Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD4808 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT PAPER ON A PROPOSED ADDITIONAL CREDIT IN THE AMOUNT OF EUR 26.1 MILLION (US$29.6 MILLION EQUIVALENT) AND A PROPOSED ADDITIONAL GRANT IN THE AMOUNT OF US$15.0 MILLION FROM THE GLOBAL FINANCING FACILITY TO THE REPUBLIC OF CAMEROON FOR THE CAMEROON COVID-19 PREPAREDNESS AND RESPONSE PROJECT APPROVED SEPTEMBER 22, 2020 UNDER THE COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROGRAM (SPRP) DECEMBER 23, 2021 USING THE MULTIPHASE PROGRAMMATIC APPROACH (MPA) WITH A FINANCING ENVELOPE OF UP TO US$6 BILLION APPROVED BY THE BOARD ON APRIL 2, 2020 AND UP TO US$12 BILLION ADDITIONAL FINANCING APPROVED BY THE BOARD ON OCTOBER 13, 2020 Health, Nutrition & Population Global Practice Western and Central Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective November 30, 2021) Special Drawing Rights (SDR), Currency Unit = CFA franc (CFAF) US$1 = CFAF 581 US$1 = Euro 0.881 US$1 = SDR 0.716 FISCAL YEAR January 1 - December 31 Regional Vice President: Ousmane Diagana Country Director: Abdoulaye Seck Regional Director: Dena Ringold Practice Manager: Magnus Lindelow Task Team Leader: Yohana Dukhan ABBREVIATIONS AND ACRONYMS AEFI Adverse Event Following Immunization AF Additional Financing AMC Advance Market Commitment APA Advance Purchase Agreement AVAT African Vaccine Acquisition Trust AVATT African Vaccine Acquisition Task Team AU African Union BFP World Bank-facilitated Procurement CAA Autonomous Sinking Fund of Cameroon (Caisse Autonome d’Amortissements) CCB Climate Co-benefit CCPR Cameron COVID-19 Preparedness and Response CDC Center for Disease Control and Prevention CERC Contingent Emergency Response Component COVAX COVID-19 Vaccines Global Access COVID-19 Coronavirus Disease CPF Country Partnership Framework CTN-PBF Performance Based-Financing Technical Unit (Cellule Technique Nationale PBF) DA Designated Account DFIL Disbursement and Financial Information Letter DHIS District Health Information Software DPML Department of Pharmacy, Medicines and Laboratories E&S Environmental and Social EHS Essential Health Services EPI Expanded Program on Immunization ESCP Environmental and Social Commitment Plan ESF Environmental and Social Framework ESMF Environmental and Social Management Framework EUL Emergency Use Listing FM Financial Management GAVI Global Alliance for Vaccines and Immunization GBV Gender-based Violence GFF Global Financing Facility GoC Government of Cameroon GRM Grievance Redress Mechanism GRS Grievance Redress Service HEIS Hands-on Expanded Implementation Support HSPRP Health System Performance Reinforcement Project ICWMP Infection Control Waste Management Plan IDA International Development Association IFR Interim Financial Report IMS Incident Management System IPC Infection, Prevention and Control IPF Investment Project Financing IPP Indigenous Peoples Plan ISR Implementation Status and Results Report Janssen Janssen Pharmaceutical NV LMP Labor Management Procedures M&E Monitoring and Evaluation MINEPAT Ministry of the Economy, Planning and Regional Development MoF Ministry of Finance MoPH Ministry of Public Health MPA Multiphase Programmatic Approach NDVP National Deployment and Vaccination Plan NFCS No-Fault Compensation Scheme NGO Non-governmental Organization NITAG National Immunization Technical Advisory Group PAD Project Appraisal Document PBF Performance-based Financing PDO Project Development Objective PEF Pandemic Emergency Financing Facility PIU Project Implementation Unit PLR Program Learning Review POM Project Operations Manual PPE Personal Protective Equipment PRC People’s Republic of China RMNCAH-N Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition SAGE Strategic Advisory Group of Experts on Immunization SEA Sexual Exploitation and Abuse SEP Stakeholder Engagement Plan SH Sexual Harassment SOP Standard Operating Procedures SPRP Strategic Preparedness and Response Program SRA Stringent Regulatory Authority ToR Terms of Reference UN United Nations UNICEF United Nations International Children's Emergency Fund USA United States of America USAID United States Agency for International Development VAC Vaccine Approval Criteria VIRAT Vaccine Introduction Readiness Assessment Tool VRAF Vaccine Readiness Assessment Framework WBG World Bank Group WHO World Health Organization Republic of Cameroon Additional Financing for COVID-19 Preparedness and Response Project TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ................................................. 9 A. Introduction .................................................................................................................................... 9 B. Consistency with the Country Partnership Framework (CPF) ........................................................... 13 C. Project Design and Scope ............................................................................................................... 13 D. Project Performance ...................................................................................................................... 14 E. Rationale for Additional Financing .................................................................................................. 15 F. National Capacity and COVID-19 Vaccination Plan .......................................................................... 18 II. DESCRIPTION OF ADDITIONAL FINANCING .............................................................................. 26 A. Proposed Changes.......................................................................................................................... 26 B. Sustainability ................................................................................................................................. 36 III. KEY RISKS ............................................................................................................................... 36 IV. APPRAISAL SUMMARY ....................................................................................................... 40 V. WORLD BANK GRIEVANCE REDRESS ....................................................................................... 53 VI SUMMARY TABLE OF CHANGES ............................................................................................... 56 VII DETAILED CHANGE(S) .............................................................................................................. 56 VIII. RESULTS FRAMEWORK AND MONITORING ............................................................................. 63 Annex 1 – List of Covid vaccines meeting World Bank Approval Criteria as of December 20, 2021 ... 73 Annex 2: Summary of parent project and additional financing components and proposed changes 74 LIST OF TABLES Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment as of November 20, 2021 ....................................................................................................................................................................... 18 Table 2: National Vaccine Coverage and Acquisition Plan ..................................................................................... 24 Table 3: Priority populations for COVID-19 vaccination in Cameroon .................................................................. 26 Table 4. Project costs and financing ...................................................................................................................... 33 Table 5: Summary of vaccine sourcing and World Bank financing ........................................................................ 34 Table 6. Results Framework modifications ............................................................................................................ 36 Table 7. Major Procurement Risks and Proposed Mitigation Measures ............................................................... 48 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) BASIC INFORMATION – PARENT (Cameroon COVID-19 Preparedness and Response Project - P174108) Country Product Line Team Leader(s) Cameroon IBRD/IDA Yohana Dukhan Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P174108 Investment Project HAWH2 (9322) AWCC1 (6544) Health, Nutrition & Financing Population Implementing Agency: Ministry of Public Health ADD_FIN_TBL1 Is this a regionally tagged project? No Bank/IFC Collaboration No Expected Approval Date Closing Date Guarantee Environmental and Social Risk Classification Expiration Date 22-Sep-2020 30-Jun-2022 Substantial Financing & Implementation Modalities Parent [✓] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [✓] Hands-on Expanded Implementation Support (HEIS) Development Objective(s) Page 1 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) MPA Program Development Objective (PrDO) The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Project Development Objectives (Phase 031) To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in selected regions in Cameroon. Ratings (from Parent ISR) RATING_DRAFT_NO Implementation Latest ISR 20-Jan-2021 09-Aug-2021 Progress towards achievement of PDO S MS Overall Implementation Progress (IP) S MS Overall ESS Performance S S Overall Risk S S Financial Management S S Project Management S S Procurement S MS Monitoring and Evaluation S S BASIC INFORMATION – ADDITIONAL FINANCING (Additional Financing for Cameroon COVID-19 Preparedness and Response Project - P178255) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P178255 Additional Financing for Restructuring, Scale Up No Cameroon COVID-19 Preparedness and Response Project Financing instrument Product line Approval Date Investment Project IBRD/IDA 23-Dec-2021 Financing Projected Date of Full Bank/IFC Collaboration Disbursement Page 2 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 30-Dec-2024 No Is this a regionally tagged project? No Financing & Implementation Modalities Child [✓] Multiphase Programmatic Approach [MPA] [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [✓] Hands-on, Enhanced Implementation Support (HEIS) [ ] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments IBRD % IDA 29.00 30.20 0% Grants % MPA Financing Data (US$, Millions) Financing MPA Program Financing Envelope 18,000,000,000.00 MPA FINANCING DETAILS (US$, Millions) MPA FINA NCI NG DET AILS (US$, Millions) Approve d Board Approved MPA Financing Envelope: 18,000,000,000.00 MPA Program Financing Envelope: 18,000,000,000.00 of which Bank Financing (IBRD): 9,900,000,000.00 of which Bank Financing (IDA): 8,100,000,000.00 of which other financing sources: 0.00 Page 3 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) PROJECT FINANCING DATA – ADDITIONAL FINANCING (Additional Financing for Cameroon COVID-19 Preparedness and Response Project - P178255) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFi n1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 29.00 44.60 73.60 Total Financing 29.00 44.60 73.60 of which IBRD/IDA 29.00 29.60 58.60 Financing Gap 0.00 0.00 0.00 DETAILS - Additional Financing NewFinEnh1 World Bank Group Financing International Development Association (IDA) 29.60 IDA Credit 29.60 Non-World Bank Group Financing Trust Funds 15.00 Global Financing Facility 15.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Cameroon 29.60 0.00 0.00 29.60 National PBA 29.60 0.00 0.00 29.60 Total 29.60 0.00 0.00 29.60 Page 4 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ✔ ] Yes [ ] No Explanation The project is being processed using the following waivers granted through the MPA: a partial waiver relating to the application of Anti-Corruption Guidelines to unsuccessful bidders in the context of retroactive financing and of framework agreements in place between the borrower and suppliers and financed under retroactive financing or advanced procurement. The project also applies the waiver granted on October, 2020 to enable Management approval of individual projects under SPRP rated Substantial for Environmental and Social risk classification. Has the waiver(s) been endorsed or approved by Bank Management? Approved by Management [ ] Endorsed by Management for Board Approval [✔] No [ ] Explanation The MPA-specific waivers have been endorsed by management as part of the Global SPRP MPA approval. Page 5 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) ESStandards Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance Assessment and Management of Environmental and Social Risks and Impacts Relevant Stakeholder Engagement and Information Disclosure Relevant Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and Management Relevant Community Health and Safety Relevant Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Relevant Local Communities Cultural Heritage Not Currently Relevant Financial Intermediaries Not Currently Relevant ESStandardsNote NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Page 6 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) PROJECT TEAM Bank Staff Name Role Specialization Unit Team Leader (ADM Yohana Dukhan Health HAWH2 Responsible) Rose Caline Desruisseaux- Procurement Specialist (ADM Procurement EAWRU Cadet Responsible) Cheick Traore Procurement Specialist Procurement EAWRU Henie Dahlia Takodjou Financial Management Financial management EAWG2 Meku Epse Nsinga Specialist (ADM Responsible) Financial Management Aissatou Diallo Financial management EAWG2 Specialist Social Specialist (ADM Aime Bertrand Nkouemou Social Development SAWS1 Responsible) Environmental Specialist (ADM Charlie Foyet Sonkeng Environmental safeguards SAWE4 Responsible) Social Specialist (ADM FNU Owono Owono Social Development AFWDE Responsible) Agnes Couffinhal Team Member Health HAWH2 Amba Denise Sangara Team Member Program Assistant HAWH2 Amy Champion Team Member Operations HAWH2 Andre L. Carletto Team Member Health HAWH2 Berlin Apang Team Member Procurement EAWRU Carine Clert Team Member Program Leader HAWDR Carole Ndjitcheu Team Member Program Assistant AWCC1 Christine Harmelle Ename Team Member Public Health HAWH2 Ename Epse Ekoman Elisabeth Rose Keme Team Member Operations AWCC1 Etame Faly Diallo Team Member Disbursement WFACS Ines Melissa Emma Attoua Team Member Disbursement WFACS Etty Issa Bitang A Tiati Social Specialist Social Development SAWS1 Marouan Maalouf Counsel Legal LEGAM Monique Mogue Kamga Procurement Team Procurement AWCC1 Olga Guerrero Horas Team Member Public Health HAWH2 Page 7 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Raissa Manuela Mouahba Environmental Specialist Environmental safeguards SAWE4 Wanjou Sandrine Zamedjo Social Specialist Social Development SAWS1 Abendang Extended Team Name Title Organization Location Page 8 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING A. Introduction 1. This Project Paper seeks the approval of the Regional Vice President to provide an additional financing (AF) to the Republic of Cameroon’s COVID-19 Preparedness and Response (CCPR) Project (P174108) in an amount of US$44.6 million equivalent (comprised of a US$29.6 million equivalent IDA credit and a $15.0 million grant from the Global Financing Facility (GFF)). The AF, which also includes a restructuring of the parent project, will support expanding activities of the CCPR Project under the COVID- 19 Strategic Preparedness and Response Program (SPRP) (P173789) using the Multiphase Programmatic Approach (MPA) approved by the Board on April 2, 2020, and the vaccines AF to the SPRP approved on October 13, 2020.1 The primary objectives of this AF are to enable affordable and equitable access to COVID-19 vaccines and help ensure effective vaccine deployment in Cameroon through the strengthening of the vaccination system, and to strengthen preparedness and response activities under the parent project. The CCPR project in an amount of US$29 million IDA was approved on September 22, 2020. However, the project only became effective on September 17, 2021, due to a lengthy “maturation” process required by the Government for signing financing agreement of new projects2 and is still to disburse. The proposed AF and restructuring of the parent project will: (a) adjust the content of the components, subcomponents and corresponding costs; (b) revise the Results Framework to align with the new activities; (c) adjust the institutional and implementation arrangements; and (d) extend the project closing date. The parent project is expected to start disbursing by end of January 2022. 2. The purpose of the proposed AF is to help the Government of Cameroon (GoC) purchase and deploy COVID-19 vaccines that meet World Bank’s vaccine approval criteria (VAC) and to strengthen sustainable health systems that are necessary for a successful deployment. About one third of the parent project’s funds (US$10 million) will support a revised and re-prioritized set of activities to strengthen the health system’s response to the pandemic, following the original design. The reprogrammed funds (US$19 million) and the additional resources (US$29.60 million) will support: (i) the deployment of vaccines meeting VAC criteria that have been secured, including those obtained through the COVID-19 Vaccines Global Access (COVAX) Advance Market Commitment (AMC) Facility3 and bilateral donors; (ii) key activities to strengthen the health system’s ability to successfully roll out the vaccine against COVID-19; and (iii) the acquisition of additional vaccines. In addition, a US$15 million grant from the GFF will provide complementary resources to support the continuity of essential health services (EHS) and mitigate the negative impact that the pandemic has had on the access and uptake of reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) services (see paragraph 10 for more information). 1 The World Bank approved a US$12 billion WBG Fast Track COVID-19 Facility (FTCF or “the Facility”) to assist IBRD and IDA countries in addressing the global pandemic and its impacts. Of this amount, US$6 billion came from IBRD/IDA (“the Bank”) and US$6 billion from the International Finance Corporation (IFC). The IFC subsequently increased its contribution to US$8 billion, bringing the FTCF total to US$14 billion. The Additional Financing of US$12 billion (IBRD/IDA) was approved on October 13, 2020 to support the purchase and deployment of COVID-19 vaccines as well as strengthening the related immunization and health care delivery system. 2 The financing agreement of the parent project was signed on August 20, 2021. 3 The COVAX AMC is an initiative (co-led by WHO, GAVI) which aggregates vaccine supply and demand, with the objective of providing access for 92 low and middle-income countries. COVAX aims to procure enough vaccines to cover 20 percent of the population of its member countries by the end of 2021. Page 9 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 3. The proposed AF will procure vaccines for 12.6 percent of the country’s population. The AF will support, through an allocation of US$29.60 million, the purchase of 3.5 million vaccine doses to cover 12.6 percent of the population through the African Vaccine Acquisition Trust (AVAT) chaired by the African Union (AU).4 With the proposed financing envelope, the country will be able to fulfill part of their request of 5.3 million of Janssen Pharmaceutical NV (J&J/Janssen) vaccine doses through AVAT mechanism to cover 20 percent of the population. Other financiers are expected to cover additional doses required to reach the GoC’s goal of vaccinating 40 percent of the population by end of 2022, as set out in the National Deployment and Vaccination Plan (NDVP). The NDVP was recently updated, as per AU guidance, with a target of 60 percent of the population coverage by end of 2023. However, it has not yet been approved by the Government and costing as well as financing arrangements still need to be identified.5 4. The project will also support vaccine deployment for about 36 percent of the population.6 Through an allocation of US$18.00 million, the project will finance in coordination with other partners, the deployment of vaccines received through the COVAX mechanism to cover 20 percent of the country’s population7. Additional vaccines have been acquired through AVAT8 and received from other bilateral donations9. World Bank financing for the COVID-19 vaccines and deployment will follow the World Bank’s VAC. As of April 16, 2021, the World Bank accepts as threshold for eligibility of IBRD/IDA resources in COVID-19 vaccine acquisition and/or deployment under all World Bank financed projects: (i) the vaccine has received regular or emergency licensure or authorization from at least one of the Stringent Regulatory Authorities (SRA) identified by the World Health Organization (WHO) for vaccines procured and/or supplied under the COVAX Facility, as may be amended from time to time by WHO; or (ii) the vaccine has received WHO Prequalification (PQ) or WHO Emergency Use Listing (EUL) (see Annex 1). The country will provide free vaccination to the population. 5. The GoC formally requested the World Bank to re-allocate resources under the CCPR project to procure and deploy COVID-19 vaccines on July 26, 2021. The need for additional resources to purchase 4 The AVAT is a COVID-19 vaccine procurement agreement signed by all AU Member States on March 28, 2021. The AU, beginning in late 2020, embarked on an ambitious effort to vaccinate at least 60 percent of Africa’s population as quickly as possible through a continental approach. The effort to acquire more vaccines has been led by the AU Vaccine Acquisition Task Team (AVATT) –the AU Special Envoys for COVID-19, Africa Center for Disease Control (CDC), the African Export-Import Bank (Afreximbank) and United Nations Economic Commission (UNECA). The AU sees this effort as complementary to COVAX and the World Bank has worked alongside AVATT since January 2021 to inform the design of the AVAT mechanism and to ensure that World Bank financing can be used by participating member countries to purchase vaccine doses. On June 21, 2021, the AU and the World Bank held a joint meeting with African Ministers of Finance to officially launch the partnership to accelerate vaccination in Africa. AVAT has already successfully negotiated 220 million doses of J&J/Janssen COVID-19 vaccine for use by African countries, with an option for 180 million more based on demand. AVAT is negotiating with other suppliers and expected to secure more doses. World Bank financing and technical assistance is available to help countries obtain vaccines from eligible suppliers through AVAT and to effectively deploy them. Once Cameroon enters into a commitment undertaking with AVAT to purchase eligible vaccines under the mechanism and signs an agreement with UNICEF as the procurement agency, World Bank financing under this project will be made available for the purchase. 5 Given the current status of the NDVP, low acceptancy of vaccine in Cameroon and delays observed to reach effectiveness of the parent project, the approach under this project will be rather conservative and will focus on reaching the 40 percent target coverage. Additional resources may be mobilized at a later stage at the request of the Government to increase vaccination effort. 6 Cameroon has so far secured vaccines for 40 percent of the population (Cf. Table 2) and has administered vaccines to 4 percent of the population. The project will help deploying the remaining. 7 As of November 18, 2021, the country has received around 1.4 million doses from COVAX sufficient to cover more than 4.5 percent of the population. 8 As of November 18, 2021, the country has received 460,800 doses from AVAT sufficient to cover 2.8 percent of the population. 9 As of November 18, 2021, the country has received 200,000 doses from the People’s Republic of China , sufficient to cover 0.4 percent of the population. Page 10 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) COVID-19 vaccine doses was formally conveyed by the GoC on October 4, 2021. The proposed AF, based on the World Bank agreement with the AU/AVAT, will allow the country to access Janssen COVID-19 vaccines at a lower cost to cover 12.6 percent of the population. This operation will become part of an expanded health response to the pandemic, which is being supported by development partners under the coordination of the GoC. Additional World Bank financing will provide essential resources to enable the expansion of a sustained and comprehensive pandemic response that will appropriately include vaccination in Cameroon. 6. Critically, the AF will enable the acquisition of vaccines from AVAT and the deployment of vaccines from a range of sources to support Cameroon’s objective to have a portfolio of options to access vaccines under the right conditions (of value-for-money, regulatory approvals, and delivery time among other key features). The COVAX AMC Facility has put in place a framework that will anchor Cameroon’s strategy and access to vaccines: on December 15, 2020, the GoC entered into an agreement with COVAX to access vaccine doses to cover at least 20 percent of the population10, potentially more subject to financial commitments and vaccine donations to COVAX.11 The proposed AF and restructuring will contribute to the deployment of 5.5 million doses requested by the GoC through COVAX as a priority for 20 percent of the population, and beyond COVAX to the funding of 3.5 million doses and deployment of the 5.3 million doses of Janssen vaccine ordered through AVAT in June 2021. The availability and terms of vaccines remain fluid and prevent the planning of a firm sequence of vaccine deployment, especially as the actual delivery of vaccines is unlikely to be immediate. Rather, the proposed financing enables a portfolio approach that will adjust during implementation in response to developments in the country pandemic situation and the global market for vaccines. 7. COVID-19 situation in Cameroon. The first case of COVID-19 was reported in March 2020 and as of December 8, 2021, a total of 107,662 confirmed cases and 1,836 deaths have been reported.12 Although adult men seem to have been affected by COVID-19 slightly more than women (sex ratio M/F 1:1.1), this trend is reversed for age groups below 19 years of age. Further, no differences in case fatality rates between the different sexes have been reported.13 As of December 8, 2021, 519 cases are active and the majority of new cases reported are in the Central, North-West, North and Adamawa regions. Cameroon saw a slow increase in the number of daily cases recorded at the beginning of the pandemic and experienced a first peak at the end of June 2020. A second wave of infections began in March 2021 which tapered down by June 2021. The country has been undergoing a third wave since August 2021, with weekly cases reported over 6,000 in certain weeks of September. New cases appear to have decreased and plateaued around 500/week in in the most recent weeks of November and December. Case fatality rate has remained low at approximately 1.7 percent, but slightly above rates observed in neighboring countries (Republic of Congo 1.66 percent; Nigeria 1.37 percent; Gabon 0.70 percent). Despite the increase in cases attributed to the Omicron variant in the Southern Africa region, no cases of this new variant of concern have been reported in Cameroon until now. 10 This represents 8,365,000 doses of COVID-19 vaccines for 5,431,867 individuals (with a two-dose regimen). 11 COVAX has also been financing Technical Assistance (TA) and funding the purchase of cold chain equipment as well as operational expenses for vaccine deployment. 12 Cameroon SitRep, n 106. Period 02/12 to 8/12 2021. 13 Ibid. Page 11 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Figure 1. Weekly new confirmed COVID-19 cases (seven day rolling average), March 2020 – December 17, 2021 Source: WHO Emergency Dashboard [Accessed 20 December 2021]. 8. The current trends observed, coupled with concerns around the emergence of new, and highly transmissible COVID-19 variants have propelled the GoC to introduce the COVID-19 vaccine. The roll- out of the vaccination campaign in Cameroon began in April 2021 and as of November 24, a total 727,013 people (5.4 percent of eligible population aged >18) have received at least one dose and 565,882 (4.1 percent of eligible population (aged >18) are fully vaccinated. Currently, 244 vaccination centers have been established and three major vaccination campaigns in April, July and November 2021 have taken place. The roll-out of the campaign has been progressive yet slow, with around 1,000 – 1,500 doses administered per day of AstraZeneca, Sinopharm or Janssen vaccines. The Ministry of Public Health (MoPH) has adjusted its immunization strategies due to the slow vaccine uptake, including: (i) increasing the number of immunization centers from 244 to 1939; (ii) establishment of large vaccination centers with permanent teams in big cities such as Douala, Yaoundé and Bafoussam; (iii) quarterly immunization campaigns with massive deployment of mobile vaccination teams; and (iv) immunization sessions in specialized centers (chronic disease management centers, elderly people's homes, etc.) or in institutions such as refugee camps, displaced persons' camps, prisons, hotels, schools and universities. The MoPH also seeks to integrate COVID-19 vaccination into the routine vaccination system and primary healthcare, by adding COVID-19 vaccination as a recommendation in the case management protocol of chronic diseases as diabetes, hypertension, or obesity. At the community level, health centers will have to establish a system for active research of people who have dropped the vaccination after their first dose. 9. Vaccine hesitancy for COVID-19 vaccination persists in Cameroon. A study conducted in November 2021 through the social media platform Facebook by the research department of the World Bank indicates that one in two respondents are hesitant about getting vaccinated and only one in three people are willing to take up the vaccine. Hesitancy among health workers, cited as one of the main reasons for the slow uptake of vaccines at the beginning of the vaccination rollout, remains an important concern. Mitigation measures to enhance vaccine uptake are planned under the project, including: an expansion of the number of vaccination centers, an increase in the number and cadres of trained health workers (eg. including pharmacists), the use of online platforms and digital media for peer-to-peer exchanges between vaccinated and non-vaccinated people and support from experts and religious leaders. In addition, the project will continue to support surveys to monitor and respond to behavior changes through different initiatives and messaging. 10. The COVID-19 pandemic has strained primary healthcare services and reduced utilization rates of primary healthcare services. According to a World Bank and GFF assessment carried out in July 2021, health care services were moderately affected particularly during the first and second waves of the Page 12 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) pandemic. Utilization of services were decreased in comparison to the previous year, including outpatient consultations (-7 percent), Antenatal Care (ANC-4) (-8 percent), immunization: Penta 3 (-5 percent), Polio (-5 percent), measles (-7 percent), and hospitalizations (-10 percent). Disruption in services was particularly important in the Western region of Cameroon. Whilst most services have rebounded, they are likely to be cyclically affected mirroring peaks from the pandemic. Further, effects of the pandemic are straining services already weakened in areas affected by internal conflicts (Far North, North-West and South-West regions) or conflicts in neighboring countries such as Nigeria and the Central African Republic. B. Consistency with the Country Partnership Framework (CPF) 11. The AF is fully aligned with the Cameroon CPF for FY17-21 and the Program Learning Review (PLR) FY17-21. The FY17-21 CPF (presented to the Board of Executive Directors on February 28, 2017, Report No. 107896-CM) draws on the 2016 Systematic Country Diagnostic which identified three main areas in supporting the twin goals of eliminating poverty and fostering shared prosperity in a socially and environmentally sustainable way. The PLR FY17-21 (reviewed by the Board on July 30, 2019, Report no. 137218-CM) extended the CPF by one year until FY22 in the light of new political, economic, social and security trends. The PLR considered that the three pillars remained relevant but included several adjustments including a greater focus on Human Capital challenges, particularly through the improvement of access, efficiency and equity of social services and by bringing in a multi-sector approach. The revised CPF pillars are: (i) Addressing multiple poverty traps and fragility; (ii) Fostering infrastructure and private sector development; and (iii) Improving governance. 12. Specifically, the AF and the parent project are consistent with CPF’s Pillar 1 (Addressing multiple poverty traps and fragility), which captures Human Capital dimensions through Objective 2 (Improved maternal and child health, and nutrition). Overall, Pillar 1 of the CPF highlights the need to invest in health systems to ensure the productive capabilities of the population, as well as the challenge of overcoming a legacy of limited investment in human capital and social resilience systems. COVID-19 vaccination and immunization systems will be a critical foundation for restoring and advancing these objectives, while reflecting the increased importance and prioritization of health protection and the health system resilience in a fragile context. The AF, like the parent project, is also aligned with both global health priorities and IDA priorities on improving pandemic preparedness. C. Project Design and Scope 13. The project development objective (PDO) of the CCPR Project and of this AF is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in selected regions in Cameroon. The parent project, as described in the Project Appraisal Document (PAD),14 comprises four components each of them designed to support a pillar of the national COVID-19 Response Plan of the GoC. Component 1 supports the Emergency COVID-19 Response, notably improvements in surveillance, diagnostic, treatment and the implementation of social distancing measures (US$20.5 million equivalent). Component 2 supports National and Sub-national Prevention and Preparedness (US$5.0 million equivalent). Component 3 supports Community Engagement and Risk- Communication (US$2.0 million equivalent) while Component 4 finances project management and Monitoring and Evaluation (M&E activities related to the implementation of the project (US$1.5 million 14 PAD is available at: https://imagebank2.worldbank.org/Search/32572732. Page 13 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) equivalent). A more detailed description of the CCPR project as initially designed is available in the PAD for the parent project. The main adjustments to these components are described in section II of this paper. 14. The MoPH remains the implementing agency for the AF. Day to day management of the project is carried out by the Project Implementation Unit (PIU) of the Health System Performance Reinforcement Project (HSPRP, P156679). The PIU, which also serves as the national Performance-based Financing (PBF) technical unit, will be reinforced to effectively support the CCPR Project. Moreover, the technical oversight of CCPR will be updated to include key Directorates involved in the national COVID-19 response plan, the NDVP and RMNCAH-N services. In addition, at the GoC’s request, the World Bank will provide Hands on Expanded Implementation Support (HEIS)15 to strengthen fiduciary functions needed for the successful completion of the project. D. Project Performance 15. The project’s progress towards achievement of the PDO and overall implementation progress were downgraded to Moderately Satisfactory in the last Implementation Status and Results Report (ISR) of August 9, 2021 due to lengthy and slow processing of the signing of the financing agreement16 and delays to reach project effectiveness preventing project implementation. On September 17, 2021, the project became effective, however no activities have been implemented so far, prompting the World Bank and the GoC to agree on restructuring the project to support COVID-19 vaccine purchase and deployment costs. 16. In order to prevent delays in the signing of the AF financing agreement and to ensure implementation readiness, the following actions are being taken: (i) support MoPH technical Directorates to prepare documents and budgets that will be required by Ministry of the Economy, Planning and Regional Development (MINEPAT) as part of the “maturation” process for the signing of the AF; (ii) prepare a procurement plan for the first six months of project implementation which was validated during project negotiations; (iii) facilitate project procurement by extending the mandate of the special tender board of HSPRP which was confirmed during project negotiations; (iv) finalize contractual arrangements with UNICEF for the acquisition of vaccines through AVAT by February 2022; (v) start the implementation of re-prioritized activities from the parent project (e.g communication and vaccine deployment activities, etc.) as soon as the AF is approved, provided that disbursement conditions are met.17 17. The documentation required to comply with the Environmental and Social Framework (ESF) Standards have been updated and include assessments and measures for vaccine related activities. The Parent Project had prepared and disclosed the environmental and social (E&S) safeguards instruments, including the Environmental and Social Commitment Plan (ESCP) and Stakeholder Engagement Plan (SEP) disclosed on July 25, 2020. These ESF instruments have been updated within the framework of the AF and 15 HEIS is a close World Bank assistance to its Borrowers to deliver effective procurement processes beyond the normal implementation support on an Investment Project Financing (IPF). Providing HEIS through the procurement process can enable projects to progress faster and provides a direct opportunity to transfer procurement skills as World Bank and Borrower staff work more closely together. 16 Financing agreement was signed on August 20, 2021. 17 Financing agreement of the parent project has been amended with the following disbursement conditions: (i) POM prepared and adopted; (ii) safeguard specialist, finance officer and internal auditor hired; and (iii) vaccine delivery and distribution manual adopted. These conditions should be met within one month of AF approval. Page 14 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) the SEP was disclosed on December 15, 2021.18 The Environmental and Social Management Framework (ESMF), Infection Control Waste Management Plan (ICWMP), Labor Management Procedures (LMP), Indigenous Peoples Plan (IPP) have been prepared after parent project effectiveness as agreed and this timeline allowed opportunity to also cover AF activities. They were disclosed on December 15, 2021.19 E. Rationale for Additional Financing 18. The restructuring of the CCPR Project and this AF will play a critical role in enabling affordable and equitable access to COVID-19 vaccines and in ensuring an effective vaccine deployment in Cameroon. A key motivation for the restructuring is thus to provide upfront financing for safe and effective vaccine acquisition and deployment, which will allow the GoC to deploy vaccine doses as soon as they become available, recognizing that there is current excess demand for vaccines from both developed and developing countries. Immunization in turn will be of paramount importance to protect most at risk groups rapidly, to limit the burden of the pandemic on the health system, to limit the spread of the virus and to allow the country to safely resume economic activities that have been slowed as a consequence of the COVID-19 pandemic. 19. This restructuring is justified by the current epidemiological situation, lessons learned from the management of the pandemic so far and the financing gaps in the national COVID-19 vaccine deployment plan. The parent project was prepared during the early stages of the pandemic. Since then, global and context-specific knowledge has been accumulated which justify a recalibration of the country’s response and guide the restructuring of the project. A critically important change in the state of science has been the successful development and expanding production of COVID-19 vaccines (see Annex 1 for status). Vaccines represent a realistic pathway to controlling the pandemic globally and constitute a new pillar of the response of all countries, including Cameroon. So far, Cameroon has received 1,889,450 doses of vaccines, including 589,600 doses of Astra Zeneca, and 639,050 doses of Janssen (from COVAX AMC facility, including a donation from the Government of the United States of America (USA)), 460,800 doses of the Janssen vaccine (from AVAT financed by the GoC) and 200,000 doses of Sinopharm (donation from People’s Republic of China). More resources are required to procure additional stocks of vaccines to deploy vaccines which have been secured, and to support the overall strengthening of the health system and increase the chances of a successful roll out – for instance by financing communication campaigns to reduce vaccine hesitancy and increase the demand for COVID-19 vaccines. Overall, the strategy for vaccination in Cameroon outlined in the NDVP is substantially underfunded and project funds should be used strategically to support its implementation. 20. Strengthening the health system’s ability to identify control and manage the disease remains a priority. In addition to country-level factors such as vaccine hesitancy and operational constraints which have slowed down the roll out, demand for vaccines from both high-income and lower-income countries as well constraints on production are likely to limit effective availability of vaccines in the short to medium- 18https://www.minsante.cm/site/?q=en/content/plan-de-mobilisation-des-parties-prenantes-ou-stakeholder-engagement- plan-pmppsep. 19 - https://www.minsante.cm/site/?q=en/content/cadre-de-gestion-environnemental-et-social-ou-environmental-and-social- management-framework; - https://www.minsante.cm/site/?q=en/content/plan-de-gestion-des-d%C3%A9chets-biom%C3%A9dicaux-ou-infection- control-and-waste-management-plan; - https://www.minsante.cm/site/?q=en/content/plan-de-gestion-de-la-main-d%E2%80%99%C5%93uvre-ou-labor- management-plan-pgmolmp. Page 15 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) term. Vaccination of the population at a large scale will take time and, at least in the next two years, the population will remain susceptible to rapid propagation of COVID-19, particularly as new variants emerge. Consequently, although the current levels of transmission are not exceedingly concerning, it remains critically important to invest in the country’s ability to detect and treat COVID-19 cases in a continued manner. Since the beginning of the pandemic, Cameroon has mobilized funding for the immediate response and successfully implemented some of the measures and activities which were initially envisaged to be covered by the CCPR Project. National protocols and strategies have also been refined, including the treatment strategy. As a result, this restructuring allows for the partial reallocation of funding to vaccine-related activities. At the same time, the project continues to contribute to financing the overall national response based on the updated priorities and evolving needs. 21. In addition, the AF will mitigate the negative impact that the pandemic has had on the access and uptake of essential RMNACH-N services. With financing from the GFF, three subcomponents within the project will capture activities to support the continuity of EHS. This will include supporting health facilities to plan and provide facility and community-based care primarily for women and children. Quality of services will be supported through trainings, mentoring and by ensuring the availability of key commodities and essential drugs. In addition, community outreach and sensitization to both promote the demand for services and to disseminate information related to the COVID-19 pandemic and vaccines will be carried out, as this has been identified as one of the major gaps in the current Community and Risk Communication Plan and key to address vaccine hesitancy and misinformation. Support to better capture, monitor analyze information and data will be provided at regional and central level, so that indicators are monitored against targets on a regular basis and activities are introduced to mitigate the impact of future waves on COVID-19 on primary healthcare services and indicators. 22. The MoPH is leading donor coordination efforts. The Ministry recognizes the role of financial and technical partners in providing technical assistance and resources. Key partners have been engaged systematically through regular coordination meetings, notably the Global Alliance for Vaccines and Immunization (GAVI), United Nations International Children's Emergency Fund (UNICEF), the WHO and the World Bank. The Box 1 outlines the main roles played by partners involved in the vaccine deployment process. This situation is fast evolving and it is important to maintain a certain degree of flexibility to direct funding to the most critical gaps over time. Box 1: Development partners’ support for COVID-19 vaccine deployment in Cameroon WHO’s role Financing amount • Provide technical support for vaccine introduction and deployment through support in priority population targeting according to WHO/Strategic Advisory US$1 million Group of Experts on Immunization (SAGE) norms. (European Union) • Provide technical support to identify and delivery outreach strategies. EUR 0.8 million • Develop guidelines on Adverse Event Following Immunization (AEFI), vaccine (European security and other issues of vaccine pharmacovigilance. Commission • Develop a training plan and identify key training partners. Humanitarian Aid) • Develop and adapt surveillance and monitoring tools (both electronic and paper project for March- based). December 2022) Provide technical support to NDVP costing and microplanning. UNICEF’s role Financing amount • Support assessments of dry storage and cold-chain capacity. N/A • Strengthen the national logistic working group. Page 16 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) • Support the GoC in the implementation of a demand generation plan (advocacy, communication, social mobilization, community engagement, and training) to generate confidence, acceptance and demand for COVID-19 vaccines. • Act as the procurement agent for the COVID-19 vaccine through the COVAX facility and facilitate the procurement and delivery of vaccines. Provide the freight and transportation of vaccine doses acquired through the AVAT mechanism. Gavi/COVAX’s role Financing amount • Provide subsidized vaccine doses to cover at least the first prioritized 20 percent US$32. 6 million of the population. US$0.7 million • Finance support for cold chain strengthening. US$0.7 million • Finance technical assistance (VIRAT/VRAF). US$5.5 million Finance deployment operational costs. United States Agency for International Development (USAID) role • Provide subsidized vaccine doses (donation from the Government of the United States). Provide technical assistance and resources for vaccines deployment including N/A demand generation, community engagement, rumors management, central coordination. AU/ AVAT’s role Financing amount • Provide vaccine doses (per country’s demand) and transportation to country. Financed through this AF, government budget and other financiers Other partners • The Islamic Development Bank, among others, may facilitate the provision of additional doses but this is yet to be confirmed. • The African Development Bank has facilitated the procurement of sequencing equipment for monitoring the circulation of COVID-19 variants. • The French Development Agency (Agence Francaise de Développement) will N/A strengthen surveillance through the COVID-19 RNA sequencing. • The Africa CDC and Centre Pasteur have been providing technical assistance. • Danish Government and Japan International Cooperation Agency have supported cold chain strengthening and logistics. 23. The restructured project will form part of an expanded health response to the pandemic. When the pandemic was detected in Cameroon, support to respond was immediately provided through the Contingent Emergency Response Component (CERC) of the HSPRP in the amount of US$6 million, which financed the purchase of medical equipment and other supplies required for the emergency response as well as limited rehabilitation of health facilities. Around US$0.8 million projects funds were also earmarked for the initial response. A US$7.3 million Pandemic Emergency Financing Facility (PEF) grant was made available to the GoC and implemented through four United Nations (UN) agencies (UNICEF, WHO, the United Nations Population Fund (UNFPA) and the World Food Program (WFP) to support COVID- 19 response activities in the North-West and South-West regions of Cameroon. More broadly, the country program was adjusted along the four pillars of the World Bank Group (WBG) COVID-19 Approach Paper, and to encompass the three stages of relief, restructuring and resilient recovery. Page 17 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) F. National Capacity and COVID-19 Vaccination Plan (i) Vaccine Readiness Assessment 24. The GoC with the support of the World Bank, WHO and other partners has conducted the COVID-19 vaccine readiness assessment using the integrated VIRAT/VRAF 2.0 instrument (see Table 1 below). Considering the uncertainties related to the COVID-19 vaccine market, including testing, approval, availability and pricing, which require flexibility and close monitoring, the assessment will continue to be an evolving process and will be dynamically revised and updated as necessary to continue to improve project implementation. Table 1: Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 Assessment as of November 20, 202120 Readiness Key gaps to address before Readiness of Government domain deployment Planning and • A National Coordinating Committee (NCC) for • Validate micro-plans to coordination COVID-19 vaccine introduction is operational since operationalize the NDVP in the November 2020, including five technical working 190 health districts by January groups: (1) service delivery; (2) vaccine, cold chain 2022. and logistics; 3) demand generation and • Vaccine procurement for communication; (4) prioritization, targeting and remaining target population from COVID-19 surveillance; and (5) surveillance and AVAT order yet to be finalized by monitoring, including security and AEFI detection January 2022. and response. • NDVP to be updated and validated • The National Immunization Technical Advisory in January 2022. Group (NITAG), and key stakeholders related to • Additional equipment for medical COVID-19 vaccine introduction have been briefed waste management to be on their expected roles in December 2020 and procured and deployed by January 2021. The WHO has regularly informed, February 2022. disseminated guidance and support to NITAG working groups. • COVAX Facility, bilateral cooperation (People’s Republic of China and Russia) and AVAT have been identified as key partners for provision of vaccines. • The NDVP has been developed with the technical support of development partners and validated in January 2021 and updated on April 24, 2021. The NDVP has all key elements recommended by WHO and represents a central part of Cameroon’s vaccination readiness. The COVID-19 vaccine introduction is being planned, coordinated, and implemented through existing immunization structures of the Expanded Program on 20 A multi-partner effort led by WHO and UNICEF developed the Vaccine Introduction Readiness Assessment Tool (VIRAT) to support countries in developing a roadmap to prepare for vaccine introduction and identify gaps to inform areas for potential support. Building upon the VIRAT, the World Bank developed the Vaccine Readiness Assessment Framework (VRAF) to help countries obtain granular information on gaps and associated costs and program financial resources for deployment of vaccines. To minimize burden and duplication, in November 2020, the VIRAT and VRAF tools were consolidated into one comprehensive framework, called VIRAT-VRAF 2.0. Page 18 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Immunization (EPI), which is under the MoPH Directorate of Family Health. Budgeting and • Budget was prepared with WHO guidance based • Based on the World Bank costing financial on the COVID-19 Vaccine Introduction and tool, the Government would need sustainability Deployment Costing tool (CIVIC tool). to mobilize an additional US$12 • The estimated total cost of the NDVP is US$135 million to purchase remaining million for the original target of 20 percent of the doses to cover 40 percent of the population. The WHO has updated the CIVIC tool population.21 and the adjusted cost of the NDVP is US$160 • NDVP costing to be updated by million for the target of 40 percent and US$228 January 2022 with realistic million for the target of 60 percent. However, estimates for vaccination target of these very high estimates have not been validated 60 percent of the population as by the Government. well as resource mapping to • Coordination with the Ministry of Finance identify funding gap. (MoF) to formally allocate national budget to vaccination activities is effective. The MoF has been financing operational cost for the deployment of vaccines during phase 1 (vaccination of 3 percent of the population). • The MoF has also transferred the 15 percent of advance requested by AVAT on the 5.3 million doses order. • The World Bank will provide US$58.6 million equivalent to support the NDVP through the proposed AF and restructuring. Regulation • The Department of Pharmacy, Medicines and • MoPH to issue guidance for Laboratories (DPML) has been leading the regulatory procedures to regulatory pathway for approval of COVID-19 investigate AEFI involving autopsy, vaccines. Regulatory procedures are in place and January 2022. functional, having already approved Sinopharm, Sputnik V, Covishield (AstraZeneca), Moderna, and Pfizer vaccines. • All regulatory requirements of VRAF/VIRAT tool, including expedited approval pathways for vaccines, regulatory procedure streamlining, import permit issuance and expedited lot release waiver generation have been completed. • The MoPH has issued Emergency Use Authorization to Sinopharm, Sputnik V, Astra Zeneca and Johnson and Johnson vaccines. Prioritization, • Decision-making on identification of target • Validation of population targeting, populations has been based on the WHO SAGE estimation numbers (455,000 surveillance Values Framework for the allocation and refugees and 1,032,942 IDPs) and prioritization of COVID-19 vaccination and the confirmation of their geographical WHO SAGE Roadmap for prioritizing uses of location for vaccination COVID-19 vaccines in the context of limited supply. deployment by January 2022. • Under the leadership of the NITAG and the Scientific Council for Public Health Emergencies, 21 GoC has not replied to World Bank offer to mobilize these additional resources. Page 19 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) the process of prioritization, identification of priority population and coordination for surveillance has been completed. • In May 2021, Cameroon extended its target for immunization from 20 percent to 40 percent of the population. The priority is to vaccinate health and security personnel, and to start immunizing people with comorbidities (3 percent). Coverage is then to be extended to other priority groups (all people over 50, IPDs and refugees, and teachers, etc.) until about 20 percent of the population has been reached. The 40 percent target corresponds to the inclusion of all people aged 18 and older. The revised target announced in September is 60 percent, with a total population target to vaccinate 16,246,000 by December 2023. Service delivery • Standard Operating Procedures (SOPs) relating to • MoPH to increase the number of infection prevention and control and personal vaccination centers from 244 to protective equipment (PPE) have been updated. 1939 and train additional staff • Existing EPI arrangements are being utilized for recruited at the new immunization COVID-19 vaccination particularly for storage, sites on Infection Prevention, and transport, and distribution. Control (IPC) procedures by March • Vaccine delivery strategies and outreach strategies 2022. leveraging both existing vaccination platforms and • MoPH to update protocols by non-vaccination approaches to best reach January 2022. identified target groups have been identified. • EPI to carry out microplanning and • Strategies, service providers and points of delivery, each Health District to develop an including fixed and outreach and associated immunization plan for its target medical supplies that could effectively deliver population including specialized COVID-19 vaccine to target populations, are well populations such as elderly described in the NDVP. people, refugees, displaced • 244 vaccination centers have been identified. persons, prisoners, etc. Training and • The MoPH has designated a focal point who is • Development of vaccines supervision responsible for training of staff administering administration SOP’s by January vaccines, and a COVID-19-specific training plan has 2022. been developed. This plan includes key groups of participants and all topics areas related to vaccination. Key training partners (WHO and CHAI) and training methods (in-person or virtual) have been identified. With CHAI support, training materials developed by WHO have been adapted and translated. • Virtual and in person training are ongoing as outlined in the training plan. As of June 21, 2021, the following have been trained: 43 COVID-19 vaccination trainers out of 50; at the central level; 10 regional trainers out of ten; 220 staff out of 220 at district level; and 575 vaccination teams comprised of 4 staffs (2300/5660 health personnel) at health facility level. Page 20 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) M&E • The Health Information Department of the MoPH • Mechanism with multiple intake with support from WHO has developed a points operational for feedback surveillance and monitoring framework with a set and grievances in relation to the of WHO recommended indicators for COVID-19 vaccine program by January 2022. vaccine. • The integration of the electronic • An electronic immunization records system has immunization registry in DHIS-2 to been set up. The integration of the electronic be finalized by January 2022. immunization registry in the District Health • Vaccination card to be printed Information Software (DHIS-2) is ongoing. Paper- with QR authentication by January based monitoring tools have been adapted and 2022. made available to vaccination centers, including • Training for data managers on vaccination cards, facility-based nominal registers electronic records to be carried and tally sheets, vaccination reports, out by January 2022. immunization records, systems entry, and analytical tools to monitor progress and coverage among different at-risk categories. Vaccine, cold • Exhaustive inventory of the cold chain equipment • Funding from the GoC, Gavi, chain, logistics, has been carried out using the Inventory Gap COVAX facility, Danish infrastructure Analysis and Supply Chain Sizing Tool as well as dry cooperation and Japanese storage capacity and transport and infrastructures cooperation expected to be need. available by January 2022 to • A national logistics working group with address gaps in cold chain appropriate terms of reference (ToR) and SOPs to equipment at regional level. coordinate COVID-19 vaccines and ancillary • The GoC to furnish a warehouse products deployment has been put in place in for the storage of injection September 2021. UNICEF has recruited an material near the EPI building by international consultant with expertise in COVID- January 2022. 19 vaccines management to strengthen the working group. • A distribution plan is in place with periodic updates. • Protocols for tracking and monitoring the stock management and distribution of vaccines and key supplies through the Government's existing Stock Management Tool and DHIS-2 are in place. A WhatsApp group has been set up for a daily data collection vaccine stock. • Security arrangements to ensure the integrity of COVID-19 vaccines and ancillary products throughout the supply chain and waste management are being carried out in accordance with the established mechanism are in place. Safety • COVID-19 surveillance is currently ongoing in the • Identify provisions that require surveillance country. All health districts (190) have a system in manufacturers to implement risk place for the notification and management of AEFI management plans and collect by focal points. and report COVID-19 vaccine • The DPML is responsible for monitoring the safety safety data to the National of all health products, including vaccines, through Regulation Authority by January the national medicines commission. 2022. Page 21 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) • Guidelines, procedures, and tools for planning and • Implementation of genomic conducting vaccine pharmacovigilance activities surveillance and serological (i.e., AEFI reporting, investigation, causality surveys during vaccination assessment, risk communication and response) program. have been developed and disseminated to • Clinical audit of severe cases and surveillance facilities/sites. deaths during vaccination • All the actors have been trained to conduct program. surveillance of event attributable to vaccination. The pocket guide developed is made available to them as well as all related documentation (investigation protocol, case definition, notification forms, investigation form, national surveillance manual). • Channels of data sharing mechanisms to share COVID-19 vaccine safety data and findings with relevant regional and international partners have been identified and secured. Vaccine safety data are shared via the ODK platform and then the data are inserted into Vigibase. Demand • A national communication plan was developed in • Establishment of social media generation and March 2021. It includes 4 strategies namely listening and rumor management communication advocacy, communications, social mobilization, system by January 2022. risk and safety comms, community engagement, • Assessment of behavioral and and training. But lacks elements such as crisis social data during vaccination communication preparedness, planning, and program. management that explain how complaints may be • Dissemination of key messages in lodged and how they will be resolved at all levels. local media to promote vaccination, reduce hesitation and secure proper information to the public during vaccination program. • Vaccination coverage is lower amongst women. As of November 10, 2021, only 38 percent of doses have been administered to women. This contrasts with the proportion of women amongst Cameroon’s population (49 percent). Page 22 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) (ii) NDVP 25. The GoC has prepared a comprehensive NDVP, which draws on the findings of the VRAF/VRAT 2.0 assessment and gap analysis. The GoC established a National COVID-19 Vaccine Committee (NCC) and technical working groups to prepare the NDVP. The plan was developed with technical support of development partners, validated in January 2021 and updated on April 24, 2021. The NDVP has all the key elements recommended by the WHO and represents a central part of Cameroon’s vaccination readiness. 26. In the area of planning and coordination, Cameroon has chosen to integrate vaccination into the (existing) Incident Management System (IMS) of the COVID-19 pandemic activity within the Center of Public Health Emergency Operations Coordination (Centre des Opérations d’Urgence Sanitaires, COUSP). The operations of the vaccination unit of this IMS are carried out by the EPI. The identification of target populations was made in accordance with the guidelines of the Scientific Council for Public Health Emergencies and the NITAG which prioritized as target groups health workers, people living with co- morbidities and people aged 50 and over. Vaccine administration strategies have been diversified with the switch to routine vaccination in all health areas, periodic intensification through campaigns with the deployment of mobiles teams, and the establishment of large vaccination centers with logistical means adapted for mobile outreach in urban areas. 27. In terms of supply chain management and health care waste, the NDVP focused on the assessment of the supply chain with an estimate of the gaps in the storage volumes to be filled, including ultra-cold chain. Human resources management and training are articulated around a training plan for vaccination teams, supervisors, stock managers and communication stakeholders. The deployment of vaccines requires the periodic recruitment of additional health workers during intensification campaigns. 28. In terms of acceptance and use of vaccines, the national communication plan adopted five main strategies: (i) advocacy and political commitment; (ii) community engagement; (iii) crisis communication; (iv) management of disinformation; and (v) capacity building of communication stakeholders. Surveillance of vaccine safety and management of AEFI is carried out through a national network of focal points designated and trained in the detection, notification, investigation and management of all cases of AEFI. An expert committee was created by Decision of the MoPH for the final classification of all AEFI cases, including those related to other vaccines. This area also deals with the issue of waste management which includes on-site collection and sorting, reverse logistics and disposal through a national network of incinerators. 29. Vaccination monitoring has been integrated into DHIS-2. Data on each vaccinated person is recorded on paper and entered into an electronic disaggregated data form (tracker). From this data, a secure vaccination certificate is edited and made accessible with a unique access code sent by automatic SMS. Page 23 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Table 2: National Vaccine Coverage and Acquisition Plan Population Estimated Vaccines already arrived in Vaccines Number of World Source of Targeted* total Contract the country doses Bank’s VAC financing Price Shipping status % Number Source Name needed (US$ million) Status Name Doses (US$/dose) (US$/dose) Phase 1_H1 2021: Health care workers at the frontline, elderly people (50 and above), and persons with comorbidities – Population Target 3% Astra COVAX AMC 2.6% 737,360 COVAX 3 0.072 2 4,530,340 Yes Signed Covishield 589,600 Zeneca PRC Donation 0.4% 100,000 PRC Sinopharm 7 0.07 2 1,414,000 Yes Signed Sinopharm 200,000 Phase 1 total 3.0% 837,360 5,944,340 789,600 Phase 2_H2 2021: Others elderly people (50 and above), other sectors - Population Target 17% COVAX AMC 6.3% 1,747,736 COVAX Pfizer 7.5 0.072 2 26,467,714 Yes Signed Pfizer 152,000 Astra COVAX AMC 3.9% 1,098,792 COVAX 3 0.072 2 6,750,978 Yes Signed Covishield N/A Zeneca COVAX AMC 2.3% 641,976 COVAX Janssen 7.5 0.95 1 5,424,697 Yes Signed Janssen 639,050 PRC Donation 1.7% 475,000 PRC Sinopharm 7 0.07 2 6,716,500 Yes Signed Sinopharm N/A GoC / EXIM 2.8% 781,536 AVAT Janssen 7.5 0.95 1 6,603,979 Yes Signed Janssen 460,800 Phase 2 total 17.0% 4,745,040 51,963,868 1,251,850 Phase 3_H1_H2_2022: Other eligible population - Population Target 20% COVAX AMC 5.2% 1,464,952 COVAX Pfizer 7.5 0.072 2 22,185,233 Yes Signed Pfizer N/A GoC /EXIM 2.2% 614,489 AVAT Janssen 7.5 0.95 1 5,192,432 Yes Signed Janssen N/A /TBD** IDA 12.6% 3,502,959 AVAT Janssen 7.5 0.95 1 29,600,000 Yes Processing Janssen N/A Phase 3 total 20.0% 5,582,400 56,977,665 N/A NATIONAL 40.0% 11,164,800 114,885,873 2,041,450 TOTAL * Total population for Cameroon is estimated in 27,912,000 inhabitants. ** Funding to be sourced by the GoC. Page 24 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Box 2: Liability and Indemnification Issues in Vaccine Acquisition and Deployment Key Issues: • The rapid development of vaccines increases manufacturers’ potential liability for adverse effects following immunization. • Manufacturers want to protect themselves from this risk by including immunity from suit and liability clauses, indemnification provisions, and other limitation of liability clauses in their supply contracts. • Contractual provisions and domestic legal frameworks can all operate to allocate that risk among market participants, but no mechanism will eliminate this risk entirely. COVAX-financed vaccines for AMC countries: • COVAX has negotiated model indemnification provisions with manufacturers for vaccines purchased and supplied under the COVAX AMC. • In providing vaccines through COVAX AMC, COVAX requests COVAX AMC Participants to have in place an indemnity agreement directly with manufacturers, and the necessary indemnity and liability frameworks for that purpose – either in the form of the COVAX model indemnification arrangements or prior bilateral arrangements with manufacturers. • The COVAX Facility will have a no-fault compensation scheme (NFCS) for AMC countries as part of its risk mitigation strategy. This will cover vaccines supplied only through COVAX AMC. • Cameroon will have to consider what it will take to implement these indemnification provisions (including statutory implementation) and how they can avail of the benefits of the NFCS. For vaccines purchased through AVAT: • The Advance Purchase Agreement (“APA”) signed on March 28, 2021 by AVAT, Janssen Pharmaceutica NV (“Janssen”) and the African Export-Import Bank includes indemnification provisions in favor of Janssen for vaccines purchased and supplied under the APA. Participating countries will assume those indemnification obligations upon execution and delivery of a deed of adherence to the APA. • As a condition for the delivery of vaccine doses under the APA, participating countries shall also participate in or establish and adequately fund a NFCS in accordance with certain minimum requirements. Participating countries shall either: (i) participate in the NFCS to be established by AVAT, or (ii) establish and maintain their own NFCS. For the avoidance of doubt, AMC countries will not be able to rely on their participation in the COVAX NFCS to meet the conditions under the Janssen APA. • For vaccines purchased through AVAT, Cameroon will have to consider how to implement the indemnification provisions and NFCS requirements under the APA with Janssen. For vaccines purchased outside of COVAX and AVAT: • Cameroon will need to enter direct indemnification arrangements with manufacturers. • Cameroon does not currently have legislation in place to provide statutory immunity for manufacturers. • Cameroon does not have national no fault compensation scheme. • Adoption of any such indemnification provisions or compensation scheme would have to be in accordance with Cameroon own national strategy and framework. Possible World Bank Assistance support to Cameroon, depending on needs, may include: • Information sharing on (i) statutory frameworks in Organization for Economic Cooperation and Development (OECD) countries and other developing countries; and (ii) overall experience in other countries; • Training and workshops for government officials to familiarize them with the issues; and • HEIS for World Bank-financed contracts. 30. The project operational documents (Vaccine Delivery and Distribution Manual/POM) will make clear that the country’s regulatory authority is responsible for its own assessment of the project COVID- Page 25 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 19 Vaccines’ safety and efficacy and is solely responsible for the authorization and deployment of the vaccines in the country. II. DESCRIPTION OF ADDITIONAL FINANCING A. Proposed Changes 31. The proposed AF will support the GoC’s efforts to further strengthen its response to the COVID- 19 pandemic by purchasing COVID-19 vaccines, preparing the immunization system for deployment of the vaccines, and supporting their distribution. The AF will support vaccination of the population groups as summarized in Table 3. The GoC has validated through the interagency coordination mechanism for immunization (Comité de Coordination Inter agence) its COVID-19 NDVP in January 2021 and updated it on April 28, 2021. Cameroon, intends to roll out COVID-19 vaccines in phases, according to the prioritization of the population, as follows: • Phase 1: will target the most vulnerable 3 percent of the population through COVAX facility, following the ranking of priority groups as identified in the National COVID-19 deployment and vaccination plan. This includes front line health workers, the elderly and people with high- risk co-morbidities. • Phase 2: will target additional most vulnerable, 17 percent of the population through COVAX facility. • Phase 3: The COVID-19 deployment and vaccination plan aims to vaccinate an additional 20 percent of the population by December 2022. This would depend on the evolving epidemiology of the pandemic in the world and in the country, as well as the success, effectiveness, safety, and the market availability of the vaccines. Table 3: Priority populations for COVID-19 vaccination in Cameroon22 Ranking of Share of vulnerable Target population Population size population groups Health personnel, community health agents, and health 83,736 0.3% sector administrative staff Population with co-morbidities or health conditions considered to be at significantly higher risk of serious illness 279,120 1.0% First or death Security personnel, armed forces, and police 195,384 0.7% Population over 50 years of age (start) 279,120 1.0% Total phase 1 837,360 3.0% Other population with co-morbidities or health conditions considered to be at significantly higher risk of serious illness 1,116,480 4.0% or death Second Other population over 50 years of age (complete) 1,674,720 6.0% Workers under 50 years of age essential for Government 55,824 0.2% business Teachers not part of previous groups 251,208 0.9% 22 As identified in the updated NDVP of April 28, 2021. Some numbers presented in the NDVP differ slightly from those of Table 3 to ensure consistency, but the differences are negligible in absolute term. Page 26 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Refugees, internally displaced people, and returnees in the 55,824 0.2% process of reintegration Others eligible according to NDVP criteria 1,590,984 5.7% Total phase 2 4,745,040 17% All other population according to WHO age vaccination criteria 5,582,400 20.0% Third not included in previous groups Total phase 3 5,582,400 20.0% Total 11,164,800 40.0% 32. Cameroon’s target population coverage may seem ambitious given the current low vaccination rate. However, there has been particularly significant progress in recent weeks due to the vaccination campaign in November 2021, which should accelerate further with the opening of vaccination to all segments of the population over 18 years, regardless of the phases initially selected. 33. The changes proposed for the AF involve both an expansion of the scope of activities included in the parent project and an adjustment of its overall design. Specifically, the AF will support COVID-19 vaccine acquisition and deployment as requested by GoC. Relevant project activities included in the original project will be maintained to support early disease detection capacities and emergency response activities, concurrent to the implementation of the national COVID-19 immunization plan. To mitigate the disruption of health service delivery and the decrease in demand for health services, funds from the EHS, GFF grant will support the continuity of RMNCAH-N services. 34. The PDO will remain unchanged. Given that the proposed activities to be funded under the AF are still aligned with the original PDO. The PDO is “to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in selected regions in Cameroon”. The project will be implemented in selected regions of Cameroon (Center, South, Littoral, West, East, Adamawa, North and Far North) and will be gradually expanded to other regions (such as the North-West and South-West regions). However, any engagement in conflict affected areas will be subject to an agreement between the Cameroonian Government and the World Bank, in line with the Conflict Engagement Platform (CEP)23. In terms of progress measurement, three PDO indicators and six intermediary indicators will be added to adequately measure new activities, including the percentage of the priority population fully vaccinated against COVID-19. 35. Proposed changes include: (i) an adjustment of the content of the components, subcomponents and corresponding costs (see Annex 2); (ii) a revision of the Results Framework to reflect the expanded scope and changes in the overall design of the project; (iii) an adjustment in the institutional and implementation arrangements; and (iv) an extension of the closing date. (i) Adjustment of Components, subcomponents, and cost: COMPONENT 1: Emergency COVID-19 Response - INCREASED FROM US$20.5 MILLION to US$63.10 MILLION EQUIVALENT (of which AF is US$29.6 million IDA and US$10.0 million GFF). 36. Given the evolution of the pandemic since its start in March 2020, this component has been revised to adjust some of the activities initially envisaged and to include support to national vaccination 23 Page 27 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) efforts. Funding allocations by subcomponent have also been revised. Initial Subcomponent 1.1. on case detection, confirmation, contact tracing and recording has been moved to Component 2 and renamed as Case management. Subcomponents 1.3 and 1.4 have been removed given that activities related to social distancing measures and social support to households are no longer a priority within the current context and are hence no longer included in this project. Instead, two new Subcomponents (1.2 and 1.3) have been added to capture vaccine purchase and vaccine deployment. In addition, Subcomponent 1.4 has been added to reflect activities pertaining to the continuity of essential RMNCAH-N services. 37. Subcomponent 1.1: Case management (US$5.5 million equivalent IDA). This Subcomponent 1.1 has been renamed and includes relevant activities related to health system capacity to provide medical care for COVID-19, previously under Subcomponent 1.2 and new activities related to system strengthening within the context of vaccine deployment and roll out. The cost allocation of this subcomponent has been reduced from US$12.0 million to US$5.5 million and will focus on: (i) support small rehabilitations of designated health facilities with isolation capacity for COVID-19 patients and COVID-19 vaccination centers; (ii) procure medical equipment and commodities to enhance capacity of selected HFs to ensure adequate case management for severe and critical COVID-19 patients; (iii) train healthcare workers on COVID-19 IPC and case management; (iv) procure IPC materials and PPE kits for frontline healthcare workers and vaccinators; (v) procure supplies for sanitation and hygiene materials, (vi) adequate medical waste management and disposal systems in treatment centers; (vii) install simple handwashing stations in health facilities and rehabilitate selected water supply points; and (viii) implement infection prevention and control measures. 38. Subcomponent 1.2: COVID-19 vaccine purchase (US$29.6 million equivalent IDA, of which US$29.6 million from this AF). This subcomponent has been added to capture COVID-19 vaccines procured via AU/AVAT mechanism. Given the recent emergence of COVID-19, there is no conclusive data available on the duration of immunity that vaccines will provide. While some evidence suggests that an enduring response will occur, this will not be known with certainty until clinical trials follow participants for several years. As such, this AF will allow for re-vaccination efforts if they are warranted by peer- reviewed scientific knowledge at the time. 39. Subcomponent 1.3: COVID-19 vaccines deployment (US$18.0 million equivalent IDA). This subcomponent, funded through the cancellation and reduction of other subcomponents, will support COVID-19 vaccines deployment (including cold chain and logistics costs). Under this subcomponent, the project will: (i) procure essential consumables and equipment for COVID-19 vaccination, including syringes, groves, face shields and masks; (ii) train vaccinators for the scale-up of the COVID-19 vaccination campaign, including training for the prevention of SEA/SH; (iii) strengthen vaccine safety surveillance, in terms of monitoring and addressing AEFI; (iv) support operational costs for COVID-19 vaccination deployment (periodic campaigns and mobile units) and supervision activities; (v) strengthen M&E systems, especially those related to stock management of COVID-19 vaccines; (vi) enhance cold chain and logistics to scale-up COVID-19 vaccination, including medical waste management capacity of selected sites. Best practices and lessons learnt on vaccine deployment and uptake will be documented as vaccination campaigns expand and will be taken into account during Project implementation. • Planning and management: The AF will finance: (a) support the implementation of the NDVP and associated budget; (b) support the GoC to develop legal regulatory documents and plans to ensure the swift importation of COVID-19 vaccines; (c) train health personnel for vaccine roll-out, including SEA/SH elements; and (d) support contingency measures included in the NDVP to deal Page 28 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) with any unexpected disruptions to vaccine supply from climate change and natural disasters (i.e., flooding and extreme heat). • Procurement, supply and distribution of vaccines, consumables: the AF will cover the procurement and distribution of vaccination supplies (needles, syringes, waste management boxes, cold boxes, vaccine carriers, alcohol prep pads), furniture for vaccination rooms, and PPE and hygiene products for vaccinators. • Immunization system strengthening: the AF will contribute to immunization systems strengthening for both COVID-19 vaccination, and routine immunizations, by supporting the: (a) equipment required to support efficient and low-carbon emission cold chains (storage, transportation and distribution of COVID-19 vaccines), including certified climate friendly solar powered refrigerators/freezer; (b) equipment for remote temperature monitoring; (c) operational costs for disposal, transportation and off-site treatment of vaccine-related medical waste management; and (d) climate-smart minor civil works such as small rehabilitation of health facilities, EPI dry storage space in Yaoundé. The acquisition of cold chain equipment for gaps identified at the district level, minor rehabilitation of on-site cold chain storage units and supporting the training and deployment of human resources for the vaccination campaign will ensure that the EPI program has sufficient capacity to simultaneously deploy the COVID-19 vaccine, and routine immunizations for children in the short-to medium term. • Service Delivery: further small-scale improvements will be made to health facilities designated such as vaccination centers to ensure proper patient flow and service provision. Mobile vaccine delivery units will also be established using infrastructure developed by the multisectoral Rapid Response Teams (Equipes d’Intervention Rapide). • Regulatory Systems Strengthening: The AF will cover costs to: (a) strengthen and adapt the Pharmacovigilance System to be sensitive to detect AEFI for the COVID-19 vaccines; and (b) undertake relevant traceability activities to ensure capabilities for the system to track and trace from “production to people.” 40. Subcomponent 1.4: Continuity of EHS (US$10.0 million GFF of which US$10.0 million from this AF). This subcomponent will support the continuity of essential and RMNCAH-N services at health facility and community level in response to the decrease in uptake and access to primary health care services in the context of COVID-19. To guarantee service provision basic inputs, commodities and essential RMNCAH drugs will be procured. Specifically, activities under this component will include: (i) support health facilities to develop and follow integrated planning and implementation of RMNCAH-N interventions aligned with district plans and in collaboration with community actors; (ii) intensify outreach strategies and campaigns to most affected areas by the pandemic to bring routine RMNCAH-N services closer to communities and to incentivize uptake of health-services and successful practices; (iii) address supply-chain constraints, in complementarity with SWEDD activities; (iv) improve quality of care through training and capacity building of health providers; (v) strengthen surveillance and response of maternal and perinatal deaths. COMPONENT 2: Supporting National and Sub-national, Prevention and Preparedness - DECREASED FROM US$5.0 MILLION TO US$2.0 MILLION EQUIVALENT Page 29 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 41. This component intended to strengthen laboratory and testing capacity in Cameroon at central and decentralized levels, It, has been revised given investments already made in Cameroon as part of the early response to improve diagnostic and surveillance and the support of other donors in this space such as the Global Fund. This component now also accommodates former activities related to health system strengthening and case detection initially under Component 1, given the change in needs and evolution of the pandemic. 42. Subcomponent 2.1: Surveillance (US$1.0 million equivalent IDA). This Subcomponent (1.1 in the parent project) will support improvement of disease detection and confirmation capabilities through provision of trainings and technical expertise and by strengthening surveillance systems to ensure prompt case finding and contact tracing. The cost allocation of this subcomponent has been reduced from US$5 million to US$1 million and will: (i) strengthen frontline health care workers capacity in Integrated Disease Surveillance and Response (IDSR); (ii) strengthen capacity of selected stakeholders on IMS; and (iii) strengthen events-based surveillance systems at regional and community levels; and (iv) support epidemiological investigation. 43. Subcomponent 2.2: Laboratory diagnostic (US$1.0 million equivalent IDA). This subcomponent will strengthen the quality of laboratory and testing capacity in Cameroon and the functioning of an improved referral system. Activities under this subcomponent will be primarily led by the Public Health National Laboratory (Laboratoire National de Santé Publique, LNSP) in close collaboration with the national reference laboratory (Centre Pasteur). The cost allocation of this subcomponent has been reduced from US$5 million to US$1 million and will: (i) strengthen laboratory capacity through the training of personnel on diagnostic for COVID-19 and priority diseases and provision of laboratory equipment, reagents and test kits; (ii) support selected laboratories to meet international quality standards through the accreditation in the WHO Stepwise Laboratory Improvement Progress Towards Accreditation (SLIPTA); and (v) reinforce and support an improved referral system for samples including those that will undergo genome sequencing. COMPONENT 3: Community Engagement and Risk-Communication - INCREASED FROM US$2.0 MILLION TO US$3.0 MILLION EQUIVALENT (of which AF is US$1.0 million GFF) 44. Activities initially proposed under this component related to the finalization of the community engagement and risk-communication strategy (CREC), as well as the development of guidelines and key messages for different at-risk groups. Since the Project was approved, Cameroon has advanced considerably in the finalization of this strategy and in disseminating preventive messages through different platforms. Nevertheless, as mentioned in earlier sections, vaccine hesitancy continues to pose a risk to the roll-out and uptake of the NDVP. As part of this AF, the project will continue to engage with the GoC for the implementation of dynamic and innovative activities that address existing and new gaps as the vaccination campaign advances. This will include capitalizing on national and international events (such as the Africa Cup of Nations in January 2022) or campaigns that can increase vaccine confidence and uptake. This component includes activities for demand generation for COVID-19 vaccine (amongst the general population and for specific groups such as health workers) and communication activities to respect COVID-19 preventive measures and promote continuity of access to primary healthcare services, to avoid disruptions in services that the country has experienced during peak. Specifically: 45. Subcomponent 3.1: Demand generation (US$1.0 million equivalent IDA). This subcomponent specifically supports the priorities set out by national COVID-19 vaccine communication strategy. It Page 30 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) supports a variety of mass and social media strategies to provide information about the vaccination campaign, address misinformation and promote uptake amongst the general population and specific sub- groups. The selected activities were enriched through an exchange with Côte D’Ivoire, where the communication strategy has been crucial to address vaccine hesitancy and increase vaccine coverage (close to 10 percent of the population has received at least one dose). Activities included under this subcomponent include: (i) develop media content in local languages (videos, other social media content); (ii) disseminate information on the national vaccination campaign through mass media (radios and TV); (iii) utilize social media campaigns to address misinformation, promote vaccine uptake and support fact- checking; (iv) leverage celebrities, influential figures and national events/campaigns for ad-hoc strategic campaigns; and (v) leveraging professional associations to reach specific sub-groups, including different cadres of health workers. 46. Subcomponent 3.2: Promoting health-seeking behaviors through community engagement (US$1.0 million equivalent IDA and US$1.0 million GFF of which US$1.0 million from this AF). This subcomponent responds to the drop in RMNACAH-N services such as ANC visits and routine vaccination services that Cameroon has experienced, and which have mirrored with the different waves of the pandemic that the country has suffered. Efforts promote the continued use and access of primary health care service will respecting COVID-19 preventive measure (social distancing, mask wearing, frequent handwashing etc.). Proposed activities include will: (i) integrate key health promotion messages for RMNCAH-N services into the CREC Plan messages; (ii) train decentralized territorial collectivities, civil society organizations and community-based actors in the promotion of key messages and strategies; (iii) carry out community-based awareness and sensitization activities that promote continued access to healthcare and uptake of successful RMNCAH-N practices and initiatives; and (iv) support community- based structures for crisis communication and management of information, to address misinformation and ensure a feedback mechanism to campaigns and awareness sessions conducted. COMPONENT 4: Implementation Management and M&E - INCREASED FROM US$1.5 MILLION TO US$5.5 MILLION (of which AF is US$4.0 million GFF) 47. This component will support M&E for prevention, preparedness, response whilst at the same time building capacity for clinical and public health research and joint learning within Cameroon. It includes all the activities envisaged in the initial project. AF of US$4 million has been allocated to boost M&E activities and in particular, to support decentralized planning and monitoring of results at district level. These additional funds will contribute to regular reviews of performance, so that the information can be used for decision-making purposes and mitigating actions can be introduced, particularly with regards to continuous access and uptake or routine primary healthcare services. 48. Subcomponent 4.1: Project coordination and M&E (US$1.5 million equivalent IDA). This subcomponent will continue to support the administrative and human resources needed to implement the Project and monitor and evaluate progress. It will finance staff and consultant costs associated with Project management, procurement, financial management (FM), E&S safeguards, and M&E, reporting and stakeholder engagement, as well as operating and administrative costs. It will also support technical assistance to strengthen the NDVP implementation; flexibility in the recruitment of additional short-term consultants who could help to overcome with the workload which will occur during the implementation of the COVID-19 vaccine roll out; and longer-term capacity-building for pandemic preparedness and response. Additionally, due to uncertain security situation of some regions of the country and based on Page 31 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) situation on the ground a third-party monitoring scheme could be pursued to measure the impact of project supported activities. 49. Subcomponent 4.2: Data for Decision-Making (US$4.0 million GFF of which US$4 million from this AF). This subcomponent encompasses activities supported by the GFF EHS grant to ensure the continuity of essential and RMNCAH-N services. Interventions under this subcomponent focus on improving existing national data systems and decentralized processes. Key indicators for community- based indicators on DHIS-2 will be identified and a new tracker will be piloted in selected areas for better monitoring of RMNCAH-N services. At a decentralized level, health facilities will be supported with guides, dashboards and training for better data collection, management, and analysis. Monthly data reviews will be facilitated at district level, aggregating information from the health facilities and contributing to regular bulletins and reports that can allow for data-driven decision-making. Combined, these interventions will allow central and decentralized levels of the MoPH to monitor and respond to shocks observed in the demand and uptake of RMNCAH-N services. In summary, three sets of activities are included under this subcomponent: (i) strengthen electronic data management systems; (ii) support capacity building of health facilities for data collection, management and regular analysis; and (iii) facilitate quarterly data review and validation sessions at decentralized levels to inform planning and decision making. (ii) Results framework: i. Added three new PDO level indicators and six intermediate results indicators to reflect the expanded scope of the proposed AF; ii. Revised two existing intermediary indicators to reflect changes in subcomponents and activities; iii. Reflected gender gaps specifically addressed and monitored by the project through two indicators; and iv. Considered citizen engagement through the inclusion of an indicator to capture the percentage of on grievances addressed through the Grievance Redress Mechanism (GRM). (iii) Adjustment in the institutional and implementation arrangements: the national COVID-19 Oversight Committee will continue to provide support for defining project implementation strategies and overall leadership, coordination, and strategic planning for the response. However, the composition of the Committee will be updated to include key directorates involved in the national COVID-19 response plan, the NDVP and RMNCAH-N services. The Performance Based-Financing Technical Unit (Cellule Technique National, CTN-PBF) will act as the PIU for day-to-day management of the Project, including the procurement of vaccines through UNICEF.24 Staffing of the CTN-PBF will be adjusted to reflect new needs (see paragraph 51 for more information). (iv) Extension of the closing date: The project’s closing date will be extended from June 30, 2022 to June 30, 2024. This is proposed to allow for sufficient time to implement the additional activities included as part of the AF and also considering supply side constraints which result in longer procurement and delivery timelines and the complexity of rolling out nationwide vaccination. 24 UNICEF is the designated UN agency for the provision of COVID-19 vaccines in Cameroon. Page 32 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Financing arrangements 50. A summary of changes in subcomponents and allocation is presented at Table 4 below: Table 4. Project costs and financing Revised Funding Original amount source (US$ Original allocation Revised (Parent million) Component Subcomponents (US$ Subcomponents and AF) IDA GFF million) (US$ Trust million) Fund 1.1 Case detection, confirmation, 1.1 Case 5.00 5.50 5.50 contact tracing, management recording, reporting 1.2 Health systems 1.2 Vaccines C.1 Emergency 12.00 29.60 29.60 strengthening purchase COVID-19 Response 1.3 Social distancing 1.3 Vaccines 0.50 18.00 18.00 measures deployment 1.4 Social support to 1.4 Continuity for 3.00 10.00 10.00 households essential services Subtotal 20.50 Subtotal 63.10 53.10 10.00 C.2 Supporting 2.1 Surveillance 1.00 1.00 National and Sub- No subcomponents 5.00 2.2 Laboratory national Prevention 1.00 1.00 diagnostic and Preparedness Subtotal 5.00 Subtotal 2.00 2.00 3.1 Demand 1.00 1.00 generation 3.2 Promoting C.3 Community No subcomponents 2.00 health-seeking Engagement and behaviors through 2.00 1.00 1.00 Risk-Communication community engagement Subtotal 2.00 Subtotal 3.00 2.00 1.00 4.1 Project 4.1 Project C4. Implementation 1.00 coordination and 1.50 1.50 management Management and M&E Monitoring & 4.2 Data for decision- 4.2 M&E 0.50 4.00 4.00 Evaluation making Subtotal 1.50 Subtotal 5.50 1.50 4.00 TOTAL 29.00 TOTAL 73.60 58.60 15.00 Page 33 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Table 5: Summary of vaccine sourcing and World Bank financing Source of vaccine financing and population coverage National Doses Estimated Specific plan target World Bank-financed purchased allocation of vaccines and (population COVAX Through Through with World World Bank IDA Through Other* sourcing plans %) Grant AVAT direct Bank finance financing COVAX purchase 2.6% - - COVAX (AZ) - Phase 1: 3% PRC - - - 0.4% - (Sinopharm) 12.5% - - COVAX ** - Purchase: PRC US$29.60 M 1.7% Phase 2: 17% (Sinopharm) Deployment: AVAT US$18.00 M - - - 2.8% - (Janssen) Other***: 5.2% - - - COVAX** - US$11.00 M AVAT - - - 2.2% - Phase 3: 20% (Janssen) 12.6% AVAT - - - 3.5 M (Janssen) * Other: Includes coverage financed by the government, bilaterally, from other MDBs, etc. **: Mix of vaccines, details in Table 2 ***: Other include allocation for health system strengthening activities, preparedness and laboratory diagnostic, communication, project coordination and M&E. Implementation Arrangements for NDVP Implementation and Oversight 51. Institutional arrangements from the parent project will be maintained with a few adjustments. The MoPH will remain responsible for technical oversight of the project and implementation of activities and the National COVID-19 Oversight Committee will continue to provide support for defining project implementation strategies and overall leadership, coordination, and strategic planning for the response. However, the committee will be updated to include key Directorates of the MoPH involved in the national COVID-19 response, the NDVP25 and RMNCAH-N services and coordination will be strengthened through regular meetings. The CTN-PBF of the HSPRP, which serves as the PIU, will be responsible for day-to-day management of the project and will handle fiduciary functions. The CTN-PBF will contract UN agencies for medical equipment and UNICEF for procurement of vaccines, relying on its technical expertise with COVID- 19 vaccine procurement, including integrating indemnity provisions in-line with national regulations. 52. A small team from the CTN-PBF dedicated to the new project will be set-up as follows: (i) the assignment of CTN-PBF staff (e.g., accountant, environmental safeguards and M&E specialists); (ii) the recruitment of a finance officer, an internal auditor, a consultant/ specialist in logistics to ensure logistic arrangements for vaccines and medical equipment, a social safeguards specialist with SEA/SH expertise and other advisors/consultants as required (e.g., internal audit). The ToR for the recruitment of a social safeguard specialist will be revised based on updated needs outlined in this project paper. Recruitment of 25 An oversight committee for the project was created by the MoPH, through decision No 171/D/MINSANTE on July 2020 and was updated through ministerial decision No 4043 on December 15, 2021. Page 34 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) social safeguard specialist, finance officer, internal auditor will be completed within one month of AF approval. 53. To attest for the adequate coordination, implementation, and monitoring of the AF activities, adaptive implementation support arrangements will have to be used. Additional hands-on implementation support, including technical assistance and additional supervision missions, will be conducted by the World Bank. 54. Specific arrangements related to security risks and involvement of security forces remain unchanged. While project implementation will be led by the MoPH, the military may have a very limited role related to the transportation of medical equipment and supplies in areas facing security challenges. In case of their involvement, measures provided in the World Bank’s ESF Environmental and Social Standard (ESS) 4 (paragraph 24 to 27), will be applied. Arrangements for the transportation of the medical equipment and supplies in the areas facing security challenges, which will be fully financed by the GoC, will be agreed upon with the Ministry of Defense. These arrangements will be detailed in a Memorandum of Understanding (MoU) signed between MoPH and Ministry of Defense. For each escort needed, an official request from the MoPH will be addressed to the Ministry of Defense, which will instruct its relevant departments for its organization in collaboration with the Governor of the region. The military will not undertake any procurement activities and no funds will be provided directly to the military under the project. The costs related to the military escort (personnel costs, fuel, vehicle costs, etc.) will be financed by the GoC using its own resources. 55. Mitigation Measures: To mitigate the risks, the following measures have been put in place: (i) a security risk assessment will be carried out prior to the deployment of any escort for medical supplies and equipment; (ii) a screening of the proposed military personnel and their background will also be carried out for any escort; (iii) the implementation of preventive measures (such as training of security forces, code of conducts, awareness campaigns, etc.); (iv) monitoring of field operations; and (v) the ESCP/ESMF includes additional measures to be taken by the Government. The financing agreement includes related covenants addressing these arrangements. Results Framework 56. The results framework will be modified to reflect the expanded scope and the new activities under the proposed AF, and measure overall progress in the coverage and deployment of the COVID-19 vaccine and the gender gaps the project can address. Page 35 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Table 6. Results Framework modifications Modifications PDO indicators 1 COVID-19 designated healthcare facilities with appropriate handwashing facilities in place (number) Dropped 2 Contacts followed for all 14 days (percentage) Dropped 3 Acute healthcare facilities with isolation capacity number) Dropped COVID-19 designated healthcare facilities with required equipment for treatment of critical Dropped (number) 4 Designated laboratories supported with personnel, equipment, test kits and reagents (number) New (formerly an intermediate results indicator) 5 Priority population vaccinated against COVID-19, based on targets defined in the national plan New (percentage) (% females); 6 Births assisted by skilled health personnel in the 3 Northern regions (Adamawa, North, Far North) New and in the East(number) Intermediate Indicators (1) 1 Health facilities with a COVID-19 case management unit (number) (formerly phrased as Number Revised of acute health care facilities beds with isolation capacity) 2 Households provided with food and basic supplies within quarantined population (number) Dropped 3 Health staff trained in COVID-19 vaccination deployment (number) (number of females) New 4 Doses of eligible COVID-19 vaccines procured (number) New (2) 5 Laboratories awarded with 3 stars or above based on the Stepwise Laboratory Quality Improvement Revised Process Towards Accreditation (SLIPTA) audits (3) 6 Households reached with tailored information (number) Dropped 7 Community health workers trained to deliver key messages to promote demand for COVID-19 New vaccines and other EHS (percentage) (% female) 8 Radio stations and TVs channels broadcasting COVID-19 vaccination information in official and local New languages (number) 9 Grievances addressed according to the project’s GRM timeframe and procedures (percentage) New (formerly Percentage of grievances managed according to the project’s GRM protocol) (4) 10 M&E established to monitor COVID-19 preparedness and response plan (yes/no) Dropped 11 Routine monitoring of EHS regional reports reviewed quarterly by MoPH (number) New B. Sustainability 57. There is a strong political commitment in Cameroon to mobilize financial resources for the COVID- 19 response, including for vaccine purchase and deployment. Having the funds through the proposed project restructuring for vaccine purchase and deployment will establish an enabling environment for other donors, multilateral development banks and UN agencies to also support efforts for strengthening the COVID-19 response in the country. Investments under the project original design and these proposed new activities are expected to strengthen the health system and the EPI infrastructure and capacity in the country, ensuring institutional sustainability to deal with future pandemics as well as other infectious diseases. III. KEY RISKS 58. The overall risk to achieving the PDO with the expanded scope and AF for vaccination is High. The overall project risk rating of the parent project was Substantial. Risks reflecting the unprecedented nature of the vaccination effort are now added to those which justified the initial rating. Key risks now include: (i) adverse effects on the macroeconomic and fiscal situation of the GoC stemming from COVID- Page 36 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 19; (ii) vaccine hesitancy; (iii) health sector institutional capacity, which can be overwhelmed by a surge in the number of new cases and the scale of effort needed to deploy vaccines for the entire population; and (iv) fiduciary concerns, including risk of use of funds for non-project related expenditures and procurement related problems, stemming from potential difficulties in procuring critical equipment given the disruptions in global supply chains, and vaccine doses due to uncertainties in the global production. Further risks and mitigation measures related to this restructuring are identified below, as well as the residual risks. 59. Political and governance risks are Substantial. The recent increase in COVID-19 cases, the emergence of COVID-19 variants and global pressure to vaccinate populations, could create undue pressure to (i) advance rapidly in the procurement of vaccines before they have been properly certified; and (ii) deploy before critical infrastructure has been put in place. The Government has adopted a collaborative approach with leading health partners to develop its national COVID vaccination strategy and is currently working through established channels to obtain vaccines (e.g., COVAX, AU). The AF will mitigate this risk by only financing the procurement and deployment of vaccines that meet the World Bank VAC eligibility requirements. A second risk relates to the capacity and commitment of local authorities to ensure appropriate targeting of vaccines to priority populations based on objective public health criteria. To mitigate this risk, the project will include support to the implementation of a distribution based on objective public health guidelines, and robust M&E systems to monitor that vaccines reach their intended beneficiaries. Governance risks will also be mitigated through the application of anti- corruption guidelines for vaccine purchase and deployment and robust FM oversight of the use of funds, as elaborated in the fiduciary risks below. 60. The macroeconomic risk is Substantial. The COVID-19 pandemic negatively affected Cameroon’s economy and despite reprioritization the overall fiscal deficit reached 3.9 percent of gross domestic product (GDP) in 2020 and is expected to remain around 3.5 percent in 2021. In the face of competing priorities, Cameroon may not have sufficient fiscal space to purchase vaccines at scale, as well as to finance related interventions that are needed to ensure the effective deployment of vaccines. The restructuring partly mitigates this risk by providing upfront financing to ensure the deployment of doses availed to the country by COVAX and any additional vaccines purchased with project funds. The residual macroeconomic risk to achieving the PDO is thus limited but the need to mobilize additional resources in the mid-term to further expand coverage should be recognized. 61. The anticipated institutional capacity risks related to vaccine deployment and distribution are High. Immunization coverage for children in Cameroon is generally below sub-Saharan and low and middle-income countries averages, attesting to the limited performance of the public immunization program. This is explained by a combination of factors including the availability of functioning cold-chain equipment, the distribution of vaccines and other commodities, as well as issues around effective access to care in hard-to-reach areas of the country. This risk will be mitigated by the funding and provision of technical support for immunization system strengthening, gaps identified in assessment conducted with the WHO, GAVI, UNICEF, and other partners, and coordinating investments with other partners. The residual institutional capacity risk remains nevertheless is High, considering the scale of the efforts needed to reach the population coverage target. 62. Vaccine hesitancy presents an additional risk to the project achieving its objective. As previously described, vaccine hesitancy has been a concern since the start of deployment, which so far has not been dispelled and then demand for vaccines remains sub-optimal. The country and World Bank-led efforts to Page 37 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) gain information on the cause of hesitancy through periodic surveys will continue to take place, and these will feed into the design of communication instruments and channels, whose deployment will be supported under the project will enhance the chances of overcoming the widespread hesitancy. Details about the dynamic and comprehensive communication strategies proposed to mitigate this risk are provided earlier in paragraphs 44-46. 63. Once mitigated, fiduciary risks associated with the parent project remain Substantial. The procurement and FM risks initially assessed for the parent project cover risks associated with the procurement and distribution of vaccines, including fraud and corruption risks. 64. The residual procurement risk is Moderate: The key procurement risk associated with vaccines relate to: (i) the complexity of the vaccines market given the significant market power enjoyed by vaccine manufacturers; (ii) inability of the market to supply adequate quantities of vaccines to meet the demand; (iii) the limited market access due to advance orders by developed countries; (iv) weak bargaining power; (v) delays in triggering emergency procurement procedures which could delay procurement and contract implementation including payments; and (vi) Government’s willingness and ability to engage in APAs, notably due to limited fiscal space and readily available resources. As per the MPA, the risks under this project will be reduced by providing options to support the country’s needs for direct advance purchase, using UNICEF through the AVAT mechanism. Other risks related to the governance of vaccine delivery and deployment to vulnerable people and at-risk groups may be slower than expected could face added hurdles. Good logistics planning and intense communication are potential means of further accelerating vaccination and limiting vaccine resources waste. 65. The audit on the use of the Government’s COVID-19 funds26 performed by the Court of Accounts, finally published in November 2021 has highlighted several major deficiencies and irregularities concerning procurement interventions to COVID-19 response. These are: (i) abusive use of emergency procurement procedures that break free from the main principles of efficiency, transparency and accountability; (ii) the lack of appropriate budget planning causes the use of emergency procurement procedures that are slower than normal procedures, intensive use of administrative purchase orders, detrimental to efficiency; (iii) awards of contracts to companies without relevant experience or offering weak guarantees with a presumption of favoritism; lack of controls and supervision occasioning poor performance of several contracts; (iv) absence of acceptance of the work completion or acceptance certificate issuance without completion of the physical work; (v) early, full or multiple payments made for many special contracts that were partially executed; etc. These repeated procurement mal practices did not establish accountability nor achieve the cost-effective use of COVID-19 funds. 66. To mitigate the serious risks above, the procurement team will carry out (i) prior review of all high value contracts regardless direct or UN contracts; (ii) technical reviews of all critical and small value contracts under the prior review thresholds. In addition, for the quality assurance and to expedite the procurement of these contracts, an additional support is recommended to be provided to the CTN-PBF with senior procurement consultant through HEIS; and (iii) it will be essential for the project coordination unit focusing on contract management at the execution phase for effective oversight of contractors’ performance in terms of quality, quantity and timing. 26Audit du Fonds spécial de Solidarité Nationale pour la lutte contre le coronavirus. (Audit of the Special National Solidarity Fund to Combat the Coronavirus) Page 38 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 67. The residual FM risk is Substantial. The key FM risks relate to: (i) inconsistent FM arrangements with the emergency nature of the operation; (ii) lack of proper staffing to respond to the increased volume of the operation; and (iii) lack of adequate controls over the transparent, prioritized distribution and application of vaccines, particularly for the most vulnerable population groups; (iv) risk of interference by line MoPH in project activities due to emergency nature making it vulnerable to fraud and corruption in the aftermath of the publication of the COVID-19 audit report. 68. The audit on the use of the Government’s COVID-19 funds has also revealed several instances of noncompliance with government budget execution procedures and irregularities in the procurement and payment of medical supplies and other COVID related expenditures. The main issues include the lack of transparency in the procurement process for medical supplies, overpriced test kits, overbilling by suppliers, lack of supporting documentation for payments. The report also notes the lack of accounting and financial information reliability between MoPH and Treasury. A number of recommendations have been formulated to the MoPH and other ministerial departments to improve technical, administrative and financial oversight in the management of the response. The World Bank team will work closely with the relevant departments to implement the recommendations and strengthen the health sector fiduciary systems. 69. The proposed mitigation measures include: (i) additional measures to strengthen the internal controls through the internal audit team’s ex-ante review of invoices for large contracts and supporting documentation for disbursement requests; (ii) updating the project’s manuals to reflect the emergency nature of the operation; (iii) using specialized UN agencies for the procurement of vaccines; (iv) designing a complaint handling mechanism; (v) hiring a dedicated finance officer and internal auditor to handle the original project and AF; and ensuring availability of data for tracking/auditing purposes and expanding the scope in the ToR of the external audit to include additional verification and oversight. 70. The anticipated overall E&S risks are Substantial. The main social and environmental risks are those related to (a) the disposal of health care waste, particularly vaccination waste, risks of traffic accidents linked to transport activities for vaccine deployment which implies also the consumption of fuel with climate change impacts; (b) the spread of the virus among health care workers and the general population; (c) occupational and community hygiene, health and safety issues related to the testing, handling, transport, disposal of medical supplies and specimens, and upgrading of designated health facilities and laboratories; (d) lack of access to vaccine supplies, facilities and services designed to control the disease by marginalized and vulnerable social groups; (e) social conflicts and risks to human safety resulting from diagnostic testing, limited availability of vaccines and social tensions related to the challenges of a pandemic situation; (f) vaccine hesitancy leading to a low demand; (g) the risks of SEA/SH among patients and health care providers, particularly with regard to vaccine distribution; (h) GBV at vaccine delivery sites due to unsafe and uncomfortable environment for women (i) labor influx of migrant workers to support small scale rehabilitation; (j) inadequate data protection measures and insufficient or ineffective communication by stakeholders on vaccine deployment strategy; (k) risks related to AEFIs, which may lead to stigmatization of vaccine-friendly populations in certain communities and may contribute to refusal of vaccines or second dose; (l) risk of disruption of primary healthcare services and reduction of the utilization rates of primary healthcare services; and (m) exclusion of disadvantaged and vulnerable groups, including refugees. These risks will be mitigated through effective risk communication and community engagement to raise awareness among the general population. Mobilizing the entire health system around the response to COVID-19 could contribute to quality deterioration and poor access to other health services. The current project paper has anticipated this, by allocating a grant from GFF to Page 39 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) provide complementary resources to support the continuity of EHS and mitigate the negative impact that the pandemic has had on the access and uptake of RMNCAH-N services. 71. Other potential social risks include the incidence of reprisals and retaliation, especially against healthcare workers and researchers related to both suspicion of the motives and legitimacy of the vaccinators and the vaccine itself, as well as to SEA/SH risk, which has been determined to be substantial for the project, especially with regard to planned rehabilitation activities and vaccine deployment-related initiatives. Women are exposed to GBV at vaccine delivery sites due to unsafe environment. This risk will be mitigated by providing separate rooms/vaccine area for women, having at least one female staff in place, elaborating a code of conduct for staff, and ensuring that GRMs are accessible to female beneficiaries. As part of the overall training to vaccinators, the project will add a training on SEA/SH. Moreover, there are some barriers that may negatively impact women’s access to information, including lower access to mobile phone and lower literacy rates. This will be addressed by utilizing a wide range of media (including radio), communicating in the local language, and by engaging female community health care workers to deliver messages. The project is supporting a quota for the recruitment of a minimum proportion of female health care workers (vaccinators) in each of the vaccination centers. The project will ensure a gender-balanced team within the framework of vaccinators training at each vaccination center. In addition, the project encourages female health workers for demand generation and community engagement of women and seeks to have at least 49 percent trained community health workers who are female, aligned with the percentage of women in the Cameroonian population. Further, and linked to the social risks stated above, it is important to have clarity on the risks that may arise related to any mandatory aspect of the national program and whether and how this mandatory element relates to cultural, social and traditional community practices and values. Such risks need to be considered in light of the mitigation hierarchy and balanced against the health-related requirements of any mandatory vaccination program. In addition, the grievance mechanisms required under the ESF should be in place and equipped to address community, worker, and/or individual grievances related to such issues. This includes requirements related to being able to have GRMs in place to address labor and working conditions, and SEA/ SH. IV. APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis 72. The economic rationale for investment in a COVID-19 vaccine is strong, considering the massive and continuing health and economic losses due to the pandemic. As of November 2021, more than 249 million people have been confirmed to be infected by the virus globally and close to 5 million have been confirmed to have died. Global output declined by 3.5 percent in 2020, and although the global economy is set to expand 6 percent in 2021, the global outlook remains subject to significant downside risks, which include the possibility of large COVID-19 waves in the context of new virus variants. 73. The successful development, production, and delivery of a vaccine has the best potential to reverse these trends, generating benefits that will far exceed vaccine-related costs. Indeed, a rapid and well-targeted and global deployment of a COVID-19 vaccine can help reduce the increases in poverty and accelerate economic recovery. Public health measures, such as distancing, masks, testing and contact tracing, would still need to continue in an effective manner while the supply of vaccines is enough to cover the entire population. Even at levels of imperfect effectiveness, a COVID-19 vaccine that is introduced and deployed effectively to priority populations can assist in significantly reducing mortality and the spread of the coronavirus and accelerating a safe reopening of key sectors that are impacted. It can also reverse Page 40 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) human capital losses by ensuring schools are reopened. The effective administration of a COVID-19 vaccine will also help avoid the associated health care costs for potentially millions of additional cases of infection and associated health-related impoverishment. Global experience with immunization against diseases shows that by avoiding these and other health costs, vaccines are one of the best buys in public health. For the most vulnerable population groups, especially in countries without effective universal health coverage, the potential health-related costs of millions of additional cases of COVID-19 infection in the absence of a vaccine represent a significant or even catastrophic financial impact and risk of impoverishment. The pandemic is also having dire effects on other non-COVID health outcomes. Increased morbidity and mortality due to interruption of essential services associated with COVID-19 containment measures hinder access to care for other health needs of the population, including maternal and childcare services, routine immunization services have been affected, threatening polio eradication and potentially leading to new outbreaks of preventable diseases, with their own related deaths, illnesses and long-term costs. In Cameroon, outpatient visits declined by 3.5 percent, ANC4 consultations fell by 2.4 percent and the coverage of Pentavalent 3 decreased by 2 percent between January 2018 and February 2020 (Shapira et al. 2021). Simultaneous epidemics are overwhelming public health systems in different countries that had few resources to begin with, and services needed to address the needs of people with chronic health conditions, and mental and substance use disorders have been also disrupted. 74. While the uncertainty around the costs and effectiveness of a COVID-19 vaccine make it difficult to calculate its cost-effectiveness, the effective launch of a COVID-19 vaccine will have direct benefits in terms of averted costs of treatment and disability, as well as strengthened health systems. Estimated COVID-19 treatment costs from low- and middle-income countries is at US$50 for a non-severe case and US$300 for a severe case. This excludes costs of testing of negative cases, as well as the medical costs associated with delayed or forgone care-seeking, which usually results in higher costs. The estimated costs of vaccinating 20 percent of the population of Cameroon are at US$94.3 million (two dose regimen); even if the vaccine averts non-severe cases and no other benefits are taken into account, the investment will break even. Further, investments in vaccine delivery systems generate health and economic benefits beyond just delivering the COVID-19 vaccine. First, investments in last-mile delivery systems to administer the COVID-19 vaccine to remote communities will require strengthening community health systems, which can have spillover effects to effective delivery of other services, helping close the significant urban- rural gap. Second, as the COVID-19 vaccine is introduced and lockdowns and movement restrictions are eased, patients can continue to access care for other conditions. Given both the economic and health system benefits, an effectively deployed COVID-19 vaccine presents significant benefits. B. Financial Management 75. The MoPH, through the CTN-PBF, of the parent project and the ongoing HSPRP (P156679) will have overall responsibility for accounting for the AF, expenditures and resources. An FM assessment of the MoPH, working through the CTN-PBF was undertaken to evaluate the adequacy of the existing FM arrangements in the light of the emergency response to be provided to mitigate the impact of the COVID- 19 pandemic. The recent reviews of the agency’s FM arrangements, based on the latest FM supervision mission, concluded that the following persistent weaknesses and uncertainties in the internal control system continue to undermine the sound implementation of the ongoing HSPRP: (i) insufficient justification of expenses leading to potential ineligible expenditures; (ii) delays in preparation of annual budgets, documentation of advances in designated accounts (DA), submission of interim financial reports (IFRs) and audit reports; (iii) qualified opinion on the 2020 annual financial statements due to the absence of accounts analyses and justifications; and (iv) slowness in the implementation of previous Page 41 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) recommendations. The FM performance of HSPRP was therefore assessed as unsatisfactory 27 with a High risk rating as substantiated by the last two FM supervision missions conducted in July and November 2021. The CTN-PBF is taking immediate corrective measures to address these shortcomings under close supervision/hands-on support from the World Bank Team. However, and given the risks, the World Bank will carry an in-depth review of FM and procurement in January 2022. 76. Considering the current capacity constraints of the implementing unit associated with the urgent nature of the activities to be undertaken, which include procurement of specialized health equipment, vaccines and other medical supplies, the assessment has noted that the same constraints and risks identified in the parent project are still applicable. The most important that need specific attention as they could undermine the project ability to reach its development objective in the specified timeline are the following: i. CTN-PBF current FM arrangements, specifically the internal control and flow of funds, are not designed for urgent operations which may lead to delays in the project implementation. ii. Planning and budgeting procedures may be impacted by the uncertainties around the scope of the emergency response due a volatile situation that could jeopardize the ability of the CTN-PBF to effectively manage the project budget. iii. The FM team of the ongoing Health Project may not adequately handle the accounting and reporting requirements due to the increase in workload (parent project and AF) and the urgent nature of the COVID-19 operation. iv. As further highlighted by the findings of the audit of the COVID-19 funds, the implementation of the project under emergency circumstances could lead to funds diversion from the intended purposes as it could be vulnerable to fraudulent or corrupt practices. v. Procurement of vaccines and other medical supplies will likely be handed over to UN agencies. As a result, the reports on the utilization of advances by selected UN agencies may be submitted with delays or may not be sufficiently detailed to provide comfort that the funds have been used for their intended purposes. 77. In addition to the complaint handling mechanism that is being designed and will be used for the project, specific mitigation measures associated with the proposed FM arrangements for the operations will help address these constraints and associated risks. They include the following: i. The POM and FM Manual will be finalized before the AF effectiveness to include planning and budgeting procedures. In addition, there will be no disbursement under Category 2 of the parent project until the POM is adopted. The project FM team will closely monitor the timely identification, approval, and documentation of any deviation/ overrun/ reallocation between project components. The manual will also include specific procedures on strengthening internal controls (see below), and the flow of funds for UN procured parts, and non-UN procured components. ii. CTN-PBF FM team will be reinforced with a dedicated and seasoned accountant. Due to the increase of activities with the AF (total financing of US$73.6 million), the project will hire a finance officer and an internal auditor under competitive selection; both finance officer and internal auditor will be on board before the AF effectiveness. In addition, there will be no disbursement 27 This rating is unrelated to the FM performance of the COVID-19 parent project which is rated Satisfactory as no implementation has begun. Page 42 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) under Category 2 of the parent project until the Recipient has hired both finance officer and internal auditor. The internal audit team will conduct risk-based reviews of the project activities, focusing on the fragility, conflict and violence (FCV) context's most vulnerable areas and components. The team will document reviews in internal audit reports and systematically submit them to the World Bank. The external auditor will assess the robustness of the internal audit function and provide recommendations to strengthen it. iii. Specialized UN agencies (including PEF accredited UN agencies) will be contracted to manage technical urgent project activities (e.g., vaccine purchase under Subcomponent 1.2). In addition, for non-UN related components, the internal controls will be strengthened to include an ex-ante review of the invoice for large contracts by the internal audit team as well as supporting documentation for withdrawal application. iv. The standard form of agreement with the UN agency will include a clear timeline, format, and content for submitting financial reporting on the use of funds consistent with the World Bank's reporting requirements. Specifically, the submission of the reports will align with the IFRs' and will provide sufficient detail to inform the preparation of the project’s IFRs. 78. While the PIU is ringfenced, the Government's COVID-19 funds audit report findings highlight the need for additional measures in the FM arrangements. As a result, the internal audit team will perform ex-ante reviews of invoices for large contracts before the PIU accountant makes payment. The internal audit team will also review withdrawal applications to ensure the request is adequately supported with evidence of eligible expenditures before submission to the World Bank. The PIU will ensure data is available for tracking and auditing purposes and expand the scope of the ToR of the external audit to include additional verification and oversight. 79. The proposed project will be implemented following the scheme that is available for all donor- funded operations in Cameroon whereby the Autonomous Debt Management Fund of Cameroon (Caisse Autonome d’Amortissements, CAA) is in charge of opening and managing the project accounts. In so doing, it will make use of the following disbursement methods: advance, direct payment, reimbursement and special commitment. Justifications for advances and reimbursements will be done on transactions basis (statements of expenditures). UN commitment and UN advances disbursement methods will be available for activities to be implemented by UN Agencies. 80. At the time of preparing the FM assessment and for the reason set forth in subsection 5.2 of the Disbursement Guidelines, the advancing of financing proceeds into a DA is not a Disbursement Method currently available under this Financing. As the foregoing measure is deemed temporary, disbursement arrangements have been designed to include the use of DAs to the extent such use is permitted later during project implementation; provided that the Disbursement and Financial Information Letter (DFIL) will first need to be amended later to reflect such arrangements, if already signed before. 81. Given that the parent operation was processed under situations of urgent need of assistance or capacity constraints, the requirement to use the Direct Payment and/Special commitment disbursement methods for contracts for goods, works, non-consulting services and consulting services procured or selected through international open, or limited competition, or Direct Selection, as set out in the procurement plan will continue to apply to the original financing . Since the AF is not triggering paragraph 12 of Section III of IPF policy, the project can use all four disbursement methods to disburse the AF funds. Advances to the DA, when allowed, will be based on a fixed ceiling to be stated in the Page 43 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) disbursement letter. Subsequent replenishments and documentation of advances will be made monthly using Statements of Expenditures. One DA in CFA francs will be opened in a Financial Institution acceptable to the World Bank and managed by the CAA. Payments to local suppliers and contractors will be made through the DA. As appropriate and following implementation needs, a sub account to the DA could be opened and managed according to procedures approved by the CAA. 82. The CTN-PBF will prepare quarterly unaudited IFRs and provide such reports to the World Bank within 45 days of the end of each calendar quarter. The project will be audited annually by CTN-PBF external auditors with ToR acceptable to the World Bank. As most of the project funds are likely to be advanced to UN agencies, their certified financial statements should clearly indicate the funds received under the project and expenditures incurred. 83. Specific arrangements with UN agencies will be detailed in the standard form of agreement and will reflect the following: 84. Fund flows. Funds will flow from the World Bank to the UN agencies account at the request of the Government using the UN Advance disbursement mechanism (with or without UN commitments) which entails submitting withdrawal applications electronically. They will receive and manage the funds transferred to them under the standard agreement in accordance with their own regulations, rules, instructions, and procedures. 85. Accounting and financial reporting. The UN agencies will establish a separate identifiable Account to record all receipts and disbursements for the purposes of the Agreement under the project. Related General Ledger Account is exclusively subject to the internal and external audit procedures of the United Nations Partners in accordance with the financial regulations and financial rules of the Agency. The financial utilization report (Annex [1] of the UN standard form agreement) generated from the UN agencies’ accounting systems will be submitted on a quarterly basis. Those reports should provide enough detail to explain the use of funds and contain information such as purchased equipment and goods, with detail of quantity and value, cumulative data, funds balance, disbursement plan, etc.). Based on the level of risk assessed during implementation, the project team may consider requesting more detailed financial reports submitted more regularly by the UN agencies. 86. Audit. The auditing arrangements for the contracted UN agencies would follow the single audit principle which represents de facto waiver of the World Bank’s standard audit requirement under IPF operations. Thus, the UN agencies will not be required to submit project-specific audit reports to the World Bank. However, for high fiduciary risk for the UN-implemented component, the team could consider additional assurance mechanisms that will be discussed and agreed with the UN agencies such as, more frequent reporting and supervision, Independent Verification Agent or Third-Party Monitoring. 87. The overall FM residual risk is Substantial as noted above. The project will benefit from an implementation support mission three times a year or at more frequent periodicity if the need arises. The FM implementation support will include field visits, desk-based reviews (review of IFR, UN agencies reports, progress reports prepared by the Borrower), and remote support as needed (via phone, Webex or Skype). 88. Retroactive financing. An amount not exceeding 20 percent of the financing amount (up to EUR 5.3 million with respect to Category (1), and up to with respect to Category (2) will be considered for Page 44 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) eligible expenditures paid between June 1, 2021 and the date of the signing of the financing agreement. In so doing, the MoPH will have to pre-finance those payments for eligible expenditures from their own resources following the World Bank’s procurement and FM policies and procedures. Payments made for retroactive eligible expenditures, will be “reimbursed” upon effectiveness, at the Government request into its own bank account. C. Procurement 89. Procurement for the project will be carried out in accordance with the World Bank’s Procurement Regulations for IPF Borrowers for Goods, Works, Non-Consulting and Consulting Services, dated November 2020. As with the parent project, the 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 project will use the Systematic Tracking of Exchanges in Procurement to plan, record and track procurement transactions. 90. The major planned new procurement in the AF will include: (i) vaccines and the logistics required to deliver to the Cameroon’s port of entry; (ii) additional capacity or refurbishment of national, subnational and facility based and mobile cold chain equipment and supplies including cold rooms, ice lined refrigerators and vaccine carriers; (iii) vehicles including refrigerator vehicles and vaccinator personnel transport; (iv) technical assistance for demand creation – including mass media and communication campaigns; (v) other technical assistance to support in-country implementation including assessments of effective vaccine management capacity and training of front-line delivery workers; and (vi) vaccine logistics and information management systems and information systems to monitor adverse effects from immunization. 91. The current demand for COVID-19 vaccines exceeds the supply in the market which makes it more difficult for client countries to negotiate terms and conditions. Procurement of vaccines will therefore follow Direct Selection. The combination selected by the GoC is: (i) purchase through COVAX – AMC; and (ii) purchase through the AVAT mechanism. Contracts for vaccines purchase financed by the World Bank will be subject to the World Bank’s prior review irrespective of value and procurement approach. The CTN-PBF will contract procurement of vaccines to UNICEF, relying on its technical expertise with COVID-19 vaccine procurement, including integrating indemnity provisions in-line with national regulations. Building on the positive experience with capital equipment and PPE under the parent project and at Borrower request, the World Bank will offer World Bank-facilitated procurement (BFP) as support to Cameroon’s own procurement. 92. Given the need to accelerate delivery and deployment of vaccines to the country, it was agreed that the Borrower will prepare the Project Procurement Strategy for Development document within three (3) months of the project implementation phase. The Borrower has already prepared an initial procurement plan which will determine the procurement approach for the emergency procurements during the first six (6) months of project implementation period. This simplified procurement plan was approved by the World Bank before project negotiations. The project will use the operational manual that is already adopted for the HSPR Project, which will be updated no later than one month after project approval, to include specific guidelines and procedures for the proposed project, and the national adopted texts simplifying procurement processes during COVID-19 pandemic. Page 45 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 93. The proposed procurement approach prioritizes fast track emergency procurement for the required emergency goods, works and services, particularly for the prevention phase and the relief phase. In this regards, key measures to fast-track procurement include the following measures: • Direct Contracting and/or Limited Competition with identified manufacturers, suppliers and providers for most of the items; • UN agencies and non-governmental organizations (NGOs) will be used for speeding responses and any other fit for purpose methods that the Accredited Procurement Specialist approves in the procurement plan; • Other measures like shorter bidding time, no bid security, advance payments, direct payments, will be applied on a case-by-case basis upon advice/guidance from the Accredited Procurement Specialist; • Conducting post reviews. 94. The procurement approach for the other non-vaccine procurement may include: (i) streamlined competitive procedures with shorter bidding time; (ii) use of framework agreements including existing ones; (iii) procurement from UNICEF enabled and expedited by World Bank procedures and standard agreements; and (iv) increased thresholds for Requests for Quotations and national procurement, and Direct Selection. The World Bank’s Standard Procurement Documents for Procurement under COVID-19 Emergency Operations shall be used. Recognizing the significant disruptions in the usual supply chains for medical consumables and equipment, the World Bank will provide technical assistance, at the Borrower’s request, to assist them in accessing existing supply chains. 95. Any contracts concluded with the UN will follow the standard forms of agreement agreed and applicable to those agencies and contract types. A Standard Agreement shall be signed between the Government and the UNICEF that will clearly indicate the level of involvement and the specific role of the agency under the project. The agreement shall contain specific annexes on the payment schedule and reporting requirements by the UN. Therefore, the fiduciary arrangements pertaining to contracting of the UNICEF will follow the agreed upon arrangements that will be included as part of the Standard Agreement to be signed between the Government and the UNICEF. 96. Procurement capacity and risk assessment. The summary of the procurement assessment is given below: • Staff from implementing agency involved in the project may not have enough knowledge of the New Procurement Framework (NPF) and/or may confuse the NPF with the former Procurement and Consultant Guidelines or with the national procurement regulations; • The number of procurement staff within implementing agency that have the required experience to implement procurement actions effectively, on time, and in line with World Bank’s policies and procedures is insufficient; • Administrative routines may result in procurement delays with the potential to affect project implementation; • Limited capacity in conducting emergency procurement; • Insufficient overall capacity may lead to poor contract management and administration of big contracts; • The overall procurement risk is “Substantial”. It will be mitigated by (i) intensive hands- on support all through procurement steps, on use of World Bank new procurement framework and on emergency procurement; (ii) mobilization of upstream potential Page 46 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) suppliers, putting in place measures for supplier preferences like direct payments by the World Bank, advance payments when needed; and (iii) prior review of all vaccines contracts. • To minimize unnecessary delays in the acquisition of specialized and urgent goods in needs, Specialized UN agencies will be contracted by the implementing agency using the Standard Form of Agreement, to procuring critical medical equipment, PPE, and laboratory equipment as well as to providing training of health care workers. 97. All procurement under the project will be undertaken by the CTN-PBF. However, the mandate of the special tender board of the HSPRP need to be extended to include responsibility for overseeing the review of procurement documentation related to the project. Given the limited capacity of this unit and the urgent requirements and specific arrangements, it has been agreed that MoPH will nominate an experienced staff to support the procurement officer of the CTN-PBF. In addition, and as requested by the Borrower, the World Bank will provide procurement HEIS to help expedite all stages of procurement – from help with supplier identification, to support for bidding/selection and/or negotiations to contract signing and monitoring of implementation. This could include periodic site visits to spot check the availability and performance of medical equipment and other critical supplies at various health facilities. 98. World Bank procurement accredited staff/consultants will provide support to the implementation unit during all emergency procurement stages. The project may be significantly constrained in purchasing critically needed supplies and materials due to significant disruption in the supply chain, especially for PPE. The supply problems that have initially impacted PPE are emerging for other medical products (e.g., reagents and possibly oxygen) and more complex equipment (e.g., ventilators) where manufacturing capacity is being fully allocated by rapid orders from other countries. 99. Upon the Borrower’s request, and in addition to the above procurement approach options, the World Bank has agreed, as part of its HEIS, to provide BFP, to proactively assist the implementing agency(ies) in accessing existing supply chains for the agreed list of critical medical consumables and equipment needed under the project. Once the suppliers are identified, the World Bank will proactively support the Borrower with negotiating prices and other contract conditions. The Borrower will remain legally responsible for signing, entering into and implementation of contracts, including assuring relevant logistics with suppliers such as arranging the necessary freight/shipment of the goods to their destination, receiving and inspecting the goods and paying the suppliers, with the World Bank direct payment disbursement option available to them. If needed, the World Bank may also provide HEIS in contracting to outsource logistics. 100. BFP to access available supplies may include aggregating demand across participating countries, whenever possible, extensive market engagement to identify suppliers from the private sector and UN Agencies. The World Bank is coordinating closely with the WHO and other UN agencies (specifically UNICEF) that have established systems for procuring medical supplies and charge a fee which varies across agencies and type of service and can be negotiated (around 5 percent on average). In addition, the World Bank may help Borrowers access governments’ available stock. 101. In providing BFP, as part of HEIS, the World Bank will remain within its operational boundaries and mandate of providing project implementation support, and not engaging in project implementation, all to support the Borrower to achieve the PDOs. Procurement for good, works and services outside this Page 47 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) list will follow the World Bank’s standard procurement arrangements (which may include traditional, non- BFP, HEIS) with the Borrower responsible for all procurement steps. 102. The risks identified in this area include the Borrower’s limited knowledge of the World Bank’s New Procurement Framework, the lack of realistic planning and weak contract management capacity including insufficient involvement of civil servants in procurement process, from the identification of project needs to plan contract award and contract management. The risk estimated as high will be mitigated by the mitigation measures summarized below, notably the BFP with HEIS. The residual risk is therefore evaluated as Moderate. Table 7. Major Procurement Risks and Proposed Mitigation Measures Risks Mitigation Measures Limited capacity to conduct CTN-PBF will maintain staff with the appropriate capacity dedicated to the COVID- emergency procurement. 19 response. World Bank has agreed to provide HEIS and BFP to proactively assist the implementing agency(ies) in accessing existing supply chains for the agreed list of critical medical consumables and equipment Managing fraud and corruption Ex ante due diligence of firms being selected will be attempted using databases and noncompliance. available in country and externally. Post review of contracts will be scheduled immediately on award of contracts for all contracts that would have been usually prior reviewed. Capacity of the market and Proposed mobilization of existing service providers, with use of framework supply chain to meet the agreements including existing ones/ amendments of existing contracts to address demand. the emergency medical service requirements. Measures for supplier preferences like direct payments by World Bank, advance payments, etc. will be applied on need basis. . D. Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . E. Environmental and Social 103. Activities introduced by the project restructuring and AF will have positive E&S impacts as they should improve COVID-19 surveillance, monitoring, containment and response in accordance with WHO and Good International Industry Practice, as well as prepare the country for future health emergencies. However, they could also cause substantial adverse environmental, health and safety impacts due to the dangerous and potentially infectious nature of the pathogen, chemicals, vaccines and other materials to be used in the project-supported laboratories and health facilities, as well as the associated waste materials. Multiple disadvantaged or other vulnerable groups stand to benefit, starting with the elderly and those with compromised immune systems due to pre-existing conditions. 104. The parent project has not been implemented, therefore the AF cannot rely on lessons learnt from the implementation of a COVID-19 vaccine project. However, the client can rely on an extensive Page 48 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) experience in the implementation of nationwide vaccination campaigns for the control of other illnesses. The overall project activities will seek to ensure inclusion of these groups. The identification of target groups (phase 1) that will receive vaccination based on the WHO recommendations has been achieved. COVID-19 vaccine social mobilization, risk and crisis communication strategy and routine surveys to track knowledge and attitudes has been initiated. Specific risks linked to vaccination campaigns, include: (i) risk that project-related impacts fall disproportionately on individuals or groups who, because of their circumstances, may be disadvantaged or vulnerable; (ii) the risk of inequal access to vaccination. It is anticipated that population will not have equal access to the vaccine program. Discrimination towards individuals or groups in providing access to development resources and project benefits, particularly in the case of those who may be disadvantaged or vulnerable, including risks related to SEA and SH; and (iii) risk related to vaccine hesitancy. 105. This hesitancy can lead to a low uptake among Cameroon population to the vaccine component of the project. World Bank does not endorse nor support mandatory vaccination. A draft roadmap has been prepared to boost vaccination. One of the actions of this roadmap was for GoC to define a series of measures to incentivize the vaccination. Low vaccine uptake will be mitigated through the following measures: first, the Government has developed explicit, contextually appropriate, and well communicated criteria for access to vaccines. There is consensus to first target heath workers, other essential workers, and the most vulnerable populations, which will include a mix of the elderly and people with co-morbidities. All targeting criteria and implementation plans are reflected in the NDVP. Second, the Government will actively use the National COVID Risk Communication and Community Engagement strategy to address misinformation and distrust as a main barrier to vaccination. In addition, risk mitigation measures be outlined in a SEA/SH Prevention and Response Action Plan, which will incorporate an accountability and response framework, including codes of conduct to be signed by all individuals engaged in the project activities (including if possible MoPH relevant partners, healthcare workers staff, and all suppliers linked to the execution of project activities) outlining prohibited conduct and applicable sanctions, procedural adaptations to the project grievance mechanism to ensure safe and confidential management of SEA/SH claims with timely referrals to appropriate survivor care, as well as training and sensitization activities. In addition, SEA/SH risk will be addressed through robust stakeholder identification and consultation processes, which will take into specific account consultation with women and other vulnerable groups in safe and enabling, sex-segregated environments (including with same-sex facilitators). 106. Under the parent project design, an ESMF, HCWMP, LMP have been prepared and disclosed28 as agreed after effectiveness. The SEP, which has been updated in November 2021 and disclosed on December 15, 2021, identifies the presence of disadvantaged and vulnerable groups, such as older population segments, and isolated communities. The community engagement activities proposed under Component 3 will seek to ensure the inclusion of these groups. In terms of the prioritization of the population groups that will receive vaccination first, the WHO’s Fair Allocation Framework guidance will be followed, as well as the National Risk Communication and Community Engagement Strategy for outreach and consultation. 107. The ESMF includes (i) specific guidance on the selection of priority population groups to be vaccinated and monitoring of adverse health effects from vaccination are included in accordance with 28 https://www.minsante.cm/site/?q=en/content/cadre-de-gestion-environnemental-et-social-ou-environmental-and-social- management-framework. Page 49 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) emerging WHO guidance, in addition to guidance on mitigation measures to address SEA/SH risk in the context of project activities; and (ii) measures to ensure the quality of vaccines is maintained throughout the supply chain in accordance with WHO guidance for storage and transportation of vaccines. The mitigation measures are largely based on the WHO technical guidelines on COVID-19 response, the EHS guidelines of the World Bank Group and other IPMIs (International Performance Management Institutes), with the responsibilities within the MoPH, the required trainings, implementation schedule and budget. In addition, an ICWMP to safeguard health care workers, patients and the larger community from transmission and infection by the COVID-19 virus as the result of their daily routines that include testing, quarantining and treating patients and managing the safe disposal of the resulting medical waste has been prepared as an annex of ESMF. The ESMF adequately covers E&S infection control measures and procedures for the safe handling, storage, and processing of COVID-19 materials including techniques for preventing, minimizing, and controlling E&S impacts during the operation of project supported laboratories and medical facilities. 108. Ensure equitable access to services for vulnerable people. The vulnerability of a group of people may be due to race, ethnic or social origin, color, sex, language, religion, political or other beliefs, age, education, illness, physical or mental disability, and poverty or economic insecurity. There is a risk that vaccine roll-out plans may leave these individuals behind, given their physical and moral circumstances. They may be disproportionately affected by the project. As outlined in the Project Paper, this risk will be attenuated by community engagement activities, information sharing, stakeholders’ consultations with vulnerable populations (organizations of people with disabilities, economically vulnerable people) and other targeted activities contained in the SEP. 109. Citizen engagement and outreach. The MoPH will also use the parent project’s stakeholder engagement mechanism to ensure access to public information while updating it to include more information on the E&S risks of the project activities and new modalities that take into account the need for social distancing. The SEP also helps identify stakeholders and beneficiaries that will provide CE feedback throughout the project implementation. An updated GRM for addressing any concerns and grievances raised regarding vaccinations will be implemented providing access to submit complaints and procedures for timely resolutions. In addition to the GRM, the project will conduct periodic consultations and will use beneficiary feedback to inform project intervention and any necessary course correction. 110. The community engagement approach is detailed in the national COVID-19 vaccine deployment plan and focuses on demand generation in communities through periodic consultations, clarifying target groups and removing misconceptions related to vaccinations while ensuring a community feedback loop. The community engagement plan’s main objectives are: (i) building trust and awareness on COVID -19 vaccines through use of different channels and a social mobilization approach; (ii) using data and evidence to dispel rumors and public misperceptions; (iii) development and provision of context specific Information Education and Communication/ behavior change and communication materials to targeted priority groups; (iv) training journalists about COVID-19 vaccine and its importance for safety and wellbeing of the public; and (v) promoting the COVID-19 vaccine through social media and mass media campaigns. Community engagement in health facility management will be monitored. To ensure that the Project develops an accurate, effective behavior change communication strategy a detailed baseline quantitative and qualitative survey will done at the beginning of the Implementation phase. This will allow the Project to monitor progress and message efficiency. Page 50 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 111. In line with WHO Interim Guidance (February 12, 2020) on “Laboratory Biosafety Guidance related to the novel coronavirus (2019-nCoV)”, and other guidelines, the Waste Management Plan and ESMF for the Project consider WHO standards on COVID-19 response. The plan includes training of staff to be aware of all hazards they might encounter. This provides for the application of international best practices in COVID-19 diagnostic testing and handling the medical supplies, disposing of the generated waste, and road safety. 112. In terms of modalities for handling personal data, as risk mitigation measures, personal data will be collected and used only for necessary and intended proposes to ensure data accuracy without unnecessary correction or deletion and ensure the confidentiality and anonymity of personal data when stored. When formative research is planned, the Ethics Review Committee reviews and ensures the use of written consent forms to be filled by study participants. The project implementation manual will design a section on modalities for handling personal data. For now, personal data are kept in registers designed for COVID-19 vaccination and only aggregate data are transmitted for up-scale reporting. F. Climate co-benefits 113. Climate change risks and vulnerabilities. The parent project and AF have been screened for short and long-term climate change and disaster risks and the exposure risk is High. This includes exposure to extreme temperatures, extreme precipitation, droughts, and strong winds. This exposure risk is assessed at this level for both the current and future timescales. Given its geographical location, topographical and geological conditions, Cameroon is one of the most vulnerable countries in the world that are exposed to the adverse risks of natural disasters, climate change and disease outbreaks. The increasing temperatures, changes in rainfall pattern, and desertification in the country is leading to food insecurity and scarcity of resources, which has implications on the nutritional status of the population including the lack of water availability. Moreover, climate change is also exacerbating conflict, deepening poverty, and disrupting traditional means of survival (i.e., farming and herding). Extreme rainfall in the region has also produced more flooding, which may increase vector- and water-borne diseases and can impact the structural integrity of health facilities. Dust storms and other strong wind events are becoming commonplace in Cameroon, which can contaminate water supplies and cause power outage leading to food storage issues increasing the risk of foodborne and waterborne diseases. Moreover, dust storms can increase exacerbations of asthma and other respiratory diseases in vulnerable populations. 114. The parent project addresses the above-described climate vulnerabilities and assists the GoC in climate adaptation and mitigation activities. The proposed AF is exclusively financing vaccine acquisition via IDA financing and support for EHS via the GFF and therefore, no climate co-benefits (CCBs) are expected for the AF. Under Component 1: Emergency COVID-19 Response, the COVID-19 vaccine acquisition will consume US$29.6 million. This includes the costs of the COVID-19 vaccines, international freight, procurement fees to UNICEF. While no direct climate financing is expected to be assigned at this time to any of these investments, it is expected that some suppliers are taking active steps to ensure climate resilient considerations are taken into account during the manufacturing, shipment and distribution stages of the vaccines. The World Bank team, together with UNICEF, WHO, GAVI and the AVAT will continue to explore these areas in order to provide latest information on any specific climate adaptation and mitigation actions taken with regard to the vaccines. Page 51 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) G. Gender Gender gap analysis and identification 115. Despite Cameroon’s progress in advancing gender equity, several gaps persist. The country has a Human Development Index value of 0.563, ranking it 153 out of 189 countries and territories.29 Further, the country's Gender Development Index is 0.864 (United Nations Development Programme Country Profile 2019), indicating considerable inequities between women and men with regards to basic dimensions of human development Specifically, the mean years of schooling amongst women in Cameroon is 4.7, almost half of the mean for men (8).30 Estimated gross national income per capita is also almost half for women when compared to men (2,973 PPP/US$ for women vs 4,189 PPP/US$ for men). Cameroon, 27.1 percent of parliamentary seats are held by women, while 39 percent of the national population lives below the poverty line, this rate rises to 51.5 percent for women, and 79.2 percent of them are underemployed. Women make up 71.6 percent of workers in the informal agricultural sector and 32.5 percent of women over 25 have some level of secondary education (39.2 percent for men). Boys have a privileged access to education with a gross enrollment rate is 125 percent in primary school (110 percent for girls) and 65 percent are enrolled in secondary school (53 percent for girls). On average, every Cameroonian woman gives birth to 5.1 children, with a maternal mortality rate of 782 per 100,000 live births. The impact of COVID-19 is likely to exacerbate these inequities. As such, the Project will consider specific activities to mitigate the health and socioeconomic impacts of COVID-19 on women in Cameroon by ensuring vaccine deployment plans and strategies that are gender responsive and mindful of gender- related barriers to immunization. 116. Evidence from previous infectious disease outbreaks indicates that men and women are often differentially affected, with women impacted more negatively than men. The effects of COVID-19 will likely exacerbate pre-existing gender differences. Gender gaps are affected differently depending on the context and specific characteristics of different groups of women. Some women may not be reached by relevant information on the pandemic due to their more limited access to mobile phones or other devices or their constrained ability to leave their house. Gender norms that restrict women’s mobility, working outside of the home, or others might be exacerbated due to confinement measures and the increased burden of care. There is also a risk that vaccine deployment plans could leave women behind, considering the larger male mortality of COVID-19 and the tendency in many countries to overlook the importance of gender inequalities in social and economic activity. Currently there is limited epidemiological data disaggregated by sex for key indicators related to infection, morbidity, mortality and even vaccination coverage. This hampers the ability to quantify and understand the real impact of COVID-19 on women. 117. For women in Cameroon, access to health care is not without constraints. COVID-19 restrictions have exacerbated these constraints and negatively impacted access and uptake of primary healthcare services that hinder on women’s reproductive health, as evidenced earlier in the paper (see paragraph 10). This raises legitimate concerns over women’s barriers to access testing and to vaccines. For those women who have access to health care facilities, they may feel more comfortable to only engage with female health workers. This becomes a problem that is difficult to overcome given the shortage of female health workers in the health care system. 29 UNDP, Human Development Report 2020. 30 UNDP, Gender Development Index 2019. Page 52 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Measures to close some of the gaps identified 118. The project will encourage collection and reporting on key gender-disaggregated indicators to address existing knowledge gaps, particularly related to the percentage of women that are vaccinated. This is achieved by ensuring that the PDO Indicator 1 (percentage of target population vaccinated) is provided for females, which will require routine data collection systems to capture and report this. Further, the project will advocate and support the disaggregation by sex of key indicators related to cases and mortality in the regular official Situational Reports. 119. The project will consider women’s access barriers to information (including preventive information for COVID-19 as a disease, COVID-19 vaccines and routine primary health care services). This will be addressed through different activities and strategies. With regards to information and messaging, the project will ensure gender sensitive, contextualized and accurate information about COVID-19, accounting for differences in literacy rates amongst women and men. In terms of communication channels, the Project will ensure the dissemination of messages through a variety of channels catering for women with different literacy levels and ownership of assets by using campaigns through social media, radio and other toll-free helplines. Furthermore, the Project will support the mobilization and training of female community health workers (CHW) will engage face-to-face with women. These figures are key to reach rural women with through trusted figures in the community with reliable and accurate information about routine services, whilst also promoting preventive COVID-19 practices and providing information about the vaccine and its availability at established vaccination centers/health facilities. Female CHW will also play a key role in managing misinformation regarding COVID-19 vaccination and other concerns related to women’s sexual and reproductive health that may emerge during the roll-out and deployment. 120. In addition, the Project will require that teams of vaccinators at the established centers have a balanced representation of women. A minimum percentage of female health care workers (vaccinators) per site will be agreed for each of the vaccination centers, so that favorable conditions are in place for women to access centers and comfortably engage with providers. The percentage of female vaccinators will be monitored and reported under the project as an intermediary indicator. 121. Finally, by engaging female community health workers and female health workers and ensuring agender sensitive communication and information sharing approaches, the Project will mitigate the risk of sextual exploitation, harassment and abuse as well as addressing social/cultural barriers to women’s access to information and access to vaccine. The Project will ensure that all the vaccine centers have measures in place to promote gender friendly environment and enhance women and girls’ safety. These include separate rooms/vaccine area for female, having at least one female staff in place, Code of Conduct for all the staff, and ensuring that GRMs are accessible by female beneficiaries. Further, female health workers trained in vaccine deployment will be trained for the prevention of SEA/SH. V. WORLD BANK GRIEVANCE REDRESS 122. Communities and individuals who believe that they are adversely affected by a World Bank- supported project may submit complaints to existing project-level GRMs or the World Bank’s Grievance Redress Service (GRS). 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, Page 53 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) 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 World Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate 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. 123. GRM. The project incorporates a comprehensive GRM which will enable a broad range of stakeholders to channel concerns, questions, and complaints to the various implementation agencies and COVID-19 Call centers. The project supports the COVID-19 Call Centers with toll-free numbers. These numbers have been publicly disclosed throughout the country in the broadcast and print media. The GRM will be equipped to handle cases of SEA/SH, as rapid guidance on how to respond to these cases will be developed and shared with operators. This will follow a survivor-centered approach The GRM will continue to be publicized by the MoPH and other relevant agencies. Page 54 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Page 55 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) VI SUMMARY TABLE OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Implementing Agency ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Legal Covenants ✔ Financial Management ✔ Procurement ✔ Other Change(s) ✔ VII DETAILED CHANGE(S) Page 56 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) MPA PROGRAM DEVELOPMENT OBJECTIVE Current MPA Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Proposed New MPA Program Development Objective EXPECTED MPA PROGRAM RESULTS Current Expected MPA Results and their Indicators for the MPA Program Progress towards the achievement of the PDO would be measured by outcome indicators. Individual country- specific projects (or phases) under the MPA Program will identify relevant indicators, including among others: • Country has activated their public health Emergency Operations Centre or a coordination mechanism for COVID-19; • Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents; • Number of acute healthcare facilities with isolation capacity; • Number of suspected cases of COVID-19 reported and investigated per approved protocol; • Number of diagnosed cases treated per approved protocol; • Personal and community non-pharmaceutical interventions adopted by the country (e.g., installation of handwashing facilities, provision of supplies and behavior change campaigns, continuity of water and sanitation service provision in public facilities and households, schools closures, telework and remote meetings, reduce/cancel mass gatherings); Page 57 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) • Policies, regulations, guidelines, or other relevant government strategic documents incorporating a multi- sectoral health approach developed/or revised and adopted; • Multi-sectoral operationalmechanism for coordinated response to outbreaks by human, animal and wildlife sectors in place; • Coordinated surveillance systemsin place in the animal health and public health sectors for zoonotic diseases/pathogens identified as joint priorities; and • Mechanisms for responding to infectious and potential zoonotic diseases established and functional; and • Outbreak/pandemic emergency risk communication plan and activities developed and tested Proposed Expected MPA Results and their Indicators for the MPA Program COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Emergency COVID-19 20.50 Revised Emergency COVID-19 63.10 Response Response Supporting National and 5.00 Revised Supporting National and 2.00 Sub-National Prevention Sub-National Prevention and Preparedness and Preparedness Community Engagement 2.00 Revised Community Engagement 3.00 and Risk Communication and Risk Communication Implementation 1.50 Revised Implementation 5.50 Management and Management and Monitoring & Evaluation Monitoring & Evaluation Page 58 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) TOTAL 29.00 73.60 LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline Closing(s) Closing for Withdrawal Applications IDA-67830 Effective 30-Jun-2022 30-Jun-2022 28-Jun-2024 28-Oct-2024 Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2020 0.00 0.00 2021 0.00 0.00 2022 25,000,000.00 25,000,000.00 2023 20,000,000.00 45,000,000.00 2024 20,000,000.00 65,000,000.00 2025 8,600,000.00 73,600,000.00 SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance ⚫ Substantial ⚫ Substantial Macroeconomic ⚫ Moderate ⚫ Substantial Sector Strategies and Policies ⚫ Moderate ⚫ Moderate Page 59 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Technical Design of Project or Program ⚫ Moderate ⚫ Moderate Institutional Capacity for Implementation and ⚫ Substantial ⚫ High Sustainability Fiduciary ⚫ Substantial ⚫ Substantial Environment and Social ⚫ Substantial ⚫ Substantial Stakeholders ⚫ Substantial ⚫ Substantial Other ⚫ Substantial ⚫ Substantial Overall ⚫ Substantial ⚫ High LEGAL COVENANTS2 LEGAL COVENANTS – Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Sections and Description AF FA, Schedule 2, Section I, B, 2: Without limitation on Section I.B.1 above, in order to ensure adequate implementation of Part 1.2 of the Project, the Recipient shall, by no later than thirty (30) days after the Effective Date, prepare and adopt, a manual for the Project COVID-19 Vaccine delivery and distribution (“Vaccine Delivery and Distribution Manual”), in form and substance satisfactory to the Association AF FA, Schedule 2, Section I, 6, (a) on work plan and budget: by no later than one (1) month after the Effective Date, prepare a draft work plan and budget for Project implementation, setting forth, inter alia: (i) a detailed description of the planned activities, including any proposed conferences and Training, under the Project for the period covered by the plan; (ii) the sources and proposed use of funds therefor; (iii) procurement and environmental and social safeguards arrangements therefor, as applicable and; (iv) responsibility for the execution of said Project activities, budgets, start and completion dates, outputs and monitoring indicators to track progress of each activity. Per ESCP a comprehensive training plan shall be prepared not later than 60 days after the effective date. Page 60 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Conditions Type Financing source Description Effectiveness Trust Funds GFF Agreement, Article IV, 4.01(a): The execution and delivery of this Agreement on behalf of the Recipient has been duly authorized or ratified by all necessary governmental action. Type Financing source Description Effectiveness Trust Funds GFF Agreement, Article IV, 4.01(b): The IDA Financing Agreement has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Recipient to make withdrawals under it (other than the effectiveness of this Agreement) have been fulfilled. Type Financing source Description Effectiveness IBRD/IDA AF FA, Article IV, 4.01(a): The Project Operation Manual and the Project FM Manual has been updated and adopted in form and substance satisfactory to the Association. Type Financing source Description Effectiveness IBRD/IDA AF FA Article IV, 4.01(b): The Recipient has hired a finance officer, an internal auditor, and a safeguard specialist in accordance with Section I.A.2 of Schedule 2 to this Agreement, each with qualifications, integrity and under terms of reference satisfactory to the Association. Type Financing source Description Disbursement IBRD/IDA Schedule 2, Section III, B, 1 (b) – No withdrawal shall be made under Category (1) and (2), for delivery or distribution of Project COVID-19 Vaccines under Part 1.2 and 1.3 of the Project, unless and until the Vaccine Page 61 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Delivery and Distribution Manual, in form and substance acceptable to the Association, has been duly adopted in accordance with Section I.B.2 of Schedule 2 to the Financing Agreement. Page 62 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Cameroon RESULT_NO_PDO Additional Financing for Cameroon COVID-19 Preparedness and Response Project Project Development Objective(s) To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in selected regions in Cameroon. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems Number of COVID-19 designated healthcare facilities with 400.00 3,000.00 appropriate handwashing facilities in place (Number) Action: This indicator has been Marked for Deletion Priority population vaccinated against COVID-19, based on targets defined in the national plan (proportion of females) 5.70 40.00 (Percentage) Action: This indicator is New Females (Percentage) 36.00 49.00 Action: This indicator is New Designated laboratories supported with personnel, equipment, test kits and reagents (Number) 0.00 16.00 Page 63 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target Action: This indicator is New Births assisted by skilled health personnel in the 3 Northern regions (Adamawa, North, Extreme North) and East region 178,282.00 285,600.00 (Number) Action: This indicator is New To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems (Action: This Objective has been Marked for Deletion) Percentage of contacts followed for all 14 days (Percentage) 70.00 80.00 Action: This indicator has been Marked for Deletion To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems (Action: This Objective has been Marked for Deletion) Number of acute healthcare facilities with isolation capacity 50.00 250.00 (Number) Action: This indicator has been Marked for Deletion •To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems (Action: This Objective has been Marked for Deletion) Number of COVID-19 designated healthcare facilities with required equipment for treatment of critica (Number) 50.00 250.00 Action: This indicator has been Marked for Deletion PDO Table SPACE Page 64 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Emergency COVID-19 Response Health facilities with a COVID-19 case management unit 91.00 200.00 (Number) Action: This indicator has been Revised Number of households provided with food and basic supplies within quarantined populations (Number) 0.00 10,000.00 Action: This indicator has been Marked for Deletion Health staff trained in COVID-19 vaccination deployment 4,548.00 9,000.00 (Number) Action: This indicator is New Female health staff trained in COVID-19 vaccination (Number) 2,106.00 4,400.00 Rationale: Sex disaggregation of the parent indicator: Number of health staff trained in COVID-19 vaccination deployment. Target is Action: This indicator is New based on the expected number of teams made up of 2 people for the planned vaccination centres (details in the parent indicator) Doses of eligible COVID-19 vaccines procured (Number) 0.00 3,500,000.00 Action: This indicator is New Supporting National and Sub-national, Prevention and Preparedness Laboratories awarded with 3 stars or above based on the Stepwise Laboratory Quality Improvement Process Towards 0.00 16.00 Accreditation (SLIPTA) audits (Number) Page 65 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Action: This indicator has been Revised Community Engagement and Risk-Communication Number of households reached with tailored information 0.00 10,000.00 (Number) Action: This indicator has been Marked for Deletion Radio stations and TV channels broadcasting COVID-19 147.00 300.00 vaccination information in official and local languages (Number) Action: This indicator is New Grievances addressed according to the project's GRM timeframe 0.00 80.00 and procedures (Percentage) Action: This indicator is New Community health workers trained to delivery key messages to promote demand for COVID-19 vaccines and other essential 25.00 75.00 health services (Number) Action: This indicator is New Female community health workers (Number) 0.00 49.00 Action: This indicator is New Implementation Management and Monitoring and Evaluation M&E system established to monitor COVID-19 preparedness and No Yes response plan (Yes/No) Action: This indicator has been Marked for Deletion Page 66 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Routine monitoring of essential health services regional reports 0.00 36.00 reviewed quarterly by the MoPH (Number) Action: This indicator is New IO Table SPACE Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Number of COVID-19 Designated Number of COVID-19 designated designated healthcare Quarterly health Self-assessment MoPH healthcare facilities with appropriate facilities with appropriate facilities handwashing facilities in place hand-washing facilities in place Numerator: Number of people who have received at least one dose of COVID- 19 vaccine through financing to vaccine Priority population vaccinated against acquisition or deployment . Reports shared by the Quarterly DHIS2 MoPH COVID-19, based on targets defined in the Denominator: Number of PEV national plan (proportion of females) target population (Aged 18 or above) as per national plan. Numerator and denominator are also provided for women for the sub-indicator. Quarterly DHIS2 Reports shared by PEV MoPH Females Page 67 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Number of laboratories benefitting from project Designated laboratories supported with Reports prepared my funds to train Quarterly Self reported MoPH personnel, equipment, test kits and DLMP existing/additional reagents personnel, purchase equipment, reagents or kits DHIS2. Targets have been estimated Number of births assisted using an by trained health personnel agreed Births assisted by skilled health personnel in the three northern Reports prepared by Quarterly methodology MoPH in the 3 Northern regions (Adamawa, regions of Cameroon PLMI reflected in a North, Extreme North) and East region (Adamawa, North and Far technical note North) and in the East with PLMI in region December 2021 Numerator: the number of contacts that are called daily for symptoms reporting and follow-up during the whole period of Percentage of contacts followed for all 14 their quarantine (14 days) Quarterly MoPH Self assessment MoPH days Denominator: the number of all contacts to be followed-up (meeting the definition of contact), in a period time of 14 days. Number of acute healthcare facilities with Number of acute health Quarterly MoPH/PHEOC Self assessment MoPH isolation capacity care facilities with isolation Page 68 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) room/ beds. Number of COVID-19 designated healthcare facilities with the required equipment below: Number of COVID-19 designated Pulse Oximeter Quaterly MoPH Self assessment MoPH healthcare facilities with required Volumetric pumps equipment for treatment of critica Ventilators for treatment of critical patients as per approved national protocol ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Database from the Centre de Number of health facilities Coordination MoPH, DLMP Health facilities with a COVID-19 case Quarterly Self-assessment with a COVID-19 case des Urgences management unit management unit de santé Publique (CCOUSP) Number of households Administrative Number of households provided with provided with food and data Self-assessment MoPH/MINEPAT food and basic supplies within basic supplies within Quarterly quarantined populations quarantined populations in affected communes Page 69 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Number of trained health personnel in COVID019 vaccination deployment following MoPH-approved protocols. Target is based Health staff trained in COVID-19 Quarterly MoPH Self-reports MoPH on the assumption that vaccination deployment there will be appeximately 4,500 teams of 2 people for each team working with the planned vaccination centres (1946 centres) Female health staff trained in COVID- 19 vaccination Number of doses of eligible Doses of eligible COVID-19 vaccines Quarterly MoPH Reports MoPH COVID-19 vaccines procured procured Number of laboratories awarded three stars or above by the Stepwise Laboratories awarded with 3 stars or Laboratory Quality Quarterly above based on the Stepwise Laboratory MoPH Reports from LNSP MoPH Improvement Process Quality Improvement Process Towards Towards Accreditation Accreditation (SLIPTA) audits (SLIPTA) based on on-site audits by qualified personnel Number of households reached with tailored Administrative Number of households reached with information regarding Quarterly Self-assessment MoPH/MINEPAT data tailored information COVI19 mitigation strategies including social distancing measures Radio stations and TV channels Number of radio stations Quarterly MoPH CREC reports MoPH Page 70 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) broadcasting COVID-19 vaccination and TV channels information in official and local languages broadcasting COVID-19 vaccination information in official and local languages Proportion of grievances Grievances addressed according to the received that have been Quarterly MoPH Self-Assessment MoPH project's GRM timeframe and procedures addressed through the GRM sequential process Percentage of community health workers trained to Community health workers trained to delivery key messages to delivery key messages to promote Quarterly MoPH Reports MoPH promote demand for demand for COVID-19 vaccines and other COVID-19 vaccines and essential health services other essential health services Quarterly MoPH Reports MoPH Female community health workers Whether an M&E plan have M&E system established to monitor been established in country Quaterly MoPH Self assessment MoPH COVID-19 preparedness and response to monitor COVID19 plan preparedness and response plan Evidence (reports) from Number of routine the quarterly monitoring reports Routine monitoring of essential health reviews of produced by the 4 regions Quarterly Reports from PLMI PLMI services regional reports reviewed regional on a quarterly basis ( quarterly by the MoPH reports North, Extreme North, performed by Adamaoua, East) MoPH Page 71 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) ME IO Table SPACE Page 72 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Annex 1 – List of Covid vaccines meeting World Bank Approval Criteria as of December 20, 2021 Vaccine SRA Emergency Use Approval WHO PQ/EUL31 BNT162b2/COMIRNATY United Kingdom (UK): December 2, 2020 WHO EUL: December 31, Tozinameran (INN) - Canada: December 9, 2020 2020 Pfizer BioNTech USA: December 11, 2020 European Union: December 21, 2020 Switzerland: December 19, 2020 Australia: January 25, 2021 mRNA-1273 - Moderna USA: December 18, 2020 WHO EUL: April 20, 2021 Canada: December 23, 2020 EU: January 6, 2021 UK: January 8, 2021 Switzerland: January 12, 2021 AZD1222 (also known UK: December 30, 2020 WHO EUL: February 15, as ChAdOx1_nCoV19/ EU: January 29, 2021 2021 for vaccines commercialized as Australia: February 16th, 2021 (overseas manufactured by SK Bio COVISHIELD in India) - manufacturing); March 21, 2021 (for local and Serum Institute of AstraZeneca/Oxford manufacturing by CSL – Seqirus) India Canada: February 26, 2021 Ad26.COV2.S - Johnson USA: February 27, 2021 WHO EUL: March 12 2021 & Johnson Canada: March 5, 2021 EU: March 11, 2021 Switzerland: March 22, 2021 SinoPharm/BIBP WHO EUL: May 7, 2021 31 WHO. Status of COVID-19 vaccines with WHO EUL/PQ evaluation process. December 20, 2021 edition. https://extranet.who.int/pqweb/sites/default/files/documents/Status_COVID_VAX_20Dec2021.pdf Page 73 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Annex 2: Summary of parent project and additional financing components and proposed changes Original Components IDA Revised Components IDA GFF Total (US$, (US$, grant million) million) (US$, million) Component 1: Emergency COVID-19 Response 20.50 Component 1: Emergency COVID-19 Response 52.10 10.00 62.10 1.1 Case Detection, confirmation, contact tracing, 5.00 Moved to Subcomponent 2.1 under surveillance. recording, reporting to: (i) strengthen event-based surveillance; (ii) improve cross-border surveillance (containment unit, standard operation procedures (SOPs), equipment, training; (iii) purchase ICT equipment to support subcomponent implementation; (iv) conduct risk- assessment risk mapping, prioritization of the risk emerging from EIDs at the human, animal and ecosystem interfaces; (v) strengthen early warning systems for priority zoonotic diseases; (vi) interconnect sectorial information systems for monitoring of key zoonotic diseases; and (vii) develop guidelines to improve information sharing between relevant agencies and their respective information systems. 1.2 Health Systems Strengthening to: (i) support new 12.00 Moved to Subcomponent 1.1. isolation and treatment centers including field hospitals in hard hit communes; (ii) strengthen COVID-19 designated Health Facilities with isolation capacity for COVID-19 patients; (iii) enhance HF capacity to provide care for severe and critical COVID-19 patients through the procurement of medical equipment and commodities; (iv) train healthcare workers on COVID-19 case management; (v) procure specialized PPE for healthcare workers; and (vi) install handwashing facilities in health care facilities. Originally in 1.2. 1.1. Case Management to: (i) support small rehabilitations of 5.50 5.50 designated health facilities with isolation capacity for COVID- 19 patients and COVID-19 vaccination centers; (ii) procure medical equipment and commodities to enhance capacity of selected HFs to ensure adequate case management for severe and critical COVID-19 patients; (iii) train healthcare Page 74 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Original Components IDA Revised Components IDA GFF Total (US$, (US$, grant million) million) (US$, million) workers on COVID-19 IPC and case management; (iv) procure IPC materials and PPE kits for frontline healthcare workers and vaccinators; (v) procure supplies for sanitation and hygiene materials, (vi) adequate medical waste management and disposal systems in treatment centers; (vii) install simple handwashing stations in health facilities and rehabilitate selected water supply points; and (viii) implement infection prevention and control measures. Not in original project. 1.2 COVID-19 Vaccine Purchase to procure COVID-19 29.60 29.60 vaccines. 1.3 Social Distancing Measures to: (i) develop and 0.50 Removed. implement at the sub-national level a framework for decision making on the implementation of social distancing interventions; (ii) support additional preventive actions in highly crowded places (i.e. markets) such as personal hygiene promotion, including promoting handwashing, and distribution and use of masks. Not in original project. 1.3 Vaccines Deployment to: (i) procure essential 18.00 18.00 consumables and equipment for COVID-19 vaccination, including syringes, groves, face shields and masks; (ii) train vaccinators for the scale-up of the COVID-19 vaccination campaign, including training for the prevention of SEA/SH; (iii) strengthen vaccine safety surveillance, in terms of monitoring and addressing AEFI; (iv) support operational costs for COVID-19 vaccination deployment (periodic campaigns and mobile units) and supervision activities; (v) strengthen M&E systems, especially those related to stock management of COVID-19 vaccines; (vi) enhance cold chain and logistics to scale-up COVID-19 vaccination, including medical waste management capacity of selected sites. Page 75 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Original Components IDA Revised Components IDA GFF Total (US$, (US$, grant million) million) (US$, million) 1.4 Social Support to Households to Support isolated and 3.00 Removed. quarantined patients through the provision of food and other basic supplies. Not in original project. 1.4 Continuity of essential services to: (i) support health 10.00 10.00 facilities to develop and follow integrated planning and implementation of RMNCAH-N interventions aligned with district plans and in collaboration with community actors; (ii) intensify outreach strategies and campaigns to most affected areas by the pandemic to bring routine RMNCAH-N services closer to communities and to incentivize uptake of health- services and successful practices; (iii) address supply-chain constraints, in complementarity with SWEDD activities; (iv) improve quality of care through training and capacity building of health providers; (v) strengthen surveillance and response of maternal and perinatal deaths Component 2: Supporting National and Sub-National 5.0 Component 2: Supporting National and Sub-National 2.00 2.00 Prevention and Preparedness to: (i) strengthen national Prevention and Preparedness laboratory diagnostic capacity through the procurement of laboratory equipment, supplies, reagents and diagnostic kits for COVID-19; (ii) support the establishment of a decentralized network of COVID-19 diagnostic units across the country through the procurement of PCR based diagnosis equipment; (iii) implement rapid-testing strategies at decentralized level; (iv) train laboratory technicians and other relevant staff to use the new equipment and tests purchased. Originally in 1.1. 2.1 Surveillance to: (i) strengthen frontline health care 1.00 1.00 workers capacity in Integrated Disease Surveillance and Response (IDSR); (ii) strengthen capacity of selected stakeholders on IMS; and (iii) strengthen events-based surveillance systems at regional and community levels; (iv) support investigation missions for COVID-19 cases Page 76 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Original Components IDA Revised Components IDA GFF Total (US$, (US$, grant million) million) (US$, million) Originally component 2. 2.2 Laboratory Diagnostic to: (i) strengthen laboratory 1.00 1.00 capacity through the training of personnel on diagnostic for COVID-19 and priority diseases and provision of laboratory equipment, reagents and test kits; (ii) support selected laboratories to meet international quality standards through the accreditation in the WHO Stepwise Laboratory Improvement Progress Towards Accreditation (SLIPTA); and (v) reinforce and support an improved referral system for samples including those that will undergo genome sequencing. Component 3: Community Engagement and Risks 2.0 Component 3: Community Engagement and Risks 2.00 1.00 3.00 Communication Communication Not in original project. 2.0 3.1 Demand generation to strengthen behavioral risk 1.00 1.00 communication to ensure compliance with non- pharmaceutical mitigation strategies, through development and testing of messages and materials and identification and advocacy to key influencers in the community: i) develop media content in local languages (videos, other social media content); ii) disseminate information on the national vaccination campaign through mass media (radios and TV); (iii) utilize social media campaigns to address misinformation, promote vaccine uptake and support fact-checking; and (iv) leverage celebrities and influential figures for ad-hoc strategic campaigns. Not in original project. 3.2: Promoting health-seeking behaviors through 1.00 1.00 2.00 community engagement to i) integrate key health promotion messages for RMNCAH-N services into the CREC Plan messages; (ii) train decentralized territorial collectivities, civil society organizations and community-based actors in the promotion of key messages and strategies; (iii) carry out community-based awareness and sensitization activities that promote continued access to healthcare and uptake of Page 77 of 78 The World Bank Additional Financing for Cameroon COVID-19 Preparedness and Response Project (P178255) Original Components IDA Revised Components IDA GFF Total (US$, (US$, grant million) million) (US$, million) successful RMNCAH-N practices and initiatives; and iv) support community-based structures for crisis communication and management of information, to address misinformation and ensure a feedback mechanism to campaigns and awareness sessions conducted. Component 4: Implementation Management and M&E 1.50 Component 4: Implementation Management and M&E 1.50 4.00 5.50 4.1 Project Management 1.00 4.1 Project management and M&E 1.50 4.2 M&E for M&E activities, capacity building, joint learning 0.50 Moved to 4.1 activities, trainings, evaluation workshops. Not in original project 4.2 Data for decision-making 4.00 TOTAL 29.00 58.60 15.00 73.60 Page 78 of 78