Management and Geodesy. The most common administrative sanction is a fine of up to 10 minimal monthly salaries for individuals and up to 15 minimal salaries to officers of organizations. The 1998 Criminal Code also covers crimes against ecological safety and the environment, 7 These provisions concern the hampering of gatherings (Article 106); disorderly conduct (Article 460); disobedience to police (Article 479); and violation of rules of conducting gatherings (Article 480). 8 National Law require Environmental Impact Assessments (EIAs); however, for World Bank Financed Projects, Environmental and Social Impact Assessments (ESIAs) are generally required wherever an EIA would be required. Please note that in future chapters, the term ESIA is used. 22 Tajikistan Emergency COVID-19 Project ESMF such as violations of ecological safety at work, poaching and spoiling land, as well as a violation of rules for the protection and use of underground resources. The maximum fine is up to 2,000 minimal monthly salaries and the maximum sentence is up to eight years in prison. Medical Waste Policies and Procedures. 32. The MOHSP Order#5 dated 10.04.2009 No. 5 approved the “Rules of Collection, Storage and Disposal of Health Facility Wastes –Sanitary Regulations and Norms (SanPiN 2.1.7.020-09). These rules directed to all health facilities, organizations engaged in collection, storage, transportation of health care wastes and organizations designing and operating the devices for wastes treatment, neutralization and fields for solid wastes burial. The document establishes rules for collection, storage, processing, disposal and removal of all types of waste in health care facilities. 33. The SanPiN 2.1.7.020-09 is the most detailed document regarding healthcare waste. The classification system classifies the Class B waste as hazardous waste contaminated by Class III and IV microorganisms and Class C waste is especially hazardous waste contaminated with microorganisms of the Class I to IV. 34. This document also governs the (i) general rules on collection, temporary storage and transportation system of HF wastes; (ii) rules on wastes collection within the medical wards; (iii) general disinfection rules of reusable inventories and wastes; (iv) general rules on equipment and container places for collection and transportation of wastes; (v) conditions on wastes’ temporary storage and removal; and (vi) scheme on collection and transportation of wastes. 35. According to the MOHSP "Recommendations on preventing the spread of the new coronavirus infection 2019-nCov" dated from 03.02.2020, in health care institutions, the health care waste including biological waste from patients (sputum, urine, feces, etc.), is disposed of in accordance with sanitary-epidemiological requirements for the treatment of health care waste related to Class B waste. Health workers who are responsible for collecting and disposing of health care waste are required to adhere to respiratory protection requirements, referring to waste class B. COVID-19 Testing Procedures. 36. COVID-19 testing procedures are regulated by several orders and instructions developed and approved by the MOHSP. In particular, the Instruction on the activities of mobile rapid response groups to prevent the penetration and spread of the Covid-19 was approved by the Order of the MOHSP dated 02.02.2020 #59 “On Strengthening the epidemiological control of the outbreak of Covid-2019 in Tajikistan”. The both Institute of Preventive Medicine and the National Public Health Laboratory have been authorized as the institutions responsible for organizing the activities of mobile rapid response teams. The National Public Health Laboratory has been designated to test samples of materials 23 Tajikistan Emergency COVID-19 Project ESMF suspected of being infected with Covid-19. 37. According to the “The MOHSP Preliminary Recommendations on prevention of spreading COVID-19 infection in health care institutions” dated 03.02.2020, patients diagnosed or suspected of having Covid-19 detected by PHC facilities should be conveyed to hospital facilities by the specially designated vehicles. 38. “The MOHSP temporary recommendations for Covid-19 laboratory diagnosis” from 03.02.2020 determine the following testing procedures: a. Organization of Covid-19 laboratory tests is carried out in accordance with the sanitary requirements on the work with pathogenic microorganisms of the second level of biological safety. b. The testing is subject to: i. Persons who have entered the Republic of Tajikistan from other countries with registered cases of Covid-19 and have clinical signs of acute respiratory viral infection (SARS); and ii. Patients of the departments of severe infectious or respiratory diseases of unknown etiology, including after traveling abroad or after contact with people who arrived from other countries where Covid-19 is registered. c. All samples collected for laboratory research should be considered infectious, therefore, medical personnel collecting or transporting clinical samples must strictly comply with biosafety requirements when working with pathogenic microorganisms of group II-III. 39. By the MOHSP Order #188 dated 03.03.2020 “On establishing a high level of preparedness for the health care institutions to prevent transmission and spread of the COVID-19 in Tajikistan”, the specialized teams and groups of health, social and sanitary- epidemiological care are transferred to a high level of readiness, and round-the-clock duty and hotlines are created in all health care institutions. The following documents have been approved by this order: (i) The List of designated hospitals in the country including data on bed capacity for hospitalization of patients with COVID-19; (ii) Instructions for the health and social services of suspected and infected patients, (iii) Responsibilities of the Deputy Ministers in the high-preparedness phase for the prevention of transmission and spread of COVID-19; (iv) A list and work schedule for the mobile teams of laboratory specialists. According to this order, all patients with suspected COVID-19 infection should be transported to the designated health care facilities for additional examination and testing for COVID-19. 40. So far, in Tajikistan, only one Public Health Laboratory in Dushanbe has been designated to conduct COVID-19 testing. Transportation of samples for testing from the 24 Tajikistan Emergency COVID-19 Project ESMF regions of the country to the city of Dushanbe is carried out in compliance with relevant national requirements and WHO recommendations. All laboratory service specialists involved in the process of samples collection, storing, transporting, and undertaking of testing were trained in accordance with WHO recommendations and national qualification requirements. 41. According to the recommendations of the WHO Mission in May 2020, the MOHSP has decided to expand the number of laboratories for testing COVID-19. Thus, the National Reference Laboratory, the Laboratory of the Institute of Preventive Medicine, and the SES Laboratory in Dushanbe, as well as laboratories in the cities of Khujand (Sughd Region), Kulob, and Bokhtar (Khatlon Region) are starting testing COVID-19. 42. To date, the MOHSP has received through the WHO, 23 thousand test systems from Russia, 22 thousand test systems from China, and 1.9 thousand test systems from Germany for Covid-19 testing. Social and Citizen Engagement Administrative and Institutional Framework. 43. The Law on Targeted Social Assistance articles contain basic provisions on state social assistance provided to the low-income households. The Targeted Social Assistance (TSA) program is in the rollout phase and has reached so all 68 districts of the country. It is managed by the Social Protection Agency under the MOHSP. Key pending action of the Government is approval of the Decree on the TSA roll out in the remaining districts. When fully rolled out, the program is expected to cover about 200,000 of the households or about 15 percent of the total number of households in the country, primarily focusing on the extreme poverty. 44. As an important milestone in the national roll-out of a Targeted Social Assistance Program (TSA), the Government of the Republic of Tajikistan adopted the Resolution No. 271 (as of May 14, 2020). According to the Resolution, the Targeted Social Assistance Program is rolled-out at the national level, and covers about 200,000 households, or about 15% of the total number of households in the country, mainly with a focus on extreme poverty. 45. At this stage, several adjustments in design of the program are required at this stage in order to respond to specific risks and needs of the population during COvid-19 operations. While some improvements need to apply to general design, it is also important to recognize that preparing the TSA as a mitigation mechanism for Covid-19 outbreak, which goes beyond the original objectives and design of the TSA program. Certain groups of the population may be hit particularly hard. For example, various shocks may have larger impact on female-headed households given lack of income sources and limited copying mechanisms. To respond dynamically to various needs and shocks - in time and in space - a mechanism of periodic adjustments in the TSA threshold will be required. At the moment, the eligibility threshold is quite static, which affects which families can be admitted and how effectively the budget of the program can be utilized, especially in the geographic 25 Tajikistan Emergency COVID-19 Project ESMF dimension. 46. District Administrations are responsible for addressing and solving the social protection issues at the district level. A project District Coordination Committee (DCC) will be established in each district to coordinate, facilitate and monitor implementation of the project activities., including TSA eligibility criteria and application. This Committee also addresses and resolve complaints within 30 days of receiving complaints. The DCC will be headed by a Deputy Chair of Khukumat on social sectors and comprise key relevant departments: social protection, health, education, sanitary and epidemiological service, as well as environment protection, public relations department, Civil Society Organizations (CSOs) and water utility. The DCC will select the Grievance Focal Point (GFP), who will be responsible for maintaining feedback logs. If the issue cannot be resolved at the district level, then it will be escalated by the DCC to the regional coordination committee or to the MOHSP/PIU. 47. The World Bank Environmental and Social Framework (ESF). As discussed above, the project is required to comply with the ESF. The ESF sets out the World Bank’s commitment to sustainable development, through a Bank Policy and a set of Environmental and Social Standards (ESS) that are designed to support Borrowers’ projects, with the aim of ending extreme poverty and promoting shared prosperity. 48. The ESSs 9 set out the requirements relating to the identification and assessment of environmental and social risks and impacts associated with projects supported by the Bank through Investment Project Financing. The World Bank believes that the application of these standards, by focusing on the identification and management of environmental and social risks, will support Borrowers in their goal to reduce poverty and increase prosperity in a sustainable manner for the benefit of the environment and their citizens by: a. Supporting Borrowers/Clients/Implementing Agencies in achieving good international practice relating to environmental and social sustainability; b. Assisting Borrowers/Clients/Implementing Agencies in fulfilling their national and international environmental and social obligations; c. Enhancing nondiscrimination, transparency, participation, accountability and governance; and d. Enhancing the sustainable development outcomes of projects through ongoing stakeholder engagement. 49. Of the ten ESSs 10, five are relevant to the Tajikistan COVID-19 Emergency Project. 9 www.worldbank.org/en/projects-operations/environmental-and-social-framework/brief/environmental-and-social-standards and http://projects- beta.vsemirnyjbank.org/ru/projects-operations/environmental-and-social-framework/brief/environmental-and-socialstandards 10 The ten World Bank ESSs are: ESS 1 - Assessment and Management of Environmental and Social Risks and Impacts; ESS 2 – Labor and Working Conditions; ESS 3 – Resource and Efficiency, Pollution Prevention and Management; ESS 4 – Community Health and Safety; ESS 5 – Land Acquisition, Restrictions on Land Use, and Involuntary Resettlement; ESS 6 – Biodiversity Conservation and Sustainable Management of 26 Tajikistan Emergency COVID-19 Project ESMF They establish the standards that the Implementing Agency and the Project will meet through the project life cycle, as follows: a. ESS 1 - Assessment and Management of Environmental and Social Risks and Impacts. ESS 1 sets out the Client’s responsibilities for assessing, managing and monitoring environmental and social risks and impacts associated with each stage of a project supported by the Bank through Investment Project Financing, in order to achieve environmental and social outcomes consistent with the ESSs. b. ESS 2 – Labor and Working Conditions. ESS 2 recognizes the importance of employment creation and income generation in the pursuit of poverty reduction and inclusive economic growth. Borrowers can promote sound worker- management relationships and enhance the development benefits of a project by treating workers in the project fairly and providing safe and healthy working conditions. ESS2 applies to project workers including full-time, part-time, temporary, seasonal and migrant workers. c. ESS 3 – Resource and Efficiency, Pollution Prevention and Management. ESS 3 recognizes that economic activity and urbanization often generate pollution to air, water, and land, and consume finite resources that may threaten people, ecosystem services and the environment at the local, regional, and global levels. d. ESS 4 – Community Health and Safety. ESS 4 recognizes that project activities, equipment, and infrastructure can increase community exposure to risks and impacts. In addition, communities that are already subjected to impacts from climate change may also experience an acceleration or intensification of impacts due to project activities. e. ESS 10 – Stakeholder Engagement and Information Disclosure. ESS 10 recognizes the importance of open and transparent engagement between the Borrower and project stakeholders as an essential element of good international practice. Effective stakeholder engagement can improve the environmental and social sustainability of projects, enhance project acceptance, and make a significant contribution to successful project design and implementation. 50. The World Bank Group Environmental Health and Safety (EHS) Guidelines 11. The EHS Guidelines are technical reference documents with general and industry-specific examples of Good International Industry Practice (GIIP) and are referred to in the ESF. The EHS Guidelines contain the performance levels and measures that are normally acceptable to the World Bank Group, and that are generally considered to be achievable in new facilities at reasonable costs by existing technology. The World Bank Group requires Living Natural Resources; ESS 7 - Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities; ESS 8 – Cultural Heritage; ESS 9 – Financial Intermediaries; and ESS 10 – Stakeholder Engagement and Information Disclosure. See https://www.worldbank.org/en/projects-operations/environmental-and-social-framework 11 http://documents.worldbank.org/curated/en/157871484635724258/Environmental-health-and-safety-general-guidelines 27 Tajikistan Emergency COVID-19 Project ESMF borrowers to apply the relevant levels or measures of the EHS Guidelines. When host country regulations differ from the levels and measures presented in the EHS Guidelines, projects will be required to achieve whichever is more stringent. 51. In the case of the Tajikistan Emergency COVID-19 Project, the General EHS Guidelines apply. The implementing agency will pay particular attention to the following General EHS Guidelines: a. EHS Section1.5 – Hazardous Materials Management; b. EHS Section 2.5 – Biological Hazards; c. EHS Section 2.7 – Personal Protective Equipment (PPE); d. EHS Section 2.8 – Special Hazard Environments; e. EHS Section 3.5 – Transportation of Hazardous Materials; and f. EHS Section 3.6 – Disease Prevention. 52. Additionally, the EHS for Health Care Facilities (HCF) 12 also apply to the project. The EHS Guidelines for Health Care Facilities include information relevant to the management of EHS issues associated with HCFs which includes a diverse range of facilities and activities involving general hospitals and small inpatient primary care hospitals, as well as outpatient, assisted living, and hospice facilities. Ancillary facilities may include medical laboratories and research facilities, mortuary centers, and blood banks and collection services. 53. World Bank Interim Guidance on COVID-19 Considerations. The World Bank has issued an interim guidance note for World Bank projects. The note, which contains links to the latest guidance for responding to COVID-19, is found as Annex VII to this ESMF. 54. World Health Organization (WHO) Guidance. The WHO is maintaining a website specific to the COVID-19 pandemic 13 with up-to-date country and technical guidance. The website also provides a number of technical guidances. As the situation remains fluid it is critical that those managing both the national response as well as specific health care facilities and programs keep abreast of guidance provided by the WHO and other international best practice. Current technical guidance provided by the WHO includes the following topics, which are updated regularly: a. National laboratories; 12 https://www.ifc.org/wps/wcm/connect/960ef524-1fa5-4696-8db3-82c60edf5367/Final%2B- %2BHealth%2BCare%2BFacilities.pdf?MOD=AJPERES&CVID=jqeCW2Q&id=1323161961169 13 https://www.who.int/emergencies/diseases/novel-coronavirus-2019 28 Tajikistan Emergency COVID-19 Project ESMF b. Risk communication and community engagement; c. Early investigation protocols; d. Country-level coordination, planning, and monitoring; e. Clinical care; f. Essential resource planning; g. Virus origin/Reducing animal-human transmission; h. Humanitarian operations, camps and other fragile settings; i. Surveillance, rapid response teams, and case investigation j. Infection prevention and control (WASH, quarantine, safe management of a dead body, etc.); k. Guidance for schools, workplaces & institutions; l. Points of entry/mass gatherings; m. Health workers; and n. Maintaining Essential Health Services and Systems. 29 Tajikistan Emergency COVID-19 Project ESMF IV. Environmental and Social Baselines Environmental Characteristics 55. Physical Environment. Tajikistan is a landlocked country in the mountainous part of Central Asia, between the latitudes 36°40'N41°05'N and latitudes 67°31'E-75°14'E. The area of Tajikistan is 143.1 thousand km2. In the north and west, Tajikistan borders with Uzbekistan and Kyrgyzstan, in the south it borders with Afghanistan and in the east with China. The perimeter borders of the country extend to 3,000 km. K y rg y z stan Afghanistan China Figure 1. Map of Tajikistan 56. Air and Climate. The climate of Tajikistan is characterized by the interaction of the main climate factors (geographical location, atmospheric circulation and solar radiation) that determine the main features of its climate: aridity, abundance of heat and light, and its continentality, which is expressed by a large interannual and inside the year variability of almost all climate elements. Relatively cold winter gives place to the rainy spring which rapidly changes to the dry summer characterized by the near absence of precipitation within the several months. Climatic features in Tajikistan are determined by its inland location and remoteness from the oceans (lack of humidity), location in relatively low latitudes (the magnitude of the radiation balance), and topography that impacts atmospheric circulation processes. Air quality in all project regions is of good quality due to a lack of industrial pollutants and a relatively low level of vehicular use. 30 Tajikistan Emergency COVID-19 Project ESMF 57. Water Resources. Hydrographic network of Tajikistan is constituted of more than 25 thousand rivers with a total length of 69,200 km. Out of these, 947 rivers have a length from 10 to 100 km, 16 rivers - from 100 to 500 km, and 4 rivers longer than 500 km. The river systems are divided into four river basins: 1) the Syrdarya river basin (with Zarafshon river basin in the form of a sub-basin); 2) the Kofarnihon River Basin (Kofarnihon river system and tributaries Ilyak its, Sorbo and Varzob, with sub-basin of the Karatag river); 3) the Vakhsh River basin with the Vakhsh River and all its tributaries; and 4) the Pyanj river basin with Panj River and its tributaries. Accordingly, four sub-basins, namely, the Zarafshon, Surkhob, Kofarnihon and Karatag have been acknowledged. 58. Sanitation. Assessment of water supply in selected health centers indicated that Rural Health Centers (RHCs) have no access to drinking water and adequate treatment of drinking water and potentially infectious/hazardous sewage is not carried out of the facility. In summer, the RHC staff boils water in buckets using water heaters, and in winter - in kettles and pans on potbelly stoves in minimum quantities. Poor quality water carried in buckets by the RHC workers from residential areas and office buildings can result in illnesses linked to pathogenic bacteria, viruses, and parasites. There is a close direct dependence correlation relationship between morbidity rate and poor water quality (40- 50%). 59. The sewage systems in the RHC are typically non-concrete pit located in the RHC backyards (some RHCs having no such a lavatory on their territory, use the services of the neighboring buildings, schools, and institutions). Once filled, pits are covered up and new pits are dug and lavatories constructed over them. These lavatory construction methods, typical for almost all rural areas in the country, have the potential of gradual soil and groundwater contamination. The wastewater from washing etc. is discharged to open trench drains at the side of the roads. 60. Under the Health Services Improvement Project, 37 RHCs were constructed in three districts of the Sughd Region, four districts of the Khatlon Region, Ishkashim district in the Gorno-Badakhshan Autonomous Province (GBAO) and Faizabad district under the republican subordination. Constructed health centers have septic tanks with sufficient capacity for the collection of sewage. For most of the health centers, individual water supply systems have been constructed. Thermostats for hot water supply are installed in all RHCs. However, many of these health centers are experiencing water shortages. 61. Waste Management. Waste management is one of the main environmental problems in Tajikistan and it includes waste from industry, mining, households, medical, and other wastes. The current waste management system in Tajikistan relies heavily on landfilling and it faces several problems, such as lack of landfill space, a small amount of recycling and composting measures, and other related environmental problems. Municipal solid waste is neither sorted nor treated in the country. Because of trucks and fuels shortage, the collection of municipal solid waste is poor in urban areas, where there is almost no municipal waste service. 31 Tajikistan Emergency COVID-19 Project ESMF 62. Medical Waste Management. There are no centralized healthcare waste management facilities or sanitary/secured landfills in Tajikistan. Medical waste generated from HCFs typically includes sharps (discarded needles/syringes, scalpel blades, empty vials), anatomical and infectious waste, including syringes, needles, cotton wool, bandages, etc. These are collected in first aid boxes and burned in incinerators located on-site or, for many RHCs, pits located on RHC grounds once or twice per month. These pits are 1- 3 m in depth pits and are located within premises of the RHC areas. Once the pit is filled, another is dug nearby. As many RHCs have no secure fencing, these pits are not secure from contact with people and animals. Almost all RHCs are located close to (or even in the same area) the resident households, schools, public and private buildings (pharmacies, chayhona (teahouse), café, stores). The smoke generated by burned waste can cause health impacts and are an annoyance for the neighboring communities. All new RHCs financed by the Health Services Improvement Project have waste incinerators and laboratory wastes (urine, blood samples, tampons, and culture medium and biological reagents) are being disposed of in incinerators. The staff is provided with the necessary equipment and materials (waste containers, colored plastic bags, face masks, gloves, etc.). Medical waste which includes sharp objects is collected in special containers and regularly transmitted by the act to the district central hospital. Socio-Economic Characteristics 63. Population. The Republic of Tajikistan is referred to the countries with rapidly growing population; it has reached 9,1 million people (from them 49% are women, 40,6% - children under 18, and 66% young adults under 30) in 2019. 14 Average number of resident population in Tajikistan has increased from 6,1 million. people (2000) up to 9,1 million. people (2019), i.e. by 49 percent. Around 74 percent of the population resides in rural areas. Tajikistan population is very young; for the past 70 years the number of population increased in 6 times. Annual population growth rate in the country varies within 2.1 – 2.5%. According to latest estimates, average age of the population is 25, and median age is 22.2. 15 Table 3 - Population of the provinces of Tajikistan Population Area Population Population Population Population Estimate Name Capital A Census (C) Census (C) Census (C) Census (C) (E) (km²) 1979-01-12 1989-01-12 2000-01-20 2010-09-21 2019-01- 01 16 Tajikistan Dushanbe 141,400 3,801,357 5,109,000 6,127,493 7,564,502 9,126,600 Khatlon Bokhtar 24,700 1,220,949 1,701,380 2,150,136 2,677,251 3,274,900 14 TajStat, 01.01.2019 15 www.worldometers.info/world-population/tajikistan-population 16 https://www.citypopulation.de/en/tajikistan/ 32 Tajikistan Emergency COVID-19 Project ESMF Dushanbe Dushanbe 100 500,966 605,135 561,895 724,844 846,400 Gorno- Khorugh 62,900 126,783 160,860 206,004 205,949 226,900 Badakhshan Districts of 28,500 757,976 1,083,043 1,337,479 1,722,908 2,120,000 Republican Subordination Sughd Khujand 25,200 1,194,683 1,558,158 1,871,979 2,233,550 2,658,400 64. Economy. Agriculture is the main economic activity in the regions with the major share of population living in the rural areas. The main crops sown and agricultural products are cotton, cereals, oilseed, potatoes, carrots, onions, cucumbers, cabbage, melons, vines, milk, wool, honey and eggs. Kitchen gardens and smallholdings are also considered an important part of the local economies. These include apples, peaches, apricots, almonds, pears, pomegranates, mulberries and walnuts produced from the homestead plots in addition to the crops. 65. Migration and Employment by Gender. Only a very few households can rely on agriculture as their only source of income. The majority of people in rural areas are forced to pursue a “combination of subsistence agriculture, labor migration and shuttle‐trading through which the poor seek to earn a living”. People try to diversify income opportunities by working within the village or elsewhere as driver, day laborer, shopkeeper, dressmaker, nurse, shepherd, etc. The labor market on a local and district level is very limited, while casual labor is generally very low paid. The most significant way of earning money remains therefore labor migration to Russia. The rise of migration in the years following independence created both difficulties and opportunities for women. Interviews showed that wives of migrant workers took on the role of heads of households with the men leaving them to make most of the decisions. Anecdotal evidence suggests that migration has also resulted in an increased number of abandoned or divorced women in Tajikistan. Decision‐ making in the household regarding e.g. agricultural production is often reserved to males and follows criteria of age, merit, and expertise. A considerable number of female- headed households, either due to the permanent or temporary absence of the male. However, decision‐making in female- headed households is often negated as relatives or remote husbands actively interfere. Women perform most of the domestic and agricultural work in rural areas, particularly with the migration outflow among men. The share of officially registered labor migrants makes on average 5% in Khatlon and over 10% on average in GBAO areas. 66. In the villages there is a different level of migration, which accounts for about 10% of the working population of the villages. Local people migrate mostly to Russian Federation. Most of the migrants more than 90% are men - who leave to work abroad for seasonal work. There are also those who go for a few years, or as commonly called long- term migrants. Despite the fact that only 10-15% of the total population of the village left 33 Tajikistan Emergency COVID-19 Project ESMF for labor migration, they send relatively large income to their households. The level of labor migration and its growth is associated with unemployment, which amounts up to 60% of the total workable part of the community population. 67. Significant unemployment has led to large-scale migration, especially among men leaving women behind to head households, thus making them responsible for supporting their families, as well as carrying out their other domestic duties and taking care of children. By age 25, 70 percent of women have become inactive, meaning they are doing unpaid work at home, compared with 20 percent of men who become inactive at that age. Over 43 percent of Tajik women engage in unpaid home-based work, yard work, and caregiving compared with only 9 percent of men. 17 The percentage of households headed by women is growing—often driven by labor migration. One-third of men aged 20 to 39 emigrate for most of the year or longer, and about 41 percent of men divorce their Tajik wives after leaving the country. 18 Around 80 percent of Tajik women in divorce cases are denied property rights and child support. Women cope by taking on traditionally male-led responsibilities, including household maintenance and budgeting, and the tending of fields and animals, on top of their traditional roles as caregivers to children and the elderly. These additional duties limit their participation in education and income-earning activities outside the home. Further, women’s paid employment is hampered by the significant decline of the number of preschool educational facilities, especially in rural areas; a result of the collapse of the socialist system and the country’s civil war. 19 68. Food Security. Tajikistan imports approximately 70 percent of its food due to insufficient domestic food production. 20 Imports of wheat and barley mainly come from Kazakhstan and the Russian Federation. Imports accounted for 58% of Tajikistan’s domestic wheat requirements and 81% of overall food consumption for 2012-2013. Without significant investments, the lack of arable land, a growing population and an insufficient domestic supply Tajikistan’s dependence on food imports is likely to rise. High food prices in the last years have affected rural communities in Tajikistan significantly. 21 69. Tajikistan has the highest malnutrition rate among the former Soviet republics (WFP 2017). In Tajikistan, about 18 percent of all children under 5 years are stunted, according to the most recent DHS (2017). Stunting increases with age, peaking at 34 percent among children age 24–35 months. In general, rural children and children born to mothers with little education are more likely to be stunted. There is large regional variation in the prevalence of stunting, ranging from 19 percent in Dushanbe, to 32 percent in GBAO. 70. Health Care. Progress in Tajikistan’s population health outcomes over the past two decades has been mixed. Life expectancy has steadily increased to about 67.5 years in 17 Asian Development Bank, Gender Assessment (2016). 18 Tajik State Agency on Social Protection, Employment, and Migration (2009). 19 Asian Development Bank, Gender Assessment (2016); International Labor Organization, Maternity Protection and the Childcare Systems in Central Asia: National Studies in Kazakhstan and Tajikistan (Moscow: ILO, 2014). 20 Tajikistan: Nutrition Profile, USAID, 2018 21 Tajikistan National Micronutrient Survey (NMS), UNICEF (2010). 34 Tajikistan Emergency COVID-19 Project ESMF 2011, up from about 63 years in 1990, when health outcomes suffered during the transition from Soviet rule. Rates of malnutrition and micronutrient deficiencies were high, with 21% of children under-five moderately or severely stunted, and 53% iodine deficient20, but with the latest 2017 data showing some improvement.21 According to a Demographic Health Survey, in 2012-2017, the rate of attrition decreased from 10% to 6% among children under 5 years old, and the rate of children with low body weight decreased from 12% to 8%. Despite the fact that malnutrition rates are declining, there are still nutritional problems among children, which further affects the health indicators of the country's population. The infant mortality rate has also declined steadily from 34 to 27 per 1,000 live births in 2012 and 2017, down from 90.6 per 1,000 live births in 1990. In the same period, the under-five mortality rate also declined from 114 per 1,000 live births to 43 (in 2012) and 33 (in 2017). The maternal mortality rate was estimated at 65 per 100,000 live births in 2010 and 32 per 100,000 live births in 2017. 71. Inefficient health services delivery. Delivery of health services is fragmented. Continuity of care is hampered by loose linkages and communication between primary health care (PHC) and hospital care, non-functional referral pathways, absence of patient follow-up practices. Most patients directly go to secondary and tertiary level hospitals, bypassing most rural hospitals during illness. Most patients lack confidence on the quality of PHC services because of outdated facilities, lack of equipment, and untrained health care staff. Bypassing leads to disrupted patient care and more expensive health service delivery. Although regulations on referral system exist, implementation is not enforced. The current line item budgeting does not incentivize health providers to coordinate care. Japan International Cooperation Agency (JICA) has launched a referral system project in Norak, Hamadoni, Baljuvon districts of Khatlon region, however, nationwide implementation has not yet happened. 72. Access to Health Facilities. Majority of population live in rural and remote areas, as a result physical distance to health facilities is an important barrier. Rural-urban and geographic disparities in care-seeking persist as coverage rates for key PHC services are much lower in rural/remote than urban areas. 73. Financial barriers. Particularly informal charges are a key barrier to utilization of health services, particularly for the poor. Private expenditure, almost entirely represented by out of pocket spending (OOPS), is very high at about 73% (2010) of total health expenditure (THE) which suggests that households carry most of the financial burden for seeking care. Informal payments for health services represent the largest part of OOPS. Analysis of utilization rates shows that the poor have many fewer visits than the non-poor and that about a third of households have family members who delay seeking help or do not seek help at all for financial reasons (Tajikistan Living Standard Measurement Survey (TLSS), 2007 and 2009). In addition to financial barriers at the HCF level, rural households and those living in remote areas face considerably greater transportation costs and other costs associated with reaching health facilities. 35 Tajikistan Emergency COVID-19 Project ESMF V. Environment and Social Risks and Mitigation 74. The project will finance small scale infrastructure works for the rehabilitation of existing healthcare facilities in order to install 100 ICU beds around the country. The project will also rehabilitate or install medical waste management and disposal equipment (i.e. autoclaves, incinerators) within health centers. These interventions are expected to take place on the property of existing facilities; therefore, they will be mostly community- based activities and environmental issues (and impacts thereof) are not expected to be significant. The physical works envisaged are of small to medium scale and the associated environmental impacts are expected to be temporary, predictable, and easily mitigable. 75. The project will operate nationally, exposing it to common conflict and fragility risks which will have a bearing on the project outcomes. These general risks include: (i) institutional risks – inadequate capacity of the implementing agency in ESS application, particularly with regards to medical waste management and disposal; (ii) geographical- inter-regional and district risks which may make effective project implementation and supervision difficult in some areas; (iii) economic risks – high rate of unemployment in particular among youth and significant dependency of household income on remittances which is vulnerable to external economic conditions and fluctuations, which may exacerbate economic shock due to COVID-19; and (iv) social exclusion – certain segments could get excluded either due to inherent structural deficiencies and/ or due to elite capture, which may result in some social groups excluded from project benefit. 76. The major areas of environmental and social risks are: a. Risks related to rehabilitation of existing healthcare facilities; b. Risks related to medical waste management and disposal; c. Risks related to the spread of the virus among healthcare workers; d. Risks related to the spread of COVID-19 amongst the population at large; e. Risks related to social unrest, panic/conflicts resulting from false rumors; f. Risks related to quick access to appropriate and timely medical services, antiseptics, and PPEs; g. Risks related to anticipating and addressing issues resulting from people being kept in quarantine and their relatives; and h. Risks related to addressing challenges associated with providing (social and financial) assistance for vulnerable people. i. Risks associated with the installation and operation of PSA oxygen refilling stations in selected health care facilities. 36 Tajikistan Emergency COVID-19 Project ESMF j. Risks associated with the distribution and administration of vaccines as part of routine immunization activities (MMR) and disposal of waste within routine immunization activities. 77. The PIU will be primarily responsible for ensuring the environmental and social risks are mitigated at each stage of project operation. Since the World Bank ESF applies to the project, the PIU will address risk mitigation through the relevant ESSs. 78. ESS 1 - Assessment and Management of Environmental and Social Risks and Impacts. The project will have positive environmental and social impacts as it should improve COVID-19 surveillance, monitoring, and containment as well as provide targeted support for the more vulnerable households. However, the project could also cause significant environmental, health, and safety risks due to the dangerous nature of the pathogen and reagents and other materials to be used in the project supported HCFs. Other risks, associated with site specific rehabilitation of health facilities, are identified/identifiable and easily mitigable. Due to weak health system performance, the Global Health Security Index assessed Tajikistan as one of the least prepared countries for a pandemic, ranking 4 out of 5 in Central Asia 22, indicating high vulnerability to COVID- 19. To manage these risks, the MOHSP has prepared two major instruments: a. This ESMF, which includes a checklist for site specific Environmental and Social Management Plans (ESMP), see Annex II, and a template for an Infection Control and Medical Waste Management Plan (ICWMP), see Annex III, so that the ICUs and laboratories to be supported by the Project will apply international best practices in COVID-19 diagnostic testing and other COVID-19 response activities. The ESMF has an exclusion list for COVID-19 ICU and lab activities that may not be undertaken at the labs unless the appropriate capacity and infrastructure is in place). This ESMF will be reviewed and accepted by the World Bank and disclosed both in country on the MOHSP website 23 and on the World Bank website; and b. A Stakeholder Engagement Plan (SEP) for effective outreach and citizen participation, a SEP has been prepared and disclosed both in country on the MOHSP website and on the World Bank website 24. 79. To achieve the above mentioned positive environmental and social impacts, the aforementioned areas of risks must be addressed and mitigated as discussed below: a. Medical Waste Management and Disposal. Tajikistan’s Medical Waste Management System is negatively affected by socioeconomic status and by 22 Global Health Security Index. 2019. Global Health Security Index: Building Collective Action and Accountability. Washington, D.C.: GHD Index. 23 The ESMF is found on the MOHSP website here: http://moh.tj/social-protection/?lang=en 24 The SEP is found on the MOHSP website here: http://moh.tj/social-protection/?lang=en and the World Bank website at http://documents.worldbank.org/curated/en/774511585018022894/Stakeholder-Engagement-Plan-SEP-Tajikistan-Emergency-COVID-19- Project-P173765 37 Tajikistan Emergency COVID-19 Project ESMF limitation in health services and has no clear organizational concept and legal framework. Given that the medical waste generated by laboratories and health care facilities is a potential vector for the contagion, improper handling of medical waste runs the risk of further spread of the disease. Therefore, the ESMF includes an ICWMP template specifically designed for COVID-19 identification, testing, and treatment. b. Worker Health and Safety. Workers in healthcare facilities are particularly vulnerable to contagions like COVID-19. Healthcare-associated infections due to inadequate adherence to occupational health and safety standards can lead to illness and death among health and laboratory workers as well as the wider spreading of the disease within communities. The ICWMP contains detailed procedures, based on WHO guidance, for protocols necessary for treating patients and handling medical waste as well as environmental health and safety guidelines for staff, including the necessary PPE (masks, gloves, aprons, surgical scrubs, etc.). Proper disposal of sharps (see medical waste above), disinfectant protocols, and regular testing of healthcare workers is included. c. Use of military/Security forces to assist in COVID-19 OPERATIONS - guidelines as to how the risk related to using security forces can be mitigated are attached as Annex V. d. Community Health and Safety. The SEP is a key instrument for outreach to the community at large on issues related to social distancing, higher risk demographics, self-quarantine, and quarantine. It is critical that these messages be widely disseminated, repeated often, and clearly understood. e. Inclusion. Discriminative targeting shall be adopted to ensure that the targeted social assistance will be extended to the most vulnerable. 80. Each HCF will apply infection control and waste management planning following the requirements of this ESMF, national law, and relevant EHS Guidelines, GIIP, WHO etc. satisfactory to the Bank. The ESMF covers environmental and social infections control measures and procedures for the safe handling, storage, and processing of COVID-19 waste materials in order to prevent, minimize, and control environmental and social impacts during the operation of project-supported laboratories and medical facilities. The ESMF will also clearly outline the implementation arrangements to be adopted by the MOHSP to manage environmental and social risks; training programs focused on biosafety issues in COVID-19 laboratories, the operation of quarantine and isolation centers and inspection posts, and compliance monitoring and reporting requirements, including with respect to waste management based on the existing ICWMP. 81. ESS 2 – Labor and Working Conditions. The project shall be carried out in accordance with the applicable requirements of ESS 2, in a manner acceptable to the World Bank, including through, inter alia, implementing adequate occupational health and safety 38 Tajikistan Emergency COVID-19 Project ESMF measures (including emergency preparedness and response measures), setting out grievance arrangements for project workers, and incorporating labor requirements into the ESHS specifications of the procurement documents and contracts with contractors and supervising firms. 82. The project is expected to encompass the following categories of workers: direct workers and contracted workers. Direct workers could be either government civil servants or those deployed as ‘technical consultants’ by the project. The former will include health care providers and workers in health care facilities. The latter includes chiefly construction workers involved in the minor civil works. The civil servants will be governed by a set of civil services code and the ‘technical consultants’ by mutually agreed contracts. The project proposes some small-scale civil works and the expectation is that the majority of labor will be locally hired and hence no large-scale labor influx is envisaged. This ESMF includes an ESMP checklist for the works which contains a section on worker health and safety requirements. The workers will not work in contaminated areas and will be safeguarded with protective measures as appropriate. 83. The ESMF also contains sections on Environment Health and Safety (EHS) including specific instruments that will need to be prepared either by the PIU and/or the contractor prior to commencement of works (EHS checklists, codes of conduct; safety training etc.). Civil works contracts will incorporate social and environmental mitigation measures based on the World Bank Group’s EHS Guidelines and the ESMF where the EHS Guidelines will include incident investigation and reporting procedures in accordance with the World Bank Environmental and Social Incident Response Guidelines (ESIRT), recording and reporting of nonconformities, emergency preparedness and response procedures, and ongoing employee training / awareness, other referenced plans e.g. SEP. All civil works contracts will include industry standard Codes of Conduct that include measures to prevent Gender Based Violence (GBV) and Sexual Exploitation and Abuse (SEA) or Sexual Harassment (SH). A locally based GRM specifically for direct and contracted workers will be provided. A technical note on SEA/SH for COVID-19 Projects is attached as Annex VI. 84. In line with ESS 2 and Tajik law, the use of forced labor or conscripted labor is prohibited in the project, including for the construction and operation of health care facilities. 85. ESS 3 – Resource and Efficiency, Pollution Prevention and Management. Medical wastes 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 a significant impact on the environment and human health. Wastes that may be generated from medical facilities and 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. Each beneficiary medical facility/lab, following the requirements of the ESMF, WHO COVID-19 guidance 39 Tajikistan Emergency COVID-19 Project ESMF documents, and other best international practices, will prepare and follow an ICWMP to prevent or minimize such adverse impacts. The ICWMP mandates that any waste associated with COVID-19 testing or treatment will be incinerated on site whenever possible. It also contains strict protocols for disinfecting and packing such waste for transportation to the nearest medical waste incinerator if on-site destruction is not possible. 86. The ESMF includes guidance related to transportation and management of samples and medical goods or expired chemical products, as well as small scale rehabilitation activities. 87. The site specific ESMPs, to be prepared for rehabilitation of the 10-bed ICUs will include procedures for handling construction waste. Facilities with asbestos insulation, pipe lagging, etc. will be excluded from financing under the project. 88. Resources (water, air, etc.) used in health care and quarantine facilities and labs will follow standards and measures in line with State Sanitary Hygienic Service of MOHSP and WHO environmental infection control guidelines for medical facilities. 89. ESS 4 – Community Health and Safety. Medical wastes and general waste from the labs, health centers, and quarantine and isolation centers have a high potential of carrying microorganisms that can infect the community at large if they are 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 (e.g., seismic). Laboratories, quarantine and isolation centers, and screening posts, will thereby have to follow procedures detailed in the ESMF and ICWMP. 90. The operation of quarantine and isolation centers needs to be implemented in a way that staff, patients, and the wider public follow and are treated in line with international best practice as outlined in WHO guidance for COVID-19 response as above under ESS 1 and ESS 2. 91. The SEP will also ensure widespread engagement with communities in order to disseminate information related to community health and safety, particularly around social distancing, high risk demographics, self-quarantine, and mandatory quarantine. 92. The project will mitigate the risk of Sexual Exploitation and Abuse by applying 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. Sexual Exploitation and Abuse (SEA), and Sexual Harassment (SH) risks are substantial and could emerge in and around HCFs and at the household-level of beneficiaries. Female healthcare workers or patients may be subject to harassment. In addition, there are project-related SEA/SH risks at the household level. Global evidence suggests that safety net interventions, including cash/in-kind transfers, and income-generating schemes, among others, can affect household power 40 Tajikistan Emergency COVID-19 Project ESMF dynamics, which can exacerbate incidents of GBV/SEA/SH. Global evidence also suggests that intimate-partner violence and unequal gender dynamics can limit women’s ability to access these interventions. The Project will mitigate these risks by taking the following steps: a. The Project will disseminate key messages to the public focusing on: (i) no sexual or other favor can be requested in exchange for medical assistance; (ii) medical staff are prohibited from engaging in sexual exploitation and abuse; and (iii) any case or suspicion of sexual exploitation and abuse can be reported to the Project GRM. b. The Project will make information available to health service providers on where SEA/SH psychosocial support and emergency medical services can be accessed. c. The Project will promote two-way communication between health authorities and communities that would allow information on instances. 93. More details are provided in the Stakeholder Engagement Plan (SEP) prepared for the Project. 94. The project will also ensure via the above-noted provisions, including stakeholder engagement, that quarantine and isolation centers and screening posts are operated effectively throughout the country, including in remote and border areas, without aggravating potential conflicts between different groups. 95. In case quarantine and isolation centers are to be protected by security personnel, it will be ensured that the security personnel follow strict rules of engagement and avoid any escalation of the situation, taking into consideration the above-noted needs of quarantined persons as well as the potential stress related to it. 96. ESS 10 – Stakeholder Engagement and Information Disclosure. The project recognizes the need for effective and inclusive engagement with all of the relevant stakeholders and the population at large. Considering the serious challenges associated with COVID-19, dissemination of clear messages around social distancing, high risk demographics, self-quarantine, and, when necessary, mandatory quarantine is critical. Meaningful consultation, particularly when public meetings are counter to the aims of the SEP, and disclosure of appropriate information assume huge significance for ensuring public health and safety from all perspectives – social, environmental, economic, and medical/ health. In this backdrop, the project has prepared a SEP which serves the following purposes: (i) stakeholder identification and analysis; (ii) planning engagement modalities viz., effective communication tool for consultations and disclosure; and (iii) enabling platforms for influencing decisions; (iv) defining roles and responsibilities of different actors in implementing the Plan; and (v) a grievance redress mechanism (GRM). 97. Project preparation has included a detailed mapping of the stakeholders. Individuals 41 Tajikistan Emergency COVID-19 Project ESMF and groups likely to be affected have been identified. Risk-hot spots on the international borders as well as in-country have been delineated. Mapping of other interested parties such as government agencies/authorities, NGOs and CSOs, and other international agencies have also been completed. Drawing upon their expectations and concerns, a SEP has been prepared by the Government of Tajikistan and disclosed publicly (disclosed on a website). The SEP will be updated during implementation. The PIU has also developed and put in place a GRM to enable stakeholders to air their concerns/ comments/ suggestions, if any. Planning and Design Stage 98. Rehabilitation work at existing HCFs. The PIU will screen each HCF for potential environmental and social risks per World Bank Group EHS Guidelines, WHO COVID-19 Guidelines 25, and the screening form contained in Annex I. Screening will include: a. Determination of any needed design changes in the facility or its operation such as ICUs, isolation facilities, structural and equipment safety, universal access, nosocomial infection control, medical waste disposal, etc.; b. Identification of the scope of works expected (i.e. wards rehabilitated into ICUs, installation of box chambers, installation/augmentation of water supply and installation of sanitary stations, rehabilitation or installation of medical waste incinerators, etc.); c. Determination that utilities (power, water, heat, etc.) are adequate for planned works; d. Identification of how such works might interfere with normal operation of the HCF; e. Determination if works are eligible for financing - for example, activities excluded from financing under the project include those requiring the acquisition of land or works conducted in wards or areas where patients are being treated where asbestos insulation or pipe lagging was used in original construction (a list of excluded activities is found in Annex II); f. Determination as to whether external or additional security personnel are needed; and g. Preparation of a site-specific ESMP based on the ESMP checklist found in Annex II. 99. Medical waste management and disposal. The PIU will screen each HCF’s 25 The World Bank ESF, including ESS 4, also contain relevant information. See https://www.worldbank.org/en/projects- operations/environmental-and-social-framework 42 Tajikistan Emergency COVID-19 Project ESMF medical waste management and disposal practices to determine if they are in keeping with the World Bank Group’s EHS Guidelines and current WHO Guidelines for COVID-19. The site-specific ESMPs will include mitigation measures for those HCFs to be financed under the project. The screening will be conducted based on the screening form found in Annex I and include: a. Identification of current methods of medical waste management and disposal at the HCF; b. Identification of any on-site facilities for disposal of medical waste including incinerators, pits for burning medical waste, pits for burial of medical waste, etc.; c. Identification of any off-site disposal of medical waste, including how material is gathered and stored, routes taken to the disposal facility, and disposal procedures; d. Review of protocols for dealing with medical waste specifically related to infectious diseases like COVID-19; e. Review of training procedures for healthcare workers and other relevant HCF employees for medical waste management and disposal; f. Preparation of an ICWMP, based on the sample contained in Annex III, for the HCF. 100. Protecting healthcare workers. The PIU will conduct a review of the HCF’s protocols for protecting healthcare workers from infectious disease based on current WHO Guidelines for COVID-19 and the Infection and Prevention Protocol contained in Annex IV. The review will include: a. Determination if training given to healthcare workers and other HCF employees is adequate; b. Determination if HCF staff are trained on how to deal with the remains of those who might die from COVID-19, including those conducting autopsies; c. Determination if adequate stores of PPE are available on-site; and d. Identification of supply lines for required PPE. 101. Containment of COVID-19. The PIU will also conduct a review of the HCF’s protocols for dealing with the general public based on current WHO Guidelines for COVID-19 and the Infection and Prevention Protocol contained in Annex IV. The review will include: 43 Tajikistan Emergency COVID-19 Project ESMF a. Review of identification, testing, and treatment protocols for those exposed to or suspected of being infected with COVID-19 for groups of higher sensitivity or vulnerability like the elderly, those with preexisting conditions, heavy smokers, or the very young; b. Updating visiting rules and regulations for families and friends of patients; c. Briefing procedures for families and friends of COVID-19 patients on how the disease is spread and how to minimize that spread; d. Briefings available for the general public on COVID-19; and e. Ensuring those HCF employees and any outside personnel charged with handling remains of patients who have died from COVID-19 are familiar with WHO Guidelines. 102. Communication Approaches and Strategy. Under Component 2, the project will support information and communication activities to increase the attention and commitment of government, private sector, and civil society, and to raise awareness, knowledge and understanding among the general population about the risk and potential impact of the pandemic and to develop multi-sectoral strategies to address the pandemic. Communication (b) A national communications and outreach strategy and implementation plan will be developed, which will include social and behavioral communication change across multiple channels, and implementation of community outreach focusing on preventive and social distancing measures aligned to the national communications and outreach strategy, including the development and dissemination of communication materials adapted for target audiences in the relevant languages and Mobile Engage text messaging system. Training of journalists on responsible reporting and emergency response procedures covering all media types and national and regional-based outlets, as well as supporting the training and activities which are COVID-19 specific to community public health teams (consisting of primary health care workers and trained community leaders) at jamoat level will be part of the communication strategy. The Republican Center for Healthy Lifestyles will play an active role to increase awareness of preventive measures and promote community participation in slowing the spread of the pandemic. 103. During the project preparation stage, the project team has developed the Stakeholder Engagement Plan (SEP), which outlines the ways in which the project team will communicate with stakeholders and includes a mechanism by which people can raise concerns, provide feedback, or make complaints about project and any activities related to the project. The SEP has included a detailed mapping of the stakeholders. Individuals and groups likely to be affected (direct beneficiaries) have been identified. Risk-hot spots on the international borders as well as in-country have been delineated. Mapping of other interested parties such as government agencies/authorities, NGOs and CSOs, and other international agencies have also been completed. Drawing upon their expectations and 44 Tajikistan Emergency COVID-19 Project ESMF concerns, the SEP has been publicly disclosed. 26 The PIU has also developed and put in place a GRM to enable stakeholders to air their concerns/ comments/ suggestions, if any. 104. Access to appropriate and timely medical services, antiseptics and PPEs. Considering the geographic location and remoteness of majority of rural villages the timely medical assistance and availability of personal protective equipment is important. The HCFs will conduct a review the HCF’s protocol’s for securing quick access to appropriate and timely medical services based on current WHO Guidelines for COVID-19. The review will include: a. Number of ambulance teams and equipment available to cover distance locations and timelines of medical services to be reached; b. The location of ICUs to be selected based on existing services and expanding geographical access to health care services in order to ensure equitable access to highly specialized care across the country; c. Pain medications, antibiotics and other routine medicines needed for the ICUs; d. Staff at all ICUs are trained in COVID-19 care and infection prevention, as well as longer-term capacity building in critical care provision; e. Emergency referral mechanism in rural areas to access timely medical services; f. Determination if adequate stores of hand sanitizers and PPE are available in rural areas; and g. Identification of supply lines for required PPE. 105. Challenges associated with providing (social and financial) assistance for vulnerable people. In response, the project will finance targeted, nutrition-sensitive temporary social support for food-insecure household cash transfers to provide time- limited support to food-insecure households under Component 3. The cash transfers will be delivered using the existing Targeted Social Assistance (TSA) system, implemented by the State Agency for Social Protection (SASP). The TSA system includes an additional module to allow for additional payments in emergency situations and the eligibility criteria can be adapted to target the most food-insecure communities. The transfers will be triggered at the oblast-level based on the spikes in the prices of key food groups (wheat, milk and dairy, eggs). Food prices in each oblast will be monitored through the routine market monitoring systems of the Ministry of Economic Development and Trade. A specific price increase threshold will be identified in consultation with the MOHSP, SASP, and key technical partners: WFP and UNICEF. Once triggered, the program will target TSA beneficiary households with children under the age of 2. This component will finance the cash transfers, and cover the costs of benefit administration, including the cost of 26 http://moh.tj/wp-content/uploads/2017/07/P173765-Tajikistan-COVID-19_SEP_RUSSIAN_DISCLOSED.pdf 45 Tajikistan Emergency COVID-19 Project ESMF adjusting and administering the beneficiary data base. The proposed cash transfers will also provide an opportunity to use accompanying measure to promote optimal nutrition, appropriate hygiene, preventive health services, and COVID-19 infection prevention messaging. 106. TSA program is in the rollout phase and has reached so far 68 districts of the country. The Government has approved the Decree on the TSA roll out in the remaining 28 districts on May 14, 2020. The Program is rolled-out nationwide and aimed to cover about 200,000 of the households or about 15 percent of the total number of households in the country, primarily focusing on the extreme poverty. Adjustments in the design of the program were proposed by the team to respond to specific risks and needs of the population. While some improvements need to apply to general design, it is also important to recognize that preparing the TSA as a mitigation mechanism goes beyond the original objectives and design of the TSA program. Certain groups of the population may be hit particularly hard. For example, various shocks may have larger impact on female-headed households given their lack of income sources and limited coping mechanisms. By investing in targeted social support, the Project will increase the resilience of food-insecure households and enable them to use prevention and treatment services. Minor Works Stage 107. Rehabilitation work at existing HCFs. The PIU will ensure that all rehabilitation work done under the project will be carried out in compliance with a site-specific ESMP prepared based on the checklist found in Annex II. The PIU will also ensure that the site- specific ESMP will be included in any works or supervision contracts entered into for a specific HCF. The site-specific ESMP will include: a. Environmental risks and issues such as resource efficiency and material supply; b. Construction-related solid wastes, wastewater, noise, dust and emission management; c. Hazardous materials management; d. Occupational Health and Safety (OHS) issues; e. Labor influx, security personnel management, GBV/SEA/SH risks, gender issue; and f. Labor and working conditions. Operational Stage 108. Medical waste management and disposal. The PIU and HCF will ensure the following: 46 Tajikistan Emergency COVID-19 Project ESMF a. Each HCF is operated in accordance with the ICWMP prepared for the project; b. Waste segregation, packaging, collection, storage disposal, and transport is conducted in compliance with the ICWMP and WHO COVID-19 Guidelines; i. Onsite waste management and disposal will be reviewed regularly and training on protocols contained in the ICWMP conducted on a weekly basis; ii. The PIU will audit any off-site waste disposal required on a monthly basis and institute any remedial measures required to ensure compliance; and c. Waste generation, minimization, reuse and recycling are practiced where practical in the COVID-19 context. 109. Protecting healthcare workers. The PIU and HCF will ensure the following: a. Regular delivery and proper storage of goods, including samples, pharmaceuticals, disinfectant, reagents, other hazardous materials, PPEs, etc.; b. Ensure protocols for regular disinfection of public rooms, wards, ICUs, equipment, tools, and waste are in place and followed; c. Ensure handwashing and other sanitary stations are always supplied with clean water, soap, and disinfectant; d. Ensure equipment such as autoclaves are in working order; and e. Provide regular testing to healthcare workers routinely in contact with COVID- 19 patients. 110. Containment of COVID-19. The PIU and HCF will ensure the following: a. Quarantine procedures for COVID-19 patients are maintained; b. When practical, COVID-19 patients are given access to phone or other means of contact with family and friends to lessen the impact of isolation in quarantine; c. The public is regularly updated on the situation and reminded of protocols to prevent the spread of COVID-19; and d. Members of the general public (family and friends) who have been exposed to confirmed COVID-19 patients are tested on mandatory basis. Decommissioning Stage 111. If any temporary HCFs or medical waste management facilities were established 47 Tajikistan Emergency COVID-19 Project ESMF under the project, they will be decommissioned after the end of the outbreak is declared in accordance with regular decommissioning procedures and international best practice. 48 Tajikistan Emergency COVID-19 Project ESMF VI. ESMF Procedures 112. MOHSP is responsible for the overall implementation of the project through the established PIU. The PIU will have day-to-day responsibility for project management and support, including ensuring that project implementation is compliant with the World Bank’s ESF, particularly the relevant ESSs; the World Bank Group’s EHS Guidelines; WHO COVID-19 Guidelines; and this ESMF. The PIU will be adequately staffed to oversee the project’s work nationally and ensure that each HCF complies with all project procedures and receive professional implementation and project management support, including for procurement. PIU staffing will include at two core team members, including an individual consultant who have experience with implementation of medical waste management and disposal systems as well as some knowledge of general occupational health and safety issues for healthcare workers and minor works. These staff members will be responsible for the implementation of the ESMF including: screening of HCFs; working with HCFs to prepare site specific ESMPs and ICWMPs; management of GRMs; and monitoring and reporting on ESMF implementation. 113. Each individual HCF undertaking activities financed by the project will assign one staff member who will be responsible for liaising with the PIU on ESMF implementation throughout the life of the project at that specific HCF. 114. Implementation of this ESMF will include the following activities, to be undertaken by the PIU working closely with the individual HCFs: a. Screening – all activities undertaken by the project will be screened using the form found in Annex I in order to exclude certain risky activities, identify potential environmental and social issues, and classify the environmental and social risks. Copies of each of these screening forms will be kept at the PIU and individual HCFs. The PIU’s quarterly report to the World Bank will include copies of each screening undertaken during the subject quarter. It is noted that the ESCP sets out the following list of activities that are excluded from financing under the project: i. Activities that may cause long term, permanent and/or irreversible (e.g. loss of major natural habitat) adverse impacts on the environment; ii. Activities that may have significant adverse social impacts and may give rise to significant social conflict; iii. Activities that may affect lands or rights of indigenous people or other vulnerable minorities; and iv. Any other activities excluded from this ESMF. b. Environment and Social Instruments – The PIU and individual HCF will prepare and implement the necessary environmental and social instruments for each of the activities financed under the project. The instruments will be 49 Tajikistan Emergency COVID-19 Project ESMF prepared in Tajik and Russian in order to ensure the widest degree of understanding by the concerned parties. The scope of this COVID-19 Emergency Project requires the following three types of environmental and social instruments: i. ESMPs – after the screening, ESMPs, based on the sample found in Annex II, will be prepared for any small-scale works to be conducted at an associated HCF including the creation or rehabilitation of ICUs, the installation of box chambers, the rehabilitation of laboratories, the rehabilitation or installation of sanitary stations and hand washing facilities; ESMP also provides recommendations for installation and safe operation of oxygen refilling stations. Once approved (see below), the ESMP will be included as an integral part of any works or supervision contract for the activity. If the HCF undertakes the works on its own, the ESMP will remain applicable for the activities being undertaken. ii. ICWMPs – each HCF will prepare and implement an ICWMP, based on the sample found in Annex III. Given the potential lack of testing availability in some areas of Tajikistan, ICWMP protocols for individual HCFs will be implemented on the assumption that the COVID-19 pathogen is present and that all healthcare workers and patients are potential carriers. iii. SEP – an SEP has been prepared for the project and it is applicable to all project financed activities. Individual HCFs will augment the overall SEP with a site-specific SEP to ensure patients and their families, local authorities, and the general public are aware of the situation and have access to community-based hotlines, GRMs, and other important information channels. iv. Technical Note on Use of Military Forces to Assist COVID-19 Operations - the government can use military or security forces during public health emergencies. Military or security forces can be used in different ways to respond to COVID-19. Or they can be mobilized more generally to implement government programs to respond to the COVID- 19 coronavirus infection. v. Vaccine Delivery and Deployment Manual - the Vaccine Delivery and Deployment Manual describes plans for the supply, procurement and distribution of vaccines, and monitoring of COVID-19 vaccination in Tajikistan, as well as plans to support these efforts through the World Bank's COVID-19 Emergency Response Project in Republic of Tajikistan (TES-19). Its goal is to ensure consistency, transparency and accountability for those involved in the management and implementation 50 Tajikistan Emergency COVID-19 Project ESMF of the procurement and supply of COVID-19 vaccine through the TEC- 19 Project. c. Consultation and Disclosure – given the need for social distancing during the COVID-19 pandemic, stakeholder consultations for the environmental and social instruments will be conducted virtually whenever possible. The PIU and individual HCFs will identify key stakeholders for each of the five instruments and organize consultations via phone, email, and, for HCF employees, small meetings of no more than ten individuals at a time. For the ICWMP, key stakeholders must include patients and their families – meaning consultations will need to be continuous as new patients are identified. For SEP, the general public around a given HCF are stakeholders, therefore some sort of public call for input will be made via print and/or broadcast media. All instruments will be disclosed on the PIU and individual HCF’s websites with print copies also available, on demand, at both. Copies of instruments prepared and disclosed will be included in the PIU’s Quarterly Report to the World Bank and disclosed on the World Bank website at that time. d. Review and Approval – the individual instruments will be prepared by the concerned HCFs and then reviewed and approved by the PIU before implementation. The first three of each of the instruments prepared will also be submitted to the World Bank by the PIU for review and approval before implementation. Thereafter, the World Bank will conduct a post-review of each instrument via the PIU’s Quarterly Report and provide comments when necessary. If, during post review, it is evident that instruments are not meeting World Bank standards, the Bank may change the procedures and require prior review of new instruments. e. Implementation – the individual HCF will be responsible for the implementation of the instruments. For ESMPs, this responsibility will be shared with contractors and supervising consultants when applicable. The PIU will provide implementation support and supervision. f. Monitoring and Reporting – PIU will be submitting to the Bank semi-annual Project Progress Reports: i. Monthly Reports - individual HCFs will prepare monthly reports to the PIU on each activity being undertaken. These reports will include progress on any on-going small works, statistics related to the implementation of the ICWMP, statistics related to local hot-lines, any grievances received via the GRM and information on their resolution, and any other relevant information. ii. Quarterly Reports – the PIU will submit an overall report of project implementation to the Bank every quarter the project is active. These 51 Tajikistan Emergency COVID-19 Project ESMF reports will include statistics on national project implementation; a summary of grievances received and their resolution, a summary of activities for each individual HCF, and copies of screenings and individual HCF instruments prepared during the subject quarter. Infection Control and Waste Management 115. The PIU and individual HCFs are responsible for implementing actions to prevent the spread of COVID-19 and ensure proper treatment of medical waste at all stages of project operations. The three main instruments to be used, ESMP (which contains information about the installation and safe operation of the oxygen refilling stations) and ICWMP, are described above and further outlined in Annexes II and III, as well as Recommended measures for the safe disposal of medical waste that generated due to COVID-19 vaccination. Key principles, included in those instruments, that are to be maintained by the project throughout implementation include the following: a. Ensuring occupational health and safety standards for workers. The ESMP and ICWMP should address applicable, essential elements of occupational health and safety management as described in the World Bank Group ESH Guidelines (see Chapter III, above) for small-scale works and working in an HCF, respectively. Each instrument should identify specific potential occupational hazards, including those related to the COVID-19 pathogen. The ICWMP specifically will deal with the ensuring adequate facilities for hand washing, cleaning and decontamination procedures, use of PPEs, and disposal of medical waste. i. Detailed procedures for regular testing of healthcare workers and patients. The ICWMP will include procedures for regular testing of healthcare workers exposed to COVID-19 as well as patients who present symptoms. These testing procedures may vary between HCFs depending on the availability of testing kits and laboratories in different parts of the country and at different times. b. Requirements for handling dead bodies. The WHO Guidelines include guidance on the management of dead bodies in the COVID-19 context 27 . Healthcare workers, mortuary staff, and others handling bodies should apply standard precaution including hand hygiene before and after interaction with the body, and the environment; and use appropriate PPE according to the level of interaction with the body, including a gown and gloves. If there is a risk of splashes from the body fluids or secretions, personnel should use facial protection, including the use of face shield or goggles and medical masks. c. Safe handling of medical waste and sharps disposal. The ICWMP should contain detailed instructions on handling medical waste at a given HCV, given the options available. Medical waste, including any waste suspected to contain pathogens should 27 https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf 52 Tajikistan Emergency COVID-19 Project ESMF be segregated and marked “infectious” with international infectious symbol in a strong, leak proof plastic bag, or a container capable of being autoclaved. Medical waste should be sterilized via chemical disinfection, wet thermal treatment (i.e. autoclave), microwave irradiation, or incineration prior to disposal. Sharps, including needles, scalpels, blades, knives, infusion sets, saws, broken glass, and nails etc. should be segregated in a rigid, impermeable, puncture-proof container (e.g. steel or hard plastic) container for sterilization and disposal in accordance with the guidelines. Additionally, needles and syringes should undergo mechanical mutilation (e.g. milling or crushing) prior to treatment, particularly chemical, wet thermal treatment, and microwave irradiation. d. Personal Protective Equipment (PPE). In addition to the World Bank Group EHS Guidelines on PPEs, the WHO has published guidelines on the rational use of PPEs during the COVID-19 pandemic 28, which highlight the issues faced by the global shortage of PPEs. The ICWMP will take these guidelines into account and ensure that healthcare workers involved in the critical care of COVID-19 patients have the necessary protection and that patients, particularly those who do not require hospitalization, understand their responsibilities for obtaining and wearing PPEs when around others. Labor Management 116. Under ESS 2, the project is expected to encompass direct workers and contracted workers. Direct workers could be government civil servants, or those deployed as ‘technical consultants’ by the project. The healthcare workers and civil servants will be governed by a set of civil services code and the ‘technical consultants’ by mutually agreed contracts. Some minor construction works are anticipated under the Project and it is expected that most of the labor force will be hired locally and therefore no large-scale labor influx is envisaged. Each HCF’s ICWMP will also provide guidance on occupational health and safety for these workers as well as how they can register workplace grievances, should they arise. 117. Contracted workers will be chiefly construction workers involved in minor civil works, who are expected to be locally hired. This ESMF includes an ESMP checklist for the works that contains a section on worker health and safety requirements. The workers will not work in contaminated areas and will be safeguarded with appropriate protective measures that will be detailed in the site-specific ESMP to be prepared. The ESMP will also include information on how workplace grievances can be registered should they arise. 28 https://apps.who.int/iris/bitstream/handle/10665/331695/WHO-2019-nCov-IPC_PPE_use-2020.3-eng.pdf 53 Tajikistan Emergency COVID-19 Project ESMF VII. Public Consultation and Disclosure 118. Consistent with requirements for stakeholder engagement, this section describes the consultation process and how project specific information would be disclosed during development of this particular ESMF. 119. Given the emergency situation and the need to address issues related to COVID-19, no dedicated consultations beyond public authorities and national health experts, as well as international health organizations representatives, have been conducted so far. Table 4, below, summarizes the methods used to consult with key informants. Table 4 – Consultation Methods Used Timetable: Topic of Target Methods used Location and Responsibilities consultation stakeholders dates Development DCC meetings, On need donors, World Bank one-on-one basis, donor Project design international team, MOHSP meetings organizations’ health Leadership offices organizations Sectoral and MOHSP and Health World Bank Institutional Interviews other line institutions Health team Context agencies management MOHSP Project Health PIU, MOHSP Implementing implementation Discussions and Social International agency arrangements Protection department PIU Discussions with ESF team, Community Republican Office of Medical project design outreach Healthy HLSC educators team approaches lifestyle center staff Hospital Management WHO readiness Site visit report 3-6.03.2020 and staff of 4 Consultant assessment hospitals UNICEF Behavior Summary 78 children and Behavior Rapid March 2020 findings adolescents Change Assessment Specialist 54 Tajikistan Emergency COVID-19 Project ESMF Timetable: Topic of Target Methods used Location and Responsibilities consultation stakeholders dates Phone call, e- CEP, MOHSP mail March-April, sanitary and ESF team, ESMF drafting correspondence, 2020 epidemiological MOHSP PIU virtual meetings divisions Virtual consultations via list serve dissemination ESMF draft May, 2020 NGOs, CSOs MOHSP PIU to NGOs/CSOs, publication on the site for comments Disclose at MOHSP Finalization of website and June, 2021 NGOs, CSOs MOHSP PIU ESMF update virtual consultations Proposed strategy for information disclosure and consultation process 120. It is critical to communicate to the public what is known about COVID‑19, what is unknown, what is being done, and actions to be taken on a regular basis. Preparedness and response activities should be conducted in a participatory, community-based way that are informed and continually optimized according to community feedback to detect and respond to concerns, rumours and misinformation. Changes in preparedness and response interventions should be announced and explained ahead of time and be developed based on community perspectives. Responsive, empathic, transparent and consistent messaging in local languages through trusted channels of communication, using community-based networks and key influencers and building capacity of local entities, is essential to establish authority and trust. 121. It will be important that the different activities are inclusive and culturally sensitive, thereby ensuring that the vulnerable groups outlined above will have the chance to participate in the Project benefits. This can include household-outreach and information boards at the village level, the usage of different languages, the use of verbal communication (audio and video clips, pictures, booklets etc.) instead of direct verbal contacts. 122. The project will thereby have to adapt to different requirements. While country- wide awareness campaigns will be established, specific communication around borders and 55 Tajikistan Emergency COVID-19 Project ESMF international airports, as well as quarantine centres and laboratories will have to be timed according to need and be adjusted to the specific local circumstance. 123. Under Component 2, the project will support information and communication activities to increase the attention and commitment of government, private sector, and civil society, and to raise awareness, knowledge and understanding among the general population about the risk and potential impact of the pandemic and to develop multi- sectoral strategies to address the pandemic. A Strategic Coordination Advisor and a Communications Advisor are recruited to support the MOHSP PIU in activities that will include: (a) support to a multisectorial task force to coordinate the COVID-19 emergency response in Tajikistan, and support to national, oblast and district bodies in mobilizing effective response activities (operating expenses, technical assistance, communication costs); (b) development of a national communications and outreach strategy and implementation plan, including social and behavioral communication change across multiple channels, and implementation of community outreach focusing on preventive and social distancing measures aligned to the national communications and outreach strategy, including the development and dissemination of communication materials adapted for target audiences in the relevant languages and Mobile Engage text messaging; (c) training of journalists on responsible reporting and emergency response procedures, covering all media types and national and regional-based outlets; (d) supporting the training and activities which are COVID-19 specific to community public health teams (consisting of primary health care workers and trained community leaders) at jamoat level, coordinated by the Republican Center for Healthy Lifestyles, to increase awareness of preventive measures and promote community participation in slowing the spread of the pandemic. Stakeholder Engagement 124. In compliance with the ESS10, the Stakeholder Engagement Plan (SEP) was prepared and disclosed during the project preparation. SEP was updated accordingly given that AF-1 and AF-2 are effective. It outlines the ways in which the project team will communicate with stakeholders and includes a mechanism by which people can raise concerns, provide feedback, or make complaints about project and any activities related to the project. The involvement of the local population is essential to the success of the project in order to ensure smooth collaboration between project staff and local communities and to minimize and mitigate environmental and social risks related to the proposed project activities. In the context of infectious diseases, broad, culturally appropriate, and adapted awareness raising activities are particularly important to properly sensitize the communities to the risks related to infectious diseases. The SEP has included a detailed mapping of the stakeholders. Individuals and groups likely to be affected (direct beneficiaries) have been identified. Risk-hot spots on the international borders as well as in-country have been delineated. Mapping of other interested parties such as government agencies/authorities, NGOs and CSOs, and other international agencies have also been completed. Drawing upon their expectations and concerns, a SEP has been prepared and disclosed publicly. For more details on the proposed stakeholder engagement activities 56 Tajikistan Emergency COVID-19 Project ESMF please refer to the SEP disclosed in Russian and English at the MOH website 29 and WB portal. 30 SEP will be updated during implementation, if needed. The PIU has also developed and put in place a GRM to enable stakeholders to air their concerns/ comments/ suggestions, if any. Grievance Redress Mechanism (GRM) 125. The main objective of a Grievance Redress Mechanism (GRM) is to assist to resolve complaints and grievances in a timely, effective and efficient manner that satisfies all parties involved. Specifically, it provides a transparent and credible process for fair, effective and lasting outcomes. It also builds trust and cooperation as an integral component of broader community consultation that facilitates corrective actions. Specifically, the GRM: a. Provides affected people with avenues for making a complaint or resolving any dispute that may arise during the course of the implementation of the project; b. Ensures that appropriate and mutually acceptable redress actions are identified and implemented to the satisfaction of complainants; and c. Avoids the need to resort to judicial proceedings. 126. GRM Description. Having an effective GRM in place will also serve the objectives of reducing conflicts and risks such as external interference, corruption, social exclusion or mismanagement; improving the quality of project activities and results; and serving as an important feedback and learning mechanism for project management regarding the strengths and weaknesses of project procedures and implementation processes. 127. Who can communicate grievances and provide feedback? The GRM will be accessible to a broad range of project stakeholders who believe they are affected directly or indirectly by the project. These will include beneficiaries, community members, project implementers/contractors, civil society, media—all of who will be encouraged to refer their grievances and feedback to the GRM. 128. What types of grievance/feedback will this GRM address? The GRM can be used to submit complaints, feedback, queries, suggestions or compliments related to the overall management and implementation of the project activities, including: a. Violation of project policies, guidelines, or procedures, including those related to procurement, labor procedures, child labor, health and safety of contract workers and gender violence; 29 http://moh.tj/social-protection/?lang=en; 30 http://documents.worldbank.org/curated/en/774511585018022894/Stakeholder-Engagement-Plan-SEP-Tajikistan-Emergency-COVID-19- Project-P173765 57 Tajikistan Emergency COVID-19 Project ESMF b. Disputes relating to resource use restrictions that may arise between or among targeted districts and communities; c. Grievances that may arise from members of communities who are dissatisfied with the project planning measures, or actual implementation of project investments; and d. Any issues with land donations, asset acquisition or resettlement specifically for project supported activities. 129. The project specific GRM will be based on the Laws of the Republic of Tajikistan “Appeals of Individuals and Legal Entities” (2016) and “On Civil Service”, as well as the Instructions of the Government of the Republic of Tajikistan “On the Procedures of Records Management on the Appeals of Citizens”. 130. The GRM’s functions will be based on the principles of transparency, accessibility, inclusiveness, fairness and impartiality and responsiveness. GRM Structure. Grievances will be handled at the local and national levels, including via dedicated hotline and MOHSP’s web site - www.moh.tj/covid-19. The project-specific GRM for Component 1 (COVID-19 patients hospitalized in health care facilities where refurbishment is underway, the general population, health care workers, the population at risk over 60 years of age, PLHIV, patients with diabetes mellitus, TB, CVD, viral hepatitis, acute and chronic respiratory diseases) will include the following steps: District level: The grievance is raised to the chief/deputy chief doctor (manager) of the Health centre, Health house or HCF, which is addressed and resolved within 30 days of receiving. The Chief doctor will appoint a responsible grievance filing officer who will be responsible for maintaining a grievance log. National level: The MoHSP shall address and resolve a grievance within 30 days of receiving. If a grievance cannot be resolved or the decision does not satisfy the complainant, then the complainant may directly contact the PIU at the email address: social@tec-19.com. At PIU, a Specialist on Social Issues is responsible for registering and forwarding all grievances and appeals. The project-specific GRM for Component 2 (People with COVID-19 and isolated due to COVID-19, as well as their relatives. A set of people isolated from the community, different nationalities, frustrated family members and uninformed caregivers, terrified family members and nervous people around them. Public health workers) will include the following steps: Grievance filed through the 24/7 COVID-19 hotline or the MOHSP website. 58 Tajikistan Emergency COVID-19 Project ESMF The grievance is submitted to the e-mail address available at the MOHSP website www.moh.tj/covid-19. Grievance shall be addressed and resolved within 30 days of receiving. These complaints will be registered by the PIU's Specialist on Social Issues and the complainant will be informed of the decision immediately, but no later than 5 days from the date of the decision. The hotline operator will redirect project-specific grievances to the PIU, which will maintain a dedicated grievance log. If a grievance cannot be resolved or the decision does not satisfy the complainant, then the complainant may directly contact the Ministry of Health and Social Protection of Population. The project-specific GRM for Component 3 (households with children under 7, women-headed households with children under 16, and households with children with disabilities under 18) will include the following steps: District level: A grievance filed through the Local executive authority to the Deputy Chair in charge of Social Protection (who handles TSA related complaints). That Deputy Chair will appoint a Grievance Focal Point who will be responsible for maintaining a grievance log. Agency for Social Protection of Population maintains a procedure for assigning and paying targeted social assistance to low-income families and is responsible for the correct determination of the low-income households and citizens; same procedure will applied for the one-off Emergency cash transfers. Local executive authority, in order to prevent corruption and ensure transparency, shall create local committees and determine its composition and powers. The project-specific GRM for Component 3 will be guided by the GRM set at the Agency for Social Protection of Population. During the implementation of the project activities, if necessary, the Emergency cash transfers GRM will be updated. National level: If a grievance cannot be resolved or the decision does not satisfy the complainant, then the complainant may directly contact the State Agency for Social Protection (an authorized body for Emergency cash transfers) and/or PIU. 24/7 Hotline and website level. Project stakeholders and citizens can submit complaints on any issues by addressing the hotline established by the MOHSP at the national level. The hotline number is 511. The hotline operator will accept and register all complaints and grievances received through phone calls, letters, SMS and e-mail messages. The hotline center will forward all grievances for further consideration to the Grievance Management Group at the MOHSP PIU described below. Citizens can also file their complaints through the MOHSP website at www.moh.tj/covid-19, as well as through the MOHSP’s official pages in Facebook, or via regional dedicated phone lines: • Dushanbe: 903-20-00-47; (44) 600-65-14; 901-55-09-09; 55-805-81-11 • GBAO: 93-584-37-70 • Bokhtar: 907-75-47-00 59 Tajikistan Emergency COVID-19 Project ESMF • Kulob: 904-43-77-17 • Sugd: 92-712-03-30 The GRM will establish clearly defined timelines for acknowledgment, update and final feedback to the complainant: • Confirmation of receipt of the complaint - no later than 5 days from the date of receiving and registration of the complaint; • Handling of the complaint - no more than 30 days from the date of receiving and registration of the complaint; • Providing a response to the person who submitted the complaint - no later than 45 days from the date of receiving and registration of the complaint To enhance accountability, these timelines will be disseminated widely to the project stakeholders. The timeframe for resolving the complaint shall not exceed 30 days from the time that it was originally received; if an issue is still pending by the end of 30 days, the complainant will be provided with an update regarding the status of the grievance and the estimated time by which it will be resolved; and all grievances will be resolved within 45 days of receipt. Appeal Mechanism. If the complaint is still not resolved to the satisfaction of the complainant, then s/he can submit his/her complaint to the appropriate court of law. The Project Implementation Unit made a decision to perform the Hotline Assessment. To assess the Hotline, the “Yakdu” company was involved. The Hotline Assessment was carried out in March 2021. After conducting the Hotline Assessment and providing recommendations, the specialists of the PIU of the MOHSP began to develop the necessary forms and protocols for recording and registering incoming complaints. In the event of a COVID-19 emergency, existing complaint and complaint procedures should be used to encourage reporting of coworkers if they manifest any symptoms such as persistent and severe coughing with fever, and if they do not voluntarily show up for testing. In the event of an emergency, there are many other channels available in rural areas through which rural residents (including those living in remote areas) can get access to relevant information and submit emergency notifications. Mahalla leaders, village-level jamoat representatives, and volunteers from the International Red Crescent Society and the Youth Committee can be critical resources for volunteering in the community when needed. Grievance Logs 131. The Grievance Focal Points (GPFs) will maintain local grievance logs to ensure that each complaint has an individual reference number and is appropriately tracked, and recorded actions are completed. When receiving feedback, including grievances, the 60 Tajikistan Emergency COVID-19 Project ESMF following is defined: • Type of appeal; • Category of appeal; • People responsible for the study and execution of the appeal; • Deadline of resolving the appeal; and • Agreed action plan 132. The GFPs will ensure that each complaint has an individual reference number and is appropriately tracked, and recorded actions are completed. The log should contain the following information: • Name of the project affected party, his/her location and details of his / her complaint; • Date of reporting by the complaint; • Date when the Grievance Log was uploaded onto the project database; • Details of corrective action proposed, name of the approval authority; • Date when the proposed corrective action was sent to the complainant (if appropriate); • Details of the Grievance Committee meeting (if appropriate); • Date when the complaint was closed out; and • Date when the response was sent to the complainant. 133. The PIU Social Development Specialist is the person responsible for recording and filing complaints, who can be contacted via social@tec-19.com 5.3 Grievance Monitoring and Reporting 134. The MOHSP PIU M&E Specialist will be responsible for: • Collecting and analyzing the qualitative data from GFPs on the number, substance and status of complaints and uploading them into the single project database; • Monitoring outstanding issues and proposing measures to resolve them; and • Preparing quarterly reports on GRM mechanisms to be shared with the World Bank. 135. Quarterly reports to be submitted by World Bank shall include Section related to GRM which provides updated information on the following: • Status of GRM implementation (procedures, training, public awareness campaigns, budgeting etc.); • Qualitative data on number of received grievances \ (applications, suggestions, complaints, requests, positive feedback), highlighting those grievances related to the involuntary resettlement and number of resolved grievances, if any; • Quantitative data on the type of grievances and responses, issues provided and grievances that remain unresolved; 61 Tajikistan Emergency COVID-19 Project ESMF • Level of satisfaction by the measures (response) taken; • Any correction measures taken. World Bank Grievance Redress System 136. Communities and individuals who believe that they are adversely affected by a World Bank supported project may submit complaints to existing project-level grievance redress mechanisms or the World Bank’s GRS 31 . The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the World Bank’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of World Bank non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank’s attention, and Bank Management has been given an opportunity to respond. Institutional Arrangements, Responsibilities and Capacity Building 137. The Ministry of Health and Social Protection is the implementing agency for the project. It is designated as the central operational body within the Government and Standing Headquarters for COVID-19 prevention and response. The Project Implementation Unit (PIU) of the World Bank-funded Social Safety Network Strengthening Project (SSNSP) functioning under the MOHSP is responsible for the day- to-day management of project activities. The SSNSP was closed on June 30, 2020 and the PIU staff has gradually transferred to implement the project components, including those related to stakeholder engagement plan update and implementation. The PIU has also deployed the staff needed for proper implementation of the environmental and social framework elements of the project, as this project is implemented under the new ESF standards. 138. The MOHSP is the overall implementing agency for the Project. State Agency on Social Protection (SASP) under the MOHSP will ensure the implementation of Component 3 (temporary social support for vulnerable households), given that this agency is responsible for the overall Targeted Social Assistance (TSA) system. The MOHSP is the designated central operational body within the Government and Standing Headquarters, which is also responsible for coordination and liaison with development and humanitarian partners. The Minister of Health and Social Protection will be the Project Director. The Minister of Health and Social Protection will delegate day-to-day operational issues, including Project signatory rights in procurement, financial management etc., to the Deputy Minister of Health and Social Protection acceptable to the Association, who will be the Project Coordinator. The Project Coordinator will report twice a month to the Standing Headquarters and Prime Minister on project activities as part of the overall COVID-19 31 For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org. 62 Tajikistan Emergency COVID-19 Project ESMF response. 139. The MOHSP’s Division of Sanitary and Epidemiological Safety, Emergencies and Emergency Medical Care (DSESEEMC) will be responsible for the day-to-day management and coordination of COVID-19 response activities supported under Components 1 and 2 of the Project. Component 3 activities will be coordinated with the MOHSP’s Division for Social Protection of Population (DSPP) and technically managed by the SASP under the MOHSP. The MOHSP’s Division for Health Care Economics and Budget Planning will be overseeing proper and timely execution of financial management (FM) functions and funds flow under the Project. In addition, other technical divisions at the MOHSP, research institutes, national medical services, regional and local health authorities, community councils, religious leaders, and other key agencies will be involved in project activities based on their functional capacities and institutional mandates. 140. The new PIU supports the DSESEEMC and SASP/DSPP, and directly implement certain technical activities, including procurement of medical supplies, equipment, and facility repurposing works for activities under Component 1 as well as selected activities under Component 2. The PIU is also responsible for preparing a consolidated annual workplan and a consolidated activity and financial report for the project components. For Components 1 and 2 directly related to COVID-19, the PIU will report to the Deputy Minister of Health and Social Protection/National Coordinator for COVID-19 Counteraction; while for Component 3, the PIU will report to the Deputy Minister of Health and Social Protection in charge of social protection area through SASP similar to the current arrangements for SSNSP. 141. The nature of the project requires a partnership and coordination mechanisms between national, regional and local stakeholders. 63 Tajikistan Emergency COVID-19 Project Annex I ESMF Screening Form Annex I - Screening Form for Potential Environmental and Social Issues This form is to be used by the Ministry of Health and Social Protection (MOHSP) Project Implementation Unit (PIU) and relevant healthcare facilities (HCF) to screen potential environmental and social risk levels of a proposed subproject under the Tajikistan COVID- 19 Emergency Project. The screening will determine the relevance of Bank environmental and social standards (ESS), propose its environment and social risk levels, and the instrument to be prepared for the sub project. It is noted that the ESCP sets out the following list of activities that are excluded from financing under the project: a. Activities that may cause long term, permanent and/or irreversible (e.g. loss of major natural habitat) adverse impacts on the environment; b. Activities that may have significant adverse social impacts and may give rise to significant social conflict; c. Activities that may affect lands or rights of indigenous people or other vulnerable minorities; and d. Activities that may involve permanent resettlement or land acquisition or adverse impacts on cultural heritage. e. Any other actions excluded by this ESMF. Subproject Name Subproject Location Subproject Proponent (HCF) Estimated Investment Start/Completion Date 64 Tajikistan Emergency COVID-19 Project Annex I ESMF Screening Form Questions Answer ESS Due relevance diligence / yes no Actions Does the subproject involve civil works ESS 1 Activity that include new construction or the excluded expansion of the HCF? Does the subproject involve civil works ESS 1 ESMP, including upgrading or rehabilitation of ICWMP, SEP the HCF and/or associated waste management facilities? Is the subproject associated with any ESS3 ESMP, external waste management facilities ICWMP, SEP such as a sanitary landfill, incinerator, or wastewater treatment plant for healthcare waste disposal? Is there sound regulatory framework, ESS1 ESMP, institutional capacity in place for HCF ICWMP, SEP infection control and healthcare waste management? Does the subproject involve recruitment ESS2 ESMP, SEP of workforce including direct, contracted, primary supply, and/or community workers? Does the subproject involve ESS3 ICWMP, SEP transboundary transportation of specimen, samples, infectious and hazardous materials? Does the subproject involve use of ESS4 ESMP, security personnel during construction ICWMP, SEP and/or operation of healthcare facilities? Is the subproject located within or in the ESS6 Activity vicinity of any ecologically sensitive Excluded areas? 65 Tajikistan Emergency COVID-19 Project Annex I ESMF Screening Form Are there any vulnerable groups, living ESS7 Not in the area of the sub-project that are applicable likely to be negatively or positively affected by the proposed sub-project? Is the subproject located within or in the ESS8 ESIA/ESMP, vicinity of any known cultural heritage SEP sites? Does the project area present ESS1 ESIA/ESMP, considerable Gender-Based Violence SEP (GBV), Sexual Exploitation and Abuse (SEA), and Sexual Harassment (SH) risks? Is there any territorial dispute between OP7.60 Governments two or more countries in the subproject Projects in concerned and its ancillary aspects and related Disputed agree activities? Areas Will the sub project and its ancillary OP7.50 Notification aspects and related activities involve the Projects on use or potential pollution of, or be International (or located in international waterways 32? Waterways exceptions) Conclusions: 1. Proposed Environmental and Social Risk Ratings (High, Substantial, Moderate or Low). Provide Justifications. 2. Proposed environment and social Instruments. i. ESMPs – after the screening, ESMPs, based on the sample found in Annex II, will be prepared for any small-scale works to be conducted at an associated HCF including the creation or rehabilitation of ICUs, the installation of box chambers, the rehabilitation of laboratories, the rehabilitation or installation of sanitary stations and hand washing facilities; ESMP also provides recommendations for installation and safe operation of oxygen refilling stations. Once approved (see below), the 32 International waterways include any river, canal, lake or similar body of water that forms a boundary between, or any river or surface water that flows through two or more states. 66 Tajikistan Emergency COVID-19 Project Annex I ESMF Screening Form ESMP will be included as an integral part of any works or supervision contract for the activity. If the HCF undertakes the works on its own, the ESMP will remain applicable for the activities being undertaken. ii. ICWMPs – each HCF will prepare and implement an ICWMP, based on the sample found in Annex III. Given the potential lack of testing availability in some areas of Tajikistan, ICWMP protocols for individual HCFs will be implemented on the assumption that the COVID-19 pathogen is present and that all healthcare workers and patients are potential carriers. iii. SEP – an SEP has been prepared for the project and it is applicable to all project financed activities. Individual HCFs will augment the overall SEP with a site-specific SEP to ensure patients and their families, local authorities, and the general public are aware of the situation and have access to community-based hotlines, GRMs, and other important information channels. 67 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist Annex II - ESMP Checklist Introduction. The project was prepared under the World Bank’s Environment and Social Framework (ESF). An Environmental Risk Rating of "Substantial" and a Social Risk Rating of “Substantial”, resulting in an overall ESF Risk Rating of Substantial. This Environmental and Social Management Plan (ESMP) has been developed in accordance with ESS 1 and the project-specific Environmental and Social Management Framework developed for Dushanbe City Infectious Diseases Hospital (IDH). The purpose of this ESMP is to identify and further manage environmental and social risks and impacts during refurbishment works at the HCF (Healthcare facility) as part of the Tajikistan Emergency COVID-19 Project (hereinafter referred to as the Project). The ESMP also has a checklist that identifies the main risks and outlines mitigation measures for environmental and social impacts, as well as a plan for monitoring the implementation of the ESMP. Many of the mitigation measures and best practices presented in the World Bank Group Environmental Health and Safety (Occupational Safety) Guidelines, WHO technical guidance documents and other GIIPs were used while developing the ESMP. In identifying mitigation measures, the views of stakeholders, with the direct involvement of healthcare professionals and medical waste management specialists, were taken into account. The Infection Control and Waste Management Plan (hereinafter - ICWMP) is an integral part of the ESMP. 68 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist PART A: GENERAL PROJECT AND SITE INFORMATION INSTITUTIONAL & ADMINISTRATIVE Country Tajikistan Project title Tajikistan Emergency COVID-19 Project Scope of the Prevent, detect and respond to the COVID-19 threat and strengthen project and the preparedness of national health system. project activities Scope of site- specific activity Institutional Task Team Leader: Environmental specialist arrangements (WB) Social development specialist Implementation Implementing entity: Works supervisor: Works contractor: arrangements Ministry of Health Republic of and Social Tajikistan Protection of Population SITE DESCRIPTION Name of institution whose premises are to be rehabilitated Address and site location of institution whose premises are to be rehabilitated Who owns the land? Who uses the 69 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist land (formal/informal )? Description of physical and natural environment, and of the socio- economic context around the site Locations and distance for material sourcing, especially aggregates, water, stones? LEGISLATION List of National Laws and Regulations National & local Table 1 legislation & Title of Legal Document Line Ministry/Agency permits that responsible for implementation apply to project and enforcement activity Law on Environment Protection, Committee for Environment 2011 (2017) Protection Water Code, 2000 (2012) Ministry of Energy and Water Resources Law on Ecological Monitoring Committee for Environment 2011 (2014) Protection Law on Ecological Education of Committee for Environment Population, 2010 Protection Law on State Ecological Committee for Environment Expertise, 2012 Protection Law on Targeted Social Ministry of Health and Social Assistance, 2017 Protection of Population Law on Appeals of Individuals All state and non-state bodies and Legal Entities, 2016 Law on Public Associations, Ministry of Justice 2007 (2019) 70 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist Law on Local Governments Local municipalities/ administrations Public Health Code, 2017 Ministry of Health and Social Protection of Population Law on Production and State Unitary Enterprise “Khogajii Consumption Waste 2002 Manziliyu Kommunali” (2011) Order on Healthcare Waste Ministry of Health and Social Management No. 272, 2005 Protection of Population Regulation on Emissions No. Committee for Environment 800 Protection Sanitarian Rules on Safe Ministry of Health and Social Handling of Healthcare Waste, Protection of Population 2009 San Pin 2.1.7.020-09. Sanitary Ministry of Health and Social protection of soils - rules for the Protection of Population, WHO collection, storage and disposal of waste from healthcare facilities, 2019 List of International Treaties and Convention ratified by Tajikistan. Table 2 Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal (2016) Convention on Biological Diversity (1997) and to its Cartagena Protocol on Biosafety (2004) Convention for the Protection of the World Cultural and Natural Heritage (1992) Convention for the Safeguarding of the Intangible Cultural Heritage (2006) International Covenant on Economic, Social and Cultural Rights Convention on the Elimination of all forms of Discrimination Against Women Labor Inspection Convention (2009) The United Nations Convention on the Rights of the Child (1993) WB Environmental and Social Standards: ESS 1 – Assessment and Management of Environmental and Social Risks and Impacts; ESS 2 – Labor and Working Conditions; 71 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist ESS 3 – Resource Efficiency and Pollution Prevention and Management; ESS 4 – Community Health and Safety; ESS10 – Stakeholder Engagement and Information Disclosure. World Bank Group Environmental, Health, and Safety Guidelines (known as the "EHS Guidelines"): (a) EHS 2.5 – Biological Hazards; (b) EHS 2.7 – Personal Protective Equipment (PPE); (c) EHS 3.5 – Transport of Hazardous Materials; and (d) EHS 3.6 – Disease Prevention; IFC: Environmental, Health, and Safety Guidelines for Health Care Facilities; World Health Organization technical guidance on: - Laboratory biosafety, - Infection prevention and control, - Rights, roles and responsibilities of health workers, including essential aspects of occupational safety and health, - Water supply, sanitation, hygiene and waste disposal, - Quarantine of persons, - Rational use of PPE, - Oxygen Sources and their Distribution for COVID-19 Treatment Facilities. PUBLIC CONSULTATION When / where the public consultation process will take /took place ATTACHMENTS Attachment 1: Site plan / photo Attachment 2: Safety measures for the use of oxygen in the Healthcare Facilities Attachment 3: Infection Control and Waste Management Plan (ICWMP) Attachment № 4: Construction waste collection / disposal contract (as required) Other permits/agreements – as required 72 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist PART B: ENVIRONMENT AND SOCIAL INFORMATION ENVIRONMENTAL /SOCIAL SCREENING Activity/Issue Status 1. Building rehabilitation 2. Small-scale construction at existing facilities 3. Individual wastewater treatment system 4. Historic buildings and areas 5. Acquisition of land 6. Hazardous or toxic materials 7. Traffic and Pedestrian Safety 8. Social Risks 73 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist PART C: MITIGATION MEASURES ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST RESPONSIBILITY Section A. Air Quality General Rehabilitation Noise and /or Construction Water Quality Activities Waste management Section B. Water Quality Individual wastewater treatment system Section C. Asbestos Toxic management Materials Toxic / hazardous waste management Section D. Direct or Traffic and indirect hazards Pedestrian to public traffic Safety and pedestrians by construction 74 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist activities Section E. Public Social and relationship Labor Risk management Management Public Safety Labor issues management Worker health and safety requirements TSA social exclusion risks 75 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist PART D: MONITORING PLAN What Where How When Why Who Activity (Is the (Is the (Is the (Define the (Is the (Is responsible parameter to be parameter to be parameter to be frequency / or parameter being for monitoring?) monitored?) monitored?) monitored?) continuous?) monitored?) CONSTRUCTION PHASE Transportation of construction materials and wasteMovement of construction machinery Maintenance of construction equipment Generation of construction waste Production of domestic wastes Construction site re-cultivation and landscaping Workers’ health and safety, labor issues 76 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist OPERATION PHASE Medical waste - Separation of Premises of - Inspection of Total period of - Maintenance management medical waste HCF HCF premises; operation of the of good from other types facility sanitary of waste - Checking conditions at generated at presence and HCF; HCF; validity of waste removal and disposal agreement with a licensed entity Household waste management Operation and maintenance of the healthcare waste incinerator Emergency - preparedness 77 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist RECOMMENDATIONS FOR THE USE OF OXYGEN IN HCFs Recommendation Recommendations to be followed by the senior management of Healthcare Facility Scope of Liquid oxygen is a blue liquid, odorless, not fire-explosive, not The chief doctor of the HF must provide application flammable, but is a strong oxidizing agent. Combustible porous materials information support (information impregnated with liquid oxygen (asphalt, expanded polystyrene, posters, prohibitory and guiding signs, polyurethane foam, wood, etc.) form explosives of high sensitivity - stickers) on the use of oxygen stations oxyliquits. Liquid oxygen is dangerous for living organisms. Contact with and cylinders in the HF. liquid oxygen on open areas of the body causes frostbites, as well as Arrange training of personnel on the damage to the mucous membrane of the eyes. use, risks and safety measures of oxygen stations and cylinders. This Standard specifies the design and installation requirements for an Training on the safety measures of oxygen concentrator supply system used in a medical gas pipeline system oxygen stations and cylinders in the HF in accordance with ISO 7396-1. to be conducted at least once a month. These recommendations apply only to piped supply systems with oxygen concentrators that produce oxygen-enriched air with an oxygen concentration of at least 90%. This standard applies to oxygen concentrators for use in healthcare facilities. Specific 1. Installation of the oxygen production units in residential, public and The chief doctor of the HF must requirements for domestic buildings, as well as in the premises adjacent to them, is not appoint (approve) the focal points for the premises and allowed, installation in premises adjacent to other industrial buildings is monitoring (overseeing) the safety of placement of allowed, provided that they are separated from the building by a solid oxygen use in the HF by an internal equipment for wall. order. oxygen stations 2. It is not allowed to place oxygen equipment in rooms adjacent to explosive and chemically hazardous industries as it may cause corrosion of equipment or have a harmful effect on the human body. It is also not 78 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist allowed to install oxygen equipment to any rooms adjacent to any dust emitting facility. 3. It is not allowed to store explosive and flammable materials in the room where the oxygen equipment is installed. 4. The placement of equipment in the premises should ensure the possibility of inspection, repair and cleaning from the inside and outside. Walkways between equipment must be at least 1.5 m, and the distance between equipment and walls must be at least 1.0 m 5. Doors and windows of premises must open outward. 6. Installation in production facilities is carried out in accordance with industry safety rules. 7. Electrical equipment must comply with the requirements for the P-1 fire hazard zone according to the EIC and industry regulatory and technical documentation. 8. The premises must have a concrete floor, be equipped with fire detection, fire extinguishing and air control systems, general air exchange and emergency ventilation, heating, lighting, communications and have a ground loop in accordance with the necessary regulatory requirements. 9. The volume fraction of oxygen in the indoor air must be at least 19% and not more than 23%. 10. Dust accumulation on engineering structures and equipment is not allowed 11. All rooms must have a concrete floor, supply and exhaust ventilation and a ground loop. 12. The compressor and generator rooms must be dry and dust-free. The room temperature should not be lower than +10 С0 and not exceed +35 С0 13. In the compressor room or nearby, special places should be provided for closed storage of cleaning materials, tools, consumables and operating materials, etc., as well as for storing of spare oil. 79 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist 14. The compressor and generator rooms must have operational communication equipment, first aid kits and a supply of drinking water. 15. To reduce the impact of vibrations caused by the operation of the compressor, the following should be observed: the connection of the pipelines with the compressors should be made with flexible hoses or expansion joints. 16. Air collectors and receivers should be installed in places free from concourse. The distance between the air collectors must be at least 1.5 m, and between the air collector and the wall - at least 1.0 m 17. Pipelines should be laid at a distance of at least 0.5 m from electrical wires and other electrical equipment. 18. Pipes and pipe fittings must be made of steel. Pipelines passing through walls or floors of buildings should be enclosed in special sleeves or cases. Welded and threaded pipe connections inside cases or sleeves are not allowed 19. The inner diameter of the sleeve is taken to be 10-12 mm larger than the outer diameter of the pipeline 20. Piping should be mounted on supports or hangers. General 1. The oxygen supply system must be installed in accordance with the The chief doctor, deputy chief doctor guidelines for manufacturer's instructions in a well ventilated and fire resistant room. on Housekeeping Unit and focal points placement of Depending on the specific conditions, it is allowed to install some of the HF must provide information oxygen delivery components (for example, cylinders), outdoors, protected from support (information posters, systems meteorological conditions and in a fenced area. Regional or national prohibitory and guiding signs, stickers) regulations, if any, may apply for the installation site of the supply on the use of oxygen stations and system. cylinders in the HF. 2. Access to the premises in which the cylinders are located and to the protected areas must be multi-tier: such premises shall be kept clean. All doors must at any time be properly opened from the inside without a key, and should also be opened from the outside. Doors and gates of rooms or fences separating the source of oxygen supply must be properly closed. There must be at least one emergency exit, which must 80 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist be clear of obstructions at all times and lead to outdoor or some other safe location. З. Premises or areas for oxygen supply systems should not be used for any other purpose. 4. Only designated personnel should be allowed to operate and maintain the oxygen supply equipment. 5. Cylinders should be stored in accordance with the supplier's/manufacturer’s recommendations. For one side of the manifold, one group of filled cylinders is sufficient, which can be stored in the same room or in the same area. Empty cylinders, disconnected from the supply equipment, can be stored pending transfer. Filled and empty cylinders should be kept isolated from each other and the areas where they are stored should be marked 6. Systems or containers with flammable gases or liquids should not be stored in or near the location of the oxygen supply system. 7. The heating system can be used to heat fenced or guarded areas, for which it is determined that the temperature of no part of the heating system in contact with the air inside the room does not exceed 225 °C and that the cylinders do not come into contact with the heating system 8. The positions of all electrical lighting fixtures should be fixed and protected to minimize the risk of physical damage. 9. Fire extinguishing equipment should be provided. 10. The room or fenced area must be clean and well lit. 11. Fencing (internal or external) for the oxygen supply system must meet the following requirements: a) when the fence is near a heat source, for example, near a stove, incinerator or boiler room, its design must prevent the cylinder from heating above 40 ° C: b) the fence should be located at least 3 m from open-type electrical wires or transformers: c) the fence should not be located near the storage area of the oil tanks: 81 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist d) the fencing must be performed in accordance with local construction codes; e) fences must have concrete floors; f) warning signs and labels must be located on both sides of each door For instance: Attention - Oxygen!!! No smoking!!! Avoid open flame or sparks!!! Do not use oil or lubricants!!! Do not use flammable materials at a distance near than 5 m!!! g) the height of fences and walls must be at least 1.75 m. 12. The fencing must be easily accessible for transporting empty cylinders and must be installed at ground level or at vehicle height, depending on the loading method used. 13. The fence must be at least 3 m away from residential buildings, roadways or sidewalks. 14. Hand-held mobile devices, such as specially designed trolleys, must be provided to move the cylinders. Recommendations 1. Before installing a supply system with an oxygen concentrator, the Persons at least 18 years of age who for installation installing team/person should ensure that the piping system to which the have passed a medical examination, concentrator is to be connected complies with the ISO 7396-1. relevant training and certified may be Requirements. allowed to preventive maintenance of 2. Before installing a supply system with an oxygen concentrator, the cylinders and pipelines. manufacturer should assess the natural and geographical conditions of the intended location in terms of factors that may affect the reliability A periodic check of the theoretical and duration of the system performance. knowledge and practical skills of the 3. The ambient air supplied to the oxygen concentrator supply system operating personnel should be carried should be taken from a place that is minimally contaminated with out at least once every 12 months. exhaust from internal combustion engines, anesthetic gases from their evacuation systems, ventilation, vacuum relief systems and other Persons who have not passed the sources of contamination. knowledge test on occupational safety issues in the permanent commissions 82 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist 4. Oxygen concentrator supply systems should be installed in a well-lit, of institutions and do not have a ventilated environment, in clean and reasonably accessible places certificate shall not be allowed to 5.Special precautions may be necessary to allow gases to escape from unsupervised work. the work area and safely disperse into the atmosphere. 6. Oxygen concentrator supply systems, especially oxygen concentrator components including air compressor (s), and if required vacuum pump (s), should be located separately from other medical gas supply systems, excluding air compressors and vacuum pumps. 7. Means should be provided to reduce the transmission of vibrations from the supply system to the pipeline. 8. Means should be provided to ensure that the noise level from the operation of the supply system complies with any local, regional and other regulations in force. 9. If required, drainage should be provided for items such as receivers.. 10. Work and emergency alarms, according to their intended use, should be located in at least one occupied room 11. Due to the high power consumption of the oxygen concentrator- based supply system, power upgrades may be required Dangers when Working with oxygen is associated with the following hazards: Chief doctor, deputy chief doctor on working with - ignition of equipment, pipelines and fittings operating with oxygen or Housekeeping Unit and focal points oxygen air with an increased oxygen content; for the safety of operation of oxygen - ignition of clothing and hair of maintenance personnel in an stations and cylinders at HF: environment of gaseous oxygen or air with an increased oxygen content; - explosion of hydrocarbons and other explosive impurities when their If anyone’s clothes catch fire, he/she content in liquid oxygen is exceeded; should immediately dip into a bathtub - explosion when impregnating porous organic materials with liquid of water or get under an emergency oxygen (asphalt, polystyrene, wood, etc.); shower. In the absence of water, - structural and sealing non-metallic materials (fiber, nylon, clothing should be thrown off polycarbonate, rubber based on natural gum elastic, etc.) can easily immediately or ripped off the hurt ignite in high-pressure oxygen when exposed to an ignition source man. Clothes saturated with oxygen can burn for some time without oxygen, so you should not shoot down 83 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist the flame or wrap the victim in a felted cloth. Recommendations 1 General requirements The chief doctor of the HCF must for emergency 1.1 A sudden cease or decrease in gas supply in one or more ensure the availability of technical procedures departments of the healthcare facility may lead to emergencies. In these documentation for each pipeline. cases, it is vital to establish procedures that can guarantee the following Documentation includes: prompt actions: -welding log; - notifying about problems affecting people and premises; - pipeline executive diagrams; - protection of gas supply; - the certificate of completion of the - repair measures. installation of oxygen pipelines; 1.2. For fire safety measures, national and local regulations may apply. - Certificates of degreasing of oxygen pipelines and the quality of their inner 2 Notification surface; 2.1 Procedures should be established to ensure that any emergency that - Certificates of testing oxygen occurs is immediately communicated to all departments within the pipelines for strength and density. healthcare facility and to all technical personnel involved in gas supply and repair. During operation, pipelines must be 2.2 Such notification will include: subject to operational and periodic a) the nature of the emergency: control. b) its likely duration: c) details of the procedures applied for the repair of the gas supply: Operational supervision is carried out d) remedial actions (repair). at least once a month. During winter, 2.3 Qualified personnel should be dispatched to each room of the the condition of the steam traps is healthcare facility to coordinate and report required actions. checked daily. 2.4 In accordance with the World Bank Guidelines for Responding to Environmental and Social Incidents (ESIRT), it is necessary to Malfunctions and defects discovered immediately (within 48 hours) notify the WB of any incidents or during the inspection, as well as the accidents related to the Project that have or may have a significant terms and methods for their correction adverse impact on the environment, the population or workers. Provide should be recorded in the pipeline information in sufficient detail about the incident or accident, indicating operation log signed by the persons that immediate remedial action has been taken or planned, and any who discovered and corrected such information provided by any contractor and regulatory authority, as 84 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist appropriate. Subsequently, at the request of the Bank, prepare a report defects, as well as those responsible on the incident or accident and propose any measures to prevent their for the maintenance of the pipelines. recurrence. All personnel authorized to work with З. Gas supply protection oxygen must be trained and have 3.1 Once informed about the emergency, emergency focal point in each practiced emergency response tactics. clinic room should reduce the use of pipeline gas to the required minimum level. Provide oxygen training at least 3.2 During emergency, technical personnel should check at all points of quarterly. use, connected cylinders on the back-up pipeline, gas storage cylinders and auxiliary equipment 3.3 If necessary, an additional supply of gas should be provided by suppliers or other health care providers in accordance with the expected duration of the emergency. 4 Maintenance and repair activities 4.1 If the gas supply is not available, the cause of the malfunction should be immediately identified and remedial action shall be taken. 4.2 Investigation of the cause of the malfunction may indicate that other areas of the healthcare facility not affected by the malfunction may need be isolated during repairs. In this case, warning and protection procedures should be carried out in these rooms before the gas supply is interrupted. 4.3 Repairs should be carried out using an effective method of monitoring the integrity of the system. 5 Training 5.1 Technicians should be trained in the use of medical gases and piping systems and be familiar with the location of the medical gas piping and the location of all shut-off valves. 85 Tajikistan Emergency COVID-19 Project Annex II ESMF ESMP Checklist 5.2 Emergency trainings should be conducted at least twice a year. It is advisable to eliminate any possible problems and provide the necessary retraining. 5.3 Real emergencies should be assessed and appropriate actions taken to improve procedures and training. 6 Additional spare cylinders 6.1 It is recommended that additional spare cylinders are not connected to the supply source and connected (to supply sources) back-up cylinders. The amount of additional supplies should be calculated based on normal daily gas consumption, the location of the supply sources and the maintenance/repair procedures that will be required in the event of a supply system malfunction. 6.2 Intensive care facilities require their own spare cylinders to minimize gas supply delays in an emergency. If cylinders with attached pressure regulators are used for this purpose, then their outlets should allow the connection of only a certain gas and be connected to low pressure gas supply hoses. 86 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Annex III - Infection Control and Waste Management Plan (ICWMP) Template 1. Introduction 1.1 Describe the project context and components; 1.2 Describe the targeted healthcare facility (HCF): - Type: E.g. general hospital, clinics, inpatient/outpatient facility, medical laboratory; - Special type of HCF in response to COVID-19: E.g. existing assets may be acquired to hold yet-to-confirm cases for medical observation or isolation; - Functions and requirement for the level infection control, e.g. biosafety levels; - Location and associated facilities, including access, water supply, power supply; - Capacity: beds 1.3 Describe the design requirements of the HCF, which may include specifications for general design and safety, separation of wards, heating, ventilation and air conditioning (HVAC), autoclave, and waste management facilities. 2. Infection Control and Waste Management 2.1 Overview of infection control and waste management in the HCF - Type, source and volume of healthcare waste (HCW) generated in the HCF, including solid, liquid and air emissions (if significant); - Classify and quantify the HCW (infectious waste, pathological waste, sharps, liquid and non-hazardous) following WGB EHS Guidelines for Healthcare Facilities and pertaining GIIP. - Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non-hazardous may be considered hazardous. It’s likely the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak. Special attention should be given to the identification, classification and quantification of the healthcare wastes. - Describe the healthcare waste management system in the HCF, including material delivery, waste generation, handling, disinfection and sterilization, collection, storage, transport, and disposal and treatment works; 87 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template - Provide a flow chart of waste streams in the HCF if available; - Describe applicable performance levels and/or standards; - Describe institutional arrangement, roles and responsibilities in the HCF for infection control and waste management. 2.2 Management Measures - Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety consideration. - Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of the hazardous medical goods. - Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. - Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. - Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours. - Onsite waste treatment and disposal (e.g. an incinerator): Many HCFs have their own waste incineration facilities installed onsite. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended. Good design, operational practices and internationally adopted emission standards for healthcare waste incinerator can be found in pertaining EHS Guidelines and GIIP. - Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well-performed incinerator onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government 88 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template or private sector are probably needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. - Wastewater treatment: HCF wastewater is related to the hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged. In cases where municipal sewage system is not in place, HCF should build and proper operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There’re also cases HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted. 3. Emergency Preparedness and Response Emergency incidents occurred in an HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, community, HCF’s operation and the environment. Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed. The key elements of an ERP are defined in ESS 4 Community Health and Safety (para. 21). 4. Institutional Arrangement and Capacity Building A clearly defined institutional arrangement, roles and responsibilities should be included. A training plan with recurring training programs should be developed. The following aspects are recommended: - Define roles and responsibilities along each link of the chain along the cradle-to- crave infection control and waste management process; - Ensure adequate and qualified staff are in place, including those in charge of 89 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template infection control and biosafety and waste management facility operation. - Stress the chief of an HCF takes overall responsibility for infection control and waste management; - Involve all relevant departments in an HCF, and build an intra-departmental team to manage, coordinate and regularly review the issues and performance; - Establish an information management system to track and record the waste streams in HCF; and - Capacity building and training should involve medical workers, waste management workers and cleaners. Third-party waste management service providers should be provided with relevant training as well. Specific topics to be included in the training plan, as agreed in the ESCP, include, but are not limited to: - Recommendations; - Laboratory biosafety guidance related to the COVID-19; - Specimen collection and shipment, both within Tajikistan and abroad; - Standard precautions for COVID-19 patients; - Risk communication and community engagement; and - WHO guidelines on quarantine and Tajikistan Sanitary Regulations and Norms. 5. Monitoring and Reporting Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams. HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow. As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing system should be in place. Externally, reporting should be conducted per government and World Bank requirements. 90 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Table 1 – ICWMP Potential environment Proposed Mitigation Key Activities and social Issues and Responsibilities Timeline Budget Measures Risks The Head of the Medical General HCF operation – • General wastes, Facility must issue an order Environment wastewater and air to supervise the emissions environmental quality of the Medical Facility with the appointment of responsible persons, as part of the response to COVID-19. General wastes must be handled within the framework of national Head of Medical standards. Medical Facility Within the Facility and wastewater must be Ongoing Medical Facility Infection Control disinfected in accordance budget Team with the regulations for channeling of wastewater to the centralized sewer systems. All soil, water and air safety measures are carried out within the framework of "Sanitary Rules and Standards" 2.1.7.020-09" of 2019. 91 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Potential environment Proposed Mitigation Key Activities and social Issues and Responsibilities Timeline Budget Measures Risks Conducting daily rounds of General HCF operation – • Physical hazards OHS issues the structural units of the • Electrical and explosive Medical Facility in order to hazards conduct supervision over the Head of the safety and labor protection of Medical Facility Within the • Fire personnel. Conducting and responsible Monthly Medical Facility training of medical personnel persons for labor budget • Chemical use on personal safety and labor protection and protection. safety measures. • Ergonomic hazard Safety and labor protection manual and instructions. • Radioactive hazard Internal order for the HCF operation - Infection organization of the Infection control and waste Control and Medical Waste Disposal System with the Head of Medical management plan No costs appointment of responsible Facility and Monthly persons. Providing training Infection Control for medical personnel on Team Infection Control and Medical Waste Disposal. 92 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Potential environment Proposed Mitigation Key Activities and social Issues and Responsibilities Timeline Budget Measures Risks Organization of measures for Waste minimization, reuse safe separation, collection, and recycling temporary storage and removal from structural units, internal transportation and accounting of the volume of generated Medical Waste Head of Medical Within the in accordance with national Facility and Ongoing Medical Facility standards. Infection Control budget Team Inventory of existing incinerators and check for compliance with technical regulations and incineration performance. Organization of proper Delivery and storage of control over the delivery and Head of Medical Within the specimen, samples, storage of samples, reagents, Facility and Ongoing Medical Facility reagents, pharmaceuticals pharmaceuticals and medical Infection Control budget and medical supplies supplies. Team Arrangement of proper Storage and handling of handling and storage of specimen, samples, specimens, samples, reagents Head of Medical Within the reagents, and infectious and infectious materials as Facility and Ongoing Medical Facility materials part of the Infection Control Infection Control budget and Medical Waste Team Management Plan. 93 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Potential environment Proposed Mitigation Key Activities and social Issues and Responsibilities Timeline Budget Measures Risks Waste segregation, Ensuring the availability of packaging, color coding containers, packaging, color Infection Control Within the and labeling coding and labeling for the Team of the Ongoing Medical Facility collection of Medical Waste Medical Facility budget corresponding to their hazard class. Infection Control Specialist Onsite collection and makes daily rounds of the transport structural units of the Medical Facility in order to comply with the requirements for collection, sorting and transportation of Medical Waste. Infection Control Labeling of containers for Team, Head Regularly No costs collection and internal Nurse. transportation of Medical Waste in the Medical Facility (SanPiN 2.1.7.020-09). Training of medical personnel on the Medical Waste Disposal cycle. 94 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Potential environment Proposed Mitigation Key Activities and social Issues and Responsibilities Timeline Budget Measures Risks Waste storage Compliance with the requirements for proper packaging and storage of Infection Control Within the Medical Waste (storage of Team, Head Regularly Medical Facility Medical Waste in a Medical Nurse. budget Facility is not recommended). Onsite waste treatment and Monitor the Medical Waste disposal Disposal System at least once a quarter using the Guidelines for Monitoring and Evaluation of the Infection Control Within the Medical Waste Disposal Team, Head Quarterly Medical Facility System in Healthcare Facilities, approved by Order Nurse. budget No. 1119 of the Ministry of Health of the Republic of Tajikistan, dated December 27, 2014. 95 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Potential environment Proposed Mitigation Key Activities and social Issues and Responsibilities Timeline Budget Measures Risks Transportation, recycling and Waste transportation to and disposal of waste at facilities disposal in offsite located outside the Medical treatment and disposal Facility is not recommended. facilities In the absence of conditions for waste disposal on the territory of the Medical Institution, within the Infection Control Within the framework of national Team, Head Medical Facility standards, proper packaging Nurse. budget of Medical Waste is recommended within the framework of the Order of the Ministry of Health of the Republic of Tajikistan dated December 27, 2014 No. 1119. HCF operation – Transboundary movement of transboundary movement specimens, samples, Head of Medical Within the of specimen, samples, reagents, medical equipment Facility and Medical Facility reagents, medical and infectious materials must Infection Control be carried out in accordance budget equipment, and infection Team materials with national standards. 96 Tajikistan Emergency COVID-19 Project Annex III ESMF ICWMP Template Potential environment Proposed Mitigation Key Activities and social Issues and Responsibilities Timeline Budget Measures Risks Emergency events • Spillage, • As part of the Medical • Occupational exposure to Facility's Standard infectious Operating Procedures and Emergency Response • Exposure to radiation, Plans. Accidental releases of • Training of staff to infectious or hazardous respond to emergency Head of Medical substances to the situations in the Medical Facility and Quarterly No costs environment, Facility. Infection Control • Medical equipment Team failure, • Failure of solid waste and wastewater treatment facilities, -fire • -Other emergent events Operation of acquired Securing the Medical Facility assets for holding potential to prevent the spread of Head of Medical COVID-19 patients infection. Facility and Providing medical staff with Regularly No costs Infection Control PPE, compliance with sanitary and epidemiological Team standards. To be expanded 97 Tajikistan Emergency COVID-19 Project Annex IV ESMF Infection and Prevention Protocol Annex IV - Infection and Prevention Control Protocol (adapted from the CDC Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in Healthcare Settings) HEALTH CARE SETTINGS 1. Minimize Chance of Exposure (to staff, other patients and visitors) • Upon arrival, make sure patients with symptoms of any respiratory infection to a separate, isolated and well-ventilated section of the HCF to wait, and issue a facemask • During the visit, make sure all patients adhere to respiratory hygiene, cough etiquette, hand hygiene and isolation procedures. Provide oral instructions on registration and ongoing reminders with the use of simple signs with images in local languages • Provide alcohol-based hand sanitizer (60-95% alcohol), tissues and facemasks in waiting rooms and patient rooms • Isolate patients as much as possible. If separate rooms are not available, separate all patients by curtains. Only place together in the same room patients who are all definitively infected with COVID-19. No other patients can be placed in the same room. 2. Adhere to Standard Precautions • Train all staff and volunteers to undertake standard precautions - assume everyone is potentially infected and behave accordingly • Minimize contact between patients and other persons in the HCF: health care professionals should be the only persons having contact with patients and this should be restricted to essential personnel only • A decision to stop isolation precautions should be made on a case-by-case basis, in conjunction with local health authorities. 3. Training of Personnel • Train all staff and volunteers in the symptoms of COVID-19, how it is spread and how to protect themselves. Train on correct use and disposal of personal protective equipment (PPE), including gloves, gowns, facemasks, eye protection and respirators (if available) and check that they understand • Train cleaning staff on most effective process for cleaning the HCF: use a high- alcohol based cleaner to wipe down all surfaces; wash instruments with soap and water and then wipe down with high-alcohol based cleaner; dispose of rubbish by burning etc. 98 Tajikistan Emergency COVID-19 Project Annex IV ESMF Infection and Prevention Protocol 4. Manage Visitor Access and Movement • Establish procedures for managing, monitoring, and training visitors • All visitors must follow respiratory hygiene precautions while in the common areas of the HCF, otherwise they should be removed • Restrict visitors from entering rooms of known or suspected cases of COVID-19 patients Alternative communications should be encouraged, for example by use of mobile phones. Exceptions only for end-of-life situation and children requiring emotional care. At these times, PPE should be used by visitors. • All visitors should be scheduled and controlled, and once inside the HCF, instructed to limit their movement. • Visitors should be asked to watch out for symptoms and report signs of acute illness for at least 14 days. CONSTRUCTION SETTINGS IN AREAS OF CONFIRMED CASES OF COVID- 19 1. Minimize Chance of Exposure • Any worker showing symptoms of respiratory illness (fever + cold or cough) and has potentially been exposed to COVID-19 should be immediately removed from the site and tested for the virus at the nearest local hospital • Close co-workers and those sharing accommodations with such a worker should also be removed from the site and tested • Project management must identify the closest hospital that has testing facilities in place, refer workers, and pay for the test if it is not free • Persons under investigation for COVID-19 should not return to work at the project site until cleared by test results. During this time, they should continue to be paid daily wages • If a worker is found to have COVID-19, wages should continue to be paid during the worker’s convalescence (whether at home or in a hospital) • If project workers live at home, any worker with a family member who has a confirmed or suspected case of COVID-19 should be quarantined from the project site for 14 days, and continued to be paid daily wages, even if they have no symptoms. 2. Training of Staff and Precautions • Train all staff in the signs and symptoms of COVID-19, how it is spread, how to protect themselves and the need to be tested if they have symptoms. Allow Q&A and dispel any myths. • Use existing grievance procedures to encourage reporting of co-workers if they show outward symptoms, such as ongoing and severe coughing with fever, and do 99 Tajikistan Emergency COVID-19 Project Annex IV ESMF Infection and Prevention Protocol not voluntarily submit to testing • Supply face masks and other relevant PPE to all project workers at the entrance to the project site. Any persons with signs of respiratory illness that is not accompanied by fever should be mandated to wear a face mask • Provide handwash facilities, hand soap, alcohol-based hand sanitizer and mandate their use on entry and exit of the project site and during breaks, via the use of simple signs with images in local languages • Train all workers in respiratory hygiene, cough etiquette and hand hygiene using demonstrations and participatory methods • Train cleaning staff in effective cleaning procedures and disposal of rubbish 3. Managing Access and Spread • Should a case of COVID-19 be confirmed in a worker on the project site, visitors should be restricted from the site and worker groups should be isolated from each other as much as possible; • Extensive cleaning procedures with high-alcohol content cleaners should be undertaken in the area of the site where the worker was present, prior to any further work being undertaken in that area. 100 Tajikistan Emergency COVID-19 Project Annex V ESMF Technical Note on Use of Military Forces Annex V – Technical Note on Use of Military Forces to Assist COVID-19 Operations Suggestions on How to Mitigate Risk It is common practice for Governments to utilize military or security personnel during public health emergencies. The ability to do this, and the requirements relating to such mobilization, are often set out in executive orders or instructions. A ‘public health emergency’ will usually be defined under national law. For example, the US Department of Defense (DoD Instruction 6200.03, March 28, 2019) defines a public health emergency to include “the occurrence or imminent threat of an illness or health condition that poses a high probability of a significant number of deaths, serious or long-term disabilities, widespread exposure to an infectious or toxic agent, overwhelmed health care resources, or severe degradation of mission capabilities”. For the reasons set out in section 1 below, it is expected that military or security forces will be utilized in different ways in response to COVID-19. They may be used directly to carry out activities in a World Bank supported project. Or they may be mobilized more generally to implement Government programs, which are also supported by the Bank. Where military/security forces are utilized, either directly or indirectly, in connection with Bank- supported operations, questions will arise about the risk of the operation. Is it automatically high or are there effective ways of mitigating the risk? This guidance sets out suggestions for due diligence and mitigation measures to address the risk. 1. WHAT ARE THE POSITIVE ASPECTS ABOUT USING THE MILITARY? Where relevant, consider the following and document relevant details: • Human rights: Depending on the country, military personnel may be aware of the need to respect human rights (HR) and received relevant training. • “NBC” capabilities: Many military forces have nuclear, biological and chemical capabilities. They may have existing biological defense capabilities e.g. ability to deploy with personal protective equipment (PPE); training in decontamination; procedures or advice on how to carry out relevant activities. • Medical expertise: Medical and other professionals within the military are likely to be trained to deal with medical emergencies, and therefore may be better able to cope in situations in which there may be mass casualties. 101 Tajikistan Emergency COVID-19 Project Annex V ESMF Technical Note on Use of Military Forces • Disciplined response: Generally, military personnel are expected to respond in a disciplined manner to commands and will have capabilities which will be useful in these types of emergencies (medical, engineering, construction). • Civic action programs: Military may also have specific civic action programs and infrastructure to support these (e.g. mobile clinics/communication procedures). WHAT ARE THE THINGS TO WATCH FOR? (a) Diversion of materials, aid and assistance: Diversion can take the form of confiscations and reuse, misappropriation and theft. While a certain level of diversion may be inevitable in certain circumstances, this issue is likely to present reputational issues (especially when the crisis dissipates). (b) Allegations of human rights violations: This will be a risk, including as it relates to Sexual Exploitation and Abuse and Sexual Harassment (SEA/SH), and the Bank needs to be clear and transparent about what measures are being adopted to minimize these risks. Tools that should be considered include the ESF Good Practice Note (GPN) on Use of Security Forces 33, on SEA/SH 34, and the IFC Good Practice Handbook on the Use of Security Forces: Assessing and Managing Risks and Impacts 35. (c) Putting World Bank staff at risk: This is particularly a concern where military/security forces are likely to be undisciplined. The risk may be heightened when Bank staff are trying to address the risk of diversion referred to above. While staff may try to address this risk by avoiding direct interaction with the military, this is not likely to be feasible in a project setting. (d) International media comment and reaction: This will be a challenge, and it may not be possible to avoid negative comment entirely. It is important to be transparent about the activities the World Bank is supporting and the mitigation measures that are being implemented to address risks. 2. WHAT ARE THE WAYS TO ADDRESS THE RISKS? (a) Get a view of the reputation and capability of the military: Talk to those who might have up to date and accurate information: e.g. the Defense Attaché at the relevant 33 http://documents.worldbank.org/curated/en/692931540325377520/Environment-and-Social-Framework-ESF-Good-Practice-Note-on-Security- Personnel-English.pdf 34 http://pubdocs.worldbank.org/en/632511583165318586/ESF-GPN-SEASH-in-major-civil-works.pdf 35 https://www.ifc.org/wps/wcm/connect/topics_ext_content/ifc_external_corporate_site/sustainability-at- ifc/publications/publications_handbook_securityforces 102 Tajikistan Emergency COVID-19 Project Annex V ESMF Technical Note on Use of Military Forces Embassy; the US or UK Government; refer to Jane’s Defense Weekly. (b) Identify the structure under which the military will be operating: While they will continue to abide by their own rules and procedures, it is likely that the military will also be subject to relevant national requirements relating to the public health emergency and the specific activities that they are required to carry out e.g. instructions issued by public health officials. In the context of a Bank supported operation, it is good practice to document (as far as possible) the structure under which the military are operating, including the chain of command, with specific reference to the activities they will or are likely to carry out (see paragraph (i) below). (c) Clarify who is responsible for human rights issues nationally: Many countries have a Human Rights Commission. If such commissions do not exist, there is usually an Ombudsman, Human Rights office or inspector general at the national level with jurisdiction to deal with such issues. Identify the relevant parties and consider whether it would be appropriate to consult them for advice. (d) Identify other specialized parties and ask for advice: There are both national and international NGOs which follow and support these issues (e.g. Human Rights Watch (HRW), Amnesty). There is also the International Committee of the Red Cross/Red Crescent (ICRC) and the International Crisis Group. Identify relevant parties, with reference to the context and nature of the operations, who may be in a position to provide valuable advice. (e) As required under the ESF, cooperate with relevant stakeholders on a risk assessment: Carry out a risk assessment to identify the specific risks associated with the proposed use of military. This assessment needs to be conducted with those that are involved in the operation, including Government counterparts, to ensure that an accurate picture of the risks emerge, that appropriate mitigation measures are identified and that both the risk assessment and the mitigation measures are owned by the project and the Government. (f) Be transparent about what the World Bank is requiring to mitigate the risks: Document this, setting out key aspects in the ESRS and other project documentation. Consider the following: • procedures relating to: e.g. risk assessment; how allegations of HR/SEA/SH violations will be dealt with, including through the project Grievance Mechanism (GM); preventing diversion of materials, aid and assistance (build on existing requirements) 103 Tajikistan Emergency COVID-19 Project Annex V ESMF Technical Note on Use of Military Forces • presence of World Bank representatives/third party monitors on the ground • cooperation with specialist institutions/NGOs/Government agencies • specific obligations set out in the legal agreement and (if possible and appropriate) a Memorandum of Understanding (see paragraph (k) below) • monitoring and reporting (g) Consider asking a credible party to act as an observer/third party monitor: This can be considered under the ESF provisions for third party monitoring as noted in ESS1 and ESS10, as well as the ESF Good Practice Note on Third Party Monitoring. Relevant groups with experience in this field will depend on the context, and may include the parties referred to in paragraph (d) above. (h) Establish a procedure to be followed in cases of allegations of HR/SEA/SH violations or misbehavior: This should reflect the ESF Good Practice Note on SEA/SH and may include reference to the institutions referred to in paragraph (c) above. Include a specific HR and SEA/SH procedure in the project GM to address these allegations and identify specific individuals who have the expertise to address such allegations credibly. Understanding relevant Code of Conduct (CoC) requirements pertaining to such behavior is important, and, where necessary, improving the form and substance of such CoC. (i) Be clear on what the military will do: Identify the activities and set them out clearly in the legal agreement: e.g. construction, enforcing quarantine restrictions, distribution of medical supplies or vaccines, distribution of other supplies. This will support a more accurate risk assessment. Note that in some circumstances, what could otherwise be viewed as inappropriate behavior by the military (or at an extreme, a possible abuse of rights) may be authorized and necessary in situations of a public health emergency. This will depend on the activities that the military is required to carry out and will be particularly relevant where they are required to enforce public order or quarantine restrictions. (j) Set out specific requirements as covenants in the legal agreement and in the Environmental and Social Commitment Plan (ESCP) as appropriate: The provisions should set out the ‘ground rules’ for military engagement, including: (i) requirements to comply with ESS4 (see below); (ii) reporting obligations (specify on what, how often, to whom); (iii) specific prohibitions e.g. no child labor, no forced labor, restrictions on what military personnel under the age of 18 can do (if anything); (iv) health and safety requirements; (v) CoC type obligations; (vi) requirements for the GM; (vii) training required and how often (specify on what – 104 Tajikistan Emergency COVID-19 Project Annex V ESMF Technical Note on Use of Military Forces e.g. Voluntary Principles on Security and Human Rights, interactions with the community, operation of the GM, use of personal protective equipment (PPE), CoC). (k) Where possible, and if not already covered by applicable law/regulation, the Government should consider executing a Memorandum of Understanding (MoU) with the military: This should reflect the ‘ground rules’ set out in the legal agreement (see paragraph (j) above). An example of a MoU is available in the IFC Good Practice Handbook on the Use of Security Forces: Assessing and Managing Risks and Impacts30. Even where it is not possible for individual military personnel to sign a CoC, the requirements should be set out in the MoU, and training should cover these obligations (amongst others). Set out below is suggested wording on HR/SEA/SH: 1. Prior to deploying military or security personnel, the [Borrower/Recipient] shall take measures to ensure that such personnel are: (i) screened to confirm that they have not engaged in past unlawful or abusive behavior, including sexual exploitation and abuse (SEA), sexual harassment (SH) or excessive use of force; (ii) adequately instructed and trained, on a regular basis, on the use of force and appropriate behavior and conduct (including in relation to SEA and SH), as set out in the [Training Procedure, Project Operational Manual, ESMF, Security Management Plan, MoU ]; and (iii) deployed in a manner consistent with applicable national law. 2. The [Borrower/Recipient] shall promptly review all allegations of unlawful or abusive acts of any military/security personnel, take action (or request appropriate parties to take action) to prevent recurrence and, where necessary, report unlawful and abusive acts to the relevant authorities. Set out below is suggested wording on reporting: Frequency of reporting will depend on the context and the risks associated with the activities the military is carrying out, and may be required monthly, weekly or even daily. Requirements should include: • Immediate reporting (within 24 hours) of any serious incident • A written weekly or monthly report (depending on the risk) covering: o status of activities being conducted by the military o training conducted 105 Tajikistan Emergency COVID-19 Project Annex V ESMF Technical Note on Use of Military Forces (specifying subject matter) o current status of review of serious incidents (if any) and any relevant reporting or a summary of any minor (but reportable) issues, suspected incidents or potential issues or details of any incidents involving use of force or weapons o details of upcoming activities which may pose a risk (e.g. distribution of supplies) and measures being put in place to reduce such risk o lessons learnt, to inform conduct of future activities o Other reference documentation: The International Code of Conduct under the Montreux Document 36. While this relates to private security, it contains useful material. 36 https://www.icoca.ch/en/the_icoc 106 Tajikistan Emergency COVID-19 Project Annex VI ESMF Technical Note on SEA/SH Annex VI – Technical Note on SEA/SH for HNP COVID Response Operations Teams working on HNP COVID response operations have done initial assessments of sexual exploitation and abuse/ sexual harassment (SEA/SH) risks and included a place holder in packages indicating SEA/SH risk mitigation measures will be put in place during project implementation. The following is intended as technical advice to help teams support clients on rolling out these measures. It has been prepared taking into account the emergency nature of these operations, and good practice principles on SEA/SH risk mitigation. This note does not cover the broader GBV programing some HNP interventions may also be rolling out. It focuses exclusively on addressing SEA/SH risk posed by project activities themselves, and not the broader SEA/SH risks posed by the COVID pandemic. • Teams are not required to conduct SEA/SH risk assessments given the emergency context and the information already available on increased risk of SEA/SH during humanitarian situations. • Projects should focus on putting in place the following, minimum set of measures to be reflected in the ESMF/P: a. Staff in PIUs/PCUs will sign Codes of Conduct. Codes of conduct need not be signed by other health care personnel during crises as long as information on unacceptable behavior is sufficiently disseminated. Publicly post or otherwise disseminate messages clearly prohibiting SEA/SH during the provision of health care, whether healthcare providers are perpetrators or survivors. o This can include the development, adaptation, translation and dissemination of communication materials (through local radio, posters, banners, etc.) outlining unacceptable behavior on SEA/SH and where relevant referencing existing staff rules for civil servants that may already be in place. Key messages should be disseminated focusing on : i) No sexual or other favor can be requested in exchange for medical assistance; ii) Medical staff are prohibited from engaging in sexual exploitation and abuse; iii) Any case or suspicion of sexual exploitation and abuse can be reported to [insert hotline number, GM or citizen engagement/feedback mechanism]. o Can be mentioned briefly in daily medical protocol briefings. o This would not include the physical signing of Codes of Conduct by health workers, for example – which would be too time consuming or otherwise infeasible in an emergency setting. b. Make information available to health service providers on where GBV psychosocial support and emergency medical services can be accessed (within the health system). 107 Tajikistan Emergency COVID-19 Project Annex VI ESMF Technical Note on SEA/SH o Information on what facilities provide psychosocial and emergency medical services (available through the HMIS) should be widely disseminated through the health system. o Where relevant, this would also include sharing information on specialized facilities (One Stop Centers, Centers of Excellence on GBV, and available helplines) where services can be accessed. Where relevant (FCV settings for example), updated maps indicating these facilities are maintained at country level by the Inter-agency GBV Coordination Group usually chaired by UNFPA and are rapidly made available. o This would not include additional mapping of services being conducted by the project as a separate exercise. c. Promote two-way communication between health authorities and communities that would allow information on instances of SEA/SH to surface and inform strengthening of SEA/SH measures as needed. o Establish community feedback mechanisms for healthcare providers focusing on overall service provision (including adequacy of the response, areas where corrective action would be needed) and that would also cover SEA/SH. The Stakeholder Engagement Plan (SEP) would be an effective mechanism to set up and monitor community feedback, and especially so that appropriate modalities are in place for SEA/SH. o Such feedback mechanisms should be developed based on consultations with affected communities (in particular with women and girls) to determine the preferred alternative to in-person complaints (e.g. phone, online, other). Guidance on consultations in the context of social distancing is available here 37. Any change in traditional grievance mechanisms should be sufficiently highlighted to communities in relevant languages and through relevant sources (e.g. message trees, radio announcements, social media, community groups, etc.). o This could include the development of additional rapid guidance on how to deal with SEA/SH complaints in operations with existing GRMs or using hotlines (where COVID response builds on existing health operations with functioning grievance mechanisms) or in cases where new GRMs are being set up through the project. When there is room to do more and go beyond SEA/SH risk mitigation, teams should consult the note on Gender for HPN operations prepared by the Gender Group. Additional Resource: Interim Technical Note PROTECTION FROM SEXUAL EXPLOITATION AND ABUSE (PSEA) DURING COVID-19 RESPONSE Version 1.0 March 2020 37 https://worldbankgroup.sharepoint.com/sites/wbunits/opcs/Knowledge%20Base/Public%20Consultations%20in%20WB%20Operations.pdf 108 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 Annex VII - Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 RECOMMENDED MEASURES FOR SAFE DISPOSAL OF WASTE AFTER VACCINATION AGAINST COVID-19 Description of recommendations To be executed by Scope of application Coronavirus is an acute viral disease that mainly affects the respiratory system and gastrointestinal tract. The virus is transmitted by airborne droplets, airborne dust and fecal-oral routes. The danger is represented by discharge of the nasopharynx, vomit, excreta of a sick person. Vaccination against COVID-19 is critical given the nature of the disease and the importance of preventive measures to stop further transmission of the virus. It is assumed that during the COVID-19 vaccination, the medical staff of all healthcare facilities will handle the waste generated during immunization in accordance with existing procedures and standards. All vaccination sites will ensure that all waste generated during vaccine administration is properly managed and appropriate labeling, sorting and disposal of waste will be carried out. Particular attention will be paid to one of the most important components - the correct disposal of sharp items (syringes and needles), as well as the disposal of unused, open or damaged vaccine vials, 109 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 PPE and other medical and non-medical items. All medical waste after vaccination belongs to class "B" - potentially infectious waste. General requirements 1. To protect personnel, patients and the Managers and environment at each vaccination site, a employees of safe system for medical waste healthcare facilities management shall be organized, including: separation, identification, Vaccination team packaging, labeling, collection and members transportation of waste to the place of its processing / treatment permitted on the territory of the Republic. Tajikistan. 2.All HCFs and vaccination sites personnel should be familiar with these guidelines and be aware of the potentially dangerous consequences of inappropriate handling of medical waste. 3. Adequate separation of medical waste is the responsibility of every health professional, regardless of the position. 4. Each vaccination site, which generates medical waste, must be equipped with adequate equipment for the segregated collection of class "B" waste:  containers (buckets) or plastic bags and marked for collection of class "A" and class "B" medical waste;  containers for the safe collection and disposal of sharps (used syringes with needles); 110 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 5. At each vaccination site, there should be diagrams (posted on a wall) showing the order of separation and sorting of the corresponding classes of medical waste. Corresponding SOP shall be also made available at each vaccination site. Resources required 1. Containers for the safe collection and MOHSP, Managers disposal of sharp items and employees of healthcare facilities 2. Disposable waterproof bags and plastic containers of appropriate color or Vaccination team waste class labeling; members 3. Personal protective equipment: gloves, masks, caps 4. Hand sanitizer. 5. Disinfectants (according to the MOHSP standards) Safe collection at  Do not (to avoid injury) remove Managers and vaccination site needles from syringes, put caps employees of on used needles, bending or healthcare facilities breaking needles is dangerous!  Always wear personal protective Vaccination team equipment (masks, gloves, gown members or apron) when collecting medical waste  Each container must be labeled as “contaminated sharps”.  Containers should be located at all vaccination points and at distance to reach out by the vaccinator.  After administering the vaccine, immediately discard the used syringe with a needle without a cap into the container! 111 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19  Containers for sharp items and bags with other infectious medical waster should not be filled more than 3/4 of their volume and should be handed over to the responsible persons for waste disposal at the end of the working day.  All containers with used syringes should be closed with tape and marked “COVID-19 vaccination”.  All PPE items (masks and gloves) used during vaccination must be disposed of as highly hazardous infectious waste and, after adequate treatment, must be placed in special bags (labeled in red) and transported for disposal in accordance with the recommendations of the Ministry of Healthcare and Social Protection of Populations the Republic of Tajikistan.  AVOID throwing any other waste into safe containers such as empty vaccine vials, gloves, cotton balls, masks, etc.  Class B waste is collected in disposable soft waterproof packaging (bags) or containers with yellow markings indicating the time and place of collection, as well as information on disinfection/treatment.  Class B waste, before transporting for disposal/treatment, must be 112 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 thoroughly decontaminated in accordance with the MOHSP recommendations.  AVOID mixing non-hazardous household and infectious waste during collection, storage and transportation!  Used, unused and partially used vials with vaccine must be returned to the Central Vaccine Distribution Center in accordance with the MOHSP instructions for their further disposal.  At least twice a day, clean and disinfect the surfaces of the vaccination tables, paying particular attention to surfaces with a high level of contact. Separation, packaging and Separation and packaging of wastes Managers and labeling of medical waste generated at vaccination sites: All employees of medical waste generated at vaccination healthcare facilities sites shall be separated into three groups: Vaccination team 1. Sharps (syringes with needles- members class B) – are collected in safety boxes that are puncture-proof and have a biohazard sign or the inscription "Sharp waste". 2. Pathological waste (class B), containing potentially infectious particles (protective suits, cotton swabs after vaccine injections, gloves, etc.) - collected in plastic bags, inserted into containers (buckets) have a biohazard sign and the inscription "Infected waste". 113 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 3. Empty, open or damaged vaccine vials ( unclear or blurred marking, violation of the "cold chain requirements", etc. ) are placed in a yellow waterproof bag with the inscription "dangerous infectious Medical waste" and at the end of the working day are transferred to the immunoprophylaxis center for their further disposal in line with the established MOHSP rules. Labeling: Medical waste after vaccination should be labeled with the following colors: Yellow - for infectious waste and sharp items; Black - for non-infected (non- hazardous, domestic) waste 1. All vials (used / empty, unused and partially used) must be returned to the central vaccine distribution site (observing all cold chain requirements). 2. A completed and signed form must be transferred together with the vaccine container. 3. DO NOT dispose of used syringes, needles, or safety boxes in your regular (domestic) waste bin 4. The container for the collection of general non-hazardous waste is not labelled at all, but it placed in a disposable black plastic bag 114 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 5. Containers with contaminated waste should be stored at the vaccination site for no more than 48 hours, in a safe place 6. The packaging of decontaminated medical waste of class B must have a label indicating that the waste has been decontaminated. Transportation of class  Transportation of medical waste Managers and "B" medical waste to the is carried out in the same employees of decontamination/treatment containers in which they were healthcare facilities or disposal site collected  When transporting medical waste Vaccination team in bags, the bag is placed in members another plastic bag (tied or tightened with a plastic clamp). Then the package is processed by applying a disinfectant solution according to the instructions  During transportation, do not open the lids and leave containers unattended!  When transporting class B medical waste inside the hospital, medical personnel shall use specialized containers with wheels. Rules for safe handling of 1. DO NOT tamp waste with your Managers and medical waste hands! employees of healthcare facilities 2. DO NOT transfer waste of classes B and C from one container to another; Vaccination team members 3. When handling medical waste at a vaccination site, personnel MUST use personal protective equipment: gloves, puncture-resistant shoes, eye protection 115 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 devices (goggles), protective clothing or aprons 4. After removing gloves, it is necessary to carry out hygienic treatment of hands (washing with soap or applying hand sanitizer). 5. IMMEDIATELY notify the HCF manager in case of emergencies (spillage of hazardous medical waste). 6. For the temporary storage of class “B” waste, a separate room should be allocated in the HCF – with a sign on a wall “A room for temporary storage of medical waste”. Safe disposal of the 1. Full containers should be incinerated Managers and medical waste after in small numbers by open burning in a employees of vaccination fenced pit at the HCF compound or healthcare facilities transported to the Central Site for Medical Waste Disposal. Vaccination team members 2. Chemical disinfection of medical waste should be carried out in accordance with the existing MOHSP regulatory documents (SanPiN 2.1.7.020-09 and Procedural guidelines 3.5.5. 028-10). 3. Medical waste (except for sharp items) after chemical treatment (chemical disinfection) are dumped into specialized pits for incineration and burial in accordance with the existing MOHSP regulatory documents (SanPiN 2.1.7.020-09 and Procedural guidelines 3.5.5. 028-10). 116 Tajikistan Emergency COVID-19 Project Annex VII ESMF Recommended Measures for Safe Disposal of Waste after Vaccination against COVID-19 Training All staff involved in the introduction of MOHSP, PIU the new vaccine and provision of vaccination services will be trained in the use of the recently developed Standard Operating Procedures (SOPs) for waste management in accordance with the latest immunization waste management guidelines adopted by the Government of Tajikistan. 117 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Annex VIII - Vaccine Delivery and Deployment Manual Executive Summary This Vaccine Delivery and Distribution Manual describes the plans to supply, procure, distribute, and monitor COVID-19 vaccine delivery in Tajikistan, as well as plans to support this effort through the World Bank Tajikistan Emergency COVID-19 (TEC-19) project. Its intent is to ensure consistency, transparency, and accountability of those involved in management and implementation of Project COVID-19 vaccine procurement and delivery through the TEC-19 project. Adoption of this manual is a condition of TEC-19 project effectiveness along with the Environmental and Social Management Framework. The manual may be used as a guidance document at different levels of vaccine procurement, distribution, and delivery. The World Bank Tajikistan Emergency COVID-19 Project The World Bank Tajikistan Emergency COVID-19 Project (TEC-19) is an emergency investment project totaling US$ 11.3 million that was originally approved by the World Bank Board of Directors on April 2, 2020. The original Project was financed by a grant from the International Development Association (IDA). The Objective of TEC-19 is to prepare and respond to the COVID-19 pandemic in Tajikistan. TEC-19 was one of the first projects to support the Government of Tajikistan in its response to the COVID-19 pandemic, which included technical assistance for the implementation of the National Emergency Response Plan, adopted in March 2020. TEC-19 was prepared as part of the World Bank’s emergency response under the COVID-19 Strategic Preparedness and Response Program. The Project consists of four Components: (i) strengthening intensive care capacity; (ii) multisectoral response planning and community preparedness; (iii) temporary social support for vulnerable households; and (iv) Project implementation and monitoring. In response to the urgent need for COVID-19 vaccines, the TEC-19 Additional Financing (AF 1) of US$ 8.63 million was approved by the World Bank Board of Directors on February 11, 2021. The additional financing is also funded by an IDA grant of US$ 8.63 million. AF1 has been prepared to provide critical financing for the purchase and deployment of COVID-19 vaccines and related activities, with US$ 8 million available for the procurement of vaccine, and US$ 0.35 million available for national immunization system strengthening, including investments in supply chain management, monitoring of adverse events following immunization (AEFI), and monitoring vaccine deployment. The AF extends the Project Closing Date from December 1, 2021 to July 31, 2022, to accommodate implementation of the additional activities. 118 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual TEC-19 AF1 is in line with the Republic of Tajikistan’s COVID-19 National Emergency Response Plan, as well as its National Preparedness Plan for COVID-19 immunization and National Deployment and Vaccination Plan. The Project has 4 components: 1. Strengthening Intensive Care Capacity; 2. Multisectoral Response Planning and Community Preparedness; 3. Temporary Social Assistance for Vulnerable Households; and 4. Project Implementation and Monitoring. Component 1: Strengthening Intensive Care Capacity – US$ 6.3 million; AF1 allocation US$ 8.3 million (total US$ 12.6 million, of which US$12.6 million IDA Grant). Component 1 focuses on strengthening the government’s capacity to manage severe cases of the COVID-19 infection. Specifically, it provides financing for the procurement and installation of intensive care unit (ICU) equipment and training of ICU personnel on the use of the equipment. This component also provides funding for personal protective equipment (PPE) for ICU staff and essential ICU consumables such as medications and syringes in ten (10) hospitals around the country. It also finances small works to ensure that the ICUs in the selected hospitals can accommodate the equipment purchased by the Project. AF1 will finance the procurement and delivery of an initial supply of COVID-19 vaccines that have credible approval for safety and effectiveness. 38 AF1 will also support expenditures on vaccine transportation, logistics, and ancillary supplies such as syringes, safety boxes, and PPE for the initial batch of the vaccine covering the 20 percent of the population of Tajikistan, where not covered by COVAX. Finally, the remaining increased allocation to this component under the AF will finance elements of general strengthening of the national immunization system and management capacity, including providing IT support for the roll out of the electronic supply management system, adapting and rolling out the system to track AEFI and patient registries. The Bank financing for systems strengthening and vaccine deployment will be designed for the needs of vaccines that meet the Bank regulatory standards. The AF will also support strengthening of the institutional framework to enable safe and effective vaccine deployment including support for the development and/or adjustments of national policies surrounding prioritization of vaccine allocation, regulatory standards for vaccination, standards and protocols surrounding supplies management, storage, logistics, training, and beneficiary feedback mechanisms. Component 2: Multisectoral Response Planning and Community Preparedness. Current allocation – US$ 1.0 million; AF1 allocation US$ 0.18 million (total US$ 1.18 million, of which US$1.18 million 38 Based on the most recent projection, it is expected that the global supply of the COVID-19 vaccine will only be sufficient to vaccinate about 20 percent of the population of Tajikistan through the end of 2021. This is why, based on the discussions with the Government, this AF is focusing on this first batch of the vaccine. 119 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual IDA Grant). TEC-19 supports surge capacity for the MOHSP, including funding the positions of the Strategic Emergency Response Advisor, the Strategic Communication/Development Partners Liaison Officer, and other consultants supporting the MOHSP. It will also continue providing funds for media training and financial support to the MOHSP Press Center, the national hotline, and the Republican Center for Healthy Lifestyles to conduct communication and sensitization activities around the COVID- 19 pandemic. Based on the success of the national COVID-19 campaign financed by TEC-19 – support for telephone hotlines, mechanisms for delivering SMS messages to the population, communication training for media and the civil society – AF1 will expand its scope and information and messages related to COVID-19 vaccine to provide accurate and timely information to the population and minimize vaccine hesitancy. Additional advocacy campaigns financed by AF1 will include information about the vaccine and about the government’s vaccine delivery strategies and plans, with a special emphasis on the prevention and mitigation of potential risks of vaccine hesitancy. Component 3: Temporary Social Assistance for Vulnerable Households. Current allocation – US$ 3.0 million; AF1 allocation US$ 0 million (total US$ 3.0 million, of which US$3.0 million IDA Grant). The provision of one-off emergency cash transfers to the beneficiaries identified under the parent Project and the delivery of accompanying measures – messages on optimal young child nutrition and stimulation – will continue as scheduled. No changes are proposed for this Component under AF1. Component 4: Project Implementation and Monitoring. Current allocation – US$ 1.0 million; AF1 allocation US$ 0.15 million (total US $1.15 million, of which US$1.15 million IDA Grant). The parent project will continue to finance the PIU and cover staff salaries and operating costs, necessary training and equipment, support for procurement, FM, environmental and social risk management, monitoring and evaluation (M&E) and reporting activities. AF1 will finance the operating costs of the PIU, including the extension of the PIU staff contracts for the additional time period covered by AF1, as well as the cost of mobilizing short-term consultants with expertise related to vaccines. A second additional financing (AF2) of US $12.57 million, was also approved by the World Bank Board of Directors on 11 February 2021. Its objective is to provide support for oxygen supply, measles, mumps, and rubella (MMR) vaccines, and social assistance related to the COVID-19 pandemic. AF2 is described in a separate Project Document and its implementation is not addressed in this Manual. The main outcome indicators of the Project are: - Number of beds in fully equipped and functional intensive care units (ICUs) financed by the Project (Number). - Number of health personnel trained by the Project on COVID-19 preparedness and response (Number). - Percentage of population vaccinated, which is included in the priority population targets defined in national plan, disaggregated by gender. 120 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual - Number of vulnerable households who have received targeted cash assistance financed by the Project (Number). There are also nine intermediate results indicators: - Number of PPE units procured by the Project (Number). - Number of ventilators procured by the Project (Number). - Number of COVID-19 test kits procured by the Project (Number). - Number of community volunteers trained by the Project (Number) - Number of journalists trained by the Project who report that the training effectively supported their ability to share official information and to report on beneficiary feedback (Number). - Beneficiaries of Safety Net programs - Unconditional cash transfers (Corporate Results Indicator, Number). - Percentage of grievances addressed within the time specified in the Project Operations Manual (Percentage). - Semi-annual project monitoring reports include a section with feedback from civil society and reporting on actions taken that is publicly disclosed (Yes/No). Background: COVID-19 in Tajikistan On April 30, 2020, Tajikistan announced the first confirmed case of COVID-19 in the country, becoming the second-to-last country in the Europe and Central Asia (ECA) region to do so. Fifteen cases were declared, and, within weeks, cumulative cases grew to thousands, with peak incidence having occurred in late May. 39 As of April 12, 2021 official data indicates that 13,308 people have tested positive for COVID-19, and 90 people have died. This equates to a crude cumulative incidence of 139.5 per 100,000 population and a cumulative death rate of 9.0 per 100,000 population. Vaccination is the most promising solution to achieve large-scale herd immunity to the disease and reach the end of the epidemic in Tajikistan. Recently published results from the trials of at least five vaccines, including the AstraZeneca-University of Oxford ChAdOx1 vaccine, show that they are safe and produce desired immune responses. 40,41 Four vaccines have been approved or granted emergency use licensure by at least one country with Stringent Regulatory Authority status, with 23 in large-scale phase-III clinical trials. WHO emergency use licensure (EUL) has been granted to three vaccines (Pfizer- 39 The peak cumulative incidence rate of 407 was reported on May 19, 2020. Since then, the daily reported number of cases has declined and, currently, it is about 90 per day with no evidence of the “second wave” of the epidemic reported yet. 40 Folegatti P, Ewer K, Aley P, Angus B, Becker S, et al. 2020. Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomized controlled trial. The Lancet 396(10249):467-478. 41 Feng Z., Guan X., Li, Y, Huang J., Jian T. et al.. 2020. Immunogenicity and safety of a recombinant adenovirus type-5-vectored COVID-19 vaccine in healthy adults aged 18 years or older: a randomized, double-blind, placebo-controlled, phase 2 trial. The Lancet 396(10249):479-488. 121 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual BioNTech, AstraZeneca, and Johnson & Johnson), and 3 others are expected to be considered for EUL by Q2 2021. In parallel with vaccine research, the global production capacity is being developed with billions of doses of vaccine projected to be available globally in 2021. Bringing an end to the pandemic, through vaccination, is a high priority for the government of Tajikistan. The President of Tajikistan established, and the Prime Minister leads, a Multisectoral Steering Committee on COVID-19, which coordinates all aspects of the government response. On vaccinations, the Ministry of Health and Social Protection Technical Working Group on COVID-19 vaccines was established by ministerial decree in November 2020 42. It is responsible for planning and deployment of COVID-19 vaccines in Tajikistan, in coordination with relevant government ministries. Institutional arrangements for TEC-19 additional financing Key institutional arrangements defining the roles and responsibilities for the implementation of TEC-19 AF1, enabling affordable and equitable access to COVID-19 vaccines in Tajikistan have been decided upon as follows:  On February 2, 2020, the government designated the Ministry of Health and Social Protection (MOHSP) to provide the initial coordination for the COVID-19 outbreak response. On March 18, 2020, the government established a national multisectoral COVID-19 task force chaired by the Prime Minister. On March 19, the COVID-19 Preparedness and Response Plan (CPRP) was approved.  The MOHSP is the main agency responsible for implementation of the Tajikistan Emergency COVID-19 Project (TEC-19). As the Project Director, the Minister of Health and Social Protection has responsibility and oversight for overall project management to ensure that project resources are used as budgeted and that the TEC-19 objectives are achieved. The First Deputy Minister of Health and Social Protection, who is the Project Coordinator, is responsible for daily coordination and oversight of Project activities.  The Republican Centre for Immunoprophylaxis (RCIP) is the responsible state institution under the MOHSP for management and implementation of the National Immunization Program (NIP). Vaccination planning, procurement, supply and coverage monitoring, national policy development, supervisory support, and surveillance of vaccine preventable diseases are managed by the RCIP through its 6 regional branches and 65 District Centers for Immunoprophylaxis. According to the strategy elaborated by the government for the COVID-19 vaccine introduction, the administration of COVID-19 vaccines will be carried out by the routine immunization service providers, the health workers who have extensive experience in implementation of immunization campaigns. 42 Order of the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan #902 from 12/11/2020 122 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual  In November 2020, the Technical Working Group (TWG) was established through a ministerial decree, mandated to coordinate and oversee COVID-19 vaccination readiness assessment, preparations and implementation of the COVID-19 vaccination plan, and developing policies and guidelines needed for the rollout of a COVID-19 vaccination program in the country. The TWG includes representatives of the National Immunization Technical Advisory Group (NITAG), deputy ministers of health and social protection, State Service for Sanitary and Epidemiological Supervision (SSES), State Supervision Service for Health and Social Protection, State Institution Republican Center for Promotion of Healthy Lifestyles, Republican Centre for Medical Statistics and Information, representatives of international development partners, such as ADB, Aga Khan Foundation, UNICEF, World Bank and WHO.  An Inter-agency Coordination Committee (ICC) exists and is dedicated to oversight and support the national efforts to strengthen immunization services.  The National Immunization Technical Advisory Group (NITAG) was established in 2016 by the MOHSP Order to provide scientific advice on immunization policy and practice, and technical oversight for immunization.  The National Regulatory Authority (NRA) covers the basic regulatory functions for UN- procured vaccines, i.e. marketing authorization/licensing, and post marketing surveillance/AEFI including coordination between NRAs, Sanitary Epidemiological Services and Vaccine Distribution Authorities.  The State Sanitary and Epidemiological Surveillance in conjunction with RCIP and the Service of State Surveillance of Health and Social Protection of the Population is responsible for AEFI investigation and surveillance of communicable diseases with further decisions regarding the investigation, and the adoption of preventive and anti-epidemic measures.  Primary health care facilities involved with vaccination services administer vaccines to the target populations.  The Republican Healthy Lifestyle Centre and RCIP work together on risk communication and community engagement activities.  GAVI, the Vaccine Alliance (Gavi), through the COVAX Advance Market Commitment (AMC), will organize the financing of vaccines and negotiations with manufacturers.  The UNICEF Supply Division coordinates the procurement of vaccine.  WHO provides the required technical and operational support to Tajikistan in implementation of the National Immunization Program. Supply of COVID-19 Vaccine 123 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual COVAX is likely to be the main source of COVID-19 vaccines for the Republic of Tajikistan. Based on the most recent discussions between the Government and Gavi, it is expected that COVAX will provide vaccine for 20 percent of the population of Tajikistan in 2021. COVAX will fully subsidize the vaccine for 16 percent of the population and make vaccine for another four percent of the population available to the government at low prices negotiated with vaccine producers. The World Bank will provide funding for the vaccine for the four percent of the population not fully subsidized by COVAX. The vaccine will be purchased at low prices negotiated by COVAX with vaccine producers. 43 These prices will be finalized by COVAX in the coming months. It is expected that the vaccine provided through COVAX will become available in batches throughout 2021. As COVAX has several vaccines in its portfolio, it is possible that more than one type of vaccine will be allocated to Tajikistan, depending on availability. COVAX has expressed their commitment to minimizing the number of types of vaccines delivered to each country. The COVAX Facility is a mechanism through which demand and resources are pooled to support availability of, and equitable access to, COVID-19 vaccines for all economies. Under the Facility, the “Gavi COVAX AMC” (also referred to as the “AMC”) has been established to enable Gavi to purchase vaccine doses for 92 eligible lower-income countries. The COVAX AMC helps ensure that the COVAX AMC Eligible Economies can participate in the Facility and access vaccines through it. The remaining economies not covered by the Gavi COVAX AMC (also referred to as the Self-Financing Participants) are expected to fully self-finance their participation in the Facility. On February 26, COVAX announced that Tajikistan is allocated 624,000 doses of AstraZeneca/Oxford University ChAdOx1 vaccine, manufactured by the Serum Institute of India, which has been granted Emergency Use Listing by WHO on February 15. At two doses of vaccine per person, this would be sufficient to cover 3.8% of the population, assuming no vaccine wastage. An initial 30% (192,000 doses) was delivered on March 8, 2021 , while the remaining 70% (432,000 doses) will be expected through July 2021. The AstraZeneca/Oxford University vaccine, ChAdOx1, has been given to approximately 24,000 individuals aged 18 and over in four on-going clinical trials in UK, Brazil, and South Africa. Initial results show that those who received the vaccine have a 63.1% reduction in the rate of COVID-19 illness, when 2 doses of vaccine were given at a 28 day interval 44 (see Table 1). The AstraZeneca ChAdOx1 vaccine has been granted emergency use approval by several Stringent Regulatory Authorities including Australia, Canada, the European Union, and the United Kingdom for vaccination of people over the age 43 AF financing will not be used to secure Tajikistan’s participation in the COVAX AMC. 44 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/949772/UKPAR_COVID_19_Vaccine_AstraZen eca_05.01.2021.pdf 124 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual of 18. On February 15, the vaccine was granted Emergency Use Listing by WHO and is thus authorized for distribution through COVAX. As planned by COVAX, the AstraZeneca vaccine, manufactured by the Serum Institute of India (COVISHIELD™, ChAdOx1 nCoV-19 Corona Virus Vaccine (Recombinant)), will arrive in an English- labelled vial and English carton, consisting of 10 doses per vial. Tajikistan will also have received an equivalent number of 0.5mL auto-disable syringes from UNICEF Supply Division, as well as 1-inch 23- gauge needles for intramuscular injection. The recommended shelf life of the vaccine is currently 6 months, although this is a conservative estimate and may be extended. Vaccine must be stored between +2 to +8 degrees Celsius. Vials must be used within 6 hours of first puncture. According to the interim recommendation from the WHO Strategic Advisory Group of Experts (SAGE) on February 11, 2021, AZ vaccine can be used in people 18 years of age and over, on a 2-dose schedule (0.5mL each) with a recommended interval of 8-12 weeks between doses. No diluent (mixing solution) is needed for the vaccine and no mixing syringes are needed. Full product details can be found on the WHO website in English, and in Russian 45. Table 1: COVID-19 vaccines and vaccine candidates with possible availability to Tajikistan, through COVAX in 2021 (As of April 12, 2021) Vaccine Manufacturer Schedule Storage Regulatory Projected (degrees status delivery to Celsius) Tajikistan AstraZeneca Serum 2 doses, 1- 2-8C Granted 192,000 doses on Institute of 3 month WHO EUL March 8, 2021 India (India) interval Approx. 432,000 doses by end May 2021 Novavax - 2 doses 2-8C Under Decision on review allocation to Tajikistan to be determined after regulatory approval Johnson & - 1 dose 2-8C Granted Decision on Johnson WHO EUL allocation pending 45 https://www.who.int/publications/m/item/chadox1-s-recombinant-covid-19-vaccine 125 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Sanofi/GSK - 2 doses 2-8C Awaiting Decision on trial results, allocation to Q4 2021 Tajikistan to be determined after regulatory approval Other vaccines that may become available to Tajikistan in the next few months, but are not currently supplied by COVAX, are included below. As of April 12, these vaccines do not meet World Bank vaccine eligibility criteria 46 and are not eligible for direct support from TEC-19 AF1: Vaccine Manufacturer Schedule Storage Regulatory Projected (degrees status delivery to Celsius) Tajikistan Sinovac - 2 doses, 14- 2-8C Undergoing 150,000 doses 28 day WHO EUL possible by early interval review March Sputnik - 2 doses, 21- 2-8C Undergoing (Gamaleya day interval WHO EUL Institute) review Vaccine procurement Vaccines secured by COVAX – fully subsidized and those offered at negotiated prices – will be procured through the UNICEF Supply Division, COVAX’s procurement agent. As per the agreement with COVAX, no fees need to be paid by Government for the initial allocation of 624,000 doses. COVAX will supply the vaccine in vials, as well as accompanying needles, syringes, and safety boxes for safe sharps disposal. Freight costs for delivery from the manufacturer to Tajikistan are also covered by COVAX. Other disposables required for vaccine delivery, such as PPE, will not be supplied and will need to be procured by the Government. World Bank financing under TEC-19 AF1 is intended to help cover these costs. 46 “Vaccine Approval Criteria” means that the Project COVID-19 vaccine: (a) has been approved by three (3) Stringent Regulatory Authorities (including by Emergency Use Authorization) in two (2) Regions; or (b) has received the WHO Prequalification and has been approved (including by Emergency Use Authorization) by one (1) Stringent Regulatory Authority; or (c) has met such other criteria as may be agreed in writing by the Recipient and the Association. 126 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Figure 1: Global timeline to first vaccine distribution. Source: COVAX, February 2021 The AstraZeneca/SII vaccine has been approved by both WHO and Tajikistan’s regulatory authority, and shipped to Tajikistan. For any other COVID-19 vaccine, several steps need to be completed prior to the release of vaccine to Tajikistan. From the side of international partners, WHO must grant emergency use authorization for the vaccine, and vaccine doses must be available from the vaccine manufacturer. From the side of the Government of Tajikistan, the government must complete and send: 1) Signed National Deployment and Vaccination Plan, 2) Evidence of approval of the vaccine by the national regulatory agency; 3) Vaccine import permit; 4) Completed and signed Annex B of the COVAX Vaccine Request form, and 5) Evidence of completion of a final pre-shipment check, together with COVAX. a) National Deployment and Vaccination Plan: Supported by the World Bank, Gavi, UNICEF, WHO and other partners, the Government launched an assessment of its readiness to roll out the COVID-19 vaccination program. The assessment showed that, while Tajikistan is still in early stages of planning for vaccine roll-out, many important elements are already in place. Based on results from the assessment, the Government established a technical working group (TWG) within the MOHSP to lead the work on the National Preparedness Plan for the Introduction of New Coronavirus Vaccine in the Republic of Tajikistan, endorsed by the country. This formed the foundation of the National Deployment and Vaccination Plan (NDVP). Following rounds of peer review, the NDVP was finalized and submitted to COVAX on February 9, 2021. b) Regulatory approval: Approvals of all new pharmaceutical products, based on their quality, effectiveness, and safety requirements, are certified by the Government of the Republic of Tajikistan guided by the Law of the Republic of Tajikistan About Medicines and Pharmaceutical Activities No. 39 from 06.08.2001. Tajikistan’s Medical Regulatory Agency is responsible for market access and certification of new pharmaceutical products. The Agency is well established and regularly approves new vaccines. Further, as provided by the Law, production, marketing, 127 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual and use of medicines and medical supplies within Tajikistan is carried out upon their state registration in compliance with the procedures as established by the Ministry of Health and Social Protection. Medicines and immunobiological substances are subject to mandatory certification based on their compliance to the quality, effectiveness, and safety requirements in the manner determined by the Republic of Tajikistan. The Medical Regulatory Agency is currently considering licensing specific criteria for COVAX-subsidized vaccines. The vaccine financed under AF1 will need to meet the Bank’s threshold for eligibility of IBRD/IDA resources in vaccine purchase of either (i) approval by three Stringent Regulatory Authorities (SRAs) in two regions or (ii) WHO prequalification and approval by one SRA 47. Based on the assumption that the initial vaccines will be procured through the COVAX Facility, the government is aligning its regulatory criteria to that recommended by COVAX (i.e. WHO prequalification or an exceptional basis, at a minimum, licensure/authorization in place from an SRA). c) Vaccine import permit: As per the COVAX Terms and Conditions, Tajikistan is responsible for securing regulatory import permits for the importation of COVID-19 vaccines and related supplies. Import permits will need to be submitted prior to vaccine shipment. This has been submitted for AstraZeneca vaccine. d) Signed indemnity / liability Annex B: As detailed in the Terms and Conditions of COVAX, Tajikistan must indemnify the applicable vaccine manufacturer (in the case of Tajikistan, in the first instance, this will likely be AstraZeneca and the Serum Institute of India) against product liability claims associated with the use or administration of the approved vaccine. That is, each country participating in the COVAX Facility will be required to pay any legal awards in that regard towards the manufacturer. As such, the country will be required to enter into an Indemnification Agreement with the applicable manufacturer and submit it in the form of an Annex to Part B of the COVAX Vaccine Request application. Countries will need to enter into an Indemnification Agreement with each manufacturer supplying vaccines to Tajikistan through COVAX. The Indemnification Agreement will cover both vaccine doses that are donor-financed, and doses that are Government-financed. 47 Legal note: Compliance with the World Bank Vaccine Eligibility Criteria (VAC) is required for all Project COVID-19 Vaccines. The VAC does not constitute an approval, validation, or endorsement by the Bank of the Project COVID-19 Vaccine(s) safety or efficacy. The relevant regulatory authorities of Tajikistan are responsible for carrying out their own regulatory, technical, and due diligence assessment of the Project COVID-19 Vaccine(s)’ safety and efficacy, and are solely responsible for the authorization, deployment, and use of the Project COVID-19 Vaccine(s) in Tajikistan. 128 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual The COVAX Facility has established a no-fault compensation mechanism to provide compensation to individuals in Tajikistan who suffer a serious adverse event (SAE) which is found to be associated with the approved vaccine or its administration. The compensation payment to be provided to the aforementioned individuals will be in full and final settlement of any claims (whether against the manufacturer and/or any other party involved in the distribution or administration of the Approved Vaccine) arising from or in connection with the SAE in question. This compensation mechanism will cover both donor-financed and Government-financed vaccine doses. Tajikistan’s indemnity strategy has been developed as part of the National Deployment and Vaccination Plan. A special intersectoral Working Group (WG) including experts from MOHSP, the ministries of Finance and Justice, and other relevant institutions has been established to ensure appropriate and timely development of the necessary regulatory framework for indemnification against product liability claims associated with the use or administration of the approved vaccine in Tajikistan. The 2017 Health Code, which stipulates that citizens have a right to compensation for damage caused to their health in accordance with the legislation of the Republic of Tajikistan, is being used as the basic legislation governing manufacturer indemnification. Since the initial vaccines will be procured through COVAX, the Government of Tajikistan is working to align its indemnification regulatory criteria to the COVAX recommendation. On February 20, the COVAX Indemnification Agreement was signed between the Government of Tajikistan and Serum Life Sciences Ltd (the manufacturer of the AstraZeneca vaccine). e) Final pre-shipment check: is conducted prior to shipment, and includes a checklist to ensure registration, import licenses, and indemnification requirements have been completed. Placing orders for additional Government or World Bank-financed vaccine doses By late April 2021, countries will be expected to indicate the quantity of vaccines they would like to purchase through COVAX, with own or multilateral bank financing. The template letter is expected to be issued by COVAX in mid-April 2021. The initial, non-binding commitment will be followed by a legally and financially binding agreement sometime later in 2021. World Bank AF1 financing is expected to be used to cover the cost of these additional doses. Vaccine distribution 129 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Who will get the vaccine The vaccine will be given in accordance with the prioritization framework developed by the Technical Working Group on COVID-19 Vaccine Delivery, led by the Ministry of Health and Social Protection of Tajikistan. This framework is detailed below. Stage 1 covers 10 percent of the population. - The first priority group in Stage 1 accounts for 3% of the total population and includes all health personnel and 70+ age group; - The second priority group in Stage 1 accounts for approximately 7% of the total population and includes those aged 60-69, HIV patients and patients with chronic diseases such as diabetes, TB, hypertension, chronic respiratory diseases, ischemic heart diseases and cancer. Stage 2 covers the next 10 percent of the population. - The first priority group in Stage 2 accounts for 8% of the population and will be older adults age 50-59. - The second priority group in Stage 2 accounts for 2% of the population and will be those with other comorbidities including chronic kidney disease, obesity, immunodeficiency, including after transplantation, and neurological diseases. Education and science sector employees are also included in the second priority group of Stage 2. The vaccination priority target groups and sub-groups, and number of individuals in each group are presented in Table 2 Ошибка! Источник ссылки не найден.. The first batch of 192,000 AZ-SII vaccines arrived in Tajikistan on March 8, 2021, and vaccine roll-out began on March 23, 2021, starting with health-care workers as per the plan. According to the government plans for COVID-19 vaccine introduction, following immunization of the first 20%, the vaccination will be expanded to vaccinate another 50% of the population, which will ensure that approximately 70% of population is covered by the COVID-19 vaccine. The decision on expansion of vaccination will depend on the epidemiological situation in the country and availability of resources. Resources under AF1 are expected to help purchases vaccine doses to move towards these coverage targets. Table 2: Vaccination target groups, coverage and wastage rates and number of required doses Vaccination Doses Size of Wastag # of required Coverage target in Target e doses incl. target group/pers schedul Group target wastage Phase Target Group ons e Health workers 95% 2 15% 1 117,217 111,356 262,014 130 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual 70+ age group 95% 2 15% 1 180,600 171,570 403,694 60-69 age group 95% 2 15% 2 382,600 363,470 855,224 HIV patients 95% 2 15% 2 9,329 8,863 20,853 Patients with diabetes mellitus 95% 2 15% 2 34,278 32,564 76,621 TB patients 95% 2 15% 2 11,767 11,179 26,303 Hypertension 95% 2 15% 2 103,838 98,646 232,108 Chronic respiratory diseases 95% 2 15% 2 110,530 105,004 247,067 Ischemic heart disease 95% 2 15% 2 21,375 20,306 47,779 Cancer 95% 2 15% 2 17,271 16,407 38,606 50-59 95% 2 15% 3 717,500 681,625 1,603,824 Chronic kidney disease 95% 2 15% 3 28,460 27,037 63,616 Obesity 95% 2 15% 3 3,119 2,963 6,972 Patients with immunodeficiency, 95% 2 15% 3 including after transplantation 700 665 1,565 Neurological diseases 95% 2 15% 3 43,253 41,090 96,683 Education and science sector 95% 2 15% 3 employees 83,825 79,634 187,374 Totals 1,865,662 1,772,379 4,170,303 Source: National Deployment and Vaccination Plan, February 2021 The mapping of immunization target groups in line with the government strategy for COVID-19 introduction is being implemented with the UNICEF support and involvement of key non-governmental and public organizations in the field. 48 These groups will be approached to identify areas where they can support the demand generation activities. Further steps include following interventions: • Mapping and identification of the population groups targeted through the Stage 1 and Stage 2 of COVID-19 vaccine introduction; • Mapping of NGO/CBO operating in the underserved communities; • Identification and engagement of community influencers/leaders, local opinion makers (Jamoat, mahalla and religious leaders and teachers). 48 National Deployment and Vaccination Plan for introduction of COVID-19 Vaccines in the Republic of Tajikistan 131 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Delivery to Tajikistan The Republic of Tajikistan purchases all vaccines for routine immunization exclusively through the UNICEF Supply Division. A Memorandum of Understanding between the Ministry of Health and Social Protection and UNICEF on the procurement of vaccines was signed on March 30, 2004. The coronavirus vaccine will be included in the existing vaccine procurement system. The only port of delivery of vaccines to the country is the International Airport of Dushanbe. There is a unified practice of delivery of vaccines for routine immunization by the aerial route; however, in the context of the COVID-19 pandemic, they were delivered to the international airport of the city of Tashkent, Republic of Uzbekistan, and delivered using refrigerated trucks. Upon arrival, the vaccines are temporarily stored in a refrigerator at the international airport in Dushanbe. Responsible employees of the RCIP control the maintenance of the cold chain conditions during the storage period. The temperature reading is recorded in a standard UNICEF Vaccine Acceptance Report. All batches of vaccines are transported from the airport to the national vaccine warehouse in refrigerated RCIP trucks and accompanied by an authorized official of the RCIP. All immunization materials (syringes and safe disposal boxes) are delivered to the country by overhead route of international terminals in Dushanbe and Tursunzade. Distribution within Tajikistan COVID-19 vaccines will be distributed in Tajikistan through the structure and supply chain of the expanded program on immunization managed by RCIP. RCIP has one national vaccine storage warehouse in Dushanbe, which has a cold store with cold chain (CC) equipment for storing vaccines, a dry warehouse for storing immunization materials, 6 regional / zonal warehouses, and 65 city and district vaccine warehouses. Seven districts close to the Central Vaccine Warehouse bypass the administrative system and collect their vaccines directly from there. This logistic chain is used to distribute vaccines and immunization supplies to all health facilities that are responsible for routine immunization of children, as well as immunization of the population during mass immunization campaigns. Vaccines are delivered quarterly from the central level to the regional level by means of refrigerated trucks. Each district immunization center collects vaccines from the regional branches of RCIP on a monthly basis, using thermo-containers and local transport. Health facilities collect vaccines from district immunization centers on a monthly basis (Figure 2). 132 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Figure 2: Vaccine distribution system in Tajikistan Source: Reproduced from Tajikistan vaccine cold chain inventory, needs assessment, and rehabilitation plan, 2017. Please note that immunization will also be carried out at selected hospitals, for a total of 4290 vaccination points * Gissar (Hissor), Rudaki, Vahdat, Tursonzade, Faizabad, Varzob, Shahrinav. Vaccines likely available to Tajikistan are projected to be stored under the same cold-chain conditions as for routine vaccines (see Supply of COVID-19 Vaccine, above). As for routine vaccines, the AstraZeneca COVID-19 vaccine should be kept in its original carton in a refrigerator between +2 to +8 degrees Celsius, and not stored in a freezer. Exposure to direct sunlight and ultraviolet light should be avoided. After opening vials, vaccines may be used up to 6 hours after opening if kept cooled at +2 to +8 degrees Celsius. Full stability and storage conditions for AstraZeneca vaccine can be found in the COVID-19 Vaccine Explainer document 49, available in English and Russian. A cold chain assessment was conducted to assess the capacity of the cold chain system to store vaccines. The assessment showed that the existing cold chain storage capacity for vaccines stored at +2 to +8 degrees Celsius is 94.3 m3 (94,319 liters), which is sufficient to store vaccines to cover 3% of the population, while an additional 9.0 m3 (9,031 liters) would be required to store vaccines for 20% of the 49 https://www.who.int/tools/covid-19-vaccine-introduction-toolkit#Vaccine%20specific%20resources 133 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual population, including 8.3 m3 (or 8292 liters) at the central level and 0.7 m3 (or 729 liters) at the district level (see table below). Table 3: Available and required cold-chain capacity at central and regional levels (20% coverage) Vaccine Purpose of Storage Volumes Volume Gap Additional capacity temperature available equipment required AstraZenec For storage of +2 +8 72258 L 8292 L 1 Cold room 30 a vaccines m3 (AZD1222) 1 Cold room 10 m3 4 х Refrigerators (VLS 504A - 3pcs; VLS 350A – 1pcs) For -15 -25 23,533 L 7,970 L 33 freezers transportation (MF214 – 1pcs; and freezing of MF314 – 32pcs) ice packs Source: UNICEF calculations based on WHO / UNICEF measurement tool, 2021, via National Deployment and Vaccination Plan, February 2021 Table 4: Available and required cold-chain capacity at district level (20% of coverage) Vaccine Purpose of Storage temperature Volumes Volume Additional capacity available Gap equipment required AstraZeneca Vaccine +2 +8 22,061 729 л 8 refrigerators (AZD1222) storage (VLS 504A -2 pcs; VLS 400A - 1pc; VLS 300A - 2pcs VLS 200A – 3pcs.) Transportation -15 -25 9,058 ltr 4682 л 66 х Freezers and (MF114 – 50 production of pcs; MF214 – 7 х/элементов pcs; MF314 – 9pcs) Source: UNICEF calculations based on WHO / UNICEF measurement tool, 2021, via National Deployment and Vaccination Plan, February 2021 134 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual The country has submitted a cold-chain application to the COVAX Facility. The COVAX cold-chain equipment application considers procurement of cold-chain equipment for filling in existing gaps at all levels of the system, as well as procurement of the freezers for production of ice packs to ensure transportation of COVID-19 vaccines according to the regulations and existing standard operating procedures. The detailed list of equipment and deployment levels are provided in Tables 5 and 6. The cold-chain equipment requirement includes freezers for producing ice packs to ensure transportation of vaccines according to the existing SoPs. Table 5: Additional CC equipment required at all levels of the system # Technical Cost per Total cost in CC unit specifications Quantity USD equipment in USD 1. WICR-30m3 WICR 1 $40,277 $40,277 2. WICR-10m3 WICR 1 $27,405 $27,405 3. VLS 504A ILR 5 $2,440 $12,200 4. VLS 400A ILR 1 $1,693 $1,693 5. VLS 350A ILR 1 $1,601 $1,601 6. VLS 300A ILR 2 $1,485 $2,970 7. VLS 200A ILR 3 $1,311 3,933 Total $90,087 Source: RCIP/MOHSP, via National Deployment and Vaccination Plan, February 2021 Table 6: Additional required CC equipment – at -150C – 250C (transportation and production of cold-elements) # Technical CC Quantity Cost per Total cost in specifications equipment unit USD in USD 1. MF-314 MF 41 $1,130 $46,330 2. MF-214 MF 8 $1,033 $8,264 3. MF-114 MF 50 $953 $47,650 Total $102,244 Source: RCIP/MOHSP, via National Deployment and Vaccination Plan, February 2021 Table 7: Required equipment for cold chain # Technical CC Cost per Total cost Quantity specifications equipment unit in USD 135 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual in USD 1 Cold boxes CB-20-CF 456 $160,00 $72 960,00 Temperature monitoring Fridge-Tag 2 14 $73,00 $1 022,00 device_30DTR 2E (+2 ÷ +8 C) *Temperature monitoring LIBERO 3 99 $150,00 $14 850,00 device_30DTR (- Ti1 35 ÷ +70 C) Voltage SVS04-22 4 regulators for 4A 1KVA 113 $65,00 $7 345,00 equipment 230V 5 Total $96 177,00 Source: RCIP/MOHSP, via National Deployment and Vaccination Plan, February 2021 On temperature monitoring, cold chain data will be managed according to established standard operating procedures for effective vaccine management. RCIP purchased and distributed among regional and district vaccine warehouses 3,000 electronic freezing indicators and 435 30-day temperature recorders. In addition, 8 sensors for remote temperature monitoring were installed on refrigerated trucks. According to the National Deployment and Vaccination Plan, other steps taken to prepare the supply chain for COVID-19 vaccine introduction include: development of the procurement plan for COVID- 19 vaccine(s) and ancillary supplies (syringes and safety boxes), conducting an inventory of cold chain equipment, completion of a gap analysis and submission of an application to COVAX for cold chain support, development and implementation of a cold chain equipment distribution plan at the district and facility level. Procurement of goods financed through COVAX cold chain support is expected to take place in spring 2021. Other steps planned for March – April 2021 include assessment and costing of required inputs related to infrastructure for energy (primary and back-up power), communications, and water; and training for healthcare workers on cold chain management. Delivery at facilities COVID-19 immunization will be provided by the existing network of public primary care medical facilities, which includes 844 Rural Health Centers (RHCs), 54 District (Rayon) Health Centers (RHCs), 136 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual 53 City Health Centers (CHCs), 9 family medicine centers, 107 first-aid posts and 1,711 health houses – a total of 2,778 health institutions. RCIP has established additional vaccination points at selected hospitals, for a total of 4290 vaccination points. There are no plans to involve private facilities in COVID- 19 vaccination. Most vaccines will be provided at the existing network of health facilities (fixed-site), others will perform outreach, while some facilities will perform immunization through mobile clinics. • Fixed vaccination sites will be the existing network of health facilities, at the sites of routine immunization, where all necessary equipment and supplies are available (refrigerators, injection equipment and etc.). • Outreach vaccination points will be set in buildings of medical or non-medical facilities and institutions. In rural areas – in the health houses or administrative and / or re-purposed premises. On-site vaccination teams will consist of the medical staff of a territorial medical institution. • Mobile teams, which are formed at the district level, will provide services at the temporary vaccination points, that will be set at health houses (if available), administrative or adapted premises in hard-to-reach areas. Vaccination will be delivered during focused, time-limited vaccination campaigns. To ensure full coverage of the eligible population groups, preliminary lists of target groups will be developed at the facility level, where vaccinations will be carried out. The medical staff will notify the target groups (via telephone or by door-to-door visits) 10 days before the start of the campaign. During the notification process, the lists of target groups are checked and updated as necessary. During the campaign, health workers will use a notification system for people to receive the second dose to ensure high coverage of the target groups. It is as yet unclear what rules and procedures are in place for processing and collection of personal medical data. It is also unclear how vaccine site security will be established, for example whether security personnel will be deployed for crowd control or security of the vaccine supply. The vaccine will be provided to the population free of charge and on a voluntary basis. Complaints may be addressed through the grievance mechanism established by the World Bank. Where possible, clinics should be encouraged to provide a locked drop box to receive complaints anonymously, and a key official designated to be responsible for collecting and escalating issues to the grievance mechanism as needed. No forced vaccination is permitted under the law. To date, there are no plans to use security personnel in any part of the vaccination program. While use of security forces is not anticipated, in the event that they do need to be deployed, the MOHSP/PIU will take mitigation measures, listed in Annex 6 of the project ESMF dated March 2021, to ensure that the engagement of security personnel in implementation of Project activities for provision of security to Project workers, sites and/or assets, to be consistent with the WB Environmental and Social Standards. 137 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Complaints may be addressed through the project specific grievance mechanism established by the MOHSP/PIU. Where possible, clinics/vaccination points should be encouraged to provide a locked drop box to receive complaints anonymously, and a key official designated to be responsible for collecting and escalating issues to the grievance mechanism as needed. Complaints on the quality of services are also accepted at the State Control of Medical and Social Protection Service at tel. #:44 600 65 07; 44 600 65 09. Table 8: Vaccination teams and total target population by oblast and region Fixed Total number Total number of Outreach City / district / vaccination Mobile of target teams needed at vaccination oblast points teams 5% populations immunization points teams 30% teams 65% Dushanbe 237722 38 25 12 2 GBAO 50158 320 208 96 16 Sughd region 524019 942 612 283 47 Bokhtar 380715 964 626 289 48 Kulob 240964 676 439 203 34 Rasht 68856 308 200 93 15 Rudaki 115043 140 91 42 7 Hissor 61507 108 70 32 5 Tursunzoda 58754 103 67 31 5 Sharinav 22382 52 34 15 3 Vahdat 68137 149 97 45 7 Fayzobod 20018 68 44 21 3 Varzob 17387 50 33 15 3 Total 3919 2547 1176 196 1,865,662 Source: National Deployment and Vaccination Plan, February 2021 Human resources According to the strategy elaborated by the government for the COVID-19 vaccine introduction, the administration of COVID-19 vaccines is being carried out by routine immunization service providers, the health workers who have extensive experience in implementation of immunization campaigns. 138 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual a. Training The Republican Center for Immunoprophylaxis (RCIP) is training PHC service providers, who are responsible for implementation of COVID-19 vaccinations. The training materials are developed by the RCIP and cover all areas related to the vaccine specifics and vaccine management such as: basic knowledge about COVID-19 vaccines, vaccine safety and efficacy, AEFI and injection safety and contraindications to COVID-19 vaccine. Modules are included on communication for immunization and risk communication. Staff involved with planning and management are being trained in forecasting, microplanning, storage and handling of COVID-19 vaccines, recording and reporting, coverage monitoring, AEFI surveillance and supportive supervision. The training program is based on the already existing immunization training curriculum, adapted for the introduction of COVID-19 vaccine. Trainings are being carried out through a cascade method and delivered by specialists from RCIP and its branches at the central and sub-national levels (regional and city/rayon levels). Participants are family doctors, pediatricians, nurses and vaccinators. Table 9 below presents the training plan per topic. Table 9: Training plan – number of trainees per training topic Topic # of participants Target groups Managers and staff Microplanning 3024 involved Staff training (immunization in practice – safe 6048 Vaccinators injections, cold chain, waste disposal) Vaccinators and Social mobilization training 6048 doctors Interpersonal Communication Training (IPC) 6048 Vaccinators Vaccinators and Vaccine and AEFI safety training 3014 Doctors Source: National Deployment and Vaccination Plan, February 2021 The cascade method is being implemented as follows: At the first stage – A training seminar is delivered at the national level to the immunization program management. The group of trainees includes specialists from the SSES, pharmacovigilance and the Republican Center for Family Medicine. 139 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual At the second stage – Cascade training workshops are being delivered at regional, city and district levels and at PHC facilities. The supportive supervision system involves the staff of the RCIP and its regional offices as well as the district level centers for immunoprophylaxis (CIPs). The supervisors are trained in the subject and pay regular visits to the facilities where vaccinations are administered. During the visits they record their comments on issues identified using the facility supervisory visiting book. This helps to follow up on their comments during their next visits. A clear responsibility is being assigned to all four levels (national, regional, district and facility). b. Implementation Immunization sessions are being implemented in line with the recommendations of the World Health Organization regarding the implementation of vaccinations during the COVID-19 pandemic, and adherence to standard preventive measures and infection control will be ensured accordingly. It is estimated that each vaccinator will undertake approximately 80 vaccinations per day. Table 8 gives an overview of the population target and human resources required, by city, district and oblast. All vaccinators will continue to be given appropriate PPE and safety guidelines to conduct vaccinations. AF1 financing may be used to procure PPE for healthcare workers. Supply chain management Vaccine forecasting is under the responsibility of RCIP. Detailed inventories of cold chain equipment at all facilities along the supply chain is collected regularly by RCIP and can be used to inform planning for COVID-19 vaccine roll-out. The World Bank AF1 may be used to procure IT equipment and software needed to roll out the electronic vaccine supply chain management system in the regions and districts. Waste management Maintenance of appropriate waste management procedures during and after COVID-19 vaccination sessions has critical importance, considering the nature of disease and importance of prevention measures to stop transmission of disease. During COVID-19 vaccination the health staff in all health facilities is expected to treat waste generated during immunization according to the existing procedures and standards. All vaccination points, including mobile vaccination points and vaccinations delivered through outreach, will ensure management of all types of waste generated during the vaccine introduction and will carry out respective interventions for proper labeling, segregation and utilization of waste. Particular attention will be paid to one of the most important components – proper disposal of sharps (syringes and needles) as well as disposal of unused, open or damaged vaccines. 140 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Related to this, all staff members involved in the introduction of the new vaccine and immunization service delivery will be trained in application of the newly developed standard operating procedures (SOP) on waste management per the latest immunization waste management guidelines institutionalized by the Government of Tajikistan. The waste management practices will be monitored through supportive supervision, carried out in accordance with the existing supportive supervision guidelines. Public awareness-raising A Thematic Working Group (TWG) on Communication and Social Mobilization has been established by MOHSP to ensure an enabling environment for high vaccine acceptance by the population through access to accurate and reliable information, responding to misinformation and effective community feedback mechanism to address their concerns and needs related to vaccination. The TWG works on the demand generation and trust-building on COVID-19 vaccine by designing, planning, implementing and monitoring communication and social mobilization activities through effective engagement of relevant agencies working on communication and governance, as well as other stakeholders to inform the public about the COVID-19 vaccination. UNICEF, with RCIP and partners, are working on the development, design and endorsement of various information, education and communication materials including harmonized key messages, FAQs and relevant information and activities related to COVID-19 vaccination in line with the government plan of vaccine introduction.TEC-19 has supported the establishment of a national COVID-19 hotline. AF1 will finance its further strengthening, as well as the establishment of regional COVID-19 hotlines, to provide callers with information about COVID-19 (i.e., symptoms, testing options, referrals, etc.) and information about how to access other essential health services during the pandemic. The hotlines will also be used as an additional grievance filing mechanism; however, they will not be utilized to report back on the resolution of complaints. The GM group at the MOH/PIU will deal with all the grievances received, including the ones received via hotlines. Based on the success of the national COVID-19 campaign financed under the Original Project (OP) and implementation of the Stakeholder Engagement Plan prepared for the OP, the AF1 will expand its scope and information and messages related to COVID-19 vaccine. This will include information about vaccine itself, information about the Government vaccine delivery strategies and plans, with a special emphasis on the prevention and mitigation of vaccine hesitancy. AF1 will finance staff time, equipment and operational costs of the hotlines, as well as increased capacity of the MOHSP server to accommodate increased traffic on the COVID-19 website and its expanding content to ensure that the public can access it without interruptions. The Republican Healthy Lifestyle Centre will provide training for 1000 volunteers, who will be involved in risk communication and community engagement, including the dissemination of information about the stages of vaccination and target groups. In addition, the Project supports the printing and distribution of information materials and the dissemination of information through the media. 141 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Monitoring & Evaluation Adverse events following immunization (AEFI) While there is officially a national system to report AEFI, reporting efficacy can be improved. WHO EURO has conducted an in-depth assessment of the key preparedness elements including legal standards, regulations, and guidelines; AEFI guidelines; organization and management; and resources including human and financial resources, infrastructure and equipment; and pharmacological surveillance and AEFI surveillance process. Training materials for the new guidelines and tools are being developed and training for health personnel is being planned. AEFI monitoring for COVID-19 vaccine will be built into this new system. One critical gap identified by the assessment is the lack of funds to disseminate the tool and conduct the necessary training. AF1 may be used to support training and the construction of a national electronic AEFI monitoring system for more effective monitoring of AEFIs. Vaccine distribution The Republican Center for Immuno-prophylaxis (RCIP) is responsible for managing and monitoring vaccine delivery. RCIP reports related to vaccine programs using the official reporting Form 2, is transmitted to the Agency on Statistics directly under the President of Tajikistan. The following periodic independent evaluations and audits of RCIP and immunization program implementation are conducted: (i) MOHSP annual audit; (ii) annual audit by Agency for State Financial Control and Anti-Corruption; (iii) annual audit by National Accountants’ Chamber of the Republic Tajikistan; and (iv) annual evaluation of immunization program by the SES. Vaccine distribution monitoring: The evaluation of the COVID-19 vaccine introduction will be conducted through application of the Post-Introduction Evaluation methodology developed and provided by WHO. Under the National Deployment and Vaccination Plan, it is envisaged that the WHO and the European Center for Disease Control Joint Weekly Data Collection Facility on COVID-19 Vaccine Distribution and Vaccine Coverage will be used; data collection will be carried out through TESSy, the European Surveillance System. The TESSy platform is currently being used by COVID-19 surveillance coordinators in the region to provide weekly epidemiological data. The mechanism is designed to collect weekly data on (i) doses of vaccines delivered to the country; (ii) number of people who have received vaccines – first dose, second dose, or a “dose of uncertain order” – disaggregated by age group, gender,and by the type of health worker. To further support the monitoring and management of the vaccination program, the Plan includes the development and dissemination of reporting forms on COVID-19 immunization based on the currently used immunization registers. It is envisaged that World Bank-supported electronic vaccination registry pilots can be used to collect data on COVID-19 vaccination at the facility level in certain pilot districts. 142 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual According to the WHO recommendations a post-introduction evaluation (PIE) will be conducted 6-12 months after the introduction of a new vaccine. The evaluation will be coordinated by the Republican Center for Immunoprophylaxis (RCIP) and will aim at the following objectives: • to identify strengths and weaknesses associated with COVID-19 vaccine introduction • to propose solutions to identified problems • to recommend improvements in planning for introduction of new vaccines and for possible future COVID-19 vaccination • to document lessons learned from COVID-19 vaccination for other new vaccine introductions A detailed plan with the adapted methodology will be developed for the PIE. Based on previous experiences, particularly the Rotavirus vaccine introduction and PIE, it is expected that five teams will be arranged comprised of international experts, national and regional staff who will visit all five regions across the country. The teams will use standardized questionnaires at the national, regional, and district RCIP offices, and health facilities levels to collect data for the PIE. This will be complemented by qualitative data collected through interviews with medical staff, older people and others who will receive the COVID-19 vaccines under this plan. Qualitative and quantitative data will be analyzed and a report with recommendations and lessons learnt will be published. The findings and recommendations will be presented at the Interagency Coordination Committee for Immunization (ICC) and other relevant meetings to the national and development partners. The mechanisms described above will provide data for monitoring project implementation, numbers of people vaccinated, and help ensure that the vaccination is progressing according to the priorities and procedures of the National Deployment and Vaccination Plan. Financial monitoring of project activities is described below in Section IV.B. In addition, it was agreed that third-party monitoring by a civil society organization (CSO) or a consortium of CSOs will be carried out to assist the MOHSP to enhance effectiveness and transparency in project implementation and elicit public trust and support. The third- party monitoring will be financed through a World Bank-executed trust fund under the advisory services and analytics activity – Tajikistan: Third Party Monitoring of World Bank COVID-19 Operations Project, P175904 – rather than from the AF budget. Procurement Procurement under AF1 will be carried out in accordance with the World Bank’s Procurement Regulations for IPF Borrowers for Goods, Works, Non-Consulting and Consulting Services, dated July 1, 2016 (revised in November 2017 and August 2018). The Project will be subject to the World Bank’s Anticorruption Guidelines, dated October 15, 2006, revised in January 2011, and as of July 1, 2016 the provisions stipulated in the Financing Agreement. The AF will use the Systematic Tracking of Exchanges in Procurement (STEP) to plan, record, and track procurement transactions. 143 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual The current demand for COVID-19 vaccines exceeds the supply in the market, making it difficult for the government to negotiate terms and conditions. Procurement of vaccines will be done through single- source, direct agreement, with UNICEF as a procurement agent, direct payment, and prior review. 50 For other proposed packages, procurement methods as specified in the procurement plan will apply. Procurement will continue to be carried out by the MOHSP through the PIU and will follow procurement arrangements outlined under the parent project. Based on assessment of the implementation capacity of the parent project, the procurement risk for AF1 is rated Substantial. The risks for the AF, including those for vaccine procurement, along with the proposed mitigation measures, are presented in detail in the updated Project Procurement Strategy for Development (PPSD). The World Bank’s standard prior and post review arrangements will apply as specified in the procurement plan. The major goods, works and services envisaged for AF1 include (i) the initial supply of COVID-19 vaccines that have credible approval for safety and effectiveness – unless otherwise agreed, approval by three SRAs in two regions or WHO prequalification and approval by one SRA; (ii) PPE and other vaccine-related supplies for health care staff providing vaccinations; and (iii) development and dissemination of COVID-19 risk communication messages. Payment for the cost of other deployment efforts by government contractors will use the standard disbursement methods. Financial management and audits The FM arrangements established for the parent project are moderately satisfactory and will be replicated for this AF. The FM rating was assessed as moderately satisfactory, due to the shortcomings identified during the transactions review of the emergency cash transfers under Component 3 of the Project. Under the parent project, the MOHSP is responsible for the FM function, in accordance with the eligibility criteria and procedures acceptable to the World Bank, as described in the POM, which will be updated to reflect the AF arrangements. The chief accountant of the MOHSP is responsible, with the assistance of the FM consultant provided by the PIU, for establishing an effective project accounting system and for maintaining the system during implementation. The MOHSP is involved in the payments process through approval of invoices, works completion statements, and payment requests prepared by the PIU. The PIU will consolidate the reports for preparation of quarterly IFRs. The PIU has adopted a cash basis accounting for the Project’s accounting and it uses the computerized accounting software (1C) to track Project activities. The audit of the AF financial statements will be conducted: (i) by independent private auditors acceptable to the World Bank, on terms of reference acceptable to the World Bank; and (ii) according to the 50 UNICEF will act as the procurement agent of COVAX. The AF will not channel funds directly to CVOAX. 144 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual International Standards on Auditing issued by the International Auditing and Assurance Standards Board of the International Federation of Accountants. Annual audited project financial statements will be submitted to the World Bank within six months after the end of each fiscal year as well as at the Project closing. The scope of project audit will include audit of vaccination financing for 20 percent of the population under the AF Component 1 (US$ 5.8 million), and audit of funds spent on deployment of vaccines (US$ 2.2 million). The auditor will review a sample of 10 percent of such transactions to confirm the threshold for eligibility of the respective expenditures. The Recipient will disclose the audit reports for the Project within one month of their receipt from the auditors, by posting the reports on the website of the MOHSP. Following the World Bank's formal receipt of these reports from the Recipient, the World Bank will make them publicly available according to the World Bank Policy on Access to Information. Quarterly IFRs will be used for AF monitoring and supervision. These financial reports will be submitted to the World Bank within 45 days of the end of each calendar quarter. As part of the project implementation support and supervision, quarterly IFRs, audit reports and audit management letters will be reviewed, and regular risk-based FM missions will be conducted. The AF Grant proceeds will be disbursed by the World Bank in line with the World Bank Disbursement Guidelines for IPF (Dated February 2017), and using the advance, direct payment, reimbursement and special commitment disbursement methods. Disbursements to UNICEF for the purchase, transport and delivery of vaccines will be done using the UN Advances disbursement mechanism. In application of the Mandatory Direct Payment provision, disbursements for goods, works, or non-consulting services and consulting services contracts procured/selected in the international market through open competition, limited competition or through no competition, as set out in the Procurement Plan, must be made only through Direct Payment or Special Commitment disbursements methods. A new segregated Designated Account will be opened for the AF. Additional detailed procedures are included in the Disbursement and Financial Information Letter (DFIL). Social and environmental risk management The ratings for Environmental Risk and Social Risk are Substantial, resulting in an overall ESF Risk Rating of Substantial. The major areas of risk for the project are related to: (i) risks related to medical waste management and disposal; (ii) risks related to spread of the virus among health care workers; (iii) risks related to the spread of COVID-19 among the population at large; and (iv) risks related to distribution and administration of vaccines. These risks are covered by Environmental and Social Standards—ESS1, ESS2, ESS3, ESS4, and ESS10. 145 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual The more substantial risks are around ensuring that contagion vectors are controlled through: (i) strict adherence to standard procedures for medical waste management and disposal; (ii) the use of appropriate PPE for all health care workers; and (iii) working with local governments and communities to implement social distancing measures and quarantine regimes. The key social issues and mitigation measures taken by the parent project and which will be followed by the AF focus on: (i) ensuring a favorable and safe environment to prevent the spread of COVID-19 among health workers, complemented by WHO training opportunities at targeted healthcare facilities and to avoid staff burnout; (ii) assuring proper and quick access to appropriate and timely medical services, adequate hand hygiene and PPEs based on the current needs of the target healthcare facilities; and and (iii) securing explicit inclusion in robust stakeholder identification and consultation processes before and during vaccination. To manage these risks, the MOHSP will update two major instruments of the parent project – the ESMF and the SEP – to incorporate AF activities and investments to increase capacity of the MOHSP to develop and disseminate COVID-19 risk communication messages and feedback mechanisms. The ESMF and SEP will be updated to a standard acceptable to the Bank, used for stakeholder consultations, and disclosed in-country on the MOHSP website and on the World Bank website. This Vaccine Delivery and Distribution Manual for effective vaccine delivery and vaccination implementation has been developed, accepted by the Bank, disclosed by Project effectiveness, and included as an annex to the updated ESMF. 146 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Annex 1: Summary of the VRAF Assessment in Tajikistan Core Activity Assessment Readiness and Measures to Address Key Gaps Areas Area A. Planning A1. Readiness: A MOHSP TWG, which was established through and Vaccination a ministerial decree, has established target population groups Management objectives and and stages for COVID-19 vaccine roll-out. In the first stage, targets covering the first 20 percent of the population, the first priority group will include health sector workers, including health care providers, ancillary staff in health facilities, as well as staff working in long-term care facilities; older adults over the age of 60, people with certain comorbidities including diabetes, cardiovascular disease, cancer, tuberculosis (TB), and human immunodeficiency virus (HIV) – jointly accounting for 9.1 percent of population. The second priority group in Stage 1 will include people 50-59 years of age and people with other comorbidities, including chronic kidney disease, obesity, patients with immunodeficiency, including after transplantation, neurological diseases – 8.3 percent of the population). The last priority group in Stage 1 will include high-risk workers aged 30-49 years, and pregnant women – 2.6 percent of the population. Prioritization for subsequent stages of the vaccination program that will reach an additional 50 percent of the population is ongoing. It is expected that it will be completed as part of the finalization of the National Vaccine Deployment Plan by the end of January 2021. Given the acute crisis caused by the pandemic, the health system capacity constraints, and the fact that the supply of the vaccine available for Tajikistan in 2021 will most likely only be sufficient to cover 20 percent of the population, the government is focusing on the first 20 percent of the population. The TWG is also developing a National Preparedness Plan for COVID-19, and a roadmap for the implementation of that plan. As is the case for all immunization programs, the RCIP and the Sanitary and Epidemiology Service (SES) are 147 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual responsible for the implementation of the COVID-19 vaccination program. Key gaps and measures to address them: While some broad estimates have been made, there is uncertainty around the type and quantity of vaccine available in 2021, the quantities of the vaccine that will be delivered and the intervals of the delivery. The Government of Tajikistan, together with partners, is engaging actively with COVAX to coordinate planning. The National Preparedness Plan, which will include costing for the response, is under development and expected to be completed by the end of January 2021. A2. Readiness: Vaccines and therapeutics are regulated in Regulation Tajikistan through the Pharmaceutical Products Law of the and Republic of Tajikistan No. 861 from March 7, 2012. The law Standards stipulates that all medicines and medical goods produced, sold or used in Tajikistan must first be certified by the MOHSP and meet standards for quality, safety, and effectiveness. Regulation governing COVID-19 vaccines will build on this law, and a working group has been established to ensure that appropriate and timely regulatory approval systems are in place to facilitate the introduction of COVID-19 vaccine. The National Regulatory Authority is a member of the TWG for COVID-19 vaccine planning. The Government of Tajikistan has aligned its regulatory criteria to those recommended by COVAX. For future COVID-19 vaccines, a maximum of 15 working days will be required to obtain emergency approval, using defined national mechanisms that recognize WHO approval – prequalification – and approval by select SRAs – marketing authorization or emergency approval. Procedures for import and export of medicines and medical supplies are also determined by the Government of the Republic of Tajikistan. MOHSP has the right to authorize a one-time import of medicines and medical supplies not registered in the Republic of Tajikistan in case of natural disasters, emergency situations, and outbreaks/epidemics of communicable diseases. Medicines and medical supplies 148 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual transported for humanitarian purposes must comply with the standards of the Republic of Tajikistan and international standards on quality and safety. Key gaps and measures to address them: An intersectoral working group has been established to ensure appropriate and timely development of the necessary regulatory framework for indemnification against product liability claims. The 2017 Health Code, which stipulates that citizens have a right to compensation for damage caused to their health in accordance with the legislation of the Republic of Tajikistan, will serve as the basic legislation governing manufacturer indemnification. Currently, the MOHSP is developing a new National Immunization Program 2021-2025 to be approved by the Government of Tajikistan in early 2021, and the possibility of inclusion of an indemnification mechanism to the draft Program is being explored. COVAX technical assistance support for Tajikistan includes support for the necessary changes. A3. Readiness: The TWG is responsible for overseeing program Performance performance, in line with the National Preparedness Plan for management COVID-19 vaccines. The RCIP, the administrator of the and M&E national immunization program, will be responsible for collection of information on roll out of the vaccination program. Development partners such as UNICEF, WHO, and World Bank will provide support on specific areas of performance management where possible. Key gaps and measures to address them: Data systems remain a key barrier to good performance management; immunization records are almost exclusively paper-based, and supply chain monitoring architecture is weak. AF1 may be used to support the development of key data systems, including adverse event monitoring, supply chain monitoring and strengthening electronic immunization data collection. A4. Budgeting Readiness: The MOHSP TWG is completing a National 149 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Preparedness Plan, with costing for necessary activities. A request for support for technical assistance was submitted to COVAX, for support to be delivered by WHO and UNICEF. COVAX support for cold chain enhancement will also be available and approved on a rolling basis. The Asian Development Bank (ADB) will offer technical assistance for COVID-19 vaccine through a global resource pool for eligible member countries, but the allocation for Tajikistan has not yet been determined. ADB is also finalizing a package of COVID- 19 vaccine procurement support, for all of its countries, and Tajikistan will have access to this financing. However, a specific budget envelope for Tajikistan has not yet been established. Aga Khan Foundation has also indicated a possible support of vaccine procurement, delivery, cold chain equipment, awareness-raising, capacity building, and possibly medical and non-medical supplies in the Gorno-Badakshan Autonomous Oblast. Key gaps and measures to address them: Full budgeting and gap analysis still needs to be completed, with the development of the National Preparedness Plan for COVID- 19 vaccine by end January 2021. B. Supply and B1. Vaccines, Readiness: Based on information currently available, given Distribution PPEs and market unpredictability and the constraints of the Government other medical to approach vaccine suppliers directly, it is assumed that and non- COVAX AMC will be the main mechanism for purchasing medical vaccine. Based on fundraising to date, COVAX estimates that supplies it should be able to fully subsidize vaccine for between 16 and 17 percent of the population, and calls on governments to self- finance, or mobilize financing from multilateral development banks or donors, for the remaining doses, at low prices negotiated by COVAX with vaccine producers, to reach 20 percent coverage of the country’s population. The COVAX subsidy covers costs of some ancillary supplies such as syringes, cold boxes, safety (disposal) boxes and transport to country. Procurement and delivery of the vaccine will be undertaken by UNICEF’s Supply Division. 150 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Key gaps and measures to address them: Of the vaccine(s) to be supplied for Tajikistan through COVAX, the cost of 16- 17 percent of the population would be fully subsidized by COVAX, with the remaining 3-4 percent that would need to be covered by the government at low prices negotiated between COVAX and suppliers. AF1 could serve to cover this cost as well. AF1 will fund ancillary supplies not covered by COVAX, including PPE for health care workers administering the vaccine, and others. B2. Logistics Readiness: The immunization supply chain in Tajikistan and cold follows the structure of the expanded program on chain immunization and has four levels: i) the national vaccine store at RCIP; (ii) regional vaccine stores; (iii) district/city level vaccine stores; and (iv) immunization service delivery sites. In addition to routine vaccines, the immunization supply chain stores and distributes non-routine vaccines such as for influenza, yellow fever, and typhoid vaccines. Vaccine forecasting is under the responsibility of the RCIP. Detailed inventories of cold chain equipment at all facilities along the supply chain is collected regularly by RCIP and can be used to inform planning for COVID-19 vaccine roll-out. A cold chain assessment was conducted in 2017, identifying gaps particularly around refrigerated vehicles, infrastructure including warehouses, cold storage equipment, and program management. Gavi has invested over US$4.5 million in financing over the last 12 years to rehabilitate the cold chain. Despite this, the cold chain assessment in 2017 showed a pre- COVID-19 financial need. This estimate is currently being updated to include COVID-19 vaccination. An offline electronic vaccine stock management system at the national, regional and district level was developed and introduced with support from UNICEF. 151 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Key gaps and measures to address them: Government of Tajikistan submitted an application in February 2021 for COVAX cold chain equipment support. While COVAX has indicated that the financing available for further enhancements to the cold chain to accommodate COVID-19 vaccines will be capped at US$300,000, preliminary assessment by UNICEF suggests that this will provide sufficient capacity for vaccination of the first 20 percent of population. The rollout of the electronic vaccine stock management system has been limited due to the lack of information technology (IT) equipment. AF1will be used to procure the necessary IT equipment. B3. Waste Readiness: Eighty percent of immunization facilities use management “burn and bury” method for waste disposal. Less common methods are centralized disposal (17 percent), pit (10 percent), incinerator (2 percent), or none (<1 percent), although a recent investment has financed incinerators for a limited (less than 10) number of districts. WHO, financed by a Gavi health systems strengthening grant, supports the policy revision and update of a regulatory framework on healthcare waste management. A draft has been developed to cover the disposal of COVID-19 related wastes. Draft regulations on infection prevention and control supported by WHO include standard operating procedures on COVID-19 waste disposal. Key gaps and measures to address them: Waste management elements of the vaccine delivery are currently being developed as part of the National Preparedness Plan for COVID-19 vaccine. The Project’s Environmental and Social Management Framework (ESMF) will be updated for the AF project, WHO COVID-19 guidance documents, and other best international practices, will include additional measures on management of wastes resulting from vaccine delivery and disposal of used and expired vaccine vials as a result of the AF activities. The Infection Control and Waste Management Plans (ICWMPs) clearly outlines the implementation 152 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual arrangements to be put in place by MOHSP for vaccine- related waste management practices. C. Program C1. Readiness: Significant progress is being made on community Delivery Community engagement. Terms of reference have been approved for the engagement establishment of the National Risk Communication & and advocacy Community Engagement (RCCE) working group, that will be chaired by Deputy Prime Minister. A draft RCCE Strategy for COVID-19 has been developed with support from UNICEF, and communication related to COVID-19 vaccination will be a part of this strategy. The strategy has elements such as coordination, capacity building, raising awareness, mobilizing communities, developing outreach products and monitoring and evaluating progress. Also included in the RCCE strategy is a section on social media monitoring and combating misinformation. Under the parent project, the World Bank is financing the implementation of activities related to COVID- 19 risk communication. Key gaps and measures to address them: National community engagement planning and development of materials such as key messages for target populations, advocacy campaigns, and special support to health care workers are in progress. Support for national planning and design of key messages has been included in the application package for COVAX technical assistance. Advocacy campaigns will benefit from the investments made under the parent project, including support for telephone hotlines, mechanisms for delivering SMS messages to the population, communication training for media and the civil society. Additional communication measures financed by AF1 will cover information on COVID-19 vaccines and help address potential risks of vaccine hesitancy—see below, under Component 2 description. C2. Points of Readiness: In Tajikistan, 3,042 health facilities deliver delivery immunization services; 80-85 percent of vaccines are delivered at fixed sites, 10-12 percent through campaigns, and 153 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual 3-5 percent are delivered through outreach and mobile services. The delivery of COVID-19 vaccine relies on the existing immunization infrastructure—transportation, buildings, cold storage equipment, and labor. Key gaps and measures to address them: As immunization programs in Tajikistan have focused on delivering vaccines to young children, new approaches will be taken to reach adult target populations. For healthcare workers, lessons can be learned from the November 2020 seasonal influenza pilot in Dushanbe. The pilot was rolled out through November 2020 targeting 40,000 healthcare workers. This pilot program is administered by the SES and RCIP, with support from WHO. RCIP is responsible for vaccine stock management and distribution for this pilot. In parallel, SES is implementing an influenza surveillance system for the beneficiary group, with technical assistance and training from WHO. Delivery plans to reach other priority groups are still pending. C3. Vaccine Readiness: While there is officially a national system to safety report AEFI, no AEFIs have been registered in recent years, surveillance raising concerns around system efficiency. Planning to strengthen the national AEFI system is underway, with support from WHO. WHO EURO has conducted an in-depth assessment of the key preparedness elements including legal standards, regulations, and guidelines; AEFI guidelines; organization and management; and resources including human and financial resources, infrastructure and equipment; and pharmacological surveillance and AEFI surveillance process. Training materials for the new guidelines and tools are being developed and training for health personnel is being planned. AEFI monitoring for COVID-19 vaccine will be built into this new system. Key gaps and measures to address them: There is a lack of funds to disseminate the AEFI training tool and conduct the necessary training for both the national immunization agency and to healthcare workers. AF1 will be used to support 154 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual training, as well as the creation of a national electronic AEFI registry for more effective monitoring of AEFIs. D. Supporting D1. Data Readiness: Immunization records are almost exclusively Systems and quality paper-based in Tajikistan. Detailed immunization records are Infrastructure collected in notebooks by local facilities, and information is consolidated on a monthly basis through district and sub- national levels of the RCIP. Information technology infrastructure for electronic record keeping is not present in all facilities, and where it exists, it is not consistently used by facility staff to keep immunization records. At the national level, records are kept in paper format, with a single Excel sheet of electronic immunization records kept on a computer at RCIP headquarters. To date, a more robust format of a national electronic immunization registry does not exist. Key gaps and measures to address them: Digital databases to track vaccine rollout and immunization records specific for COVID-19 vaccine will be critical for effective monitoring of the vaccine program. AF1 financing will support the development of an electronic database for COVID-19 vaccine at the district level, as well as pilots for an electronic patient immunization registry. Tajikistan’s application for COVAX technical assistance has included support for paper-based facility immunization records, and patient-held immunization cards for COVID-19 vaccine. D2. Readiness: In a 2017 assessment, among the 3,042 facilities Infrastructure that deliver immunization services in Tajikistan, 394 (13.4 percent) facilities reported access to grid power supply for only 8-16 hours a day and 99 facilities (3.4 percent) - for less than 8 hours, mostly in the rural Gorno-Badakshan Autonomous Oblast. Due to the bad condition of electricity transmission and distribution systems, Tajikistan faces periodic blackouts from October to April. In winter, electricity is available only for up to 3 hours a day for the rural population. 155 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Key gaps and measures to address them: RCIP offices have uneven access to computers and internet connectivity. In cities, some offices may have computers/tablets and internet connectivity, while those in more remote areas may not. AF1 will provide funding to purchase computers and tablets and provide support for internet connectivity and power for district and subnational RCIP facilities, to enable them to operate and maintain electronic data management systems for tracking rollout of COVID-19 vaccine(s), monitor adverse reactions, and manage the supply chain. At the facility level, World Bank support may be used to pilot an electronic patient registry system, which would include investment in tablets, mobile internet connectivity, and power supply for pilot health facilities. 156 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual Annex IX - Resource List: COVID-19 Guidance Given the COVID-19 situation is rapidly evolving, a version of this resource list will be regularly updated and made available on the World Bank COVID-19 operations intranet page (http://covidoperations/). WHO Guidance Advice for the public • WHO advice for the public, including on social distancing, respiratory hygiene, self-quarantine, and seeking medical advice, can be consulted on this WHO website: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public Technical guidance • Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, issued on March 19, 2020 • Recommendations to Member States to Improve Hygiene Practices, issued on April 1, 2020 • Severe Acute Respiratory Infections Treatment Center, issued on March 28, 2020 • Infection prevention and control at health care facilities (with a focus on settings with limited resources), issued in 2018 • Laboratory biosafety guidance related to coronavirus disease 2019 (COVID-19), issued on March 18, 2020 • Laboratory Biosafety Manual, 3rd edition, issued in 2014 • Laboratory testing for COVID-19, including specimen collection and shipment, issued on March 19, 2020 • Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios, issued on March 21, 2020 • Infection Prevention and Control for the safe management of a dead body in the context of COVID- 19, issued on March 24, 2020 • Key considerations for repatriation and quarantine of travelers in relation to the outbreak COVID-19, issued on February 11, 2020 • Preparedness, prevention and control of COVID-19 for refugees and migrants in non-camp settings, issued on April 17, 2020 • Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health, issued on March 18, 2020 • Oxygen sources and distribution for COVID-19 treatment centers, issued on April 4, 2020 • Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response, issued on March 16, 2020 • Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19), issued on March 19, 2020 • Operational considerations for case management of COVID-19 in health facility and community, 157 Tajikistan Emergency COVID-19 Project Annex VIII ESMF Vaccine Delivery and Deployment Manual issued on March 19, 2020 • Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19), issued on February 27, 2020 • Getting your workplace ready for COVID-19, issued on March 19, 2020 • Water, sanitation, hygiene and waste management for COVID-19, issued on March 19, 2020 • Safe management of wastes from health-care activities, issued in 2014 • Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak, issued on March 19, 2020 • Disability Considerations during the COVID-19 outbreak, issued on March 26, 2020 • National Deployment and Vaccination Plan for introduction of COVID-19 Vaccines in the Republic of Tajikistan – issued on February 9, 2021 WORLD BANK GROUP GUIDANCE • Technical Note: Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints on conducting public meetings, issued on March 20, 2020 • Technical Note: Use of Military Forces to Assist in COVID-19 Operations, issued on March 25, 2020 • ESF/Safeguards Interim Note: COVID-19 Considerations in Construction/Civil Works Projects, issued on April 7, 2020 • Technical Note on SEA/H for HNP COVID Response Operations, issued in March 2020 • Interim Advice for IFC Clients on Preventing and Managing Health Risks of COVID-19 in the Workplace, issued on April 6, 2020 • Interim Advice for IFC Clients on Supporting Workers in the Context of COVID-19, issued on April 6, 2020 • IFC Tip Sheet for Company Leadership on Crisis Response: Facing the COVID-19 Pandemic, issued on April 6, 2020 • WBG EHS Guidelines for Healthcare Facilities, issued on April 30, 2007 • World Bank's Environment and Social incident response toolkit (ESIRT) • Vaccine Delivery and Deployment Manual, April 2021 ILO GUIDANCE • ILO Standards and COVID-19 FAQ, issued on March 23, 2020 (provides a compilation of answers to most frequently asked questions related to international labor standards and COVID-19) MFI GUIDANCE • ADB Managing Infectious Medical Waste during the COVID-19 Pandemic • IDB Invest Guidance for Infrastructure Projects on COVID-19: A Rapid Risk Profile and Decision Framework • KfW DEG COVID-19 Guidance for employers, issued on March 31, 2020 • CDC Group COVID-19 Guidance for Employers, issued on March 23, 2020 158