The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) Additional Financing Appraisal Environmental and Social Review Summary Appraisal Stage (AF ESRS Appraisal Stage) Public Disclosure Date Prepared/Updated: 04/20/2021 | Report No: ESRSAFA113 Apr 26, 2021 Page 1 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) BASIC INFORMATION A. Basic Project Data Country Region Borrower(s) Implementing Agency(ies) Cambodia EAST ASIA AND PACIFIC Ministry of Finance Ministry of Health Cambodia Project ID Project Name P176212 Additional Financing to Cambodia COVID-19 Emergency Response Project Parent Project ID (if any) Parent Project Name P173815 Cambodia COVID-19 Emergency Response Project Practice Area (Lead) Financing Instrument Estimated Appraisal Date Estimated Board Date Health, Nutrition & Investment Project 5/10/2021 6/11/2021 Population Financing Public Disclosure Proposed Development Objective To assist Cambodia in its efforts to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness. Financing (in USD Million) Amount Current Financing 21.15 Proposed Additional Financing 3.50 Total Proposed Financing 24.65 B. Is the project being prepared in a Situation of Urgent Need of Assistance or Capacity Constraints, as per Bank IPF Policy, para. 12? No C. Summary Description of Proposed Project [including overview of Country, Sectoral & Institutional Contexts and Relationship to CPF] The Cambodia COVID-19 Emergency Response Project (ERP) is part of the World Bank’s COVID-19 Strategic Preparedness and Response Program using the Multiphase Programmatic Approach. The Project intends to fill critical Apr 26, 2021 Page 2 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) gaps in implementing the Cambodia’s COVID-19 Master Plan, which has been updated from Cambodia’s existing pandemic response strategy. The specific objectives that the Project aims to support include: (i) To reduce and delay the transmission of COVID-19; (ii) To minimize serious disease due to COVID-19 and reduce associated deaths; (iii) To ensure ongoing essential health services particularly during epidemic peak periods; and (iv) To minimize social and economic impact through multisectoral partnerships. These objectives are fully aligned with the overall goal of the Cambodia COVID-19 Master Plan which is to control transmission of COVID-19, and to mitigate the impact of the pandemic in Cambodia. The PDO is to assist Cambodia in its efforts to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness. The Project will comprise the following components: Component 1. Case detection and management (US$9.65 million): establishing and upgrading laboratory, isolation and treatment centers and equipping them with medical supplies and furniture and network installation. The National Institute of Public Health will be upgraded; diagnostic capacity of the four provincial laboratories as well as capacity of the laboratories attached to the 21 provincial referral hospitals will be built; and isolation and treatment centers in all 25 municipal/provincial referral hospitals will be established. Component 2. Medical Supplies and Equipment (US$6.5 million): This component will finance the procurement of medical supplies and equipment needed for activities outlined in the COVID-19 Master Plan, including business continuity of essential services, such as (1) case management; and (2) infection prevention and control. Specifically, Public Disclosure items procured will include drugs and medical supplies for case management and infection prevention. Component 3. Preparedness, Capacity Building and Training (US$3.5 million): This component will finance activities related to preparedness, capacity building and training, guided by the different pillars and activities of the COVID-19 Master Plan. These include: (1) coordination at the national, provincial and district levels; (2) Emergency Operation Center functionalization; (3) human resources for implementation, supportive supervision and subnational support; (4) operating costs; (5) support for screening people entering in to the country at designated points of entry; (6) strengthening call/hotline centers; and (7) strengthening community- and event-based surveillance for COVID-19. The Component will also support risk communication and community engagement; behavioral and sociocultural risk factors assessments; production of risk communication and community engagement strategy and training documents; production of communication materials; and monitoring and evidence generation. Component 4. Project Implementation and Monitoring (US$1.5 million): Implementing the proposed Project will require administrative and human resources that exceed the current capacity of the implementing institutions, in addition to those mobilized through the Health Equity and Quality Improvement Project. Activities include: (1) support for procurement, financial management, environmental and social safeguards, monitoring and evaluation, and reporting; (2) recruitment and training of staff and technical consultants; and (3) operating costs. The changes proposed for the AF2 entail expanding the scope of activities in the parent project, Cambodia COVID-19 ERP. As the proposed additional activities are fully aligned with the parent project, the PDO will remain unchanged. An additional PDO Indicator will be added, per the financing source requirements, to measure the percentage of the population vaccinated, based on the targets defined in the NDVP, and additional Intermediate Results Indicators will be included for Component 1 to track AF2 progress. Apr 26, 2021 Page 3 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) There will be no change from the parent project’s implementation arrangements with the exception of including one additional technical department. The MOH, with its extensive experience in the WB’s fiduciary, environmental, social, and technical implementation arrangements, will continue to lead the coordination and implementation of project activities. An inter-ministerial committee, chaired by MOH, has been set up to coordinate efforts across the Government for responding to the COVID-19 vaccination, with this committee replicated at both provincial and operational district levels nationwide. With respect to this AF2, CMS will be involved in project implementation and is responsible for the storage and distribution of vaccines. The closing date of the AF2 will not change, and remain at December 31, 2022. The increase in scope, as outlined above, will be reflected in an increase in indicative component allocation from US$21.15 million equivalent to US$24.65 million equivalent, with the full amount of the AF being added under Component 1. The allocation to Component 1 will be increased by US$3.50 million to reflect the AF2 made available for strengthening cold chain capacity and logistics, and preparedness for vaccines deployment. The allocation to Components 2, 3 and 4 will be US$6.50 million, US$3.50 million and US$1.50 million respectively as outlined under the parent project and the AF1 with a focus on medical supplies and equipment, preparedness capacity building and training, and project implementation and monitoring. The current Component 1 of the parent project, “Case detection and management”, will be renamed as “Emergency COVID-19 Prevention and Response” to align it with the MPA. The activities in the parent project under Component 1 will remain unchanged and become sub-component 1.1 titled “Case detection and management”. A sub-component Public Disclosure 1.2, “Preparedness and deployment of COVID-19 vaccination”, will be added. The sub-component 1.2 will support: (a) the establishment (design and implementation) of a mechanism to provide identification of the defined at-risk groups and register them; (b) design and implement campaigns to familiarize the population with issues related to vaccination and roll out plan of the vaccine; (c) capacity building and training of health workers and VHSGs for appropriate and effective provision of the vaccines; (d) delivery of vaccines to reach difficult to access priority groups; and (e) building on support from WHO, management of vaccination waste, including ensuring proper waste collection, transportation and disinfection and proper disposal of vaccination wastes. With the inclusion of this AF2, the Cambodia COVID-19 ERP project components will be updated as follows: Component 1: Emergency COVID-19 Prevention and Response (U$13.15 million) Subcomponent 1.1: Case Detection and Management (US$9.65 million) Subcomponent 1.2: Preparedness and Deployment of COVID-19 Vaccination (US$3.5 million) Component 2: Medical Supplies and Equipment (US$6.5 million) Component 3: Preparedness, Capacity Building and Training (US$1.5 million) Component 4: Project Implementation and Monitoring (US$3.5million) D. Environmental and Social Overview D.1. Detailed project location(s) and salient physical characteristics relevant to the E&S assessment [geographic, environmental, social] The second additional financing (AF2) would support the cost of expanding nationwide the activities of the the Cambodia COVID-19 Emergency Response Project (CCERP) (P173815), approved in April 2020. CCERP aims to support Apr 26, 2021 Page 4 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) selected containment as well as mitigation related activities which the Cambodian government has identified in the COVID-19 Master Plan. This AF2 seeks to support the Ministry of Health (MOH) to prepare for timely, speedy and effective delivery of COVID-19 vaccines to at risk population groups in Cambodia. The project focuses on (i) procurement of the medical consumables and equipment (in particular cold chain) and (ii) planning, national set up, and capacity strengthening for COVID-19 vaccination roll out. The AF2 does not seek to finance any purchase of vaccines. With a population of around 17 million people, Cambodia recorded its first case of COVID-19 in January 2020 and had relatively low cases during the whole of 2020. For instance, as of 6 December 2020 there had been 348 cases and no deaths. Throughout 2020 mask wearing, temperature checks and provision of hand sanitizer have been common in government buildings and large shopping centers but absent elsewhere, especially outside major cities. The population is highly mobile, with young workers in the cities often traveling to rural homes for family and recreational visits. There is also a large number of informal workers who move around regularly, seeking employment. The precariousness of the situation in Cambodia was evidenced by the recent February 20, 2021 community transmission outbreak which has led to a significant rise in cases -- 4,874 cases recorded as of April 14, including 35 deaths. In one month, the confirmed cases have spread from the urban centers of Phnom Penh capital and Sihanouk province to another 8 provinces, leading to a 480 percent surge in cases. While thousands of tests are conducted on a daily basis, testing capacity throughout the country is limited. There are five testing labs for the whole country and four of them are in Phnom Penh, with the remaining one in Siem Reap. They have a combined capacity of 1,500 tests per day. In mid-April the capital Phnom Penh was placed under its first lockdown since the start of the pandemic, due Public Disclosure to soaring case numbers and limits in the number of hospital beds and ambulances available. Nevertheless, vaccination commenced in late February and has kept a consistent pace with nearly 1.5 million doses provided by mid-April, including nearly 300,000 people fully vaccinated, representing 1.7% of the population. The Covid-19 pandemic has hit Cambodia’s economy hard, particularly the tourism, construction and garment sectors on which the economy depends. With a lack of an effective social protection system, the impact of Covid-19 has further exacerbated the existing condition of vulnerability of some segments of the population. People working in the informal economy, tourism, garment sectors as well as migrant workers returning from neighboring countries have been particularly impacted. The AF2 is going to scale up activities under Component 1 of the Cambodia COVID-19 ERP to support the procurement of cold chain equipment and medical consumable for vaccine deployment as well as preparedness for effective deployment which cover (a) the establishment (design and implementation) of a mechanism to provide identification of the defined at-risk groups and register them; (b) design and implement campaigns to familiarize the population with issues related to vaccination and the roll out plan of the vaccine; (c) capacity building and training of health workers and village health support groups (VHSGs) for appropriate and effective provision of the vaccines; (d) delivery of vaccines to reach difficult to access priority groups; and (e) building on support from WHO, management of vaccination waste, including ensuring proper medical waste collection, transportation and disinfection and proper disposal of vaccination wastes. Medical wastes, including syringes and vials from vaccination program, have a high potential of carrying micro-organisms that can infect people who are exposed to it, as well as the community at large if it is not properly disposed of. It may also cause infectious risk to healthcare workers in contact or handle the waste. Apr 26, 2021 Page 5 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) Priority groups for COVID-19 immunization have been identified in the Royal Government of Cambodia’s (RGC) COVID-19 National Deployment and Vaccination Plan (NDVP). Vaccination for priority groups in Phase 1 – which has started– is focused on health care workers, essential government staff (in particular high-level officials, army and police) and Village Health Support Groups and others involved in the immunization program. Phase 2, which is the focus of World Bank financed support, targets the elderly (65 years+) and high risk groups (those with chronic conditions, hypertension, diabetes, etc.), as well as other potential priority groups (e.g. garment factories). The AF2 will not finance the procurement or development of Covid-19 vaccines that do not meet the criteria of the Stringent Regulatory Authorities (SRAs) and/or the WHO. D. 2. Borrower’s Institutional Capacity The activities under the proposed second AF will be implemented by the Ministry of Health (MOH) and no change in implementation arrangement except with an additional technical department, Central Medical Store (CMS) which will be involved in project implementation, due to its core role for the storage and distribution of vaccines. As it is unclear whether the National Immunization Program (NIP) which developed National Deployment and Vaccination Plan for MOH will be involved in the implementation of AF2, at present there is uncertainty regarding which agency will be responsible for the preparation of the COVID-19 pandemic national deployment and vaccination plan. This makes it difficult to assess the borrowers institutional capacity for the activities involving vaccine deployment planned under Component 1. MOH has over twenty years of experience implementing Bank health sector projects, including sector-wide approaches. It implemented the Avian Influenza Preparedness & Response Project (P100084) and the H1N1 immunization campaign i.e. MOH has successfully eradicated wild poliovirus, eliminated maternal and neonatal Public Disclosure tetanus and measles, and coverage levels have generally met WHO standards, despite the challenge of remote populations and transportation difficulties. Responses to adverse events have been timely. MOH’s Department of Preventive Medicines (PMD) has been tasked with the management of environmental and social risks associated with the parent project as well as the first, and this second, Additional Financing. Overall, PMD has extensive experience in implementation and management of environmental and social risks under the Bank’s Safeguards Operational Policies (the Health Equity and Quality Improvement Project (H-EQIP) (P157291), as well as under the Bank’s Environmental and Social Framework (ESF) (i.e. the Cambodia COVID-19 Emergency Response Project (P173815); Cambodia Pre-Service Training for Health Workers Projects (P169629) and the, under preparation, Health Equity and Quality Improvement Project2 (H-EQIP2)). However, the first implementation mission of the CCERP found that PMD is facing constraints to carry out E&S mitigation activities and needs more support and capacity building to adequately manage E&S risks. The first World Bank’s Implementation Support Mission has led to the Environmental and Social performance of the Project being downgraded to ‘Moderately Satisfactory’ due to limited progress in the implementation of Environmental and Social procedures and budget constraints. In consequence, the World Bank Task Team has mobilized a local consultant to support PMD, who has been challenged with shortage of staff with expertise on environmental and social framework, in implementation ESCP. Experience suggests that internal environmental and social management is most effective and efficient when E&S related activities are mainstreamed into project design. Although the country has some experience in infection prevention and control, and healthcare waste management, and training, communication, and public-awareness on emergency situations, its capacity to manage risks associated with COVID-19 vaccination is a major concern. The parent project component 3 and this second AF under component 1.2 will provide considerable funding, training, and capacity building to address these short-comings including Apr 26, 2021 Page 6 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) identification and registration of priority target population for vaccination using a digitized registration system, awareness raising and mobilization campaigns, trainings and workshops for vaccinators, recording and reporting, outreach vaccination to vaccine vulnerable groups, and proper disposal of medical waste used in the vaccination program. II. SUMMARY OF ENVIRONMENTAL AND SOCIAL (ES) RISKS AND IMPACTS A. Environmental and Social Risk Classification (ESRC) Substantial Environmental Risk Rating Substantial The Environmental Risks are considered “Substantial” given that Cambodia has limited experience in managing highly infectious medical wastes management such as those associated with COVID-19 and will require that appropriate precautionary measures are planned and implemented. In addition, capacity constraints also exist in the PMD, which is responsible for overseeing environmental and social safeguards aspects of the WB supported health sector projects and the concern over capacity to manage risks associated with COVID-19 vaccination although MOH has some experience in IPC&HCWM. WHO has reported that 20% of total healthcare waste would be an infectious waste, and inadequate management of wastes generated by immunization activities such as sharps and infectious non-sharp wastes can cause direct negative health impacts on the community and the personnel working during and after the vaccination campaign. In addition, pollution due to inadequate treatment and disposal of these wastes can cause indirect health effects in the community and impact the environment. Key environmental risks for the proposed AF2 activities relate to: (i) management of vaccination wastes, including ensuring proper medical waste Public Disclosure collection, transportation, disinfection and proper disposal of vaccination wastes and (ii) community and personnel health related risks from inadequate storage, transportation and disposal of infected medical waste. Most COVID- 19-related waste is sharps that needs special handling and disposal. There is a possibility for infectious microorganisms to be introduced into the environment if they are not contained within the vaccination sites. The waste from the campaign may also include empty vaccine vials, which are recommended to be placed into a sharps container to mitigate potential diversion or illicit use. Full or partially full vaccine vials should also be managed as regulated medical waste. Besides, vaccine packaging can be disposed of as regulated medical waste. However, MOH should check the vaccine manufacturer’s instructions for properly disposing of packaging waste. Social Risk Rating Substantial The activities under the proposed second additional financing will provide social benefits to the general population, including vulnerable groups, enabling them to access the Covid-19 vaccine in a more equitable and inclusive manner. However, there are inherent risks to the additional financing, in particular in terms of the support for screening and outreach to priority groups, as well as risks associated with the handling of vaccines. Social risks for the proposed additional finance activities relate to (i) Occupational health and safety and safe injection practices, including waste management and vaccine distribution; (ii) biosafety of the vaccine, including potential adverse reactions to the vaccine; (iii) case management of population for vaccination, including the risks associated with people who do not complete the recommended immunization schedule; (iv) community health and safety, including inherent risks in COVID transmission; (v) affordability, social inequity, and risk of exclusion, particularly if the intended vulnerable groups are not adequately targeted for prioritization, and (vi) stigma, discrimination, vaccine acceptance and misinformation, including false rumors about the efficacy of the vaccine. The Cambodian government has stated that vaccines will be free and voluntary for all groups. However, a recent sub-decree was issued making vaccination Apr 26, 2021 Page 7 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) mandatory for civil service employees and members of the armed forces. It is possible that vaccination will become mandatory in other large workforces as well, such as garment factories. It is important to highlight that while the Bank is not supporting the vaccine purchasing directly, it is supporting the equipment, mechanisms and organization for the immunization program and therefore vaccine-related risks are directly linked to the project. Given the earlier mentioned factors, social risks for the Project remain classified as ‘Substantial’, taking into account the similar nature and magnitude of the risks, coupled with MOH’s capacity and commitment to the management of the risks, and the general uncertainties around the roll-out of the Covid vaccination (timeline, sources of the vaccine, etc.). Social risks and impacts will be addressed through the implementation of an updated Environmental and Social Commitment Plan (ESCP), an updated Stakeholder Engagement Plan (SEP), including an updated Grievance Mechanism, and an updated Environmental and Social Management Framework (ESMF), including Labor Management Procedures (LMP), which are consistent with WB’s ESF, the WHO COVID-19 guidance on risk communication and community engagement, the government’s NDVP, the government’s COVID-19 Vaccination Campaign Protocol, and other national laws and regulations. B. Environment and Social Standards (ESSs) that Apply to the Activities Being Considered B.1. General Assessment ESS1 Assessment and Management of Environmental and Social Risks and Impacts Overview of the relevance of the Standard for the Project: The proposed AF2 entails expanding the scope of activities in the parent project, Cambodia COVID-19 ERP. These risks Public Disclosure and impacts are covered by the Environmental and Social Commitment Plan (ESCP), the Environmental and Social Management Framework (ESMF) including Infection Prevention and Control and Waste Management Plan (IPC&WNP) and Stakeholder Engagement Plan (SEP) prepared under the existing COVID-19 Emergency Response Project, which have been updated to cover the first additional financing. The updated version of the ESMF contains Infection Prevention and Control & Waste Management Plan (IPC&WMP) to safeguard health care workers during vaccination campaign and managing the safe disposal of the vaccination waste which include proper medical waste collection and transportation and disinfection and proper disposal of vaccination waste. The second additional financing expands the scope of activities in the parent project and will finance procurement of cold chain equipment and activities related to identification of, and communication with, priority groups for the Covid-19 vaccine. The storage and transportation of vaccines could cause substantial social risks related to occupational and community health and safety for communities, health workers, village health support volunteers, drivers and those involved in the supply chain, and others involved in the implementation of the Covid 19 Development Plan. Other social risks include the equitable distribution and access to the vaccine by the vulnerable groups, as well as the risks related to the social acceptability of the vaccine, as well as misinformation about vaccine safety and effectiveness and its potential side effects. Overall, the main social risks are expected to be: (i) Occupational health and safety and safe injection practices, including waste management and vaccine distribution for NIP’s staff, health workers, health volunteers and others who prepare and implement the Covid-19 deployment and vaccination program, including those transporting equipment; (ii) Biosafety of the vaccine, including potential adverse reactions to the vaccine; Apr 26, 2021 Page 8 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) (iii) Case management of the population for vaccination, including the risk of people who don’t complete the recommended immunization schedule; (iv) Community health and safety, including inherent risks in COVID transmission associated with people congregating near vaccination sites; (v) Affordability, social inequity, and risk of exclusion, particularly if the intended vulnerable groups are not adequately targeted for prioritization or they do not know they are eligible, or if they are unable to access the vaccine due to location, language or the need for identification (which can be an issue with some ethnic minorities), and (vi) Stigma, discrimination, vaccine acceptance and misinformation, including false rumors about the efficacy of the vaccine and support for undergoing vaccination. (vii) potential adverse impacts on the livelihoods of civil servants due to the mandatory vaccination requirements recently introduced through a government sub-decree, which could potentially expand to other sectors such as garment factories. . The main environmental risks associated with the second AF are (i) management of vaccination wastes, including ensuring proper medical waste collection, transportation, disinfection and proper disposal of vaccination wastes and (ii) community and personnel health related risks from inadequate storage, transportation and disposal of infected medical waste. The vaccines have different storage temperature requirements, ranging from temperatures as low as - 7 0C to refrigerator temperatures of 2-8 0C. Particularly the former vaccines (those based on mRNA technology) are prone to rapid decay and ineffectiveness when not stored at the proper temperature, which could lead to high wastage. Wasted or damaged vaccines may be at the very minimum ineffective, when administered and may increase the volume of wastes if no there is shortage of proper storage in remote areas. The AF will fund necessary Public Disclosure investments in cold storage and logistics to enable the safe delivery of vaccines throughout the country. The government’s NDVP is allotting over 50% of vaccines of the first phase to government staff, in particular those working at higher levels of government, the police and army. This first priority phase, which is not strictly in-line with the WHO Framework for Allocation and Prioritization, is receiving 600,000 doses of the Chinese-made Sinopharm vaccine – which has not yet been approved by the WHO – arriving in Cambodia in early February. Historically, there can be negative perceptions to “Chinese-origin” materials in Cambodia, which could have implications for people’s support and readiness to take the vaccine, even if manufactured elsewhere. Moreover, the prioritization of the first group of people could give the impression that the vaccine is targeted at people with means and connections and not the poor and most vulnerable. Nevertheless, the initial vaccine roll-out is progressing well with 1.7% of the population fully vaccinated by mid-April. The NDVP priority groups are outlined below: 1) Health care workers including auxiliary workers (#36,894 or 0.2%) for Phase 1 at fixed (HCs/health facilities) sites; 2) Essential government staff (expected to include the Prime Minister and the Council of Ministers, Royal palace, Parliament, Senate and Governors, as well as army and police) to maintain law and government services (#289,721 or 1.7%) for Phase 1 at fixed (HCs/health facilities) sites and army and police offices/Barak; 3) Village Health Support Group (Volunteers) and those involved in the immunization and health program (HCMC, Commune council member, village chief) (#50,074 or 0.3%) for Phase 1 at fixed (HCs/health facilities) sites; Apr 26, 2021 Page 9 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) 4) Elderly population (65 years above) (#123,321 or 0.8%) for Phase 1 in Phnom Penh at fixed (HCs/health facilities) and outreach sites (villages), and for Phase 2 (#821,611 or 4.87%); 5) High risk adults from 18-64 years old (Diabetes, Hypertension, etc.) (#1,521,426 or 9.0%) for Phase 2 At fixed (HCs/health facilities) and outreach sites (villages) 6) Garment factory/other workers (#621,275 plus #500,000 or 3.7%/23%) for Phase 2 At the factories/sites; all these numbers are estimated to correspond to 23% of population. The NDVP priority groups do not specifically identify poor populations, people living in densely populated areas such as slums or indigenous peoples. To ensure that environmental and social risks caused by the second additional financing are appropriately managed, an updated ESMF, updated SEP and GRM, and updated ESCP have been consulted and disclosed by MOH in April 13, 2021 (http://hismohcambodia.org/public/announcements.php?pid=32). The updated ESMF lays out all the expected risks and mitigation measures from the parent project as well as the first and second additional financing. One risk that is not yet considered as part of the ESMF is the recently introduced mandatory vaccination of civil servants and members of the armed forces, who may face penalties for refusing vaccination. There is also the possibility that other high-risk sectors, such as garment factories, may enforce mandatory vaccination. The ESMF and SEP provide linkages to the government’s NDVP and government’s Communication and Community Engagement (CCE) Strategy and Plan for COVID-19 vaccine deployment and vaccination, with a focus on ensuring the most vulnerable groups can be Public Disclosure effectively identified and prioritized, particularly in Phase 2 and other future phases. The ESMF also includes measures for safe handling, infection and prevention control, codes of conduct for workers, IPC&WMP and labor procedures. ESS10 Stakeholder Engagement and Information Disclosure The project recognizes the need for effective and inclusive engagement with all the relevant stakeholders and the population at large. The RGC is also aware of this, and of the importance of ensuring the population has consistent, updated and verified information about to the vaccine, that misinformation is targeted and challenged, and that at- risk population groups are informed of their eligibility and this has been highlighted in the NDVP. The parent project has prepared an SEP that was updated for the first AF and has been updated again based on the specific needs and activities of this second AF. The updated SEP defines a program for stakeholder engagement, including public information disclosure and consultation, throughout the entire project cycle. It also outlines a communication strategy with the project stakeholders, and offers mechanisms for them to raise concerns, provide feedback, or make complaints about project. With support of the parent project, MOH has already been actively working to develop a variety of IEC materials to raise public awareness on COVID-19 transmission and prevention. This second AF provides financing for planning the vaccination program, including the registration of priority target groups, telecoms technology deployed for public information about COVID-19 vaccination, an adequate network of trained, technically competent COVID-19 vaccination providers in accessible settings, and adverse event case reporting and investigation. This will require a robust communication and capacity building program. The SEP establishes an approach to engagement with Apr 26, 2021 Page 10 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) stakeholders including the vulnerable and disadvantaged groups, that is based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with COVID-19. There are also relevant stakeholders who could be important in supporting the vaccine roll-out, including NGOs and CSOs who work with the poor, homeless, indigenous groups, people with disabilities, at-risk women, migrants and others, who could help to spread accurate communication about the vaccine program. Health staff and Village Health Support Groups will be particularly important for relaying communication messages, as they will be at the forefront of the vaccination program and hence need to be supported to ensure they have up-to date information. This will be particularly important in more remote areas of the country, including in areas where indigenous peoples live, and where different languages are spoken. The SEP also incorporates information from a hotline already operational and rolled out by the RGC where people can call and ask specific COVID-related questions. This hotline may be further utilized once the vaccine is available and people have questions on eligibility, access or cost. The SEP follows guidance provided by the WHO on COVID, specifically, as well as in general in terms of immunization programs. Trust in the vaccine program – including its source, side effects, those administering the vaccine, etc. – will be essential in ensuring an orderly and effective vaccination program. The SEP is a living document and it will continue to be updated as needed during project implementation. The SEP has been disclosed in the MoH website. The MOH will ensure that the project reaches out to all beneficiaries, in particular disadvantaged and vulnerable groups, without prejudice or discrimination. However, one stakeholder related risk that is not considered in the SEP is the recent government sub-decree mandating vaccination for civil servants and members of the armed forces. Public Disclosure B.2. Specific Risks and Impacts A brief description of the potential environmental and social risks and impacts relevant to the Project. ESS2 Labor and Working Conditions Most activities supported by the project will be conducted by health professionals - and laboratory workers, i.e. civil servants employed by the Government of Cambodia and professional consultants and contractors (hired as contracted workers). The second AF also encompasses workers transporting the vaccines (contracted workers) and others at the Central Medical Store (CMS) who are responsible for vaccine transport and other related equipment, as well as village health support groups (who can be considered community workers) and local government officials who are involved in the vaccination program. Moreover, the supply chain system is essential for the success of the immunization program and conducting any vaccination services/campaign. The role of the supply chain is to ensure effective COVID-19 vaccine shipment, storage, handling, and stock management; rigorous temperature control in the cold chain; and maintenance of adequate logistics management information systems. The supply chain will include, among others, providers of freezer trucks, refrigerators, cold boxes, syringes, PPE, etc. The key risk to project workers is infection with COVID-19, as well as working conditions in the supply chain. The project will ensure the application of OHS measures as outlined in the ESMF’s Labor-Management Procedures (including ESMP and Infection Prevention and Control Plan) noted under ESS1, WHO guidelines as well as, as well as the government’s COVID-19 Vaccination Campaign Protocol, which has been developed and serves as an standard operating procedures (SOPs) for vaccination campaign. This encompasses procedures for safe managing of vials; entry into health care facilities; procedures for the protection of workers in relation to infection control precautions; Apr 26, 2021 Page 11 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) provision of immediate and ongoing training on the procedures to all categories of workers; and ensuring adequate supplies of PPE. It will also involve ensuring adequate OHS protections in accordance with General EHSGs and industry-specific EHSGs and that evolving international best practice will be followed in relation to protection from COVID-19. Also, the project will regularly integrate the latest guidance by WHO, in particular relating to the immunization program. The project’s LMP will also ensure a basic, responsive grievance mechanism to allow workers to quickly inform management of labor issues, such as a lack of PPE and unreasonable overtime via the Ministry of Health. Child labor is forbidden for any person under the age of 18. The project shall be carried out in accordance with the applicable requirements of ESS 2, in a manner acceptable to the Bank, including through, inter alia, implementing adequate occupational health and safety measures (including emergency preparedness and response measures), setting out grievance arrangements for project workers, and incorporating labor requirements into the ESHS specifications of the procurement documents and contracts with contractors and supervising firms. ESS3 Resource Efficiency and Pollution Prevention and Management In terms of this second AF, there is expected to be considerable waste from the vaccination program. This includes both information material (paper) but, more importantly, syringes and vials that are discarded once people are vaccinated. Following standard procedures in Cambodia, these will be placed in safety boxes that are collected and transported to designated incineration/buried sites. The IPC&WMP will mandate that any waste associated with COVID-19 testing, treatment or vaccination will be incinerated on-site whenever possible. It will also contain strict Public Disclosure protocols for disinfecting and packing such waste for transportation to the nearest medical waste incinerator if on- site destruction is not possible. The ESMF contains measures to mitigate the potential impacts from vaccine introduction (e.g., waste management, cold chain capacity, etc.). A health care waste management plan has been developed as part of the Parent Project's IPC&WMP to ensure the waste management practices at the various hospitals receiving assistance from the project comply with WHO guidance and international best practice for infectious and hazardous waste management. The HCWMP will be expanded to include the waste types emerging to the second AF components – including sharps, used and expired vaccine vials. It is worth noting the government’s NDVP, contains provisions on vaccine, cold chain, logistics and infrastructure, including mapping and inventory of current resources. The ESMF will include guidance related to transportation and management of vaccines, samples and medical goods or expired chemical products and wasted vaccines. Resources (water, air, etc.) used in health care and quarantine facilities and labs will follow standards and measures in line with State Sanitary Hygienic Service of MOH and WHO environmental infection control guidelines for medical facilities. ESS4 Community Health and Safety Vaccination wastes have a high potential of carrying micro-organisms that can infect the community at large if they are is not properly collected, transported, disinfected and disposed of. There is a possibility for the infectious microorganism being introduced into the environment if not well contained within the laboratory or due to accidents/ emergencies e.g. a fire response or natural phenomena event (e.g., seismic). Apr 26, 2021 Page 12 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) The project will mitigate the risk of Sexual Exploitation and Abuse by applying the WHO Code of Ethics and Professional Conduct -Code of Conduct using WB’s terminology- for all workers. The project’s LMP includes also provisions to prevent Sexual Exploitation and Abuse (SEA), Gender- Based Violence (GBV) and/or Violence Against Children (VAC). Training on community interaction and SEA/GBV/SEA will be provided for all teams, staff (civil servants and outsources staff/contractors) to ensure the teams respect local communities and their culture and will and do not engage in exploitative, abusive or disrespectful behaviors. Codes of Conduct code of conduct (CoC) will be included in the letter of PIU’s staff appointment and contracts (for contracted workers) in line with relevant national laws and legislations to be adopted and applied under the project. The project has put in place a grievance redress systems for general project-related to allow people to share complaints and concerns about project activities. The project is not expecting the use of security personnel in any way. ESS5 Land Acquisition, Restrictions on Land Use and Involuntary Resettlement This standard is not considered relevant at this time since no major construction works are planned for this project (only improvements to or equipping of the existing facilities in the parent project) . Therefore no land acquisition, physical or economic displacement, or restriction of access to natural resources is envisaged. Public Disclosure ESS6 Biodiversity Conservation and Sustainable Management of Living Natural Resources All works will be conducted within the existing footprint of facilities. Hence, likely impacts of the project on natural resources and biodiversity are low and so this standard is not considered relevant. ESS7 Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities ESS7 is relevant since ethnic groups (Indigenous Peoples) possessing the four characteristics listed in para 8 of ESS7 are present in the project area , given that the coverage of the project is nationwide. Approximately 1.25% percent of the population in Cambodia is considered indigenous , and there are approximately twenty two recognized ethnic groups. They live in several regions, but are mainly concentrated in the north east areas of the country. There is a risk of exclusion associated with the capacity of vulnerable and poor communities in some of these remote areas to access the vaccine and treatment. Applying the principle of proportionality, this project will not have to prepare any additional specific Indigenous Peoples Plan, as the key measures for engaging with indigenous people are included in the above-mentioned SEP. As such, project activities in areas where Indigenous Peoples are present must ensure that IPs are fully consulted and informed in a culturally appropriate manner about the project, and have opportunities to benefit from the project activities. The updated SEP guides the process of consultation to ensure that indigenous groups are incorporated in project consultations, aware of prioritization for immunization (depending on vulnerability/age), have current information about the benefits and side effects of the vaccine and can access the immunization program. This will include tackling cultural norms or beliefs if relevant. Apr 26, 2021 Page 13 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) ESS8 Cultural Heritage This standard is not relevant to the proposed project interventions. ESS9 Financial Intermediaries This standard is not relevant to the proposed project interventions. C. Legal Operational Policies that Apply OP 7.50 Projects on International Waterways No OP 7.60 Projects in Disputed Areas No B.3. Reliance on Borrower’s policy, legal and institutional framework, relevant to the Project risks and impacts Is this project being prepared for use of Borrower Framework? No Public Disclosure Areas where “Use of Borrower Framework” is being considered: Not relevant IV. CONTACT POINTS World Bank Contact: Nareth Ly Title: Senior Health Specialist Telephone No: 5721+1367 / 855-23-261367 Email: nly1@worldbank.org Contact: Ziauddin Hyder Title: Senior Health Specialist Telephone No: 1-202-7305712 Email: zhyder@worldbank.org Borrower/Client/Recipient Borrower: Ministry of Finance Implementing Agency(ies) Implementing Agency: Ministry of Health Cambodia Apr 26, 2021 Page 14 of 15 The World Bank Additional Financing to Cambodia COVID-19 Emergency Response Project (P176212) V. FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects VI. APPROVAL Task Team Leader(s): Nareth Ly, Ziauddin Hyder Practice Manager (ENR/Social) Susan S. Shen Cleared on 20-Apr-2021 at 08:00:8 GMT-04:00 Public Disclosure Apr 26, 2021 Page 15 of 15